Anorexia Nervosa
Laura Katherine Anderson
Brenau University
Anorexia Nervosa
Anorexia nervosa is a life-threatening eating disorder that is classified as restricted food intake causing low weight and many complications (Beidel, Bulik, & Stanley, 2017). People with Anorexia are typically underweight and malnourished, according to their BMI (body mass index). Anorexia nervosa signs and symptoms vary depending on the person with the illness (Beidel, Bulik, & Stanley, 2017).
Prevalence
Nagl, Jacobi, Paul, Beesdo-Baum, Höfler, Lieb, Wittchen state lifetime prevalence for Anorexia nervosa for females is 2.9% and for males, it is .1% (2016). However, The National Association of Anorexia Nervosa and Associated Disorders states .9% of women will have Anorexia nervosa in their lifetime. The ANAD reports 30 million people in the United States, including all ages and genders, battle an eating disorder. They also acknowledge eating disorders have the highest mortality rate of any mental illness (2018).
Diagnosis
In order to diagnose a patient with Anorexia nervosa, doctors and nurses must know the signs and symptoms. Murphy and Manning classify the physical signs and symptoms of eating disorders: cold extremities, cyanosis, thinning and drying of hair, face features sunken, dry skin, dry lips, chemical smell on breath, tooth decay, pale skin, fine downy hair on cheeks and neck, low blood pressure, slow pulse, gastrointestinal problems, constipation, repeated infections, poor concentration, extreme weight loss, poor temperature regulation, and cardiac abnormalities.
Psychological Signs and Symptoms
They also expand on psychological signs and symptoms for Anorexia nervosa such as depression, isolation, poor relationships, poor performance in educational studies or employment. They also lack self-esteem and believe they are unworthy (2003). Congilio, Becker, Franko, Zayas, Plessow, Eddy, and Thomas write about behavioral signs and symptoms such as refusing to eat certain foods or groups of foods, making complaints about looking or feeling fat, denying feeling hungry, making excuses to avoid meals, having distorted view of body and shape, limiting social activities, and isolating from family and friends (2017). Murphy and Manning pointed out many patients with Anorexia appear in control of their body and mind, although they typically feel desperate and out of control (2003).
Other Illnesses Causing Weight Loss
Because there are so many symptoms, some people may think it is easy to diagnose Anorexia. However, Dr. Halmi writes patients with Anorexia nervosa do not want to be diagnosed because they don’t want their illness to be treated. If their illness is treated, they fear their bodies will not look as good and they will be “fat”. Because they do not want to be diagnosed, they will often try to convince their doctors there are other medical issues causing the symptoms that appear as Anorexia nervosa (2005). Nicholls, Hudson, and Mahomed specify different illnesses that cause significant weight loss and patients may try to convince the doctors of. In the endocrine system, diabetes mellitus, hyperthyroidism, glucocorticoid insufficiency cause weight loss. In the gastrointestinal area, celiac disease, inflammatory bowel disease, and peptic ulcer disease can cause extreme weight loss. Lymphoma, leukemia, and intracranial tumors can all cause weight loss as well. Tuberculosis is also known to cause weight loss. As for psychiatric illnesses, depression can also cause weight loss because of the desire not to eat (2011). Dr. Halmi informs anorexia has two subcategories, making it even more complicated to diagnose. There is a restricting type where the person limits their intake to an extreme amount. The other is binge-eating/purging type where the person eats a lot and then completely stops (2005).
