Anorexia nervosa is refusal to maintain body weight at or above a minimally normal weight for age and height Intense fear of gaining weight or becoming fat, even though underweight. 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. This condition is both a physical illness and a psychiatric illness. Anorexia nervosa can be a very severe illness, including a risk of death from starvation.
This illness occurs most often in young women. About 5% to 10% of people with anorexia nervosa are men (Larson).
Anorexia nervosa means in Greek and Latin roots “lack of appetite of nervous origin.” Usually appears in early or middle adolescence. A girl or young woman begins to starve herself and sometimes exercise compulsively as well. Her weight falls and her health deteriorates, but she continues to deny that her behavior is abnormal or dangerous.
She may say she feels or looks fat, although everyone else can see that she is gaunt. To conceal her weight loss from parents and others, she may wear baggy clothes or secretly pocket and discard food instead of eating it. Despite her refusal to eat and despite the misleading term “anorexia,” her appetite is usually normal, at least at first. Her reasons for rejecting food are a mystery that researchers are still trying to solve (Anorexia).
According to the current diagnostic manual of the American Psychiatric Association, a woman is suffering from clinical anorexia, not just dieting or fasting, when her weight has fallen to 15% below the normal range and she has not menstruated for at least three months. Sometimes the diagnosis is made because of drowsiness and lethargy that are affecting her schoolwork. Other symptoms are dry skin, brittle nails and hair, “languor” (fine downy hair on the limbs), constipation, anemia, and swollen joints. The level of female hormones in the blood of an anorectic woman falls drastically, and her sexual development may be delayed. Her heart rate and blood pressure can become dangerously low, and loss of potassium in the blood may cause irregular heart rhythms (Bower).
Experience has shown that the more distorted an idea the victim has of herself, the more difficult the cure, and the longer the condition goes untreated the more uncertain the outcome. Anorexia nervosa must never be lightly dismissed as a passing phase, which time and maturity will cure. A person that is anorexic is not nature. Spontaneous cure rarely happen because the victim takes a positive pride in sustaining her hunger. The longer the illness lasts, more weight is lost. This deepens in the anorexic the illusion that being thin is making her significant and outstanding as an individual (Cavendish, 63).
Some believe that eating disorders are becoming more common, but the evidence from systematic surveys is inconclusive. What is clear is that fewer cases are going undiagnosed. One reason is that the average age of puberty in American women has retreated three or four years during this century, probably because of better nutrition and less infectious disease. That means a girl is more likely to develop anorexia while she is still living with her parents, and the disorder is more likely to be noticed and acknowledged as the serious problem it is. As social critics like to point out, drawing a line between eating disorders and the consequences of normal, socially approved dieting is not easy. Many women have symptoms that resemble anorexia in milder forms they may be losing too much weight but still menstruating, or binge eating without vomiting or using laxatives, or bingeing less often than twice a week (Macmillian). “According to one estimate, more than two-thirds of college women indulge in an eating binge once a year, 40% at least once a month, and 20% once a week. As many as 4% of all adults (60% of them women) and 30% of the seriously overweight are thought to be binge eaters.” Binge eating without attempts to compensate by vomiting or using laxatives is one of the conditions included in the current APA diagnostic manual under the label “eating disorders not otherwise specified.”
One cause of eating disorders could be abnormalities in the activity of hormones and neurotransmitters that preserve the balance between energy output and food intake. This regulation is a complex process involving several regions of the brain and several body systems. Nerve pathways descending from the hypothalamus, at the base of the brain, control levels of sex hormones, thyroid hormones, and the adrenal hormone “cortisol,” all of which influence appetite, body weight, mood, and responses to stress. “The neurotransmitters serotonin and norepinephrine” are found in these hypothalamic pathways. “Serotonin” activity is low in starving anorectic patients but higher than average when their weight returns to normal.
Another cause for this disease is the social pressure for slenderness. The more likely it seems that a troubled young woman will develop an eating disorder rather than other psychiatric symptoms especially if she believes that control over one’s appetite is the way to win admiration and attain social success. A wish to mold one’s body is also consistent with cultural ideals of achievement and self-sufficiency. Anorexia is especially common among girls committed to the demanding disciplines of ballet, competitive swimming, and gymnastics. According to one survey, 15% of female medical students have had an eating disorder at some time. But the common belief that high social status raises the risk for eating disorders may no longer be correct, at least for American women. In a 1996 review of 13 surveys, researchers found that eating disorders were equally common among whites and blacks and in all social classes.
