Anorexia nervosa is a psychological condition that’s shortly referred to as “anorexia.” This term is still used even though some researchers see it not precise enough as anorexia means loss of appetite and inability to eat, and this may accompany a lot of diseases, unlike anorexia nervosa, which is an eating disorder that loss of appetite may be one of its symptoms. Still, it usually appears as intended self-starvation and food restriction.
People are often normally hungry, but they refuse to eat as a result of obsessive and severe fear of weight gain and being fat or obese. They always have a strong desire to be slim even if their body shape and body mass index (BMI) are normal. They lose more weight than what is ideal and healthy for their body regarding their height, age, and other body conditions. The disease includes emotional problems and unrealistic body image perception; it is unhealthy and maybe a life-threatening condition if complications happen or if left untreated.
Anorexia nervosa is the 3rd most common chronic illness among teenagers and has the highest mortality rate in comparison with any other mental illness. It affects both males and females but with ten times higher incidence in females. The disease appears at any age but mainly in teenagers at puberty time or early adulthood, sometimes it’s seen in preteens, and it rarely appears over 40 years of age.
Most of the time, it comes along with other mental conditions such as Obsessive-compulsive disorder (OCD), depression, anxiety, or any mood disorder, as well as substance abuse making the situation worse than it is because this intensifies the anorexia symptoms thus affects the patient’s health negatively.
Anorexia nervosa types:
There are 2 main common types of anorexia :
1) Purging/ Binge eating type:
People suffering from this type have no control over themselves. They eat significant amounts of food but then end up vomiting what they ate, take laxatives, use enemas and diuretics as a compensatory way for their eating.
2) Restrictive type:
People with this condition put restrictions on the amount and type of food they eat. They often restrict carbohydrates, high caloric food as high fat-containing meals. They usually skip meals and apply obsessive and abnormal eating habits or rules as eating only food with specific colors. It’s considered as a form of self-starvation, and their caloric intake is always fewer than what their bodies need to be in the ideal weight. Besides those signs of anorexia, the person may over-exercise.
Anorexia nervosa symptoms:
There are a lot of anorexia symptoms that can occur and one may develop one or more of the following:
· Abnormal and severe weight loss, which is the main anorexia nervosa symptom, but in rare cases, people are of normal weight even if malnourished.
· Loss of appetite (in some cases).
· Eating Refusal or skipping meals.
· Cooking for others and refusing to join them.
· Denial of being hungry.
· Food restriction by eating few or specific types of food like those having low calories.
· Chewing food and then spitting it.
· Lying about the amount of food consumed.
· Always complaining about being fat or having some extra fat in specific body parts even if this is not true.
· Wearing many layers of clothes to avoid people knowing their exact weight and body shape.
· Abnormal eating habits as pushing food around the plate rather than eating and sometimes rearranging it in specific manners.
· Obsessive compulsive disorder (OCD).
· Over Excitement.
· Weighing every now and then and frequent mirror inspecting.
· Vigorous exercising and vomiting after eating resulting in bad breath and tooth decay due to acid reflux.
· Misusing laxatives, enemas and diuretics.
· Lack of nutrients that lead to:
- loss of muscle mass.
- Hypothermia (having low body temperature).
- Cold extremities.
- Constipation, Stomach distress, bloating.
- Feet and hand swelling.
- Dry skin.
- Alopecia (hair loss).
- Amenorrhea (having few or no periods).
- Brittle nails.
- Osteoporosis or loss of bone density.
- Irregular heart rhythm.
- Decrease sex drive.
- Memory loss.
- Fainting and yellow skin colour.
- Lanugo (fine soft hair covering body) and increased facial hair.
· Being irritable.
· Eating in secret.
· Social withdrawal.
· Cutting food into small pieces.
· Sudden and unusual interest in cooking and calories.
· Feeling worthless and linking self worth to being thin.
· Eating is linked to guilty feeling.
· Abnormal blood counts.
· Intolerance to cold and Bluish finger’s colour.
· Sunken eyes.
· Lethargy (lack of energy).
· Orthostatic hypotension. (fall in blood pressure upon standing).
· Poor concentration.
Although anorexia nervosa symptoms are clear and obvious, one has to be careful as some patients don’t show any anorexia symptoms or signs, and they make a lot of effort to prevent anyone from noticing they have any health concern.
