Psychology; Eating disorders
Psychology; Eating disorders
Anorexia Nervosa
Onset of an eating disorder typically follows a period of restrictive dieting; however, only a minority of people who diet develop eating disorders. Those who do are emotionally and psychologically vulnerable when they develop the self-destructive behaviors characteristic of an eating disorder (eg, practicing unsafe dieting techniques, taking unproven diet products, and maintaining arbitrary standards of weight). As purveyors of food, nutrition, and health information, registered dietitians should identify and inform health professionals and the lay public of the dangers of fad diets and diet products and should educate the public regarding healthful weight ranges and weight stabilization methods. Dietitians should also discuss risk factors for developing an eating disorder. Such interventions may play an important part in the treatment and prevention of eating disorders. Anorexia nervosa is a disorder characterized by deliberate weight loss, induced and/or sustained by the patient. The disorder occurs most commonly in adolescent girls and young women from middle class backgrounds, but adolescent boys and young men may be affected more rarely, as may children approaching puberty and older women up to the menopause. Anorexia nervosa constitutes an independent syndrome in the following sense:
A, the clinical features of the syndrome are easily recognized, so that diagnosis is reliable with a high level of agreement between clinicians;
B, 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.
Although the fundamental causes of anorexia nervosa remain elusive, there is growing evidence that interacting sociocultural and biological factors contribute to its causation, as do less specific psychological mechanism and a vulnerability of personality. The disorder is associated with undernutrition of varying severity, with resulting secondary endocrine and metabolic changes and disturbances of bodily function. There remains some doubt as to whether the characteristic endocrine disorder is entirely due to the undernutrition and the direct effect of various behaviours that have brought it about (e.g. restricted dietary choice, excessive exercise and alterations in body composition, induced vomiting and purgation and the consequent electrolyte disturbances), or whether uncertain factors are also involved.
Why do people get anorexia?
The reason some people get anorexia isn't known. People with anorexia may believe they would be happier and more successful if they were thin. They want everything in their lives to be perfect. People who have this disorder are usually good students. They are involved in many school and community activities. They blame themselves if they don't get perfect grades, or if other things in life are not perfect.
Diagnostic Guidelines
For a definite diagnosis, all the following are required:
(a) Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet's body-mass index is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth.
(b) 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 appetite suppressants and/or diuretics.
(c) There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and ...
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(a) Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet's body-mass index is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth.
(b) 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 appetite suppressants and/or diuretics.
(c) There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.
(d) A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhoea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion.
(e) If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.
Other symptoms of Anorexia Nervosa include intence fear of gaining weight, loss of scalp hair, greater amounts of hair on the body and face, delusion of being fat and anorexics usually stop having menstrual periods. People with anorexia have dry skin and thinning hair on the head. They may have a growth of fine hair all over their body. They may feel cold all the time, and they may get sick often. People with anorexia are often in a bad mood. They have a hard time concentrating and are always thinking about food. It is not true that anorexics are never hungry. Actually, they are always hungry. Feeling hunger gives them a feeling of control over their lives and their bodies. It makes them feel like they are good at something--they are good at losing weight. People with severe anorexia may be at risk of death from starvation.
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 chronic debilitating diseases, brain tumors, and intestinal disorders such as Crohn's disease or a malabsorption syndrome. Treatment of anorexia is difficult, because people with anorexia believe there is nothing wrong with them. Patients in the early stages of anorexia (less than 6 months or with just a small amount of weight loss) may be successfully treated without having to be admitted to the hospital. But for successful treatment, patients must want to change and must have family and friends to help them. People with more serious anorexia need care in the hospital, usually in a special unit for people with anorexia and bulimia. Treatment involves more than changing the person's eating habits. Anorexic patients often need counseling for a year or more so they can work on changing the feelings that are causing their eating problems. These feelings may be about their weight, their family problems or their problems with self-esteem. Some anorexic patients are helped by taking medicine that makes them feel less depressed. These medicines are prescribed by a doctor and are used along with counseling.
What is the difference between anorexia and bulimia?
People with anorexia starve themselves, avoid high-calorie foods and exercise constantly. People with bulimia eat huge amounts of food, but they throw up soon after eating, or take laxatives or diuretics (water pills) to keep from gaining weight. People with bulimia don't usually lose as much weight as people with anorexia.
