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Anorexia Nervosa

Eating disorders are a cause for serious concern from both a psychological and a
nutritional point of view. They are often a complex expression of underlying
problems with identity and self concept. These disorders often stem from
traumatic experiences and are influenced by society`s attitudes toward beauty
and worth (Eating Disorder Resource Center, 1997). Biological factors, family
issues, and psychological make-up may be what people who develop eating
disorders are responding to. Anyone can be affected by eating disorders,
regardless of their socioeconomic background (Eating Disorder Resource Center,
1997). Anorexia nervosa is one such disorder characterized by extreme weight
loss. It is the result of self imposed and severe restrictions of food and fluid
intake, a distorted body image, an intense fear of becoming fat, and a poor self
esteem. Besides dieting to extremes, anorexics often over exercise to lose
weight. Anorexics themselves are often the last to realize how undernourished
and underweight they are. Even after reaching a weight that is dangerously low,
they feel good initially, about losing the weight. No matter how much is lost,
anorexics continue to feel fat and desire to lose more weight. It is this denial
that makes it so hard to convince anorexics to seek help (Eating Disorder
Resource Center, 1997). This paper`s focus is to look in more detail at the
psychological and societal factors contributing to anorexia nervosa, as well as
the nutritional and physiological complications that arise for people on such
severely restrictive diets. Psychological and Societal Contributions Anorexia
Nervosa was first described by an English physician by the name of Richard
Morton in 1689. Until 1914, it was considered a disease that arose from a morbid
mental state and a disturbed nerve force. That year, Dr. Simmonds, a
pathologist, found one woman=s refusal to eat to be the direct result of an
anterior pituitary lesion. This shifted the focus away from the emotional
aspects of the disorder to more physiological and endocrinological terms. It was
not until 1938 that anorexia nervosa was once again considered a largely
emotional disorder (Blackman, 1996). In fact, one of the criteria for the
diagnosis of anorexia nervosa according to the manual of The American Medical
Association (DSM IV) is an intense fear of gaining weight or becoming fat, even
though underweight. Another clearly psychological requirement for diagnosis, is
a 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 (Blackman, 1996). Anorexia nervosa
may be a primary disorder in which other psychiatric conditions are secondary,
such as depression. It may also be secondary itself to a disorder such as
schizophrenia or co-morbid with obsessive compulsive disorder. As well, it can
also be a component of a personality disorder (Blackman, 1996; Carlat, 1997).

The anorexic sufferer is typically female. Ninety-percent of all cases occur
among adolescent girls or young women but the number of males with the disorder
is on the rise (Blackman, 1996; Carlat, 1997; Kinzl, 1997). It is estimated that
1% of girls ages 12-18 meet the criteria for full blown anorexia and as many as
5-10% have milder forms of such eating disorders if the criteria is applied less
stringently (Blackman, 1996). Anorexics are usually high achieving youngsters
who may be heavily involved in sports (e.g. gymnastics, swimming, cheer leading,
ballet, etc.). These people are often competitive, perfectionistic, with
obsessive compulsive personality features. Fears of growing up or discomfort
toward sexuality may also be precipitating factors (Blackman, 1996). Studies
have shown that 75% of American Women are dissatisfied with their appearance and
as many as 50% are on a diet at any one time. Even more alarming is that 90% of
high school junior and senior women regularly diet, even though only between
10%-15% are over the weight recommended by the standard height-weight charts
(Council on Size and Weight Discrimination, 1996). The majority of these women
do not develop eating disorders; however, 1% of teenage girls and 5% of
college-age women do become anorexic or bulimic (Council on Size and Weight
Discrimination, 1996). Perhaps these figures represent the women who are less
able to cope with their bodily dissatisfaction and thus are the ones who take
dieting to the extreme. The disordered eating behavior usually starts out with a
pattern of dieting or particular food choices, such as avoiding certain foods
which are seen as fattening. As the disorder progresses, anorexics become
resourceful in hiding their troublesome behavior and may start to avoid eating
with their families. They may also attempt further weight loss by compulsive
exercising. The condition can become well advanced before parents even notice,
as anorexics may wear many layers of clothes to conceal their thinness. Often
the diagnosis is not made until the person is brought to a clinic for problems
such as physical weakness, lack of energy, excessive sleepiness, and recent poor
performance in school (Blackman, 1996). Actually, certain familial relationships
seem to be more prevalent among anorexic sufferers. Studies have shown many
anorexic families are enmeshed, overprotective, conflict avoidant, and as
co-opting the anorexic in destructive alliances with one parent or another. The
parents themselves tend to be more affectionate and neglectful than parents of
non anorexic children. The father in particular is often controlling (Blackman,
1996). Physical and/or sexual abuse are also not uncommon features in families
with anorexics (Carlet, 1996; Kinzyl, 1997). Even though these trends are trends
often seen, there are many anorexic families that do not fit this profile. One
of the other major contributors to the disorder is society and its values.

