Anorexia Nervosa

With one look at any advertisement, magazine, or television show, the importance that the media puts on attractiveness is unbelievably apparent. People of all ages are constantly bombarded with the harsh reality that, according to "society," they are not good enough. Unfortunately, some young girls cave under the media's pressure to be perfect, beautiful, and ultimately, thin. Sometimes this quest for the holy grail of thinness draws girls down a frightening path called Anorexia Nervosa.

What is Anorexia?

Anorexia Nervosa is a psychiatric disorder that falls into the category of eating disorders. It is one of the most well-known eating disorders, along with Bulimia Nervosa. Anorexia, like most mental disorders, can only be diagnosed by a professional.

Upon diagnosing Anorexia Nervosa, a psychiatrist or doctor typically uses the Diagnostic and Statistical Manual (DSM) of Mental Disorders, currently revision four. The DSM was created by the American Psychiatric Association and is a manual for mental health professionals detailing different mental disorders and criteria for diagnosing each. The definition of Anorexia according to the DSM-IV is quite long.

1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during the growth period, leading to body weight less than 85% of that expected).
2. Intense fear of gaining weight or becoming fat, even though underweight.
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 denial of the seriousness of the current low body weight.
4. In postmenarcheal females, Amenorrhea (the absence of at least three consecutive menstrual cycles) (gros.org).

Of course, not all of these signs or symptoms have to be apparent, but the DSM-IV has to encompass many different aspects of Anorexia Nervosa. As far as widely accepted definitions that are not put out by the DSM, Anorexia has also been characterized as "an intense fear of fat and weight gain, despite being underweight, and the refusal to maintain body weight at or above normal weight ranges" (Lena, Fiocco, & Leyenaar, 2004).

Who Does it Affect?

As well known by most, Anorexia typically affects adolescent girls and young women (Keski-Rahkonen, Hoek, Susser, & Linna, 2007). It affects 1-3% of adolescent girls, more often of white background and middle to high socioeconomic groups. Onset of Anorexia Nervosa is most often between the ages of 12 to 14 and again between 17 and 18 (Lena, 2004). Women characteristically have higher levels of unhealthy beliefs about eating habits than men, which seems to contribute to the development and continuation of eating disorders (Jones, Leung, & Harris, 2007).

In addition to unhealthy beliefs about eating, some studies have actually linked the development of eating disorders to higher levels of perfectionism, self-criticism, and need for control (Narduzzi & Jackson, 2002). These perhaps inborn traits are all individually seen in the anorexic patient. Most people with Anorexia Nervosa have an image of perfection in their minds that they will stop at nothing-even starvation-to achieve. Whether this image was seen in the media or is just an ideal body, the goal is perfection and nothing less. Self-criticism is obvious; as many anorexics constantly tell themselves that they are ugly and fat, thus spurring on the disorder. Various interviews and studies have also shown that many young girls turn to Anorexia so that they can control something in their lives, even if that is just food.

As children grow up and school becomes increasingly more difficult, food might be the only thing left to control. As cited in Lena, et al, the constant stressors of having to work harder to keep grades up, combined with both academic and social problems (for some children), can lead to feelings of "powerless ness, low self-esteem, depression, anxiety, and suicidal ideation." One possible outcome is that adolescent girls begin thinking of their appearance as more important than anything else, and eating disorders can blossom. The feelings of hopelessness can return if dieting attempts fail, thus starting the cycle all over again.

History of Anorexia

Anorexia is not a new disorder that just started happening because of public middle schools and the stressors of the media. In 1695, a man named Richard Morton described the first case of Anorexia in Phtisiologia: a Treatise on Consumption. Baglivi, who was a well-known expert on physical medicine in the early 1700's spoke about Anorexia as a "disaffection" with food by young girls who faced love and family problems. He prescribed a doctor who is "a master in the art of persuasion" as a cure (Reda, Sacco, & Newman, 2001). We now know that it takes a bit more than talking to dissuade someone who has already fallen victim to Anorexia.

Causes of Anorexia

There is no single cause of Anorexia Nervosa, but there are some factors that play a part in the development of the disorder. One factor is culture. Quite obviously, women in this country are more constantly inundated with images of beauty and perfection than are women who live in a small village in South America or Africa. This pressure from the media makes it increasingly more difficult for women in this country to feel good about the way they look. Another important factor is family. It is proven that women with another close relative with Anorexia are more likely to develop Anorexia themselves. Also, parents who put too much emphasis on appearance, diet often, or regularly criticize their children are more likely to have children who develop eating disorders (WomensHeath.gov).

Some other large factors in the development of Anorexia could be a life-changing or stressful event, personality types, or genetics (WomensHealth.gov). As far as genetics go, instances of Anorexia in monozygotic (identical) twins are significantly higher than in dizygotic (fraternal) twins (American Psychiatric Association, 1994).

