HOW TO MANAGE ANOREXIA NERVOSA:Compulsive Weight Loss

Anorexia Nervosa is an eating disorder centered around an obsessive fear of weight gain. It is a form of self-starvation characterized by deliberate, excessive weight loss induced and/or sustained by the patient’s low body weight. It is a mental disorders but the physical consequences are serious and sometimes life threatening. It usually begins as innocent dieting behaviour but gradually progresses to extreme and unhealthy weight loss. Anorexia Nervosa is also referred to as Anorexia.
TYPES
There are two sub-groups of anorexic behaviour aimed to reducing caloric intake. These are:-
1. Restrictor Type:- This involves severely limiting the intake of food especially carbohydrates and fat containing foods.
2. Bulimia Type:- Also called binge-eating/purging type. This involves eating in binges and then inducing vomiting and/or taking large amounts of laxative or other cathartics i.e. medications which through their chemical effects serve to increase the clearing of the intestinal contents.


INCIDENCE
Anorexia Nervous occurs most commonly in females and usually begins in adolescent. It is difficult to estimate how common it is but surveys suggest that up to 1 – 2 percent of school girls and female University students develop anorexia nervosa.
The occurrence of Anorexia Nervosa has increased over the past 20 years among adolescent. It is estimated to occur in one out of every 100 females between the ages 16-18 years old. 5-10 percent of teens diagnosed with anorexia nervosa are models.
The disorder is more common in industrialized countries or western world where thinness is a positive cultural trait as in certain professions such as models and ballet dancers.
Initially Anorexia Nervosa was identified in upper and middle class families but it is now known to be found in all socio economic groups and a variety of ethnic and racial groups. 90-95 percent of those with Anorexia Nervosa are girls and young women while less than 1 percent of males develop it.
CAUSES
The fundamental causes of Anorexia Nervosa remain elusive but there is growing evidence that interacting socio cultural and biological factors contribute to its causation as well as specific psychological mechanism and a vulnerability of personality.
The causes will be discussed thus:-
1. SOCIAL CAUSES:
The cultural or social environment may cause or reinforce a propensity towards Anorexia such as:
(a) Particular professions (fashion, model, horse jockey) and sports (ballet, gymnastics) emphasize thinness and low body weight. Female athletes are particularly prone to being anorexia as coaches may encourage them to lose weight and they may notice improved performance with some weight loss. However the anorexia does not know when to stop losing weight and ultimately hinders performance by not consuming enough calories or nutrients to fuel the body.
(b) Some culture value thinness as a key element of attractiveness especially for women thus social pressure is a cause of anorexia.
(c) Families that are overprotective or emphasize over achievement or physical fitness often produce anorexia family members.
(d) There may be peer pressure to lose weight, nasty comments from others about weight that triggers dieting or an unrealistic expectation of what a normal body weight should be.
2. BIOLOGICAL CAUSES:
(a) Some research indicates that higher levels of the neurotransmitter serotonin (a brain chemical) make the individual withdraw socially and have less desire for food. However, the higher level of serotonin may be as a result of the anorexia rather than the cause.
(b) Anorexia Nervosa disorder is associated with under nutrition of varying severity with resulting secondary endocrine and metabolic changes and disturbance of body function.
(c) Individuals may have a genetic predisposition for anorexia as individuals with anorexia often have family members with the disorder.
3. PSYCHOLOGICAL AND EMOTIONAL CAUSE:
(a) Some major life events may trigger anorexia such as life transition (puberty), emotional upsets like death in the family, sexual or physical abuse and other life stresses.
(b) Some personality traits are associated with anorexia e.g. perfectionism, obsessiveness, approval seeking, low self esteem, withdrawal irritability and black-or-white (all or nothing) thinking.
(c) Teens who are dependent, immature in their emotional development and are likely to isolate themselves from others may develop anorexia.
(d) Adolescents who develop anorexia are more likely to come from families with history of weight problems, physical illness and other mental health problems such as depression or substance abuse.
(e) Mental health experts think that the feeling of being overwhelmed and powerless in adolescence can bring about a desire to maintain control in some realm of life such as control of body weight. So being in control of what enters the mouth can give the adolescent a feeling of powerfulness. Thus the period of adolescence may cause anorexia to manifest itself.
4. OTHER (COMBINATION) CAUSES
Relational or early life trauma (sometimes called developmental trauma) affects the brain, which in turn can impact both biology and psychology resulting in symptoms like obsessive, compulsive eating disorder like anorexia.