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Anorexics are sensitive to society=s approval of what is an acceptable weight or
body size (Blackman, 1996). Self worth is equated with a desirable slim
appearance. This creates a vulnerability to eating disorders for people who are
especially concerned with meeting this ideal. Western culture in particular has
an obsession with looks. Slim, attractive people are linked to beauty, success,
and happiness. Our society teaches us to value such superficial standards and
bombards us with images of the idealized female body through mediums such as
magazines, films, and television (Blackman, 1996). One only has to watch
television or read the latest magazines and take note of just how few overweight
or average looking people there are appearing in advertisements to verify this
fact. Anorexia nervosa in fact predominates in industrialized developed
countries; yet is extremely rare in less industrialized and non western
countries (Blackman, 1996). As well, immigrants who have migrated to a
westernized country have been found to become more prone to develop eating
disorders (Blackman, 1996). For the sufferer of anorexia, the onset of the
disease often begins with a chance remark by someone important to them, possibly
a coach or a friend. They may suggest that they are getting fat, big, clumsy, or
that their performance (if they are athletes) is suffering (Blackman, 1996).

These remarks, as unintentional or innocent as they may seem to the person
making them, only serve to reinforce society=s attitude that gaining weight is
unacceptable. For others, it may will be the media itself that precipitates the
development of the disorder. Some patients cite wanting to look like a favorite
film star or model as their initial motivation to lose weight (Blackman, 1996).

Males With Eating Disorders Typically, dieting and eating disorders such as
anorexia nervosa are associated with females at or near adolescence. A group
that often gets overlooked in the studies are males. Eating disorders are not
rare among males; 10-15% of all bulimic patients are male, while 0.2% of all
adolescent and young males meet the stringent criteria for bulimia. These
figures are similar for anorexia nervosa (Carlat, 1997). Males are now being
studied more frequently to determine whether or not they differ significantly
from females with respect to eating disorders. If males are found to not differ
significantly from females in this respect, then those who support a more
biologically based view of the disease, gain support. Things such as
schizophrenia or depression for instance could then be seen as major determining
factors. If however, it is found that certain cultural and psychological risk
factors are the same for both males and females, then the sociocultural view of
eating disorder etiology gains support (Carlet, 1997). Males in fact do share
some similar central features as females who suffer from anorexia; but they also
have their own unique issues with regard to social pressures and vulnerabilities
(Carlet, 1997). Unlike females who typically Afeel emailprotected, males are often obese
to begin with. Males are more likely to diet to attain goals in a particular
sport like wrestling or swimming. Males also diet to prevent themselves from
developing medical complications witnessed in other family members such as
cardiovascular disease and diabetes (Blackman, 1996). In several cases involving
males, their profession was found to be clearly related to the onset of the
eating disorder (Carlat, 1997). One patient studied by Carlat et al. reported
taking appetite suppressing pills in an effort to keep slim for acting roles and
within several months he began a pattern of binge eating and self-induced
vomiting. In the same study, which involved 135 males with eating disorders, 22%
had anorexia nervosa, 73% were single and 131 were Caucasian. The average age of
onset was 19.3 years. The average education level was 1.6 years of college at
the time of their first treatment (Carlat, 1997). This does not necessarily mean
that this group is more susceptible to developing eating disorders as these
results could have been influenced by how the sample was taken. With regard to
the core concerns about body image and weight, it appears that males with
anorexia may be more similar to their female counterparts than to male bulimic
patients (Carlat, 1997). Like females, Carlat et al. found that male anorexics
clearly feared weight gain and desired a body weight of only 75% of their ideal
body weight (Carlat, 1997). Perhaps the biggest finding with males is the high
prevalence of homosexuality/bisexuality in those with eating disorders as
compared to the general population. Recent data estimates 1%-6% of healthy males
are homosexual and that only 2% of females with eating disorders are homosexual
(Carlat, 1997). Homosexuality was found to have a 27% prevalence among male
patients with eating disorders however. Anorexic males in particular were also
found more likely to be asexual (defined as having a lack of interest in sex for
a year prior to assessment). This is also a common finding in females (Carlat,
1997; Murnen, 1997). With anorexia, it is thought to be to due to the
testosterone lowering effect of protein-calorie malnutrition, combined with
active repression of sexual desire (Carlat, 1997). The high rate of
homosexuality and bisexuality among males with eating disorders can serve as
evidence for both psychosocial and biological views of the etiology of eating
disorders. Psychosocially, homosexuality can be seen as a risk factor that puts
males in a subculture system that places the same importance on looks and
appearance in men as the larger culture places on women (Carlat, 1997). It is
these similar cultural pressures toward thinness that cause eating disorders (Carlat,
1997). From a biological point of view, it can be argued that brain structure
between homosexual men and heterosexual women are similar (Carlat, 1997),
particularly a tiny precise cell cluster known as the third interstitial nucleus
of the anterior hypothalamus or INAH3. This cluster of cells in gay men was
found to be about half the size of the cluster in straight men which puts them
in the same size range as heterosexual women. This particular part of the
hypothalamus has been strongly implicated in regulating male-typical sexual
behavior (Nimmons, 1994). It may be argued then that homosexual men react to
environmental stressors in a biologically feminine way, increasing their risk of
eating disorders (Carlat, 1997). Males, like the females studied by Carlat et
al. , were shown to have high rates of co-morbid major depression, substance
abuse, anxiety disorders, and personality disorders. One year after initially
being treated, 59% still suffered from their eating disorder. (Carlat, 1997).