An unusual, not widely accepted but interesting theory is that in some cases anorexia results from excessive physical activity. Evidence for this theory comes from experiments in which rats are allowed to exercise on a wheel at will but fed only a single daily meal and given only a brief time to eat it. When put on this “regime,” they start to run more and more and eat less and less. Eventually they may die of starvation. According to the theory, these conditions are equivalent to self-imposed diet and exercise regimens. Normally people eat more when physical activity rises. But if food intake is restricted at the same time, a self-perpetuating cycle may develop in which restricted food intake heightens the urge to move, and constantly increasing exercise depresses interest in eating (Cavendish).
Like most psychiatric disorders, anorexia run in families. The rate of anorexia among mothers and sisters of anorectic women is 2% to 10%. In one study, researchers found that 20% of anorectic patients but only 6% of people with other psychiatric disorders had a family member with an eating disorder. Several twin studies suggest that this family susceptibility is largely hereditary. In one comparison, anorexia was found in 9 of 16 identical twins of anorectic patients but only 1 of 14 fraternal twins. In another study, researchers found that when one of a pair of identical twins had bulimia, the chance that the other would also have it was 23%, eight times higher than the rate in the general population. For fraternal twins, the rate was 9%, or three times higher than average. The authors calculate a heritability of 55% (“Anorexia”).
In the vast psychological and sociological literature on eating disorders, a wide variety of influences have been suggested, from peer pressure to sexual anxieties. One common theme is starvation as a form of self-punishment with the unacknowledged purpose of pleasing a parent who is seen as needing to impose harsh restrictions. Most anorectic women before, during, and after the illness are serious, well behaved, orderly, perfectionist, hypersensitive to rejection, and inclined to irrational guilt and obsessive worry. Anorexia has been described as one way a girl with this kind of personality may respond to the prospect of adult sexuality and independence. She wants to be strong and successful, but is afraid of asserting herself and separating from her family. Being a good girl and pleasing her parents and teachers no longer sustain her. She is unable to acknowledge her sexual desires and may regard her developing woman’s body as an alien invasion. Her fear of adult femininity may also be a fear of becoming like her mother. According to this theory, fasting restores a sense of order to her life by allowing her to exert control over herself and others. She is proud of her ability to lose weight, and self-imposed rules about food are a substitute for genuine independence.
Some students of anorexia believe that these girls starve themselves to suppress or control feelings of emotional emptiness. They struggle for perfection to prove that they need not depend on others to tell them who they are and what they are worth. According to some “psychodynamic theories,” a young woman has come to this desperate pass because her parents have never responded adequately to her initiatives or recognized her individuality. Now that she is an adolescent, they are implicitly making conflicting demands: show your capacity for adult independence, but do not separate yourself from the family. According to this theory, the “anorectic” girl has trouble distinguishing her own wants from those of other people, and she fears abandonment if she takes any action on her own. Denying her needs is the only way she knows how to show that she will not permit anyone else to control her. She will not allow outside influences, including food, to invade her.
Since women with anorexia are usually living with their parents when the symptoms develop, “psychotherapists” have often found it helpful to work with the whole family. The resulting discoveries and speculations are an important source of family systems theory, in which the family is conceived as a social unit with internal structures and processes that have a life of their own. “Psychiatric” disorders are regarded as defenses that compensate for disturbances and preserve family stability in a way “analogous” to the preservation of individual stability by neurotic symptoms in “psychodynamic theory.” Family systems theorists speak of family rules, roles, rituals, and myths; they analyze the distribution of power within a family and the workings of subsystems of various combinations of parents and children. According to the theory, families with inflexible self-regulating mechanisms often produce “psychopathology” in one member, the person with obvious “psychiatric symptoms,” who is sometimes called the “identified patient.”
