Anorexia Nervosa

What is anorexia nervosa?

Anorexia nervosa, or simply anorexia, is a psychiatric and physical illness in which the sufferer basically starves herself. Clinically, a person is anorexic if she has 85 percent or less of the normal body weight for someone of her age and height, yet continues to fast or diet. An estimated 1 percent of teenage girls have the disease.

Anorexia is a serious condition that can cause grave health problems if untreated. About 20 percent of cases of anorexia end in death by suicide or starvation -- one of the highest death rates of all the psychiatric illnesses. Although the disorder is less common in men (who make up about 10 percent of all cases), research suggests the number of men with anorexia has been growing over the last 10 years.

Most of us have heard at least one story of an emaciated teenage girl who starves herself because she's convinced she's fat. But despite anorexia's TV-talk-show familiarity, misconceptions about it abound. As a result, many sufferers can often go months or even years before someone notices that they're sick and steers them toward help. The nature of the disease is such that an anorexic person can almost never bring herself to consciously acknowledge that she's ill. This is why it's important for family, friends, and healthcare providers to be aware of the symptoms and offer aid.

Are there different kinds of anorexia?

Experts have identified two different kinds that are equally common; in fact, people often alternate between them. There's the restricting type, in which someone severely limits her food intake, and the binge-eating or purging type, in which she eats a lot of food and later vomits or uses a laxative to get rid of it. The second kind is very similar to bulimia nervosa, an eating disorder that's closely related to anorexia.

What causes anorexia nervosa?

Although no one knows exactly why some people develop eating disorders, research indicates that it's probably due to a combination of several factors. These include certain personality traits (among other things, anorexics tend to be perfectionists and to have low self-esteem) and the nature of the family and home environment (they frequently come from families that place a lot of emphasis on looks, expect perfection, or discourage the expression of negative feelings like anger in the home). Societal forces, including the enormous pressure on women to be thin or even underweight, are also thought to play a role.

Often anorexia gets started when a teenager or young woman goes on a normal diet to lose a little weight. Spurred on by the compliments she gets, she may become obsessed with dieting. She may think to herself, "If losing a little weight is good, losing a lot must be great."

Even though they might appear to be outgoing and happy, people with anorexia typically have low self-esteem. It's what drives them to struggle toward perfection. They may feel powerless and unable to control their own lives, often because of family dynamics. A young person who doesn't have some control over her life, is discouraged from expressing anger or sadness, doesn't have the chance to set normal interpersonal boundaries, and is exposed to unrealistically high expectations is an environment that may contribute to the development of an eating disorder. She might find that denying herself food becomes an expression of power and control, and in many cases she believes that the "perfect body" will bring the perfect life.

Some people with anorexia suffered sexual, physical or emotional abuse as children. Recent studies suggest, however, that anorexics are not more likely to have been abused than other women who suffer from depression or anxiety.

How do I recognize anorexia?

It can take many different forms. The description below lists psychological and physical traits that are common among girls and women with anorexia, but someone you love who doesn't fit the profile could still be suffering from this or another type of eating disorder.

The typical anorexic is a middle-class or upper-class teenager around 15 years old, intelligent, perfectionistic, and a high achiever. She's usually thin but obsessed with her weight anyway. She may exercise compulsively. Although she often refuses food, she thinks about it all the time, counting calories and fat grams and studying diets. She may lie about what she eats by hiding uneaten food or telling her family that she's already had lunch. If confronted, she'll deny that she's sick. For that reason, she often ends up getting treatment only after her family takes her to the doctor for a related disorder (such as anemia, missed periods, constipation, or fatigue).

What are the symptoms?

One of the things that make it hard to recognize anorexia nervosa is that a person who has it will go to great lengths to keep her family and friends from realizing that she's sick. She herself doesn't think she is, but she knows on some level that her behavior would be disapproved of. She may lie about her food intake and wear baggy clothes to hide her shrinking body.

Despite these difficulties, it's important that an eating disorder be diagnosed as soon as possible. An illness like anorexia can cause serious health problems and even death. It's also harder to cure the longer someone has it.

Here are the typical symptoms of anorexia nervosa:

• Marked weight loss
• Amenorrhea, or the loss of menstrual periods
• Fear of getting fat, even when underweight
• Denial of hunger, accompanied by an obsession with counting calories or studying cookbooks
• Excessive exercise
• Frequent weighing
• Distorted body image
• Hyperactivity
• Constipation
• Dry, sallow (yellowish) skin
• Cold hands and feet
• Fatigue or chronic insomnia
• Loss of sexual desire
• Thinning hair
• The growth of fine body hair, especially on the arms and legs
• Fainting spells
• About half of all anorexics also binge and purge (usually by vomiting after meals or misusing laxatives).

What should I do if I think someone close to me might have anorexia?

Confronting the person is likely to be tricky, because she almost certainly won't acknowledge that she's sick. It must be done, however, and the sooner the better.

