Dr. M.J. Bazos, MD
Patient Handout
ANOREXIA
NERVOSA
About Your
DiagnosisAnorexia nervosa is a form of
eating disorder. It is a condition that can have life-threatening consequences
if not properly treated. In this condition, here is a refusal on the part of
patients to maintain body weight at or above what is normal for their age and
height. In addition, individuals with anorexia nervosa also have an intense fear
of gaining weight or becoming fat, even though they are generally underweight.
When asked about their ideal weight, patients with anorexia nervosa will never
be able to give a number because they will always believe they should be thinner
than they actually are. Individuals who have anorexia nervosa also seem to have
an abnormal perception of how their body looks, despite normal weight for their
height. There also is a strong denial about the serious physical consequences of
low body weight and rapid weight loss. In women who have already had their first
menstrual period, there is generally an absence of menstrual cycles secondary to
malnutrition and starvation. To make a diagnosis, there needs to be at least
three consecutive menstrual cycles missing. This loss of menstruation in someone
who has already begun to have periods is called secondary amenorrhea. The
individual with anorexia nervosa may have periods of binge eating behavior, but
this is usually followed fairly rapidly by some sort of activity to eliminate
the food (purging). Although anorexia nervosa is often depicted in the media, it
is actually a fairly rare illness. The groups at highest risk for this condition
are adolescent girls and young women, but even there, it affects only about
0.5% of that population. It is true, however, that the occurrence of anorexia
nervosa has increased significantly during the last 50 years, mainly related to
societal attitudes about weight loss and acceptable physical appearance.
Anorexia nervosa is basically a condition that affects women, much more commonly
than men in a ratio of 10:1 or even 20:1. It is more common in higher
socioeconomic classes. Some occupations such as modeling, ballet dancing, figure
skating, and being a jockey appear to confer a much higher risk for the
development of anorexia nervosa, probably because of the emphasis in these
occupations on thinness.Living
With Your DiagnosisAnorexia nervosa
seems to develop more rapidly in environments in which food is readily
available, but in which being thin is to perceived to be desirable. We really do
not know what causes anorexia nervosa, but some other risk factors are
associated with the disease. There may be a genetic component; that is, it may
be passed on from parents to children. The mothers of patients with anorexia
nervosa are often described as overprotective, intrusive, orderly, and very much
concerned with perfection. They are also described as being fearful of
separation. On the other hand, fathers of patients with anorexia nervosa are
often described as withdrawn,passive, very
emotionally distant, moody, workaholics and in general fairly ineffective and
absent. Undoubtedly the American fascination with thinness increases the risk
for anorexia nervosa in this population. It is much more common among Caucasian
women than among African-American or Hispanic women. In looking at the childhood
of women who later become anorexic, they were often very compliant children.
They did not go through the usual acting out and difficult stages that occur
around 2 years of age, the so-called terrible twos. When they approached
adolescence, they began to develop the eating disorder, which served as a very
powerful tool to disrupt the family and became their first rebellious act
against their parent’s wishes. In addition, there may also be some concern
among pubertal women revolving around their budding sexuality. They may have
concerns about heterosexual contact, and some fear of menstruation and the
possibility of pregnancy. The development of anorexia nervosa with its secondary
amenorrhea delays the onset of sexual maturity, leading to decreased anxiety
about sexual issues among these patients. As might be expected, there are many
medical problems associated with anorexia nervosa. These include abnormalities
of the skin, cardiovascular problems such as low blood pressure, slow heart
rate, and abnormal heart rhythms, anemia, inability to fight infection, abnormal
blood chemistry (such as low potassium, sodium, albumin, and total protein),
dehydration, constipation, low thyroid hormone levels, and osteoporosis or bone
disease. In assessing a patient with suspected anorexia nervosa, it is very
important to obtain a weight history, including the individual’s highest
and lowest weights and the weight that she would like to be now. It is also
important to take a dietary history and have the patient describe a typical day
in terms of food intake and any food restrictions. Many times anorexic patients
will engage in elaborate behavior to purge themselves of food they have eaten.
This includes self-induced vomiting, which may cause dental caries and cavities,
excessive exercise, abuse and misuse of laxatives and enemas, and use of diet
pills and water pills. Abuse of syrup of Ipecac to induce vomiting is also
fairly common. In the initial assessment, there may be a strong sense of denial
on the part of the patient about the anorexia nervosa. A complete physical
examination and laboratory testing should be done to rule out some of the
physical problems mentioned earlier, and a decision should be made as to whether
to treat the patient as an outpatient or to admit the patient to the
hospital.TreatmentThe
first goal of treatment for the patient with anorexia nervosa is to engage the
patient and her family. Frequently there are strong feelings of guilt, and these
must be addressed. The patient will often minimize problems and suggest that the
concerns of the family are simply an overreaction. A second goal of treatment is
to assess and address the patient’s active medical problems. Depending on
the severity of the illness, this may require hospitalization. Treatment usually
involves psychotherapy, and occasionally medication if there is a depressive or
anxious component. It should be remembered, however, that medications that cause
a rapid weight gain, such as antidepressants like Elavil and Sinequan, should be
avoided because the patient will rebel against any rapid weight gain. The
patient is usually weighed once a week, and a gain in body weight of about
2–3 pounds a week isexpected. Many
programs use negative and positive feedback, allowing patients to do things
that they enjoy if they gain the weight or preventing them from doing so if they
do not. It is important during this phase to provide patients with significant
emotional support and reassurance, to address their fears about gaining weight,
to educate these patients about the dangers of semistarvation, and to reassure
them that they will not be allowed to gain “too much weight.” In
most treatment units that are experienced in treating anorexia nervosa, invasive
techniques such as nasogastric feeding or intravenous feeding are rarely needed
and are only used for life-threatening circumstances. Unfortunately, a large
percentage of patients with anorexia nervosa remain chronically ill. About 30%
to 50% of patients successfully treated in the hospital require hospitalization
again within 1 year of discharge, so outpatient programs after hospitalization
are essential. There are, of course, side effects from medications used to treat
anorexia nervosa. For example, some of the tricyclic antidepressants used to
treat depression in anorexia can cause weight gain, drowsiness, blurred vision,
constipation, and a fast heartbeat. There remains a significant mortality rate
(death rate) associated with this
condition.The
DOsIf you have anorexia nervosa, it is
very important to follow your doctor’s recommendations to avoid binging
behavior, and to talk to a nutritionist about a safe diet. When shopping, you
should buy clothes that fit, not clothes that you have to lose weight to get
into.The
DON’TsIf you have anorexia
nervosa, you should not weigh yourself daily; you should avoid use of drugs,
diet pills, and caffeine designed to promote weight loss; you should not use
laxatives unless instructed to do so by your physician; and you should not
engage in activities/occupations (modeling, ballet dancer, being a jockey) where
emphasis is placed on weight loss. You should shop for food judiciously and
avoid eating alone, if
possible.When to Call Your
DoctorYou should report any unusual
problems to your physician such as unusual thoughts, paranoia or hallucinations,
significant depression, and any suicidal thoughts. Also, if you have done well
for some time, notify your doctor if your urge to binge and purge begins to
increase. Also, it is very important to minimize stress in your family, so some
sort of family therapy is often
helpful.Websites:Anorexia
and Bulimiahttp://umt.umt.edu:700/o/general/anorexia.txtEating
Disorder Resources on the Internet:http://www.stud.unit.no/studorg/ikstrh/ed/ed.hmt/