Anorexia nervosa causes :
There’s no specific single cause of anorexia. Still, according to researches, it’s a mixture of biological, environmental, psychological, and social factors, as well as some differences in personality traits that make a person more prone than others.
The possible risk factors and causes are:
1) People with depression, anxiety, OCD or social phobia or those having difficulty to handle stress.
2) Having excessive worrying about the future.
3) Being a perfectionist with some obsessive, anxiety, or depression symptoms and also being a high achiever who does very well at school, work or job, or any task they take. This makes the person always seeking to have a perfect body too. And if it comes to dieting, he/she is ever known to be the best dieter that is keen to be the thinnest, not only thinner.
4) Having low self esteem and negative self image.
5) Having an eating or anxiety disorder during childhood.
6) Having weight, shape, beauty and health concerns.
7) Feeling success by losing body weight and having control over something especially if they failed to control any other life aspect.
8) Hormonal changes during puberty.
9) The idea of whoever is thin is beautiful.
10) Emotional, sexual and physical abuse.
11) Family or relationship problems.
12) Being always bullied.
13) Fear of failing exams.
14) Huge stressful life events or situations such as breakup or death of someone special, being unemployed or moving to a new school or job.
15) Brain chemicals imbalance, some researchers link this condition with serotonin levels in the brain.
16) Wanting a career that requires being thin as modelling, fashion industry, certain sports or ballet.
17) Being in comparison among friends for who’s more thin and beautiful.
18) Genetics, about 50-80% from the risk of getting anorexia is genetic and it gets higher if a first degree relative is having the condition.
19) Being in a society that is always having tips or articles written on how to be thin and enhances the idea.
20) Premature birth or people with low birth weight.
21) Previous psychiatric disorder.
22) Being on a diet always.
23) High Body mass index (BMI) during childhood.
24) Irregular function of the brain chemicals that is responsible for eating and hunger.
25) Trying to follow the shape of models in magazine pages.
26) Being a model, athlete or actor where body shape is so crucial.
Anorexia Nervosa Diagnosis:
Anorexia nervosa treatment outcome is better with early diagnosis and it gives a higher chance of full recovery. It’s not easy to diagnose the condition, and it may take a long time to confirm it as it’s too hard for the patient to speak about his/her life, especially if he/she has a history of obesity. They usually deny having any anorexia symptoms as they even deny being sick and, therefore, never think about anorexia treatment.
First doctors have to ask about the patient’s medical history, weight loss and how they feel about their weight and their bodies as well as menstrual cycle irregularities in females.
If the health care professional sees any signs of anorexia, they have to do some tests for further investigation. This rules out the presence of other diseases that may be responsible for the weight loss or those giving the same symptoms and signs of anorexia such as diabetes mellitus, malabsorption, irritable bowel syndrome, Addison disease, immunodeficiency, cancer, hyperthyroidism, celiac disease, and irritable bowel disease. It may also help to make sure there are no complications from the energy craving of the patient’s body due to limited food intake.
They look for criteria of the Diagnostic and statistical manual of mental disorders 5th edition DSM-5 published by the American psychiatric association (APA) to help them diagnose and confirm it’s anorexia. It consists of 3 main points:
1) Energy intake restriction relative to body requirements according to sex, age and health status resulting in severe low body weight.
2) Fear of gaining weight even if underweight.
3) Disturbance in the way in which the person’s body weight and shape are experienced and the great influence of them on self-evaluation. In addition to denial of the seriousness of low body weight.
Although sometimes patients don’t meet the criteria but they can still be diagnosed with a serious eating disorder according to the national eating disorder association (NEDA).
Tests for diagnosis include:
1) Lab tests:
· Complete blood picture (CBC) to check blood counts.
· More specialized blood tests to check electrolytes levels and proteins.
· Liver kidney and thyroid function test.
· Urinalysis may be done too.
2) Physical examination:
· Height, weight and Body mass index measurements.
· Vital signs such as heart rate, blood pressure, temperature.
· Abdomen examination in addition to lung and heart listening.
· Skin and nails examination.
3) Psychological examination:
Doctors ask patients about their eating habits, thoughts and how they feel. They may ask them to Complete a psychological self assessment questionnaire too.
Then psychiatrists check for any other mental illness that may probably be present.