BEHAVIOURAL WARNING SIGNS
Behavioural warning signs of Anorexia Nervosa can manifest in the following ways.
1. Avoidance of Eating:
(a) Denies feeling of hunger
(b) Avoids social gathering where food is involved
(c) Develops food rituals that allows for eating very little such as eats in secrecy, eats foods in certain orders, excessive chewing of food, rearranges food on the plate, eats unnaturally small amount of food.
2. Dramatic Weight Loss:
(a) Refuses to maintain the minimal normal body weight for age or height.
(b) Denies the serious consequences of low body weight.
3. Obsession with dieting and weight loss:
(a) Weighs self several times a day and focuses on the smallest fluctuation in weight.
(b) Terrified of gaining weight or being fat.
(c) Even when thin, sees self as overweight.
(d) Bases self worth on body weight and body image.
4. Excessive focus on exercise regime.
GENERAL SIGNS AND SYMPTOMS
1. Low body weight (less than 85 percent of normal weight for height and age) or body weight is maintained at least 15 percent below that expected for person’s height.
2. Refusal to maintain minimum normal body weight done by self induced weight loss. Methods used include fasting, low food intake, avoidance of fattening food, use of diet pills, taking part in excessive exercise, use of laxatives or diuretics, self induced vomiting and making themselves sick.
3. There is intense constant fear of gaining weight, feeling of being fat (obese) even when their weight are less than expected i.e. the individual is losing weight.
4. There is distorted view of body weight, size of shape, sees self as too fat even when very underweight, expresses feeling fat even when very thin.
5. Rules are invented regarding how much food is allowed and how much exercise is needed after eating certain amounts of food.
6. Sufferers pursue a very low “ideal” weight by refusing to maintain minimum normal body weight.
7. Delayed development in puberty.
8. Amenorrhea (absence of at least 3 consecutive menstrual cycle without another cause in women.
9. Sufferers may feel bloated even after a small meal.
10. They lose interest in socializing with friends and family members.
11. Get involved in excessive physical activities in order to promote weight loss.
12. Denies feeling of hunger.
13. Preoccupation with food preparation.
14. Have bizarre eating habit or behaviour.
15. Bulimia (bingeing on food and then purging).
16. Emotional regression to a child-like state.
17. Irritability
18. Moody
19. Feeling of guilt or depression
20. Emaciation
However, each child may experience symptoms differently.
Essential features of Anorexia Nervosa are that the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight and exhibits a significant disturbance in the perception of the shape or size of his or her body. The individual maintains a body weight that is below a minimally normal level for age and height.
Anorexia Nervosa constitute an independent syndrome in the following sense:
1. The Clinical features of the syndrome are easily recognized so that diagnosis is reliable with a high level of agreement between clinicians.
2. Follow-up studies have shown that among patients who do not recover a considerable number continue to show the same main features of Anorexia Nervosa in a chronic form.
DIAGNOSTIC GUIDELINES
For a definite diagnosis of the problem all the following are required.
1. Body weight is maintained at least 15 percent below that expected (either lost or never achieved) or Quetelet’s body-mass index is 17.5 or less. Pre puberty patients may show failure to make the expected weight gain during the period of growth.
2. The weight loss is self-induced by avoidance of “fattening foods” and one or more of the following:- Self induced vomiting, self induced purging, excessive exercise, use of appetites suppressants and/or diuretics.
3. There is body-image distortion in the form of a specific psychopathology whereby a dread for fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.
4. A widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis is manifested in women and amenorrhea and in men as a loss of sexual interest and potency.
5. If onset of prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases: in girls the breast do not develop and there is a primary amenorrhea, in boys the genital remain juvenile).
DIFFERENTIAL DIAGNOSIS
There may be associated depressive or obsessional symptoms as well as features of a personality disorder which may make differentiation difficult and/or require the use of more than one diagnostic code.
Somatic causes of weight loss in young patients that must be distinguished include debilitating disease, brain tumors and intestinal disorders such as crohn’s disease or a mal-absorption syndrome.
The symptoms of Anorexia Nervosa may resemble other medical problems or psychiatric conditions hence there is need to always consult the child’s physician for a diagnosis.
TREATMENT
Anorexia Nervosa and the malnutrition that results can adversely affect nearly every organ/system in the body increasing the importance of early diagnosis and treatment. Because the disorder can result in death and so many sufferers deny that they have a problem, it is incumbent upon others to take action. The sooner that someone takes action the better because the length of time that a person continues with the disorder is related to the chance of death as the body slowly quit functioning hence early treatment is essential.