Physical Symptoms and Complications from AN
With binging and purging, Dr. Halmi states the symptoms and causes that appear with the disease. Dry and cracking skin is caused by dehydration and loss of subcutaneous fat. Lanugo hair on the back and neck is caused by starvation. Calluses on dorsal of hand is caused by self-induced vomiting with teeth rubbing friction into the hand and causing sores. Perioral dermatitis, enlarged parotid glands, teeth enamel erosion, and periodontitis is all caused by vomiting. Bradycardia and hypotension is caused by starvation and fluid depletion. Arrhythmias are caused from hypokalemia from purging (2005). Dr. Halmi also goes into detail about laboratory findings and causes. Leukopenia with a relative lymphocytosis is caused by starvation. Anemia, hypercholesterolemia, and reduced bone density is caused by starvation. Hypokalemia, hypochloremic metabolic alkalosis, and hyperamylasemia are all caused by purging (2005). If the patient with Anorexia nervosa continue on and becoming severely malnourished, more complications will arise. Nicholls, Hudson, and Mahomed state changes in the body found when the illness becomes extremely severe due to Anorexia nervosa. In an electrocardiogram, abnormalities are shown such as low voltage, sinus bradycardia, T wave inversions, and ST segment depression. Because of the age of affected people (adolescence to young-adulthood), the malnourishment can cause growth delay and delayed bone mineral accretion. In the long run, it can also cause gastrointestinal problems such as delayed emptying of the stomach, slowed gastrointestinal motility, constipation, bloating, and abnormal liver function. There is also a known increase for high levels of blood urea nitrogen concentration and increased risk of renal stones. Severe Anorexia nervosa can also cause cortical atrophy, seizures, and esophagitis (2011).
System
Finding
Symptom
Cardiac
Bradycardia
Low energy, fatigue
Orthostatic hypotension
Syncope
Arrhythmia, prolonged QT
Dizziness, palpitations, and syncope
Pericardial effusion
Typically none and chest pain
Myocardial atrophy
Edema and congestive heart failure
Electrolyte imbalance
Hypokalemia (purging, laxatives)
Muscle pain, arrhythmias
Hyponatremia (excessive water drinking)
Seizures
Endocrine
Hypogonadotropic hypogonadism
Amenorrhea (primary or secondary)
Osteopenia/osteoporosis
Fractures
Sick euthyroid syndrome
Gastroenterological
Gastric dysmotility
Constipation, reflux
Delayed gastric emptying
Bloating, abdominal pain
Hematologic
Bone marrow suppression
Usually none, bruising, pallor
Integumentary
Acrocyanosis
Cold hands and feet
Lanugo
Increase fine body hair
Hair loss
Russell signs
Calluses from purging
Hypercarotenemia
Yellow skin
HEENT
Parotid enlargement
From purging
Dental enamel loss
Caries
Refeeding syndrome
Hypophosphatemia
Seizure, delirium, death
Moskowitz and Weiselberg (2017). There are also many laboratory findings that can lead to the diagnosis of Anorexia nervosa. Moskowitz and Weiselberg (2017) elaborate with this table.
Test
Finding
Cause
Chemistries
Sodium
Low
Excessive water drinking
Potassium
Low
Purging
Chloride
Low
Purging
Serum CO2
High
Purging
Amylase
High
Purging
SGOT/SGPT
High
Malnutrition
Cholesterol
High
Low T3, low binding globulin
Hematologic
Hemoglobin
Normal/low
Bone marrow suppression
Hemoglobin
High
Dehydration
White blood cell
Normal/low
Bone marrow suppression margination
Platelet count
Normal/low
Bone marrow suppression
Erythrocyte sedimentation rate
Low
Low fibrinogen
Endocrinologic
Luteinizing hormone, follicle stimulating hormone
Low
Central suppression
Estradiol
Low
Central suppression
Testosterone
Low
Central suppression
Total triiodothyronine
Low
Sick euthyroid syndrome
Thyroid stimulating hormone thyroxine
Normal/low
Central suppression
Prolactin
Low
Central suppression
Causes/Risk Factors
Although Anorexia nervosa cannot be pinned down to one specific cause, there are risk factors that increase the likelihood of a person developing Anorexia. Pike, Hilbert, Wilfley, Fairburn, Dohm, Walsh, and Striegel-Moore conducted a study to begin to understand the underlying problems and risk factors for Anorexia nervosa. They state gender and age are big risk factors for AN. Females are ten times more likely to develop Anorexia nervosa than men. The age at most risk for Anorexia nervosa is adolescence and early adulthood (2008). Pike, Hilbert, Wilfley, Fairburn, Dohm, Walsh, and Striegel-Moore found many factors that could contribute to Anorexia nervosa. These most common risk factors/causes are perfectionism in self and negative affectivity. They also state patients at risk have high parental expectations, family history of depression, and childhood sexual and physical abuse (2008).