Other Related Disorders

The DSM-IV also tells of disorders that are commonly diagnosed along with Anorexia Nervosa and sometimes, instead of it. Some anorexics become severely depressed and exhibit symptoms such as withdrawal, irritability, or insomnia, which all meet the criteria for diagnosis of Major Depressive Disorder. Another disorder commonly seen concurrently with Anorexia Nervosa is Obsessive-Compulsive Disorder. Most of these obsessions and compulsions revolve around the preparation or eating of food, weight, and body shape (American Psychiatric Association).

Body Dysmorphic Disorder (BDD) is also commonly found in anorexics. One study found that 39% of people diagnosed with Anorexia also had a BDD preoccupation with something unrelated to weight. BDD is defined by the DSM-IV-TR (TR- text revision) as "a preoccupation with an imagined or slight physical defect in appearance that results in significant distress or impairment in important areas of functioning." It is said that BDD affects about 2% of the population in the United States, causing patients to experience 'poor self image, depression, anxiety...and seeking repeated cosmetic surgery for the perceived defect' (Da Costa, Nelson, Rudes, & Guterman, 2007).

Anorexia Nervosa: Nature vs. Nurture

The Nature vs. Nurture debate is prevalent in the discussion of all disorders, and Anorexia Nervosa seems to be no different. Many studies aim to discover certain traits that all anorexics possess, certain behaviors all anorexics take part in, or certain qualities in the brains of all anorexics. This alone has caused health care professionals a great deal of challenges, as there seems to be no one specific link. There are, however, many small breakthroughs in this search.

One trait that many anorexics have in common is the tendency to think negatively. In a study in which patients are to record their thoughts throughout a day, anorexic women tend to record more negative thoughts and beliefs and fewer positive thoughts and beliefs about the world and their lives than do women in the normal control group. According to Jones, et al, this means that anorexia is not just maladaptive thinking, but inherently negative feelings about the world and themselves. The question to pose now is does inherent negativity cause something like Anorexia Nervosa, or does Anorexia Nervosa cause the inherent negativity? Or are they only correlational? These are the kinds of questions that scientists, psychologists, and psychiatrists are trying so hard to answer.

Preexisting Deficits

In a study by Lena, et al, it is proposed that certain etiological factors exist before, during, and after the onset of an eating disorder like Anorexia Nervosa. These researchers also propose that there are neuropsychological deficits that preexist in all women who will eventually fall victim to Anorexia. Conclusions such as these were drawn after completing a series of neurocognitive tests on both individuals with eating disorders, and a normal control group.

"Using standardized neuropsychological test, deficits in executive functioning, visual-spatial ability, divided and sustained attention, verbal functioning, learning, and memory have been observed in eating disordered individuals" (Lena, 2004).

Although those results are concrete, many of the authors of the study do not correlate eating disorders and these cognitive deficits. They say that the deficits are merely a result of poor nutrition and probable starvation. This can be countered, however, by the fact that these cognitive deficits are found in bulimics as well, ruling out starvation and possibly poor nutrition (Lena, 2004). Therefore, it can be surmised that these deficits were there before the eating disorder began.

Another theory dealing with cognitive deficits and Anorexia Nervosa has to do with the unstable child. "It is widely recognized that children with neuropsychological deficits have diminished self-esteem and an increased prevalence of emotional and behavioral disturbances" (Lena, 2004). A child with cognitive deficits may not have the coping strategies of a child without, leaving them feeling helpless. It is postulated that some of these children turn to Anorexia Nervosa to regain control of their lives when life gets particularly taxing, especially in the already tough transition from elementary to middle school.

Medial Prefrontal Cortex

Thankfully, work is being done to hopefully someday understand eating disorders like Anorexia. In one study, twenty-six female participants with eating disorders (ten with Bulimia Nervosa, and sixteen with Anorexia Nervosa) were matched comparatively by age and education with nineteen healthy female participants. Each of the women was presented with pictures of food, and with pictures of particularly aversive emotional images. The activity of each woman's brain was scanned with an fMRI (Uher, Murphy, Brammer, & Dalgleish, 2004). fMRI, or functional magnetic resonance imaging, refers to the use of an MRI to measure the changes in blood flow or blood oxygenation related to neural activity in the brain (Radiology Info). It is used in many experiments to see how and where blood in the brain is flowing.

The results of the study showed that women with eating disorders constantly identified the images of food as threatening and disgusting. There was greater activation in the left medial orbitofrontal and anterior cingulated cortices of the eating disordered women (Uher, 2004). The orbitofrontal cortex is primarily involved in decision making, especially in regard to reward and punishment (Journal of Cognitive Neuroscience). The anterior cingulate cortex functions in error detection, task anticipation, and motivation (Oxford Journals). There was less activation, however, in the lateral prefrontal cortex, inferior parietal lobule, and cerebellum of the eating disordered women (Uher, 2004). The lateral prefrontal cortex is chiefly involved in memory and organization (Barde & Thompson-Schill, 2002). The inferior parietal lobule is involved in the function of attention, perception, and visuospatial processing (Frederikse, Lu, Aylward, Barta, Sharma, & Pearlson, 2000). Lastly, the cerebellum is involved in coordinating fine and gross motor movements.

