Anorexia nervosa is an eating disorder characterized by extremely low body weight, distorted body image and an obsessive fear of gaining weight.
The term anorexia nervosa was established in 1873 by Sir William Gull, one of Queen Victoria's personal physicians. The term is of Greek origin: a (α, prefix of negation), n (ν, link between two vowels) and orexis (ορεξις, appetite), thus meaning a lack of desire to eat.
Definitions
A definition of anorexia nervosa was established by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).
DSM-IV-TR criteria are:
- 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 period of growth, leading to body weight less than 85% of that expected).
- Intense fear of gaining weight or becoming fat, even though underweight.
- 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.
- Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women. Amenorrhea is defined as periods occurring only following hormone (e.g., estrogen) administration.
Furthermore, the DSM-IV-TR specifies two subtypes:
- Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). Weight loss is accomplished primarily through dieting, fasting, or excessive exercise.
- Binge-Eating Type or Purging Type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas).
The ICD-10 criteria are similar, but in addition, specifically mention
- The ways that individuals might induce weight-loss or maintain low body weight (avoiding fattening foods, self-induced vomiting, self-induced purging, excessive exercise, excessive use of appetite suppressants or diuretics).
- Certain physiological features, including "widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhea and in men as loss of sexual interest and potency. There may also be elevated levels of growth hormones, raised cortisol levels, changes in the peripheral metabolism of thyroid hormone and abnormalities of insulin secretion".
- If onset is before puberty, that development is delayed or arrested.
The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make in practice and there is considerable overlap between patients diagnosed with these conditions. Furthermore, seemingly minor changes in a patient's overall behavior or attitude can change a diagnosis from "anorexia: binge-eating type" to bulimia nervosa. It is not unusual for a person with an eating disorder to "move through" various diagnoses as his or her behavior and beliefs change over time.
Signs and Symptoms
- Weight changes
- Weight loss
- Thinness
- Low body weight
- Emaciation
- Obsession with food and eating
- Unusual eating habits
- Eating rituals
- Excessive care in eating
- Playing with food
- Weighing foods
- Intentional starvation
- Cooking – some anorexics will prepare food for others but not eat it themselves
- Obsession with weight
- Fear of gaining weight
- Desire to lose weight
- Denial of hunger
- Intense body dissatisfaction
- Repeatedly checking weight
- Distortion of body image
- Believing too fat even when thin
- Denial of low body weight
- Wearing layered clothing – used to hide weight loss
- Abusing other weight control methods
- Excessive exercise
- Purging
- Vomiting
- Laxative abuse
- Enema abuse
- Diuretic abuse
- Menstrual abnormalities
- Irregular menstrual periods
- Absent menstrual periods
- Delayed first period
- Physical symptoms – mainly from malnutrition and starvation
- Esophagus inflammation – from purging or vomiting
- Dry skin
- Thinning hair
- Cold sensitivity
- Vulnerable to infections
- Anemia
- Heart palpitations
- Bone loss
- Tooth decay
- Soft body hair (lanugo)
- Excess body hair
- Excess facial hair
- Hair loss
- Balding scalp
- Low breathing rate
- Slow pulse
- Low blood pressure
- Low thyroid function
- Low body temperature
- Excessive thirst
- Excessive urination
- Dehydration
- Constipation
- Muscle mass loss
- Swollen joints
- Light-headedness
- Emotional symptoms
- Low self-esteem
- Withdrawal
- Isolation
- Secrecy
- Interpersonal conflict
- Resistance to treatment
- Denial that they are ill
- Suicidal tendency
- Excessive preoccupation with food
- Consider themselves overweight despite being the contrary
- Self-starvation
- Binge eating
- Absence of menstruation
- Hyperactivity
- Depression
- Malnutrition
Causes
Genetics
Some people may be more likely to develop anorexia nervosa due to genetic factors. For example, studies have shown that people with anorexia nervosa are more likely to have a family history of the disorder.
Environment
Environmental factors may also play a role in the development of anorexia nervosa. For example, people who experience trauma or abuse in childhood may be more likely to develop the disorder. Additionally, people who are exposed to unrealistic body image ideals in the media may be more likely to develop anorexia nervosa.
Psychological
Psychological factors, such as perfectionism, low self-esteem, and obsessive-compulsive disorder, may also contribute to the development of anorexia nervosa. People with anorexia nervosa may have an intense fear of gaining weight, even if they are underweight. They may also have a distorted body image, believing that they are fat even when they are not.
Risk Factors
Anorexia nervosa is a serious eating disorder that commonly affects girls and women. It can also affect boys and men, although to a lesser extent. The incidence of anorexia nervosa in boys and men has increased in recent years, possibly due to growing social pressures.
Anorexia nervosa is most common in teenagers, but people of any age can develop it. Teens are at increased risk due to the physical and emotional changes of puberty, as well as peer pressure and sensitivity to criticism about weight or body shape.
Certain factors increase the risk of developing anorexia nervosa, including:
- Genetics: Changes in certain genes may make some people more likely to develop anorexia nervosa. People with a first-degree relative (parent, sibling, or child) with anorexia nervosa are at much higher risk.
- Dieting and starvation: Dieting is a risk factor for developing an eating disorder. There is strong evidence that many of the symptoms of anorexia nervosa are actually symptoms of starvation. Starvation affects the brain and can lead to mood changes, rigid thinking, anxiety, and reduced appetite. In vulnerable individuals, starvation and weight loss can change the way the brain works, which can perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.
