Anorexia Nervosa

Overview

Anorexia Nervosa is an eating disorder characterized by a fear of gaining weight and a tendency to misjudge one’s own body shape and weight, leading to reducing food intake and significantly low body weight. Further subtypes of the disorder are illustrated by a tendency to occasionally binge-eat, which is typically followed by purging through self-induced vomiting, or the use of laxatives or diuretics. The disorder can lead to severe medical complications, and is associated with a very high rate of mortality. Individuals may also experience difficulties in social and/or academic aspects of life. 

There is a significant female preponderance associated with Anorexia Nervosa. The onset of the disorder is typically between early or mid-adolescence. Genetic and biological factors play a role, as well as environmental factors such as socioeconomic and cultural factors.

The highest priority in treating Anorexia Nervosa is achieving healthy weight, and treatment of any possible medical complications. The efficacy of various modalities has been determined across studies, and the need for nutritional therapy has been established.

Signs and Symptoms

The signs and symptoms of Anorexia Nervosa may include: 

1. Persistently restricting amount of food consumed 
2. Exercising excessively 
3. Trying to avoid and being fearful of gaining weight 
4. Significant weight loss
5. In adolescents or children, inability to reach expected weight at developmental stages
6. Low BMI 
7. Fixating on weight and appearance and constantly checking certain body parts 
8. Being overly conscious of food and calorie intake, and refusing to eat high-calorie foods
9. Irregular menstrual cycle, or missing periods 
10. Abnormalities in pulse, body temperature, respiration, blood pressure, and oxygen saturation 
11. Digestive problems or constipation
12. Lethargy
13. Being unable to tolerate the cold 
14. Swelling in legs or hands 
15. Rash-like red spots on skin
16. Bluish discoloration of skin as seen due to bruising
17. Fine, soft hair covering the body
18. Low self-esteem
19. Depressive mood
20. Withdrawing from social situations 
21. Irritability 
22. Disturbances in sleeping patterns 
23. Reduced interest in sexual activity
24.  Not wanting to eat in public
25. Wanting to be in control of one’s environment 
26. Constantly thinking about food 
27. Engaging in obsessive behavior such as collecting recipes or hoarding food
28. Excessively limited emotional expression
29. Misusing medication in order to avoid gaining weight or to achieve weight loss 

Risk Factors

There is a significant female preponderance associated with Anorexia Nervosa. The onset of the disorder is typically between early or mid-adolescence. The manifestation of the disorder during adolescence is linked with better recovery rates and lower mortality. 

A strong genetic component has been identified across studies, with an increased risk of the disorder among individuals who have a family history of eating disorders. An increased risk of eating disorder in the offspring may also exist if the mother had an eating disorder while pregnant. 

Biological factors have included abnormalities in neurotransmitter levels, particularly the dopaminergic system, as well as anomalies of the reward pathway, which has to do with motivation to eat and satisfaction upon food intake, have been found to play a role. An imbalance in the inhibitory functions of serotoninergic and reward functions of the dopaminergic systems has been proposed.

Structural differences in the brain have also been identified, including changes in volume of grey and white matter. Individuals with the disorder may also have neurocognitive difficulties, such as with shifting among various tasks, socio-emotional processing, and the ability to regulate and express emotion. Temperamental factors may include anxious, perfectionist, and obsessive traits. 

Adverse experiences during developmental stages may increase the risk of Anorexia Nervosa. Feeding and sleeping difficulties in infancy and adverse perinatal events have been linked to the disorder. Further, hormonal changes during adolescence may interact with other biological factors as grounds for the development of the disorder. 

Environmental factors such as belonging to low or middle-income backgrounds, excessive dieting or fasting, cultural factors, going through periods of transition, parental eating habits, negative affect during mealtime or in association with food, and so on, can affect the individual’s susceptibility to eating disorders.

Excessive restriction of feeding practices by parents may inhibit the autonomy children take on in relation to eating behavior. An association has also been made with premorbid obesity among those with Anorexia Nervosa, further linked with poorer prognoses. 

Anorexia Nervosa can have significant impacts on physical and mental health, and is known to cause considerable medical complications, including dermatological, cardiovascular, gastrointestinal, hematologic, neurologic, ophthalmic, pulmonary, endocrine and metabolic issues. The disorder is also known to have a high rate of mortality. 

Diagnosis

In a majority of cases, individuals with Anorexia Nervosa receive medical attention due to the concern exhibited by their family members or close friends upon significant weight loss. Due to the preoccupation with weight loss and desire to be “thin”, it is unlikely for patients to complain about their own weight loss. When individuals approach health practitioners it is more likely due to somatic or psychological consequences that are experienced after starvation. 

The process involved in the diagnosis of Anorexia Nervosa includes in-depth physical and well as psychological assessment. Physical examinations and laboratory tests involve weight, pulse, BMI, body temperature, blood pressure, and so on, and may also include urine tests, blood tests, endocrine tests, electrocardiography and electroencephalography, as well as x-rays and bone mass assessments. These are often carried out in order to assess the type of care required, as well as to rule out possible underlying causes. 