First, say experts, learn everything you can about the disease. Then pick a good time to talk, preferably when the two of you are alone and there are no distractions. As nonjudgmentally as you can, tell her that you're concerned about her and want her to get help. It's a good idea to cite specific examples of behavior that illustrate your point; for instance, you might say, "I've noticed that you've lost a lot of weight and seem to be preoccupied with dieting."

Be aware that she may react angrily and deny that she has a problem. She'll most likely feel embarrassed and humiliated at realizing that someone is onto her secret. Keep that in mind, and be careful to avoid getting into an argument with her. Don't try to cure this illness yourself; if your loved one has anorexia, she needs professional help.

If you're her parent and can do it, set up a thorough physical exam for her and let the doctor talk to her as well. You can get a referral to a mental health practitioner from your doctor if it seems to be indicated. Monitor her computer use so you know if she is visiting pro-anorexia Web sites, which can encourage dangerous habits.

If you're a friend or relative and the person you suspect of being anorexic has denied it, stay supportive and make it clear that you're still concerned about her. Try to let her know anything you find out about eating disorder counselors and support groups in her vicinity. If you think she's in danger, consider contacting her family.

Avoid making any comments, positive or negative, about losing or gaining weight; they could have the effect of reinforcing her anorexia. This is a dangerous and complex illness, so don't try to make her eat or attempt to solve her problem for her. If you see any signs of physical deterioration, get her professional help as soon as possible.

Lastly, don't forget to take care of yourself. Anorexia is hard on family members and friends, too. Look into joining a support group where you can air your feelings and get additional information.

How do doctors diagnose anorexia?

A physician uses general guidelines to diagnose the disease, but he or she will also ask patients how they feel about weight and obesity and whether they've been dieting. Clinically, you must be 15 percent below your normal weight and must have ammenorrhea (a condition in which your periods stop or are erratic) to be diagnosed as anorexic. (You don't have to meet these criteria in order to get help for the disorder, though.)

If anorexia is diagnosed, a doctor will also do a complete physical exam to check for any damage the illness may have caused, such as malnutrition, dehydration, anemia, or heart problems.

What kinds of treatment are available?

Usually treatment is divided into two phases. In the first, a doctor will concentrate on saving the life and health of the anorexic person and on restoring body weight. The person may need to be hospitalized, especially if her weight has fallen below 85 percent of normal, if she's suffered damage to a major organ (like the heart or kidneys), or if she's clinically depressed or suicidal. Restoring body weight is a complicated undertaking, since what someone who's anorexic fears most is gaining weight. Often, however, this phase of the treatment can be done on an outpatient basis. It usually calls for the help of a psychologist and a nutritional counselor as well as a physician.

The second phase is a long-term one aimed at treating the psychological side of the disease and preventing a relapse. Also conducted as either an inpatient or outpatient process, it usually involves medical monitoring by a physician, treatment by a psychiatrist or psychologist (preferably a specialist in eating disorders), and often family therapy in the case of a younger patient or one living at home. Antidepressants such as fluoxetine (better known as Prozac) may also be prescribed.

Although complementary treatments for anorexia have not been well studied, Mayo Clinic suggests that such treatments as acupuncture, massage, yoga, or meditation may help with the anxiety that accompanies anorexia.

What can happen if anorexia isn't treated?

The semi-starvation that may result from the disease can damage most organ systems. It may cause anemia, kidney dysfunction, cardiovascular problems, changes in brain structure, hormonal disturbances, amenorrhea, and osteoporosis (bone weakness due to lack of calcium). The mortality rate among people with eating disorders (including bulimia nervosa) may be as high as 20 percent. That includes deaths from related heart attacks and intestinal hemorrhaging, as well as suicide.

Where can I get more information?

The National Association of Anorexia Nervosa and Associated Disorders, P.O. Box 640, Naperville, IL 60566, will send you information and provide referrals to experts and support groups near you. Its Web site address is http://www.anad.org.

References

Darcy A.M. et al. All Better? How former anorexia patients define recovery and engaged in treatment. European Eating Disorder Review,

Mayo Clinic. Anorexia nervosa, 2016. http://www.mayoclinic.org/diseases-conditions/anorexia/diagnosis-treatment/treatment/txc-20179528#!

Mayo Clinic. Anorexia nervosa. http://www.mayoclinic.com/health/anorexia/DS00606

DSM-IV-TR:583-9. American Psychiatric Association.

National Guideline Clearinghouse. Source: American Psychiatric Association. Practice guideline for the treatment of patients with eating disorders. 2006. www.guideline.gov/summary/summary.aspx?doc_id=9318

Webster JJ et al. The childhood and family background of women with clinical eating disorders: a comparison with women with major depression and women without psychiatric disorder. Psychol Med, Vol. 30(1):53-60.

Palo Alto Medical Foundation. Eating disorders. http://www.pamf.org/teen/life/bodyimage/eating-disorders.html

National Women's Health Resource Center. Eating Disorders. http://www.healthywomen.org/healthtopics/eatingdisorders

National Alliance on Mental Illness. Anorexia nervosa.