Treatment of Anorexia Nervosa involves both the body and the mind. Early treatment involves behavioural techniques, psychotherapy for improved self-esteem and a variety of approaches including nutritional therapy, massage and relaxation exercises. It also involved combination of individual therapy, family therapy, behavioural modification and nutritional rehabilitation. This should be based on a comprehensive evaluation of the adolescent and family.
Treatment will vary depending on the individual’s circumstances. There is no single treatment that has proven to be effective in all cases. Treatment aims to:-
§ Restore the person to a healthy weight.
§ Restore healthy eating pattern.
§ Treat any physical complication or associated mental health problems.
§ Address, thought, feelings and beliefs concerning food and body image.
§ Enlist family support.
Treatment of Anorexics is especially difficult because these individuals are resistant to getting help. More than 95 percent of anorexics deny that they have a problem and view treatment as an attempt to “make them fat”. They behave that their low body weight is the solution and not the problem. This means that those who are close to the anorexic individuals must take an active role in getting help. They may need to accompany the anorexic to appointments to make sure that the anorexic’s behaviour is adequately described.
Early treatment is essential. The effects of anorexia nervosa on the mind and body are severe. Not only does the anorexic look and feel awful but also the disorder can be life threatening. Treatment work best before too much weight is lost as weight held at a low level for a long time gives poor prognosis for recovery.
A. EARLY RECOGNITION OF PROBLEM:
Parents, teachers, coaches and instructors may be able to identify the child or adolescent with Anorexia Nervosa although many persons with the disorder initially keep their illness very private and hidden. However, a child’s psychiatrist or a qualified mental health professional usually diagnose Anorexia Nervosa in children and adolescents.
In this a detailed history of the suspected child’s behaviour taken from parents, teachers, coaches or instructors, clinical observations of child’s behaviour and sometimes psychological testing contribute to the diagnosis.
Parents who note symptoms of Anorexia Nervosa in their child or teen can help by seeking an evaluation and treatment early as this can often prevent future problems.
B. DETERMINANTS OF TREATMENT
Specific treatments for Anorexia Nervosa will be determined by the child’s physician based on:-
§ Child’s age overall health and medical history.
§ Extent of the child’s symptoms.
§ The child’s tolerance for specific medication or therapies.
§ Expectation for the cause of the condition.
§ Parents opinion or preference.
C. RESTORATION OF BODY WEIGHT AND EATING PATTERN:
The first order of treatment is to restore normal body weight and eating pattern as along with weight gain comes and improved body functioning.
After the body weight is stabilized, treatment can progress to dealing with the psychological and physical problems that are as a result of not eating.
A dietician can be instrumental in guiding the anorexic individual to better eating habits for sound nutrition can repair the weakened body.
Normal body weight can be restored by the use of:-
§ Supplementary feeding
§ Electrolyte imbalance treatment
§ Nutritional Counseling.
D. PSYCHOTHERAPY
By the use of :-
§ Cognitive-behavioural therapy (CBT)
§ Interpersonal therapy (IPT)
§ Support groups.
Therapy can address the need for increased self-esteem, which helps the individual to see that they are not really overweight.
Use of support groups are helpful but because anorexics deny their problems they may be unwilling to attend support group hence sometimes family therapy is used. Support groups play a role in treating anorexia, as patients are encouraged to often meet in-groups to discuss their fears and help each other recover.
Family therapy is the best approach as the most important thing that family and friends can do to help a person with anorexia is to unconditionally love them. They can talk to physicians and/or counselor for help in determining the best way to approach and deal with the situation as people with anorexia will beg and lie to avoid eating and gaining weight which means giving up the illness and giving up the control. Family and friends should not give in to the pleading of an anorexic patient but should not nag them incessantly.
Anorexia is an illness that can be controlled by simple willpower but rather needs professional guidance. Most importantly is to support the individual without supporting their actions.
E. MEDICATION AS TREATMENT
Medications do not cure anorexia but antidepressant drugs may be prescribed for the depression and anxiety that often accompany anorexia. Medication is usually used only after normal body weight has been re-established e.g.
§ Antidepressants
§ Selective serotonin re-update inhibitors (SSRIs)
ROLE OF THE HEALTH TEAM
If the weight loss becomes serious (more than 20-25 percent less than total normal body weight) admission into hospital may be required for medical complications related to weight loss and malnutrition.
Anorexia Nervosa which is a mental problem manifest in a physical form hence treatment should include both the mental health professionals as well as the primary health care physicians.
