Anorexia Nervosa

The World Health Organization (WHO) states, “A mental disorder is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour. It is usually associated with distress or impairment in important areas of functioning”. If we start counting, the existing number of diagnosable mental disorders is somewhere near 200, with more than 450 definitions, as per the American Psychological Association. The common types of such psychological illnesses are :

• Anxiety disorders
• Mood disorders like Bipolar disorder
• Eating disorders like Anorexia and Bulimia
• Personality disorders like Narcissistic Personality Disorder
• Obsessive Compulsive Disorder
• Psychotic disorders like Schizophrenia

Now, have you ever encountered someone who survives on almost no food, every day? Like they are willingly starving themselves? Or, have you seen people who are constantly worried, and therefore emphasize on –

“I am turning fat”, even though they are visibly and extremely underweight,

“I wish I could be more fit and slim”, when they are suffering from malnutrition to such an extent that even their ribs could be counted,

“I ate too much. What if I become a fatso? What if my friends reject me?”, and thereafter induce forceful vomiting.

“I look so ugly and unfit”, and adapt to a routine of daily starvation.

Sometimes it may appear to be a part of someone’s lifestyle. For example, there are people who proudly exclaim to their friends and other acquaintances – “oh I just don’t eat. I am quite conscious about my figure”. But what if I say you, that it is not normal? In fact, this a clear cut picture of a person suffering from an Eating disorder.

Definition of Eating Disorder

Eating disorders are a serious and complex type of mental disorder in which the disordered person develops maladaptive ways of eating habits (like excessive eating or extreme starvation), causing clinically significant distress to the individual. Like any other mental disorder, eating disorders too, bring about dysfunction in the personal, occupational and social lives of the person. If not paid medical attention in due time, then the condition of the person might get worse and may lead to severe consequences like the death of the sufferer. Concerning the medical diagnosis of mental disorders, we refer to the following as established and verified guidebooks, worldwide:

• DSM: The Diagnostic Statistical Manual of Mental Disorders; by the American Psychological Association
• ICD: International Classification Of Diseases; by the World Health Organization

According to DSM-5 TR (2022), eating disorders are defined under the classification of ‘feeding and eating disorders’ and, “are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.” The different types of eating disorders according to DSM-5-TR, are:

• Pica
• Rumination disorder
• Avoidant/restrictive food intake disorder
• Anorexia Nervosa
• Bulimia Nervosa
• Binge-eating disorder

Anorexia Nervosa

The term Anorexia Nervosa means “lack of appetite induced by nervousness”. It is one of the most common eating disorders, found to be more prevalent among women. It is a type of psychological condition in which the person loses their insight (i.e., their reality perception of what is true and what is not). Also, they develop a disfigured perception of their self-image. In other words, a person clinically diagnosed with anorexia is observed to be obsessed with their ‘figure’ in terms of how slim they are, with a perfect and socially attractive body.

They would restrict their food intake to absolutely minimal amounts and even choose to starve for days, to achieve their preferred body shape. Even when they get dangerously underweight, they will persistently stick to their abnormal ways of eating habits, being obnoxiously incapable to change or modify such habits. If left untreated for a long time, the person may even die of starvation.

Not to mention, the problem of anorexia nervosa is often bound to occur as a result of social pressure to fit into a particular framework of body image, induced into the person as a form of cultural expectation and a parameter of social acceptance. There are numerous examples of anorexia nervosa around us. It is a common psychological disorder many models, actors and public figures are diagnosed with. Citing a few evidences below:

Brazilian model Ana Carolina Reston suffered from anorexia nervosa, which took her life, while she weighed only 88 pounds. She suffered from kidney failure, resulting in a generalized body infection. As per the reports are concerned, the illness began when she was criticized for being “too fat”. Model Luisel Ramos from Uruguay reportedly died of a cardiac failure during of fashion show.

She weighed 97 pounds when her anorexia took her life. Her death marked the beginning of scrutiny of fashion models by big-shot agencies like the Madrid Fashion Week, to address the situations which were alike. A recent study has estimated that about 20% of ballet students suffer from an eating disorder, with anorexia nervosa being the most common one. It was seen that this disorder developed because the students desperately wanted to fit into the framework of how an ideal ballet dancer should look.

