Anorexia Nervosa: A Complex Disorder Both
Eating disorders are a cause for serious concern from both a psychological and a nutritional point of view. They are often a complex expression of underlying problems with identity and self concept. These disorders often stem from traumatic experiences and are influenced by society=s attitudes toward beauty and worth (Eating Disorder Resource Center, 1997). Biological factors, family issues, and psychological make-up may be what people who develop eating disorders are responding to. Anyone can be affected by eating disorders, regardless of their socioeconomic background (Eating Disorder Resource Center, 1997). Anorexia nervosa is one such disorder characterized by extreme weight loss. It is the result of self imposed and severe restrictions of food and fluid intake, a distorted body image, an intense fear of becoming fat, and a poor self esteem. Besides dieting to extremes, anorexics often over exercise to lose weight. Anorexics themselves are often the last to realize how undernourished and underweight they are. Even after reaching a weight that is dangerously low, they feel good initially, about losing the weight. No matter how much is lost, anorexics continue to feel fat and desire to lose more weight. It is this denial that makes it so hard to convince anorexics to seek help (Eating Disorder Resource Center, 1997). This paper=s focus is to look in more detail at the psychological and societal factors contributing to anorexia nervosa, as well as the nutritional and physiological complications that arise for people on such severely restrictive diets.
Psychological and Societal Contributions
Anorexia Nervosa was first described by an English physician by the name of Richard Morton in 1689. Until 1914, it was considered a disease that arose from a morbid mental state and a disturbed nerve force. That year, Dr. Simmonds, a pathologist, found one woman=s refusal to eat to be the direct result of an anterior pituitary lesion. This shifted the focus away from the emotional aspects of the disorder to more physiological and endocrinological terms. It was not until 1938 that anorexia nervosa was once again considered a largely emotional disorder (Blackman, 1996). In fact, one of the criteria for the diagnosis of anorexia nervosa according to the manual of The American Medical Association (DSM IV) is an intense fear of gaining weight or becoming fat, even though underweight. Another clearly psychological requirement for diagnosis, is a disturbance in the way in which one=s body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight (Blackman, 1996).
Anorexia nervosa may be a primary disorder in which other psychiatric conditions are secondary, such as depression. It may also be secondary itself to a disorder such as schizophrenia or co-morbid with obsessive compulsive disorder. As well, it can also be a component of a personality disorder (Blackman, 1996; Carlat, 1997). The anorexic sufferer is typically female. Ninety-percent of all cases occur among adolescent girls or young women but the number of males with the disorder is on the rise (Blackman, 1996; Carlat, 1997; Kinzl, 1997). It is estimated that 1% of girls ages 12-18 meet the criteria for full blown anorexia and as many as 5-10% have milder forms of such eating disorders if the criteria is applied less stringently (Blackman, 1996). Anorexics are usually high achieving youngsters who may be heavily involved in sports (e.g. gymnastics, swimming, cheer leading, ballet, etc.). These people are often competitive, perfectionistic, with obsessive compulsive personality features. Fears of growing up or discomfort toward sexuality may also be precipitating factors (Blackman, 1996). Studies have shown that 75% of American Women are dissatisfied with their appearance and as many as 50% are on a diet at any one time. Even more alarming is that 90% of high school junior and senior women regularly diet, even though only between 10%-15% are over the weight recommended by the standard height-weight charts (Council on Size and Weight Discrimination, 1996). The majority of these women do not develop eating disorders; however, 1% of teenage girls and 5% of college-age women do become anorexic or bulimic (Council on Size and Weight Discrimination, 1996). Perhaps these figures represent the women who are less able to cope with their bodily dissatisfaction and thus are the ones who take dieting to the extreme.
The disordered eating behavior usually starts out with a pattern of dieting or particular food choices, such as avoiding certain foods which are seen as fattening. As the disorder progresses, anorexics become resourceful in hiding their troublesome behavior and may start to avoid eating with their families. They may also attempt further weight loss by compulsive exercising. The condition can become well advanced before parents even notice, as anorexics may wear many layers of clothes to conceal their thinness. Often the diagnosis is not made until the person is brought to a clinic for problems such as physical weakness, lack of energy, excessive sleepiness, and recent poor performance in school (Blackman, 1996).
Actually, certain familial relationships seem to be more prevalent among anorexic sufferers. Studies have shown many anorexic families are enmeshed, overprotective, conflict avoidant, and as co-opting the anorexic in destructive alliances with one parent or another. The parents themselves tend to be more affectionate and neglectful than parents of non anorexic children. The father in particular is often controlling (Blackman, 1996). Physical and/or sexual abuse are also not uncommon features in families with anorexics (Carlet, 1996; Kinzyl, 1997). Even though these trends are trends often seen, there are many anorexic families that do not fit this profile.