Other Contributing Factors
Biological Psychological Social
Susceptibility loci (i.e., chromosomes 1, 2, and 13)
Traits (i.e., perfectionism, obsessionality, inflexibility, neuroticism, and harm avoidance)
Cultural influences
Neurotransmitter abnormalities (i.e., OPRD1 and HTR1D)
Low self-esteem
Family influences
Hormone abnormalities (i.e., cortisol and leptin)
Autonomy issues
Peer influences
Family studies (i.e., higher rates in offspring)
Maturity fears
Dieting
Twin studies (i.e., higher rates in mono vs. dizygotic twins)
Comorbid psychiatric disorders (i.e., depression, anxiety, and personality disorders
Stressors (i.e., college, moving bullied, abuse, and death)
Moskowitz and Weiselberg (2017).
Psychiatric Disorders Causing AN
Anorexia Nervosa is typically found with other psychiatric illnesses. These illnesses put a person at risk for Anorexia nervosa. Moskowitz and Weiselberg state in a study 73.3% of women also had another psychiatric disorder with their Anorexia nervosa. One study showed 60.4% of that are mood disorders. Another study Moskowitz and Weiselberg write about found the anxiety disorder rates in women with Anorexia nervosa from 64% to 83%. Obsessive compulsive disorder is also common in women with Anorexia coming to about 41% (2017). The ANAD states around half of patients with Anorexia nervosa have comorbid anxiety disorders. About 33-50% of anxiety patients have comorbid mood disorder (2018).
Social Stigmas with AN
Dimitropoulos, Freeman, Muskat, Domingo, and McCallum dig deep into the social stigma that comes with Anorexia nervosa by interviewing random people. They state the public believes that Anorexia nervosa is a choice and patients that have it can begin eating whenever they want. They found that the public thinks people with AN only have it because they want to be skinny like the supermodels in the media. Many people do not find eating disorders to be true mental disorders like they do with Schizophrenia or Post-traumatic stress disorder (2016). Dimitropoulos, Freeman, Muskat, Domingo, and McCallum also found the people they surveyed believed treatment for Anorexia is simple and it is not a real illness. Some people even used the word “weird” and “crazy” (2016).
Treatment
There are many different types of treatment. One of these treatment options is psychotherapy. Morris and Twaddle specify the different types of psychotherapies such as individual therapy, cognitive analytic therapy, cognitive behavior therapy, interpersonal psychotherapy, motivational enhancement therapy, dynamically informed therapies, group therapy, family work, conjoint therapy, separated family therapy, multifamily groups, and relatives’ support groups. Individual therapy is usually done about one hour weekly. A therapist and patient talk about the eating disorder and coping mechanisms. Cognitive analytic therapy is where the psychotherapist analyzes the habitual patterns of the patient around other people and help them work on it. Cognitive behavior therapy looks in the patients’ feelings and helps them become aware of them. It also helps educate the patients about their bodies and teaches them about behavior to be aware of when having Anorexia nervosa. Interpersonal therapy is where the psychotherapist takes a look at patients’ relationships. This helps the patients find new ways to cope with stress in relationships and transitions in life. Motivational enhancement therapy uses an interviewing technique with the patients and helps them become more positive and motivated to recover. Dynamically informed therapies inform the patients of the complications and problems that can arise and stay long after being in recovery from Anorexia nervosa. This is typically accompanied with being weighed weekly and constant visits to the doctor. Group therapy is therapy patients go to a group with other patients of Anorexia nervosa and talk about their problems. Family work is where the family goes to therapy to learn how to properly support the person struggling with Anorexia nervosa. Conjoint therapy is where whole families attend therapy together to work on their emotions. Separated family therapy is when the patient and parents go to therapy but at separate times for separate meetings and often times with two different therapists. This is just as effective but not more effective than conjoint family therapy. Multifamily group therapy is when several families and the patients meet all together that go on for a whole day. Relatives’ support groups teach skills to help patients recover and have the support they need from their support group (2007).