The diagnostic criteria of anorexia nervosa, according to DSM-5-TR are briefed below:

• Restriction of food consumption to adequate amounts, which leads to significantly low body weight. In clinical terms, ‘significantly low weight’ refers to the weight which is less than minimal.
• The extreme level of fear leading to interfering behaviour that prohibits any possibility of weight gain.
• The undue influence of body weight on the perception of self-image leads to a persistent lack of recognition of the seriousness of the current body mass index.

Effects of Anorexia Nervosa

As we know, anorexia is concerned with relentless pressure to attain a certain body image, leading to severe restrictions on food intake. But, it is the food we eat, that provides us with all sorts of nutrition for building, protection and survival of all bodily systems in our body. Nevertheless to mention, Starvation Kills! Let us discuss some effects of anorexia on the human body (Hooley, Butcher, Nock, Mineka):

• Brain and nerve: Due to a lack of adequate nutrition to fuel the cognitive process and other brain and neural functioning of the nervous system, the brain finds a lack of resources to be able to think right. Along with it, the disorder carries maladaptive perceptions like intense fear of gaining weight, melancholic mood, bad memory, irritation, and undesirable changes in brain chemistry.
• Heart: due to lack of adequate food, the blood pressure decreases intensely, leading to slow heart rate, palpitation, which may eventually lead to heart failure, if not addressed in due time.
• Hair and nails: with passing days, the hair loses its strength and gets brittle, and thin, leading to excessive hair fall. The nails too, get weak and break under any minor pressure.
• Blood: the red blood cell count decreases as the intensity of the disorder increases. This can develop anaemia and other blood-related problems in the person.
• Hormones: lack of proper food and nutrition mess up the whole hormonal system of the person. It leads to periods loss (also known as amenorrhea), bone loss, problems in getting pregnant, higher risks of having miscarriages, having C-section baby with low birth weight and postpartum depression in women. In men, it reflects in the form of hypogonadism, hormonal resistance in the secretion of growth hormone and hypercortisolemia, reduced production of sperms, and profound forms of neuroendocrine dysregulation.
• Muscles and joints: this particular eating disorder leads to weak muscles, swollen joint, fractures and even osteoporosis in people.
• Kidneys: the excretory functions of the kidneys fall short of detoxifying the body as required. It may even lead to kidney stores or kidney failure.
• Body fluids: lack of appropriate food leads to decline in the levels of sodium, potassium, magnesium, manganese, calcium, and other important minerals required for the proper development of the body,
• Intestines: the intestinal fluids don’t get adequate food to react on and digest it, to produce essential nutrition for the body. It thus leads to bloating and constipation in the long run.
• Skin: our skin being the largest organ of our body, shows signs of any minute problem inside our body. As the white blood cells don’t get enough glucose to replenish them, they suffer from increasing wear and tear with time. Anorexia makes the skin to bruise more easily, dry up, increases the growth of fine hair all over the body, makes the skin yellow, nails and hair getting brittle, etc.

Types of Anorexia Nervosa

Now, according to the DSM, Anorexia can be of the following types:

A. The Restricting type :

In this type of anorexia, every effort is made to limit the quantity of food consumed. Caloric intake is tightly controlled. it is also affected by social influence, in terms of how the person behaves in front of other people. When they are at the table, they may eat excessively slowly, cut their food into very small pieces, or dispose of the food secretly (Beaumont, 2002).

B. The Binge eating/purging type :

Patients with the binge-eating or purging type of anorexia either binge, (i.e., eat uncontrollably), purge (i.e., force out whatever is eaten, from the stomach, through medicine or force), or binge and purge. A binge refers to an out-of-control consumption of an extreme amount of food that is far greater than what most people would eat in the same amount of time and under the same circumstances. These binges may be followed by efforts to purge or remove from their bodies, the food they have eaten. Methods of purging commonly include self-induced vomiting or misusing drugs, like laxatives, diuretics, and enemas.