One of the other major contributors to the disorder is society and its values. Anorexics are sensitive to society=s approval of what is an acceptable weight or body size (Blackman, 1996). Self worth is equated with a desirable slim appearance. This creates a vulnerability to eating disorders for people who are especially concerned with meeting this ideal. Western culture in particular has an obsession with looks. Slim, attractive people are linked to beauty, success, and happiness. Our society teaches us to value such superficial standards and bombards us with images of the idealized female body through mediums such as magazines, films, and television (Blackman, 1996). One only has to watch television or read the latest magazines and take note of just how few overweight or average looking people there are appearing in advertisements to verify this fact. Anorexia nervosa in fact predominates in industrialized developed countries; yet is extremely rare in less industrialized and non western countries (Blackman, 1996). As well, immigrants who have migrated to a westernized country have been found to become more prone to develop eating disorders (Blackman, 1996).
For the sufferer of anorexia, the onset of the disease often begins with a chance remark by someone important to them, possibly a coach or a friend. They may suggest that they are getting fat, big, clumsy, or that their performance (if they are athletes) is suffering (Blackman, 1996). These remarks, as unintentional or innocent as they may seem to the person making them, only serve to reinforce society=s attitude that gaining weight is unacceptable. For others, it may will be the media itself that precipitates the development of the disorder. Some patients cite wanting to look like a favorite film star or model as their initial motivation to lose weight (Blackman, 1996).
Typically, dieting and eating disorders such as anorexia nervosa are associated with females at or near adolescence. A group that often gets overlooked in the studies are males. Eating disorders are not rare among males; 10-15% of all bulimic patients are male, while 0.2% of all adolescent and young males meet the stringent criteria for bulimia. These figures are similar for anorexia nervosa (Carlat, 1997). Males are now being studied more frequently to determine whether or not they differ significantly from females with respect to eating disorders. If males are found to not differ significantly from females in this respect, then those who support a more biologically based view of the disease, gain support. Things such as schizophrenia or depression for instance could then be seen as major determining factors. If however, it is found that certain cultural and psychological risk factors are the same for both males and females, then the sociocultural view of eating disorder etiology gains support (Carlet, 1997). Males in fact do share some similar central features as females who suffer from anorexia; but they also have their own unique issues with regard to social pressures and vulnerabilities (Carlet, 1997). Unlike females who typically Afeel [email protected], males are often obese to begin with. Males are more likely to diet to attain goals in a particular sport like wrestling or swimming. Males also diet to prevent themselves from developing medical complications witnessed in other family members such as cardiovascular disease and diabetes (Blackman, 1996). In several cases involving males, their profession was found to be clearly related to the onset of the eating disorder (Carlat, 1997). One patient studied by Carlat et al. reported taking appetite suppressing pills in an effort to keep slim for acting roles and within several months he began a pattern of binge eating and self-induced vomiting. In the same study, which involved 135 males with eating disorders, 22% had anorexia nervosa, 73% were single and 131 were Caucasian. The average age of onset was 19.3 years. The average education level was 1.6 years of college at the time of their first treatment (Carlat, 1997). This does not necessarily mean that this group is more susceptible to developing eating disorders as these results could have been influenced by how the sample was taken.