Bulimia Nervosa
Bulimia Nervosa is an illness that is most commonly found in girls of later adolescence and early adulthood the age and sex distribution is similar to that of anorexia nervosa, but the age of presentation tends to be slightly later. It is very rarely found in men. It is characterised by episodes of binge eating; eating large quantities of food in a short time. This behaviour may be very severe with enormous quantities of food, most typically carbohydrates being consumed. To prevent the otherwise inevitable consequence of weight gain there are periods of food restriction and often vomiting, laxative abuse or excessive exercising. When vomiting is used then the binges may become multiple with repeating cycles over several hours in which the sufferer eats until full, then vomits and eats again. With increasing severity the girls' lives become more chaotic with the focus increasingly on the bulimic behaviour.Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the 'fattening" effects of ingested food. The term should be restricted to the form of the disorder that is related to anorexia nervosa by virtue of sharing the same psychopathology. The disorder may be viewed as a sequel to persistent anorexia nervosa (although the reverse sequence may also occur). A previously anorexic patient may first appear to improve as a result of weight gain and possibly a return of menstruation, but a pernicious pattern of overeating and vomiting then becomes established. Repeated vomiting is likely to give rise to disturbances of body electrolytes, physical complications such as tetany, epileptic seizures, cardiac arrhythmias, muscular weakness, and further severe loss of weight.
Diagnostic Guidelines
For a definite diagnosis, all the following are required:
(a) There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time.
(b) The patient attempts to counteract the "fattening" effects of food by one or more of the following: self-induced vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment.
(c) The psychopathology consists of a morbid dread of fatness and the patient sets herself or himself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. This earlier episode may have been fully expressed, or may have assumed a minor cryptic form with a moderate loss of weight and/or a transient phase of amenorrhoea.
Bulimics are usually people that do not feel secure about their own self worth. They usually strive for the approval of others. They tend to do whatever they can to please others, while hiding their own feelings. Food becomes their only source of comfort. Bulimia also serves as a function for blocking or letting out feelings. Unlike anorexics, bulimics do realize they have a problem and are more likely to seek help.
Bulimia is a common problem among young women during late adolescence and young adulthood. Bulimics are typically normal weight and from middle to upper class socioeconomic background. Most bulimics maintain their weight but weigh less than the norm for their age and height. Bulimics are aware that they have an abnormal pattern of eating and other types of excessive behaviour are often exhibited such as drug and alcohol abuse or sexual promiscuity. The theory behind the excessive behaviour is that bulimics often have poor impulse control and may over indulge in many aspects of their lives.
Some individuals with bulimia struggle with addictions, including abuse of drugs and alcohol, and compulsive stealing. Like individuals with anorexia, many people with bulimia suffer from clinical depression, anxiety, OCD, and other psychiatric illnesses. These problems, combined with their impulsive tendencies, place them at increased risk for suicidal behavior.
Bulimia nervosa patients, even those of normal weight, can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious, problems for instence the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods and interest in sex may also diminish.
For long term bulimics there may be several clinical signs including:
Dental erosion (due to stomach acid in vomit)
Gum recession
Esophageal reflux
Esophageal stricture or rupture
Fluid and electrolyte imbalances
Parotid hypertrophy
Vitamin deficiency
Causes of Bulimia Nervosa
The causes of Bulimia Nervosa remain unknown although there is probably a small genetic contribution. In sub-clinical form bulimic behaviour is probably very common in our society. The incidence of Bulimia Nervosa is usually given as 3% of young women but the true incidence is likely to be much greater. The pressure to be thin and resulting abnormal eating patterns that are regarded as normal are probably partly to blame. Certainly the desire to be thin and attempts to restrict weight are the triggers that provoke the illness. Once established bulimia influences the way that emotions are felt. It protects the sufferer from experiencing feelings that may be to them unbearable. It is paradoxical that bulimia causes them to become increasingly out of control in a wide variety of ways and yet it is the one thing that enables them to feel in control. Their fear of being without this protection maintains and increases the severity of the illness which comes to dominate all emotional experience.
Treatment Options
Most sufferers will first go to their general practitioner. He may well have a good knowledge of the local possibilities for appropriate treatment. If specialist help is needed he should be consulted as to choice of person and place. Another source of unbiased advice is the Eating Disorders Association.
The N.H.S. has a number of eating disorder units often based on teaching hospitals. Many of these are excellent but the quality is very patchy. They often have long waiting lists and it may take several months to wait for an assessment and longer to start an agreed course of treatment. Your general practitioner should be able to find out what the situation is locally quite easily.
The private sector also runs eating disorder units and many of these are also of good quality. However inpatient stays frequently run to several months so cost may be high. For most people medical insurance is necessary. The area where you live may not have an eating disorder unit run by the N.H.S. If this is so the N.H.S. may buy treatment from the private sector under the Extra Contractual Referral scheme. Assistance will be needed from your general practitioner and from the admitting hospital but in practice this means that the area health authority may pay for private care on a private unit of your and the GP's choice.
Rachel
6/05/07
Rebecca Jones