4) Other investigations as:
· X-ray: to check bone density and fractures as well as pneumonia and heart problems.
· ECG: Specific for heart irregularities checking.
Anorexia nervosa complications:
The complications are severe and can be fatal, it can occur suddenly without any alerts and affect all body systems.
- Heart rhythm irregularities, low blood pressure, low heart rate, sometimes damage to heart muscle and heart failure.
- Abnormalities like Leukopenia, anemia, electrolyte imbalance.
- Intestinal movement becomes slow in underweight patients but it can be resolved when they are on a good healthy diet again.
- High urine concentration due to dehydration, It improves with improving patient’s body weight. Some severe cases may develop renal failure.
- Some may develop Liver failure.
- No periods in females decreased testosterone in males and infertility.
- Low levels of growth hormone that may delay growth in adolescents but can be restored with a healthy diet.
- Those whose bones aren’t fully grown yet have higher risk of osteoporosis, osteopenia and bone fractures.
- If the patient becomes malnourished already, organs may be permanently damaged making it too difficult to obtain full recovery.
- Therefore, warning signs of anorexia cannot be neglected to avoid the risk of not being able to control those serious complications. If you or a person you know noticed any of these symptoms and signs of anorexia you should seek medical help.
Anorexia nervosa treatment:
Anorexia treatment focuses on psychiatric stabilization, managing symptoms and complications by immediate medical intervention, nutrition plans and resting of the patient.
The main goals of anorexia nervosa treatment are:
- Restoring the ideal body weight for keeping the patient healthy by using good nutrition plans.
2. Increase patients self esteem and fix any other emotional problems.
3. Make the person free of any anorexia symptoms and Increase his/her quality of life.
Medical anorexia treatment:
No specific supplementation or drug shows it works well as a standard anorexia treatment. Still, Antidepressants drugs such as selective serotonin reuptake inhibitors “SSRIs” are given to treat depression, anxiety, obsessive-compulsive disorder “OCD, or any other mental problems the patient may have. But unfortunately, they don’t stop the desire to lose weight.
They can only be used as a 2nd line treatment after the antipsychotic drug “Olanzapine,” where the patient’s weight is at least 95% of the healthy weight regarding their height, age, and body conditions.
Psychotherapy anorexia treatment:
- Cognitive behavioural therapy (CBT): It changes how the patient thinks and acts and also changes his/her ideas about weight and food intake.
- Suggest ways for handling stress situations.
- Regain normal eating habits to support weight gain and know the importance of a good balanced diet to preserve health.
- Increase self esteem and cope with negative emotions.
- It’s used in helping teens to choose their diet to regain their ideal weight again.
- Gives support to the patient and teaches him/her to cope with anorexia.
Patients with severe anorexia nervosa symptoms, psychiatry or physical emergency, malnutrition, severe weight loss, or persistent refusal to eat require hospitalization and frequent monitoring of signs of dehydration, electrolyte imbalance, or any related medical conditions. If their case is so serious, they are fed by using a nasogastric tube, a tube that enters from the patient’s nose and goes to the stomach. For ensuring safe weight gain, food intake should be increased gradually. Some specialized clinics in eating disorders can treat patients by a specific day or residential programs rather than full hospitalization.
All Healthcare experts including primary care doctors, dietitians and psychiatrists should have a good experience in eating disorders and know how to deal with such cases.
Barriers to anorexia nervosa treatment:
There are some problems that may affect or delay patient treatment like:
· Fearing weight gain from treatment protocols.
· Assuming that this is a lifestyle choice not sickness.
· Believing they don’t need any medical intervention and there’s nothing serious.
People can have a 100% recovery from the condition if only their weight is restored and if they learn the proper nutrition and normal eating habits beside receiving the proper treatment.
At stress time or triggering situations the patient may have relapsing anorexia nervosa symptoms so therapy or meeting the health care expert may have a great effect preventing serious problems and help him/her stay healthy.
Lifestyle helping tips:
Never skip treatment sessions.
Ask the healthcare practitioner for a supplement if you think you’re not getting enough nutrients from food but put in consideration that this should be the last option as obtaining your body needs from food is much better.
- Don’t weigh or inspect the mirror too much.
Other alternative therapy options:
- Massage, yoga and meditation.
BY: DR. GHADEER IBRAHIM
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