C. Atypical Anorexia Nervosa:

It is a unique type of anorexia nervosa, where the person shows all types of symptoms for anorexia nervosa that includes counting calories, restricting food intake, starvation for days, a disfigured perception of body image, etc. However, the BMI or Body Mass Index of the person stays normal or above normal. It can also be called an amalgamation of both ‘restricting type’ and ‘binge-eating type’ anorexia nervosa.

Symptoms of Anorexia Nervosa

Let us now discuss the common symptoms of Anorexia Nervosa :-

Its symptoms are :

• Extremely restricted eating, persistently, for days
• Extreme thinness of the body (emaciation)
• An obsession to maintain a thin body, with tremendously low body weight
• Intense fear of gaining weight
• Distorted body image, a self-esteem that is heavily influenced by perceptions of socially accepted body shape, or a denial of the seriousness of how low their own body weight is.

Other symptoms that may develop over time, includes:

• Thinning of the bones due to the consumption of low calcium (also called osteopenia or osteoporosis)
• Anemia, muscle weakness and other blood disorders
• Brittle hair and nails
• Dry and yellowish skin
• Growth of fine hair all over the body, as an issue developed on the skin (lanugo)
• Severe constipation
• Low blood pressure
• Slowed breathing and pulse
• Dysfunctions of the heart, due to low blood pressure, or cardiac failure
• Brain damage
• Multi-organ failure
• Drop in internal body temperature, caused by falling blood pressure, making the person feel cold all the time
• Lethargy, sluggishness, or feeling exhausted all the time, with no motivation to engage in any productive work
• Infertility

Causes of Anorexia Nervosa

The prevalent causes of anorexia nervosa, are mentioned below:

Genetics:

As per the research conducted on eating disorders, it is found that there runs a tendency in biological lines of heredity to transmit the probability of developing such disorders among the offspring of next generation. This is because the tendency to develop an eating disorder has been shown to run in families (Wade, 2010). If the disorder exists in one or more family members, then it is highly likely that the next generation will also develop this disorder in their later life.

Brain Abnormalities:

The hypothalamus of the brain region is responsible for regulating all our eating behaviors. It is found that any electrical stimulation in the ventromedial hypothalamus may cause the person to behave in a way that inhibits their food intake, and thus makes them lose enormous amount of body weight.

Social Expectations:

The existing social standards and expectations of an ideal body type, both for men (sturdy and well-built) and women (slim, with least body fat) acts as a solid pressure on the youth and adults to fit into this standard. It arises from their need to be attractive and socially accepted and gain affiliation into varied social and professional groups.

For example, in the South Korean culture, girls are ideally slim, with collar bones, jaw lines, thin limbs, small faces, sharp facial features and fair, glass skin. This is why, eating less, to the extent of starving oneself for days is found there quite commonly.

Environmental:

The environment for an individual accounts for their family atmosphere, social background, peer groups, play groups, schools, etc. These environmental units make up the atmosphere of learning for the person. If, by any chance, this environment itself bears an idea that a particular body type is more acceptable, attractive and recognizable than the others, then it will develop as an aim to achieve, in that particular person. This, in the long term, is nurtured as anorexia in such people.

Psychological:

It emphasizes on the perception of the person more than any external factor. If the person believes that attaining a zero-fat, slim figure is the ultimate goal, be it means of increasing their beauty or level of social acceptance, and then such cases are manifested as anorexia in them. These people will perceive it to be a need, restrict their food intake, to reach their goal. It may take a form of compulsion in them, resulting from an inferiority complex.

Gender Stereotypes:

The overwhelming emphasizes on women to maintain a certain figure, which will help in facilitating their matchmaking with ‘eligible’ grooms, and the like, is also a potential cause. Gender stereotypes that lessen the importance of women (and even men) in terms of their body shape play a significant role in developing eating disorders like anorexia in them. Even though there are numerous causes of anorexia nervosa, it is not necessary that presence of one cause will ensure the prevalence of the disorder.

