Anorexia Nervosa

1
Anorexia Nervosa

• Andrea Toro
• Elizabeth Sherwood

2

Introduction

• 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).

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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.

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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).

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Historical Background

• 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).

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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)

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Diagnosis

• 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).

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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).

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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)

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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.

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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.

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Etiology

• 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).

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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.

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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).

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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.

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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.

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Treatment

• 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).

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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).

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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).

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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).

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Prognosis

• 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).

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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/m2 was significantly different from
  the rate of 0.6 percent of the patients whose
  body mass indexes at referral were 13 kg/m2 or
  more (Hebebrand et al., 1997, 567).
• Of the fourteen patients in our study who had
  body mass indexes less than 11 kg/m2 at referral,
  only seven survived (Hebebrand et al., 1997,
  567).