With regard to the core concerns about body image and weight, it appears that males with anorexia may be more similar to their female counterparts than to male bulimic patients (Carlat, 1997). Like females, Carlat et al. found that male anorexics clearly feared weight gain and desired a body weight of only 75% of their ideal body weight (Carlat, 1997). Perhaps the biggest finding with males is the high prevalence of homosexuality/bisexuality in those with eating disorders as compared to the general population. Recent data estimates 1%-6% of healthy males are homosexual and that only 2% of females with eating disorders are homosexual (Carlat, 1997). Homosexuality was found to have a 27% prevalence among male patients with eating disorders however. Anorexic males in particular were also found more likely to be asexual (defined as having a lack of interest in sex for a year prior to assessment). This is also a common finding in females (Carlat, 1997; Murnen, 1997). With anorexia, it is thought to be to due to the testosterone lowering effect of protein-calorie malnutrition, combined with active repression of sexual desire (Carlat, 1997). The high rate of homosexuality and bisexuality among males with eating disorders can serve as evidence for both psychosocial and biological views of the etiology of eating disorders. Psychosocially, homosexuality can be seen as a risk factor that puts males in a subculture system that places the same importance on looks and appearance in men as the larger culture places on women (Carlat, 1997). It is these similar cultural pressures toward thinness that cause eating disorders (Carlat, 1997). From a biological point of view, it can be argued that brain structure between homosexual men and heterosexual women are similar (Carlat, 1997), particularly a tiny precise cell cluster known as the third interstitial nucleus of the anterior hypothalamus or INAH3. This cluster of cells in gay men was found to be about half the size of the cluster in straight men which puts them in the same size range as heterosexual women. This particular part of the hypothalamus has been strongly implicated in regulating male-typical sexual behavior (Nimmons, 1994). It may be argued then that homosexual men react to environmental stressors in a biologically feminine way, increasing their risk of eating disorders (Carlat, 1997). Males, like the females studied by Carlat et al. , were shown to have high rates of co-morbid major depression, substance abuse, anxiety disorders, and personality disorders. One year after initially being treated, 59% still suffered from their eating disorder. (Carlat, 1997). This is a cause for concern as there are so many concurrent complications that can arise from eating disorders, especially anorexia nervosa.
Anorexic patients are often found to suffer from osteoporosis, anemia, and hypotension (Carlat, 1997). Chronic starvation due to anorexia has also been linked to seizure activity and fainting attacks (Blackman, 1996). The anorexic often looks pale, tired, wasted, bradycardia (slow heart rate) may be present, and the skin is cold to the touch. Another common feature is the presence of fine downy hair on arms and torso. Laboratory results often reveal quite abnormal values. These values are often caused by dehydration and severe electrolyte imbalances which can be life threatening. Amenorrhea, or absence of menstruation occurs in post menarchal girls who lose more than 20% of their expected body weight (Blackman, 1996; Rock, 1996). Amenorrhea, in fact is another one of the diagnostic criteria for anorexia nervosa (for females) according to the DSM IV (Blackman, 1996). The absence of menarche is related to the bodies reaction to extreme fat loss and the non viability of pregnancy under these conditions (Blackman, 1996). Starvation itself as been shown to induce many hormonal changes in the body as well as inducing mental states such as anxiety, depression, and even psychosis (Kershenbaum, 1997).
These are just a few of the consequences associated with anorexia nervosa. There are many others ranging from things as obscure as bilateral foot drop, which was observed in one 15 year old girl (Kershenbaum, 1997), to something as serious as sudden death and even suicide (Neumärken, 1997). Sudden death is defined as the sudden, unexpected, and unexplainable occurrence of death. Some of those who died suddenly, did show abnormalities in ECG recordings days prior to death. As well, upon autopsy, changes in brain structure and cardia muscles (such as atrophy) were sometimes found (Neumärken, 1997).
One would question with all of the adverse consequences, why anorexics still diet. Anorexia produces a *runners high= as does exercise. This is a result of opiate release in the brain which in turn suppresses appetite and promotes increased levels of activity. Once anorexic behavior begins and becomes established, it promotes this endorphin secretion and becomes pleasurable and self reinforcing. The sufferer then is bound to self starve and the established cycle is no longer deliberate or easily stopped (Blackman,1996).
Treatment comes in the form of psychotherapy, nutritional education, and refeeding. Nutritional education takes time however as the farther a person is below their healthy weight, the more their cognitive ability is impaired (Merriman, 1996). The first of the higher mental functions to be lost is the capacity for abstract thinking. As the condition progresses, the anorexic may not even be able to assimilate information (Merriman, 1996). The nutritionist then must carefully plan nutrition education sessions to make them as meaningful to the person as is possible.
Refeeding is also not a straightforward process as anorexics often find it quite difficult to gain weight. This is due to an increased diet induced thermogenesis and a lower metabolic efficiency. Anorexic patients can waste about 50% of the energy of their food due to this inefficient metabolism at the start of refeeding, making the maintenance of any gain in weight difficult (Moukadden, 1997). Another study concluded that even with weight gain after 3 months to a year, it was not enough to maintain a desirable nutritional status. This was because patients did not reach an adequate body mass index and their immunological indexes were lower than in control subjects during an entire one year follow-up (Marcos, 1997).