The DSM-5 mentions the following diagnostic criteria for Anorexia Nervosa: 

1. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
2. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

The diagnosis of Anorexia Nervosa may be further specified as a ‘restricting type’, referring to an absence of binge eating behavior or self-induced vomiting, use of laxatives, diuretics, or enemas over the previous 3 months, or a ‘binge-eating/purging type’, referring to the presence of the same over the previous 3 months. Specifications may also be made on the basis of the state of remission, and on the basis of severity, determined through BMI. 

Treatment

Treatment of Anorexia Nervosa can pose considerable challenges, based largely in the reluctance on the part of the patient to accept that they need treatment and the fear of gaining weight. It is essential to attempt to identify the disorder at its early stages in order to increase the chances of a high recovery.

Individuals diagnosed with Anorexia Nervosa may be in need of hospitalization, as outpatient care may not suffice or lead to improvement. During this time, adequate monitoring of the individual in order to maintain healthy vitals, as well as feeding through mechanical methods such as nasogastric tubes may be implemented. 

The highest priority in treating Anorexia Nervosa is achieving healthy weight, and treatment of any possible medical complications resultant of unhealthy eating behavior. This process involves various different specialists, the family members of the individual, and in the case of children or adolescents, the school of the individual as well. 

Psychotherapy is an important aspect of treatment for the disorder. The efficacy of various modalities has been determined across studies, including Family-Based Treatment, Specialist-Supportive Clinical Management, Maudsley Model of Anorexia Treatment for Adults, Enhanced Cognitive Behavior Therapy, and Focal Psychodynamic Psychotherapy.

The focus of most of these modalities lies in improving the individual’s relationship with food, interpersonal relationships, psychosocial adjustment, establishment of goal weight, nutritional education, and so on. 

Pharmacotherapy in the treatment of Anorexia Nervosa is dependent on any occurring psychiatric comorbidities, such as depression or anxiety. The efficacy of any form of medication has not been proved in reducing psychological symptoms of Anorexia Nervosa or aiding weight gain.

Nutritional therapy makes to use of dietary counselling as well as carefully organized refeeding programmes. Depending on the severity of malnourishment and weight loss, a weight gain of 500-1400 gm per week may be recommended.

Regular monitoring during this time is essential, as there is a risk of ‘Refeeding Syndrome’, referring to a metabolic disturbance that may occur among the individuals. Supervised meals are a protocol, and if need be, high-protein oral liquid supplements may be used.

Weight gain is also essential in order to restore bone density, and in women, to regulate menstrual cycles. 

The treatment of Anorexia Nervosa is a long-term process, and due to the chances of relapse, there is a necessity to keep following up with the individual.

Differential Diagnosis 

1. Major depressive disorder: Severe weight loss may occur, but most individuals with major depressive disorder do not have either a desire for excessive weight loss or a fear of weight gain.

2. Schizophrenia: Individuals with schizophrenia may exhibit odd eating behavior and occasionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of anorexia nervosa

3. Substance use disorder: Individuals with substance use disorders may experience low weight as a result of poor nutrition but they generally do not fear gaining weight and do not express body image issues.

4. Bulimia nervosa: Individuals with bulimia nervosa go through episodes of binge eating, practice behavior to avoid weight gain (e.g., self-induced vomiting) and are overly concerned with their  body shape and weight. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa maintain body weight at or above a minimally normal level.

5. Avoidant/restrictive food intake disorder: Individuals may show signs of significant weight loss or nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they experience their body shape and weight.

6. Social anxiety disorder, Obsessive compulsive disorder, Body dysmorphic disorder: Some of the features of anorexia nervosa are similar to the symptoms of social phobia, OCD, and body dysmorphic disorder.Individuals may feel humiliated or embarrassed to be seen eating in public, as in social phobia; may exhibit obsessions and compulsions related to food, as in OCD; or may be preoccupied with an imagined defect in appearance, as in body dysmorphic disorder.

If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social phobia should not be made, but social fears unrelated to eating behavior may require an additional diagnosis of social phobia. Similarly, an additional diagnosis of OCD should be considered only if the individual exhibits obsessions and compulsions unrelated to food and an additional diagnosis of body dysmorphic disorder should be considered only if the distortion is unrelated to body shape and size.

7. Medical conditions: Excessive weight loss may occur in medical conditions, but individuals with these disorders do not also manifest a disturbance about their body weight or shape or an intense fear of weight gain or execute behaviors that interfere with appropriate weight gain.

Comorbidity

Bipolar disorder and anxiety disorders are common disorders occurring alongside anorexia nervosa. Individuals with a restricted type of anorexia nervosa are also frequently diagnosed with OCD, alcohol use or substance use disorder. 

Specialist

The management of Anorexia Nervosa usually requires a multi-speciality team consisting of a primary family physician, psychotherapists or psychiatrists, and dietary specialists. In order to ensure success of treatment, the focus must be on establishing a therapeutic alliance with the patient as well as mobilizing the individual’s close ones and involving them whenever possible. 

In Conclusion

Society has unsaid and unrealistic beauty standards that have been imposed on minds via different channels like television, social media, beauty magazines, pageants, etc. Envy is a common emotion, but when envy turns into extreme self-consciousness, then it could be a serious issue. 

Anorexia nervosa has early symptoms that need to recognize in order to provide proper treatment. 

There are severe implications of this eating disorder and therapy could be a way out. Generally, family and friends play a significant role in the identification and prevention of this condition.

If you notice a dear one with similar symptoms, connect them with our professionals and book their therapy session today.