Anorexia Nervosa

Andrea Toro
Elizabeth Sherwood

Eating Disorders
are characterized by severe disturbances in eating behavior (American Psychiatric
Association, 1994, 539).
Anorexia Nervosa
Anorexia Nervosa often begins as an ordinary attempt at dieting to lose a few pounds
(Sondon-Hagopian, 1992, 71). With the passage of time, however, the individual may obsess
about his or her weight and appearance claiming he or she is still too fat in spite of
contradictory evidence.
DSM IV describes Anorexia Nervosa as the refusal of an individual to maintain a minimally
normal body weight, an intense fear of gaining weight, and a disturbance in the perception
of the shape or size of his or her body (American Psychiatric Association, 1994, 539).
General Overview
Two Types of Anorexia
The restricting type is characterized by weight loss due to food restriction (Davison and
Neale, 1997, 208).
The binge-eating-purging type occurs when an individual is engaged in binge eating and
purging (Davison and Neale, 1997, 208).
Many women have symptoms that resemble those of Anorexia Nervosa, but the symptoms
are not severe enough to constitute a diagnosis for the disorder (Long, P.W., 1995).
According to one study, two-thirds of college women have an eating binge at least once a
year, forty percent at least once a month, and twenty percent a least once a week.
Prevalence
This disorder affects one to five percent of the population (American Psychiatric Association, 1994,
543).
psychosociological disease which affects young and healthy girls primarily in adolescence
(Sondon-Hagopian, N., 1992, 71).
Gender related: Ninety percent of those who suffer from Anorexia Nervosa are women; it
usually begins in adolescence but may appear as early as nine years of age (Long, P.W.,
1995).
Age differences: Women of all ages rated their current figure as significantly larger than their
ideal figure; however, young womens ideals were congruent with their perceptions of male
preferences while older women seem to aim for an ideal that is significantly larger than what
they think men find attractive (Stevens &Tiggemann, 1998).



First Descriptions
Eramus Darwin in 1796 stated, Some young ladies I have observed to fall into this general
disability (can) just be able to walk about. I have sometimes ascribed this to their voluntary
fasting when they believed themselves too plump (Gordon, A.G., 1997, 1041).
William Gull in 1869 first described the disorder as a persistent lack of appetite and refusal
of food resulting from emotional conflict (Goldenson, R.M., 1970, 83). The term anorexia
refers to loss of appetite, and nervosa indicates for emotional reasons (Davison and Neale,
1997, 207).
In recent years...
Eating disorders and Anorexia Nervosa first appeared in DSM for the first time in 1980 as one
subcategory of disorders beginning in childhood and adolescence (Davison & Neale, 1997, 207).
DSM-IV recognized eating disorders as a distinct category reflecting the increased attention they
have received recently (Davison & Neale, 1997, 207).
There has been an dramatic increase in both the scientific literature and the popular press
about eating disorders (Furnham & Manning, 1997, 389). However, diet advertisements and
articles appear ten times more frequently in womens than mens magazines (Cusumano &
Thompson, 1997).
Over the last twenty years, a higher portion of women in their late teens and early twenties
have been hospitalized for Anorexia Nervosa (Long, 1995)