Life After AN
After recovering from Anorexia nervosa, people’s social lives can truly change. Deter, Schellberg, Kopp, Friederich, and Herzog conducted a study where they followed 81 patients for 12 years after their diagnosis. They looked at social and behavioral changes that played a role in the patients’ lives. Deter, Schellberg, Kopp, Friederich, and Herzog found stated the patients dropped in education during their treatment but as time went on, their functioning in an education setting increased. Between 4 and 8 years, education tripled in functioning for these patients (2005). However, in abundance and support of family, Deter, Schellberg, Kopp, Friederich, and Herzog found it lowered significantly. Starting at .517 at 4 years, going to .395 at 8 years, and ending at .094 at 12 years. During treatment of Anorexia nervosa, patients isolate themselves and often cut themselves out of social situations. When looking at the amount of personal contacts after treatment, it increased. Between 4 and 12 years, the amount of personal contacts doubled in size. Even though this is a positive outcome, the amount of social activities the patients were involved in decreased dramatically. At 4 years, the social activities were at .990. At 8 years, they were at .031 and by the end, they were at .027 (2005). Deter, Schellberg, Kopp, Friederich, and Herzog also found an increase in no sexual partners. It started at .036, rose to .734, and ended at .677. Integration into an occupation increased drastically. It began at .551, rose to .983 and ended at .996 (2005). To sum this information up, education and occupational functioning, and personal contacts increased after treatment. However, abundance of family, social activities, and sexual partners decreased.
Conclusion
Anorexia nervosa is an eating disorder classified as a mental illness. It has many signs and symptoms. Some of these signs and symptoms appear as behavioral signs and some appear as physical signs. Because there are so many, doctors can struggle to diagnose and treat Anorexia nervosa. This illness is a complicated disorder.
References
Beidel, D. C., Bulik, C. M., & Stanley, M. A. (2017). Abnormal Psychology: A Scientist-Practitioner Approach. Pearson Education.
Coniglio, K. A., Becker, K. R., Franko, D. L., Zayas, L. V., Plessow, F., Eddy, K. T., & Thomas, J. J. (2017). Won't stop or can't stop? Food restriction as a habitual behavior among individuals with anorexia nervosa or atypical anorexia nervosa. Eating Behaviors,26, 144-147. doi:https://doi-org/10.1016/j.eatbeh.2017.03.005
Deter, H. C., Schellberg, D., Köpp, W., Friederich, H. C., & Herzog, W. (2005). Predictability of a favorable outcome in anorexia nervosa. European Psychiatry,20(2), 165-172. doi:https://doi-org.2040/10.1016/j.eurpsy.2004.09.006
Dimitropoulos, G., Freeman, V. E., Muskat, S., Domingo, A., & McCallum, L. (2016). "You don't have anorexia, you just want to look like a celebrity": Perceived stigma in individuals with anorexia nervosa. Journal of Mental Health,47-54. doi:10.3109/09638237.2015.1101422
Eating Disorder Statistics • National Association of Anorexia Nervosa and Associated Disorders. (2018). Retrieved from http://www.anad.org/education-and-awareness/about-eating-disorders/eating-disorders-statistics/
Halmi, K. A. (2005). A complicated process: Diagnosing and treating anorexia nervosa and bulimia. Psychiatric Times, 22(6), 59-63.
Morris, J., & Twaddle, S. (2007). Anorexia Nervosa. British Medical Journal,334(7599), 894-895. http://dx.doi.org/10.1136/bmj.39171.616840.BE
Moskowitz, L., & Weiselberg, E. (2017). Anorexia Nervosa/ Atypical Anorexia Nervosa. Current Problems in Pediatric and Adolescent Health Care,47(4), 70-84. doi:https://doi-org:2040/10.1016/j.cppeds.2017.02.003
Murphy, B., & Manning, Y. (2003). An introduction to anorexia nervosa and bulimia nervosa. Nursing Standard,18(14-16), 45-52.
Nagl, M., Jacobi, C., Paul, M., Beesdo-Baum, K., Höfler, M., Lieb, R., & Wittchen, H. (2016). Prevalence, incidence, and natural course of anorexia and bulimia nervosa among adolescents and young adults. European Child & Adolescent Psychiatry,25(8), 903-918. doi:10.1007/s00787-015-0808-z
Nicholls, D., Hudson, L., & Mahomed, F. (2011). Managing anorexia nervosa. Archives of Disease in Childhood, 96(10), 977.
Pike, K. M., Hilbert, A., Wilfley, D. E., Fairburn, C. G., Dohm, F., Walsh, B. T., & Striegel-Moore, R. (2008). Toward an understanding of risk factors for anorexia nervosa: A case-control study. Psychological Medicine, 38(10), 1443-53.