Anorexia nervosa is a serious, potentially life-threatening eating disorder characterized by self-starvation and excessive weight loss. It is currently the deadliest psychiatric illness.
When Dr. Arnold Andersen, a long-time EDR board member, wrote about anorexia nervosa more than 15 years ago, he was well ahead of the times. In his article, “Anorexia Nervosa: Curious Past, Hopeful Future (EDR, January/February 2000)”, Dr. Andersen wrote, “Anorexia nervosa (AN) has a history as interesting as the Cheshire cat’s smile: now you see it, now you don’t. Morton’s first generally accepted account of AN appeared in the English language in 1689. Over the next 140 years AN was sequentially compressed into a medical category (“postpartum pituitary necrosis”), wedged into psychoanalytic theory, made an exclusively female disorder, relegated to a forme fruste [an atypical or incomplete form] of several other disorders (schizophrenia, depression), and fought over r egarding etiology, pathogenesis, and treatment. Recently it has spread like a virus to developing countries. Males have been reunited into the AN camp in the last 40 years.
What Is Anorexia Nervosa?
Dr. Andersen notes, “AN is a prototype of disorders of motivated behavior, all of which serve as a final common pathway for a variety of developmental, familial, intrapsychic, and societal conflicts. At its core, AN arises from a conflict between the individual’s neurobiological forces, which regulate weight stability, and social norms, which mandate thinness. The probabilistic nature of a single person developing AN from multiple risk facts may mean no single causative factor will ever be found.” Dr. Andersen further described AN as “a syndrome that blossoms when predisposing features are acted upon by specific precipitating factors, which then sustained by a combination of biomedical and psychosocial factors… Recently, the list of predisposing factors has been shown to include genetic vulnerabilities, primarily the serotoninergic system. The best estimates of the heritable vs. acquired elements hover around 50% for each, with wide differences suggested by different studies.” Between 0.5% and 1% of American women are diagnosed with anorexia nervosa, and 90% to 95% of anorexia nervosa patients are girls and women. Men are affected less often than women, and the estimate is about 0.3% of men are diagnosed with the disorder. Men are less likely to seek treatment and healthcare providers may fail to assess or diagnose eating disorders in males. AN typically begins during early- to mid-adolescence, and warning signs include sudden weight loss, extreme dieting, food rituals (e.g., taking very small bites, eating foods in a certain order), hair loss, dry skin or hair, brittle nails, growth of fine, downy hair on the face and body. Certain medical conditions may co-occur with AN and include bone loss, difficulties with temperature regulation, loss of menstrual periods, low heart rate, and low blood pressure.
AN Versus Dieting
While someone may diet in an attempt to control weight, anorexia nervosa is often an attempt to gain control over one’s life and emotions, especially in the light of traumatic events or a chaotic environment. While someone might diet in an attempt to lose weight as the primary goal, anorexics restrict their calories because they perceive losing weight as a way to achieve happiness and self-mastery. One longstanding diagnostic criteria for AN, amenorrhea, defined as the absence of at least 3 menstrual cycles, was deleted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5), and Criterion A, which focuses on behaviors, like restricting caloric intake, no longer includes the word “refusal” in terms of weight maintenance. Similarly, certain psychological conditions and features that often coincide with AN include anxiety, depression, social isolation, and perfectionism. Approximately 50-60% of individuals with AN recover over time, with better recovery rates observed in younger patients and those with a shorter duration of illness when diagnosed. For adolescents with AN, a form of family-based treatment has been shown to be successful in improving recovery from the illness. Unfortunately, the risk of death in AN is increased due to medical complications and suicide. Some telltale signs of anorexia nervosa:
- Eating too little food, leading to a weight that is clearly too low.
- Intense fear of weight gain, obsession with weight, and persistent behavior to prevent weight gain.
- Gauging self-esteem by body image.
- Inability to appreciate the severity of the situation.
- Binge-Eating/Purging Type involves binge eating and/or purging behaviors during the last three months.
- Restricting Type does not involve binge eating or purging.
- Dramatic weight loss.
- Friends and family comment on startling changes in appearance due to weight loss.
- Preoccupation with weight, food, calories, fat grams, and dieting.
- Refusal to eat certain foods, progressing to restrictions against whole categories of food (e.g. no carbohydrates, etc.).
- Frequent comments about feeling “fat” or overweight despite weight loss and thin appearance.
- Denial of hunger.
- Development of food rituals. Some examples include eating food only in certain orders, chewing excessively, or rearranging food on one’s plate.
- Using excuses to avoid mealtimes or occasions or situations involving food.
- Excessive, rigid exercise regimen–despite weather, fatigue, illness, or injury, the need to “burn off” calories, no matter how many are taken in, takes over.
- Withdrawal from usual friends and activities.
Health Consequences of ‘The Deadliest Psychiatric Illness’
Between 5% and 20% of individuals struggling with anorexia nervosa will die, making it the deadliest psychiatric illness. The anorexia mortality rate of 5.86% is dramatically higher than that of schizophrenia, which increases the risk of death 2.8-fold in males and females and bipolar disorder, which increases death risk 1.9-fold in males and 2.1-fold in females. Anorexia nervosa involves self-starvation. The body is denied the essential nutrients it needs to function normally, so it is forced to slow down all of its processes to conserve energy. This “slowing down” can have serious medical consequences:
- Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as heart rate and blood pressure levels sink lower and lower.
- Fainting, fatigue, and overall weakness.
- Dry hair and skin, hair loss is common.
- Reduction of bone density (osteopenia and osteoporosis), which results in dry, brittle bones.
- Muscle loss and weakness.
- Severe dehydration, which can result in kidney failure.
- Growth of a downy layer of hair, or lanugo, all over the body, including the face, in an effort to keep the body warm.
Weight restoration is the priority with these patients, who have serious health repercussions from malnutrition, such as an erratic heart rate and fluid and electrolyte disorders. Treatment includes three main portions:
- Medical: The highest priority in the treatment of anorexia nervosa is addressing any serious health issues that may have resulted from malnutrition.
- Nutritional: This component encompasses weight restoration, implementation and supervision of a tailored meal plan, and education about normal eating patterns.
- Psychotherapy: As the Academy for Eating Disorders (AED) notes, the goal of psychotherapy is to recognize underlying issues associated with the eating disorder, address and heal from traumatic life events, learn healthier coping skills and further develop the capacity to express and deal with emotions. There are several different types of outpatient psychotherapies with demonstrated effectiveness in patients with eating disorders. These include cognitive-behavioral therapy, or CBT, interpersonal psychotherapy, and family therapy. Some of these therapies may be used for a short time, but other therapies other psychotherapies may last years. It is very difficult to predict who will respond to short-term treatments versus longer term treatments. Other therapies which some clinicians and patients have found to be useful include feminist therapies, psychodynamic psychotherapies and various types of group therapy.