Diagnostic Criteria of Anorexia Nervosa
Refusal to maintain body weight over a minimal normal weight for age and height, e.g.,
weight loss leading to maintenance of body weight 85 percent below that expected; or failure
to make expected weight gain during period of growth, leading to body weight 85 percent
below that expected (American Psychiatric Association, 1994, 544).
Intense fear of gaining weight or becoming fat, even though underweight ( American
Psychiatric Association, 1994, 544).
Disturbance in the way in which ones 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 (American Psychiatric Association, 1994, 545).
More DSM Criteria
In postmenarcheal females, absence of at least three consecutive menstrual cycles. (A
woman is considered to have amenorrhea if her periods occur only following hormone, e.g.,
estrogen, administration.) (American Psychiatric Association, 1994, 545).
Associated features
Some people with this disorder cannot exert continuous control over their intended
voluntary restriction of food intake and have bulimic episodes,often followed by vomiting (
American Psychiatric Association, 1987).
Other peculiar behaviors concerning food are common. They may be prepare elaborate
meals for others. ( American Psychiatric Association, 1987).
DSM (Contd)
Also, compulsive behavior, such as hand-washing maybe present during the illness and may
justify the additional diagnosis of Obsessive Compulsive disorder (American Psychiatric
Association, 1987).
Many of the adolescents have delayed psychosexual development and adults have a markedly
decreased interest in sex (American Psychiatric Association, 1987).
When seriously underweight, many individuals with Anorexia Nervosa manifest depressive
symptoms such as depressed mood, social withdrawal, irritability, and insomnia (American
Psychiatric Association, 1994, 541)
Associated medical conditions
Anorexia Nervosa- Medical Consequences
The heart muscle changes. Its beat becomes irregular resulting in heart failure and death.
Dehydration, kidney stones, and kidney failure may result.
A fine body hair, called lanugo, develops on the arms and can even cover the face.
Muscles waste away, resulting in weakness and lose of muscle function.
A lack of energy and slowed body function results delayed gastric emptying which causes
bowel irritation and constipation.
Loss of bone calcium leads to osteoporosis.
More medical conditions
With the decrease of body weight and body fat, amenorrhea may result.
When left untreated it results in decreased bone density, and a higher incidence of stress
fractures and osteoporosis. ( bone loss in an amenorrheic athlete is rapid and may not be
reversible.)
Amenorrhea is defined by the absence of a menstrual cycle for at least six consecutive
months. ( the absence of a regular menstrual cycle is abnormal and unhealthy.

Biological Factors of Anorexia Nervosa
Eating disorders run in families. Twenty percent of anorectic patients have a family member
with an eating disorder of some kind (Long, 1995).
For many years, researchers studying eating disorders have looked for abnormalities in the
production and regulation of hormones and neurotransmitters by which the brain and body
govern appetite and food intake. Low concentrations of the metabolites or the
neurotransmitters serotonin and norepinephrine may occur in anorectic patients (Long,
1995).
Other research shows that eating disorders may also involve enkephalins and endorphines,
the opiatelike substances produced by the body. The spinal fluid of patients with anorexia
contains high levels of these endogenous opoids (Long, 1995).
Parental style and Perfectionism
Perfectionism has been linked specifically with Anorexia Nervosa (Ablard & Parker, 1997). High
expectations of parents and the desire to please others may foster a belief that parental love and
social acceptance are contingent upon ones high achievement.
In a study of 127 sets of parents of academically talented children where reported achievement
goals for their children (Ablard & Parker, 1997).
Most parents reported learning goals in that they were more concerned with the
understanding of the material than the external indicators.
The parents who reported performance goals were more concerned about the external
indicators of achievement. Children of these parents are at high risk for performance
anxiety and for developing depression and anorexia.
Etiologies of gender differences
Women appear to be more heavily influenced cultural standards reinforcing the desirability of
being thin (Davison & Neale, 1997, 214).
Male and female standards of beauty change differently over time. One study examined the
differences between Playboy models, representing the mens ideal, and Vogue models, the
womens ideal (Barber, 1998). The mens standard of ideal thinness correlated with the
womens standard sixteen years later, indicating that changes in the standard of beauty may
be determined by women.
Women are more concerned than men about being thin, are more likely to diet, and are
thus more vulnerable to eating disorders (Davison & Neale, 1997, 214).

More about gender differences
History of sexual harrassment
There are statistically significant associations of eating disorder symptoms with sexual assault
history (Laws & Golding, 1996, 579).
Of the women in the sample with a history of sexual assault, 46.5 percent thought they were
too fat and 48.6 percent demonstrated anorexic symptoms.
However, of the women in the sample who did not have a history of assault, 31.8 percent
thought they were too fat and 33.1 percent demonstrated anorexic symptoms (Laws &
Golding, 1996, 579).
Physiological-based theory: During puberty, females develop two years before their male
counterparts (Furnham & Manning, 1997). Females may attempt to minimize these differences by
dieting, resulting in a hormone imbalance.
Cultural influences
Eating disorders appear to be far more common in industrialized societies (Davison & Neale,
1997, 215). WHY?
Parents views about academic performance may be related to their education level, ethnic
background and parenting style (Ablard & Parker, 1997). This influences whether they
support learning goals or performance goals.
Social endorsements in Western cultures of an ideal body shape, such as those found in
print and film media formats, have been related to body image disturbance as well as
implicated in the development of eating disorders (Cusumano & Thompson, 1997).
Women of industrialized countries are pressured to be thin, attractive, successful in the
workplace and to maintain their traditional roles as nurturing homemakers (Sondon-
Hagopian, 1992, 80; Heywood, 1995, 43). A fanatical management of weight is used as a
means of coping with conflicting demands.