For example, a person who is born and brought up in an environment that is least concerned about their body types is more likely to not show any incidence of the disorder in the long run, even though there exist cases of eating disorders in their first-degree relatives. In other words, a manifestation of the disorder depends completely on the interaction of the environment with the dispositional factors of the person. Other causal factors of anorexia nervosa include the history of sexual and domestic abuse of the person, if any, negative emotionality, intense dieting, idea of perfectionism, internalizing the thin ideal and levels of serotonin in the body of the person.

Comorbidity with other Disorders:

Eating disorders may be found to coexist with many other physical or psychological ailments, that is more likely to aggravate the psychological and physiological condition of the person. Anorexia is concerned with high mortality rates among cancer patients, even resulting in the ineffectiveness of anticancer therapy in those individuals. It may also persist as a sideline psychological condition along with obsessive compulsive disorder, generalized anxiety disorder, or even social anxiety disorder. Not to mention, anorexia nervosa has high positive correlation with cardiac issues, lung or kidney malfunctions.

Treatment

The treatment of any disorder depends on the severity of its symptoms. Patients suffering from any eating disorder are generally skeptical and extremely reluctant in opting for treatment. In this regard, it is noteworthy that people suffering from anorexia nervosa are very pessimistic about their potential for recovery (Holliday, et. al ; 2005). As a result, there exists a high dropout rate of patients with anorexia, from therapy.
The most immediate concern with patients of anorexia is to restore their weight to a certain level, which is no longer life threatening to them. Simultaneously, their perceptions of the world and their self would be worked on too. Mentioned below are some probable ways of treatment of anorexia:

Use of Antidepressants as Primary medication:

Antidepressants with antipsychotic medications have been used significantly for the treatment of anorexia, as a type of primary cure (Brown and Keel, 2012). However, there is no scientific evidence that such medications are useful in the treatment of the disorder. But for certain, these medications, like Olanzapine and SSRIs (Selective Serotonin Reuptake Inhibitors) help in reducing symptoms like distorted beliefs about self, and body image, control the secretion of serotonin to regulate positive feelings and the like. More importantly, researches indicate that Olanzapine leads to weight gain of the person.

Family Therapy:

Family therapy is known to be one of the best intervention techniques for treating anorexia in adolescents and children. It takes family support, the presence and compassion of near and dear ones to be very seriously for dealing with the disorder. One of the best studied approaches under family therapy is the Maudsley Model, which focuses on parents to be more aware of the disorder and react consciously to it. The Maudsley Anorexia Treatment for Adults is a family based therapeutic approach is an amalgamation of treatment with opportunities for experiential practice in group context.

The central concept of this therapeutic intervention is to lay a foundation of support and bonding between the parents and children, instead of blaming either or both of the parties involved (le Grange & Locke, 2005). Randomized control trials show that patients treated with family therapy fir 1 year do better than patients who are treated under controlled and strict interventions. Thus, it is evident enough to state that family therapy is significantly and relatively helpful to deal with such patients and cure their problem, showing maximum chances of recovery.

Cognitive behavior therapy (CBT):

Cognitive behavior therapy refers to the systematic procedure which is widely used to modify one’s cognitions in respect to their behaviors, to align accurately with their reality. It is involved in changing one’s maladaptive thinking styles to suit effectively to their behavior and reality orientation. A major focus of the treatment procedure is to identify and reach the root core beliefs which are maladaptive and distorted. The recommended length of treatment is about 1 or 2 years to rectify such distorted beliefs about self (like “People won’t like me unless I’m thin”) and towards the surrounding society of the person. As discussed earlier, these beliefs are related to their body image, food and reality orientation.

Conclusion

Eating disorders are quite common in social contexts where the body image of the person is given more importance than the people themselves, for example in UK, USA, South Korea, China, etc. In fact, the rate of its prevalence in India is on the rise with every passing year. Occurrence of anorexia here is statistically found to be recognized as a cause of mortality and morbidity among adolescents, with the rate being about 0.5% -2%. Nevertheless to mention, the therapists and researchers are constantly working on the process to devise better strategies to address the set in of negative body image ideas among adolescents and adults. Holding up educative seminars, sociodramas are just a small part of it.