Physicians help monitor bone density loss and hear heart rhythm disturbances. Psychologist help identify the important issues and replace destructive thought and behaviour with more positive ones as help is sorted for from a psychiatrist or psychologist experienced in eating disorders.
When a person with suspected anorexia consults a doctor for diagnosis and treatment, the doctor first make sure that endocrine metabolic and central nervous system disorders do not explain the apparent weight loss. They do a physical examination and take physical history so as to be able to institute adequate and prompt treatment.
Left untreated, anorexia can cause irreversible physical damage. In addition, anorexia nervosa has one of the highest death rates of any mental disorder: 5-20 percent of those with anorexia nervosa will die. The period of time of self-starvation is the critical factor for survival. Anorexia is a life long illness and relapses are common. 40 percent of anorexics recover, 30 percent improve and 30 percent have significant problems with anorexia throughout their lives.

COMPLICATIONS
Anorexia Nervosa can have severe medical consequences. Because the anorexic individual does not consume enough calorine or nutrients to support the maintenance and growth of the body, all body process slow down to conserve energy. This slowing down has serious physical, emotional and behavioural effects on the body as a whole.
Physical effects:-
§ Dry brittle nails and hair or hair loss.
§ Lowered resistance to illness
§ Bruises easily
§ Appears to need less sleep than normal eaters.
§ Digestive problems such as bloating or constipation.
§ Muscle loss and weakness
§ Fainting fatigue and overall weakness
§ Severe dehydration which can result in kidney failure
Emotional and Behavioural effect:
§ Difficulty in concentrating at anything else except weight.
§ Feeling of guilt and depression.
§ Dependency upon alcohol or drug to handle the negative outlook.
Other possible complications of anorexia nervosa are as follows:
1. Cardiovascular (Heart)
While it is difficult to predict which anorexic patient might have life threatening heart problem that result from their illness, majority of hospitalized anorexic patients have been found to have low heart rate. Myocardial (heart muscles) damage that can occur as a result of malnutrition or repeated vomiting may be life threatening. Common cardiac complications that may occur include the following:-
§ Arrhythmias (irregular heart beat)
§ Bradycerdia (slow heart beat)
§ Hypotension (Low blood pressure)
2. Heamatological (blood)
An estimated one-third of anorexic patients have mild aneamia (low red blood cell count). Leukopenia (low white blood cell count) occurs in up to 50 percent of anorexic patients. There is also evidence of poor blood circulation in anorexic patients.
3. Gastrointestinal (Stomach and Intestines):
Normal movement in intestinal track often slows down with very restricted eating and severe weight loss explaining the reason behind the feeling of bloating and constipation.

4. Renal (Kidney)
Dehydration often associated with anorexia results in highly concentrated urine, which may result in kidney stones. Polyuria (increased production of urine) may also develop in anorexic patients when the kidney’s ability to concentrate urine decreases. Renal changes usually return to normal with the restoration of normal weight.
5. Endocrine (Hormones)
In females, amenorrhea (cessation of the menstrual cycle for at least three consecutive months when otherwise expected) is one of the hallmark symptoms of anorexia. Amenorrhea often proceeds severe weight loss and continues after normal weight is restored. Reduced levels of growth hormones are sometimes found on anorexic patients and may explain retardation (stunt growth) sometimes seen in anorexic patients. It also explains delayed or arrest of development in puberty (growth caesure - in girls the breast do not develop and in boys the genital remains juvenile). Normal nutrition usually restores normal growth.
6. Skeletal (Bones)
Persons with anorexia are at an increased risk for skeletal fracture (broken bones). When the onset of anorexic symptoms occur before peak bone formation has been attained (usually mid to late teens), a greater risk of osteopenia (decreased bone tissue) or osteoporosis (bone loss) exist. Bone density is often found to be low in females with anorexia and low calcium intake and absorption is common.
PREVENTION OF ANOREXIA NERVOSA
Prevention measures to reduce the incidence of anorexia are not known at this time. However early detection and intervention can reduce the severity of symptoms, enhance the child’s normal growth and development and improve the quality of life experienced by children or adolescents with anorexia nervosa. Encouraging health eating habits and realistic attitudes towards weight and diet may also be helpful.
CONCLUSION
Anorexia Nervosa is a potentially life threatening illness and should be treated as soon as possible. Sufferers should seek help or be encouraged to do so. People with personal experiences of eating disorders usually run self-help orgnisations for anorexia nervosa. There are also self-help books available. Most importantly early recognition of symptoms and seeking help early can reduce to a certain extent the damage done by the disorder to the individual and family.