Mortality

Although knowing where anorexics differ from normal controls is a good thing to know, it is also worth knowing that some anorexics cannot be saved. Within ten years of onset, 7% of anorexics will die (Reda, 2001). Many studies have found that the risk of mortality increases with the duration of Anorexia Nervosa (Keski-Rahkonen, 2007). These statistics are too powerful to ignore.

Curability

Although mortality statistics are rather depressing, it is good to know that some people with Anorexia Nervosa can be cured. In fact, within ten years of onset, about 23% of anorexics will be cured (Reda, 2001). There is no clear cut remedy that seems to cure all Anorexia. It is a constant struggle for doctors and psychotherapists alike, trying to find something that works.

Pharmacology

According to Reda, et al, psychiatric biochemists have been constantly looking in vain for pharmacological remedies for Anorexia Nervosa. As cited in an article by Walsh and Devlin, "There have as yet been no studies concerning the role of psychopharmacology in prevention of the onset of the illness or in long-term maintenance of remission." Many different approaches have been tested, including antipsychotic drugs, antidepressants, and other types of drugs, prescription or not.

An unusually prescribed antipsychotic drug for patients with Anorexia Nervosa is chlorpromazine. It is usually given to those Anorexia patients who exhibit signs or symptoms of Obsessive-Compulsive Disorder, anxiety, or are easily agitated. In some studies, chlorpromazine is shown to induce hunger and weight gain, but other studies show no beneficial effects, coupled with serious side effects including grand mal seizures and sometimes the development of bulimia. Because there is no clear evidence of this drug doing its job without these side effects, chlorpromazine is rarely used on patients with Anorexia (Wattula).

Anorexia and depression seem to go hand in hand more often than not. Therefore, there are many antidepressant drugs that are used on anorexic patients. Tricyclic antidepressants like clomipramine have been used on anorexics with little effect and side effects such as sedation, dry mouth, and confusion. Flouxetine, which is a serotonin reuptake inhibitor, is commonly used to treat patients with Obsessive-Compulsive Disorder, as well as patients who are depressed. When patients with these disorders use this drug, weight gain is typically a side effect. In use by patients with Anorexia Nervosa, anxiety, depression, and obsessions are decreased, and healthy eating behaviors sometimes ensue (Wattula).

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy is a form of psychotherapy that emphasizes thinking in feelings and actions. It is based on the idea that thoughts cause behaviors and feelings, not external stimuli, like events or situations. CBT is a type of therapy that actually has a time limit, only about 16 sessions per patient, therefore it is not a never-ending therapy session like some forms of psychotherapy. Therapists who use cognitive-behavioral therapy encourage their patients to ask questions and learn, not just talk. Homework is also often a cornerstone of cognitive-behavioral therapy, since sessions are limited (National Association of Cognitive Behavioral Therapists Online Headquarters [NACBT]).

One form of cognitive-behavioral therapy that has already been proven to work on patients with Anorexia Nervosa is narrative therapy. "Narrative therapy is a clinical model that is informed by postmodernism, and rejects modernist conceptions of truth, certainty, and objectivity" (Da Costa, 2007). Narrative therapy works in four stages, the first of which is mapping the influence of the problem. This stage is about questioning, and is designed for the patient to externalize the problem. Patients are strongly encouraged to think of themselves as a separate entity from the problem. They are told that they are not the problem, and are urged to find other influences (Da Costa, 2007).

The second stage of narrative therapy includes identifying unique outcomes, in which patients are to tell of any thought, behavior, feeling, or event that seems to oppose the main story or 'problem.' For example, a cognitive-behavioral therapist might ask an anorexic, "How were you able to not let the problem influence you at your sister's birthday party when you ate a small piece of cake?" (Da Costa, 2007).

Stage three is called 'restorying.' This stage involves the client coming up with a story about their problem, in which it gets fixed. It is a therapeutic process that helps clients feel empowered and hopeful about battling their problem. The fourth stage in the narrative therapy process has many parts involving externalizing the problem. Some cognitive-behavioral therapists will have their patients name their problem, write it a letter, or perform other tasks leading to basic abandonment of the problem (Da Costa, 2007).

Conclusion

Anorexia Nervosa is a complex problem that has been affecting young women for many years. Some women never get better and Anorexia Nervosa proves to be stronger than they are, and some women get help and eventually overcome. The one thing that is for sure is that doctors, psychologists, psychiatrists, and pharmacologists must continue their work to understand and ultimately cure Anorexia Nervosa.

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