From the information presented, one can only imagine just how complex the issues really are that the anorexic attempts to deal with via dieting. The anorexic may be dealing with substance abuse, depression, sexual abuse, confusion about their sexual orientation, or bodily dissatisfaction to name a few. The individual anorexic may be suffering from a combination of such issues in varying degrees. To what extent, psychological, societal, and biological factors affect the onset of the disorder is, as of yet, too complex to determine. It appears to vary from individual to individual, although there are some features seen more commonly than others. The variability seen with the disorder on an individual basis is why the anorexic sufferer can not be categorized into a particular stereotypical group. It is not just the white adolescent girl who is affected. The disorder affects various other groups as well and is being seen more frequently in groups it did not typically affect. It has been mentioned how the disorder is becoming more prevalent among immigrants who move to westernized cultures; yet, the disorder is rarely ever seen in less developed countries. Males also are being seen more frequently to be sufferers of this traditionally female disorder. This data seems not to point to a particular group as being more prone to developing anorexia, but instead points to society=s unrealistic and unachievable ideals, as encouraging more sensitive, insecure, or emotionally disturbed individual members of society to lose weight. Weight loss often provides these people with short lived confidence, and for a while they feel good about their weight loss and in control of something in their life. They inevitably desire to feel like this again so they set out to lose more weight. This cycle continues until someone steps in and helps the sufferer by convincing them to seek help. This can be hard as the anorexic is usually so far in denial that they are the last to realize just what shape they are in. The road to recovery is difficult and the body seems to resist any weight gain during the initial refeeding period. Even after an entire year of treatment, evidence suggests that recovery has not been achieved and many anorexics still continue to suffer from their disorder. There are so many complications that anorexia can be attributed to that it would appear that the quicker a person complies with treatment and can be recovered, the better. It is quite obvious that anorexia is a complex disorder that partly involves how one perceives his or her self and what physical standard society dictates they should live up to. The topic has many areas that require further research as society has been shown not to be the entire causative factor for the development of the disorder. It has been shown to be one of them however; so until society becomes more realistic in the ideals it endorses, it is responsible, at least in part, for the prevalence of this disorder.
Blackman, M. A Anorexia Nervosa: Diagnosis and Management, @ Medical Scope Monthly, July/August, 1996 (or see www.tminus10.com/children/health/anex.htm).
Carlat, D. J. ; Camargo Jr. , C. A. ; and Herzog, D. B. AEating Disorders in Males: A Report on 135 Patients, A American Journal of Psychiatry, 154, August 1997, 1127-1132.
Council on Size and Weight Discrimination. Facts and Figures. New York: Council on Size and Weight Discrimination, Inc. , 1996.
Eating Disorder Resource Centre of British Columbia. Do I Have an Eating Disorder? . Vancouver: Working Design, 1997.
Kershenbaum, A. ; Jaffa, T. ; Zeman, A. ; and Boniface, S. A Bilateral Foot Drop in a Patient With Anorexia Nervosa, A International Journal of Eating Disorders, 22, November 1997, 335-337.
Kinzl, J. F. ; Mangwelth, B. ; Traweger, C. M. ; and Biebl, W. A Eating-Disordered Behavior in Males: The Impact of Adverse Childhood Experiences, A International Journal of Eating Disorders, 22, September 1997, 131-138.
Marcos, A. ; Varela, P. ; Toro, O. ; López-Vidriero, I. ; Nova, E. ; Madruga, J. C. ; and Morandé,
G. AInteractions between nutrition and immunity in anorexia nervosa: a 1-y follow up study, A American Journal of Clinical Nutrition, 66, August 1997, 485-490.
Merriman, S. H. A Nutrition education in the treatment of eating disorders: a suggested 10 session course, @ Journal of Nutrition and Dietetics, 6, October 1996, 377-380.
Moukadden, M. ; Bouler, A. ; Apfelbaum, M. ; and Rigaud, D. A Increase in diet-induced thermogenesis at the start of refeeding in severely malnourished anorexia nervosa patients, A American Journal of Clinical Nutrition, 66, July 1997, 133-140.
Murnen, S. K. ; and Smolak, L. A Feminity, Masculinity, and Disordered Eating: A Meta-Analytic Review, A International Journal of Eating Disorders, 22, November 1997, 231-242.
Neumärker, K. A Mortality and Sudden Death in Anorexia Nervosa, A International Journal of Eating Disorders, 21, April 1997, 205-212.
Nimmons, D. A Sex and the Brain, A Discover, March 1994, 64-68, 70-71.
Rock, C. L. ; Gorenflo, D. W. ; Drewnowski, A. ; and Demitrack, M. A. ANutritional characteristics, eating pathology, and hormonal status in young women, A American Journal of Clinical Nutrition, 64, October 1996, 566-571.