Overview of the difficulties in treatment and hospitalization:
The treatment of this disorder is often difficult. This is because of the disorders insidious
nature which wreaks havoc not only with the body, but just as seriously with the individuals
negative self-perception (Mental Health Net, 1996).
The patient is often so weak and physiological functioning is so disturbed that
hospitalization is medically imperative (Davison & Neale, 1997, 221)
If a person who suffers from Anorexia Nervosa is danger of committing suicide or choking
on vomit, immediate hospitalization should be carefully considered (Mental Health Net,
1996).
Cognitive-oriented therapies, focusing on issues of self-image and self-evaluation, works to change
the patientsdistorted body image (Mental Health, 1996).
Hospitalization
Hospitalization is not only necessary, but a prudent treatment intervention since it ensures that
the patients do not starve themselves to death (Mental Health, 1996).
The patients must first gain weight; they are started on a liquid diet or frequent small meals and
are weighed everyday (Long, 1995).
Because relapse is frequent, the patient must follow a medical plan set by a dietician who sees to it
that the patient records what he or she eats and when (Long, 1995).
During three to six months of hospitalization, hypnosis is employed by some therapists but may
be resisted by many anorexic who fear even a semblance of control by others. Some success is
claimed by those teaching self-hypnosis and bio-feedback techniques (ANAD, 1998).

Medications
Medication should be carefully monitored since patients with Anorexia Nervosa may be vomiting
which may have an impact on the medications effectiveness (Mental Health, 1995).
Prozac may work by stabilizing serotonin systems in the brain, thereby correcting the
changes in brain function responsible for many of the disorders symptoms. Also, Anorexia
Nervosas accompanying symptoms like depression, anxiety, obsessions, and compulsions
could be linked to disturbances in serotonin, the neurotransmitter that helps regulate mood
and appetite (Craig D, 1998).
Antidepressants, such as amitriptyline, are the usual drug treatment for depressive symptoms.
Chlorpromazine, on the other hand, is beneficial for those individuals suffering from severe
obsessions and increased anxiety and agitation (Mental Health, 1996).
Behavior and Family therapy
Behavior therapy includes isolating the patient as much as possible and giving him or her
mealtime company, access to a television, radio, or stereo, and other privileges for eating or
gaining weight (Davison and Neale, 1997, 221).

Family therapy is advocated by Salvador Minuchin.
It is based on his theory that the eating disordered child is deflecting attention away from
underlying conflict in family relationships (Davison & Neale, 1997, 221)
It focuses on changing the pattern of family interaction. The length of this therapy is
approximately six months, with an eighty-five to ninety percent rate of cure (ANAD, 1994).



DSM-IV: The course and outcome of Anorexia Nervosa are highly variable. Some recover fully
after a single episode, some experience fluctuation in weight gain followed by a relapse, and others
have a chronically deteriorating course of the illness (American Psychiatric Association, 1994, 543).
Of individuals admitted to university hospitals, the mortality from Anorexia Nervosa is over ten
percent (American Psychiatric Association, 1994, 543).
A patient diagnosed with Anorexia Nervosa and Obsessive-Compulsive Disorder will not
necessarily have a poorer prognosis; however, the patients whose eating disorders were most
improved showed the highest reduction of obsessions and compulsions (Thiel, Zuger, Jacoby, &
Schussler, 1998, 244).
Body Mass Index
There is an association between low body weight at referral and poor general outcome
(Hebebrand, Himmelman, Herzog, Herpertz-Dahlmann, Steinhausen, Amstein, Seidel, Deter,
Remschmidt, & Schafer, 1997, 567).
The mortality rate of 11 percent in patients whose body mass indexes at referral were less
than 13 kg/m
2
was significantly different from the rate of 0.6 percent of the patients whose
body mass indexes at referral were 13 kg/m
2
or more (Hebebrand et al., 1997, 567).
Of the fourteen patients in our study who had body mass indexes less than 11 kg/m
2
at
referral, only seven survived (Hebebrand et al., 1997, 567).