- Transitions: Major life transitions, such as starting a new school, job, or relationship, or the death or illness of a loved one, can cause emotional stress and increase the risk of developing anorexia nervosa.
Prognosis
The prognosis for anorexia nervosa is variable. Some people with the disorder recover completely, while others experience ongoing symptoms and complications.
The severity of the disorder and the length of time it has been present are two factors that can affect the prognosis. People with more severe anorexia nervosa and a longer duration of illness are more likely to have a poorer prognosis.
Other factors that can affect the prognosis include:
- Comorbidities: People with anorexia nervosa often have other mental health conditions, such as depression, anxiety, and obsessive-compulsive disorder. These comorbidities can worsen the prognosis for anorexia nervosa.
- Family support: People with anorexia nervosa who have strong family support are more likely to recover.
- Treatment adherence: People with anorexia nervosa who are compliant with treatment are more likely to recover.
Treatment
Treatment for anorexia nervosa tries to address three main areas. 1) Restoring the person to a healthy weight; 2) Treating the psychological disorders related to the illness; 3) Reducing or eliminating behaviors or thoughts that originally led to the disordered eating.
Medical interventions
Medical interventions may include:
- Nutritional counseling: A registered dietitian can help people with anorexia nervosa develop a meal plan that meets their nutritional needs and helps them regain weight.
- Medical monitoring: People with anorexia nervosa may need to be monitored by a doctor or other healthcare professional to ensure that they are gaining weight safely and that their overall health is improving.
- Medications: Medications may be used to treat any comorbid mental health conditions, such as depression and anxiety.
Psychological interventions
Psychological interventions may include:
- Cognitive-behavioral therapy (CBT): CBT is a type of therapy that can help people with anorexia nervosa identify and change the negative thoughts and behaviors that contribute to their eating disorder.
- Family-based therapy (FBT): FBT is a type of therapy that involves the family of the person with anorexia nervosa in the treatment process. FBT can help families learn how to support their loved one and how to manage the eating disorder at home.
Other types of therapy that may be helpful for people with anorexia nervosa include:
- Group therapy: Group therapy can provide people with anorexia nervosa with support from others who are going through the same experience.
- Psychodynamic therapy: Psychodynamic therapy can help people with anorexia nervosa understand the underlying psychological factors that contribute to their eating disorder.
In some cases, hospitalization may be necessary for people with anorexia nervosa who are severely malnourished or who are at risk of medical complications. Hospitalization can provide people with anorexia nervosa with the medical care and supervision they need to safely regain weight and improve their health.
Nursing Interventions
Nursing interventions for anorexia nervosa focus on promoting weight gain, improving nutrition, and restoring mental health. Nurses play a vital role in educating patients about the disorder, providing support, and monitoring progress.
Here are some specific nursing interventions for anorexia nervosa:
- Assess the patient's nutritional status and weight. This includes monitoring the patient's body weight, BMI, and other nutritional markers.
- Develop a meal plan with the patient and a registered dietitian. The meal plan should be tailored to the patient's individual needs and preferences, and it should meet their nutritional requirements.
- Provide the patient with education about anorexia nervosa and its treatment. This includes teaching the patient about the importance of eating a healthy diet, gaining weight, and developing a positive body image.
- Monitor the patient's eating habits and provide support. This includes observing the patient during meals, encouraging them to eat, and helping them to identify and overcome any obstacles to eating.
- Monitor the patient's weight gain and overall health. This includes weighing the patient regularly and monitoring their vital signs, laboratory results, and other health indicators.
- Provide emotional support and counseling. This can be done individually or in a group setting.
- Coordinate care with other healthcare professionals. This includes working with the patient's doctor, registered dietitian, therapist, and other members of the healthcare team.
Complications
The list of complications that have been mentioned in various sources for Anorexia Nervosa includes:
- Weight loss
- Starvation
- Death
- Infections
- Kidney failure
- Cardiac arrest
- Electrolyte imbalance
- Suicide
- Osteoporosis
- Muscle wasting
- Delayed puberty
- Constipation
- Hyponatremia
- Hypokalemia
- Erectile dysfunction
- Female infertility
- Purpura
- Hypothermia
- QT lengthening
- Pathological fracture
- Hypercarotinemia
- Sex hormone binding globulin raised (serum)
- Amenorrhea
- Hypogonadotrophic hypogonadism
- Hypercholesterolemia
- Acanthocytosis
Prevention
Anorexia nervosa is a serious eating disorder with no guaranteed way to prevent it. However, primary care physicians (PCPs) can play a vital role in identifying early signs and symptoms of anorexia and preventing the development of the full-blown disorder.
During routine medical appointments, PCPs can ask questions about eating habits and satisfaction with appearance to screen for anorexia. If a PCP notices that a patient has low self-esteem, severe dieting habits, and dissatisfaction with appearance, they can talk to the patient about these issues and offer support and resources.
Although PCPs cannot guarantee that an eating disorder will not develop, they can help patients and their families understand the signs and symptoms of anorexia and the importance of early treatment. PCPs can also refer patients to other healthcare professionals, such as registered dietitians and therapists, who specialize in treating eating disorders.