A daughter who refuses to eat may be seen as trying to keep the family together by providing an object of common concern for parents who would otherwise be drifting apart. Or she may be trying to restore the balance of the family by siding with one parent in a conflict with the other. Families with anorectic daughters are often said to be smothering or “enmeshed.” The responsibilities of each person and the boundaries between them are indistinct. Everyone in the household is said to be over-responsive to and overprotective of everyone else. Conventional social roles are maintained, but individual needs are not met, feelings are not honestly acknowledged, and conflicts are not openly resolved. When the daughter reaches puberty, her parents are reluctant to make necessary changes in the family rules and roles. In this view, anorexia is a symptom of a rigid family system’s need and inability to adapt to a new stage of development (Macmillian).
Theories about the influence of parents raise similar questions of cause and effect. The mother and father of a child who is starving herself are under great strain, and the family is bound to be in “turmoil.” In any case, an unhappy woman with an eating disorder will naturally be dissatisfied with her family. A parent who tries to intervene may be regarded as intrusive, one who tries to avoid conflict as uninvolved. Researchers have found that anorectic women are likely to describe their fathers as distant or their mothers as over controlling, but their brothers and sisters do not necessarily agree. These and other psychological and biological explanations can be reliably tested only by difficult, expensive long-term studies in which girls who develop eating disorders are compared with others before as well as after the symptoms appear (“Anorexia”).
“Having a child in crisis with an eating disorder impacts on the entire family as well as the child. The support mechanisms that parents may have come to depend on at work or in their leisure may no longer be helpful, thus causing disruption to these patterns and to family relationships. The purpose of this study was to investigate the challenges that parents face and changes that occur, particularly in relationships, when a child is diagnosed with an eating disorder and how parents cope with these changes. The findings indicated that there is a significant impact on relationships associated with age of child, personal leisure and level of confusion in the family. The findings also showed contrasts in the way families cope with having a child in crisis, either very negatively or very positively. The qualitative anecdotes describe the tremendous strains and changes in patterns within families particularly during the initial period of diagnosis. The parents provide recommendations for researchers, practitioners and service providers that will be helpful to other families” (Gilbert).
Cultural comparisons and historical studies confirm evidence from our own society that eating habits and preoccupations with similar effects may have different causes in different circumstances. For example, a woman is temperamentally predisposed to depression or anxiety, or suffers from family troubles or a neurochemical imbalance. The value her culture places on slenderness encourages her to diet. The weight loss causes physical and emotional changes that make it still more difficult to eat normally. The resulting hunger may lead to eating binges followed by vomiting and purging with laxatives. These episodes cause anxiety and depression that lead to further bingeing and further dieting.
Treatment of anorexia can be frustrating, and recovery is usually prolonged and difficult. Even women whose most serious symptoms are relieved often relapse or suffer from various residual effects and chronic troubles. In long-term studies covering periods from 4 to 30 years, 50% to 70% are found to be no longer clinically anorectic: they are menstruating and maintaining a weight in the normal range. About 25% show some menstrual irregularities, and their weight is sometimes low. The outcome is poor for another 25%; they are not menstruating and their weight is far below normal. Whether they recover or not, many of these women are still preoccupied with weight and dieting. Women with personality disorders and those who have symptoms for a long time before seeking treatment are least likely to recover.
Evidence on the effectiveness of treatment is limited. Many women with anorexia or bulimia are never treated, and in long-term studies many drop out possibly those who are doing worst. Researchers are calling for further cross-cultural research and more studies in which women are interviewed for the first time before developing symptoms. More information about self-help groups is needed. Researchers must examine more closely the relationship between eating problems and other psychiatric disorders, including addictions and compulsive behavior, partly so that treatments can be modified for different combinations of symptoms. An especially important goal of research is finding ways to prevent eating disorders or recognize and treat them at an early stage (Anorexia).
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Bower, Bruce. “Women With Anorexic Face Ongoing Problems.” Science News 18 July. 1998: 3.
Cavendish, Marshall. “Anorexia Nervosa.” Family Health. 1986: Vol. 1.
Gilbert, Adrienne A. “The Impact of Eating Disorders on Family Relationships.” Eating Disorders. University of Waterloo, Ontario. 1998: 1-22.
Larson, David E., MD. “Anorexia Nervosa.” Mayo Clinic Family Health Book. 1996 ed. 2.
Macmillian, John. “Anorexia Nervosa.” Nutrition and Fitness. 1995.
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