This is a cause for concern as there are so many concurrent complications that
can arise from eating disorders, especially anorexia nervosa. Adverse Effects of
Anorexia Nervosa Anorexic patients are often found to suffer from osteoporosis,
anemia, and hypotension (Carlat, 1997). Chronic starvation due to anorexia has
also been linked to seizure activity and fainting attacks (Blackman, 1996). The
anorexic often looks pale, tired, wasted, bradycardia (slow heart rate) may be
present, and the skin is cold to the touch. Another common feature is the
presence of fine downy hair on arms and torso. Laboratory results often reveal
quite abnormal values. These values are often caused by dehydration and severe
electrolyte imbalances which can be life threatening. Amenorrhea, or absence of
menstruation occurs in post menarchal girls who lose more than 20% of their
expected body weight (Blackman, 1996; Rock, 1996). Amenorrhea, in fact is
another one of the diagnostic criteria for anorexia nervosa (for females)
according to the DSM IV (Blackman, 1996). The absence of menarche is related to
the bodies reaction to extreme fat loss and the non viability of pregnancy under
these conditions (Blackman, 1996). Starvation itself as been shown to induce
many hormonal changes in the body as well as inducing mental states such as
anxiety, depression, and even psychosis (Kershenbaum, 1997). These are just a
few of the consequences associated with anorexia nervosa. There are many others
ranging from things as obscure as bilateral foot drop, which was observed in one
15 year old girl (Kershenbaum, 1997), to something as serious as sudden death
and even suicide (Neumrken, 1997). Sudden death is defined as the sudden,
unexpected, and unexplainable occurrence of death. Some of those who died
suddenly, did show abnormalities in ECG recordings days prior to death. As well,
upon autopsy, changes in brain structure and cardia muscles (such as atrophy)
were sometimes found (Neumrken, 1997). One would question with all of the
adverse consequences, why anorexics still diet. Anorexia produces a *runners
high= as does exercise. This is a result of opiate release in the brain which in
turn suppresses appetite and promotes increased levels of activity. Once
anorexic behavior begins and becomes established, it promotes this endorphin
secretion and becomes pleasurable and self reinforcing. The sufferer then is
bound to self starve and the established cycle is no longer deliberate or easily
stopped (Blackman,1996). Treatment Treatment comes in the form of psychotherapy,
nutritional education, and refeeding. Nutritional education takes time however
as the farther a person is below their healthy weight, the more their cognitive
ability is impaired (Merriman, 1996). The first of the higher mental functions
to be lost is the capacity for abstract thinking. As the condition progresses,
the anorexic may not even be able to assimilate information (Merriman, 1996).

The nutritionist then must carefully plan nutrition education sessions to make
them as meaningful to the person as is possible. Refeeding is also not a
straightforward process as anorexics often find it quite difficult to gain
weight. This is due to an increased diet induced thermogenesis and a lower
metabolic efficiency. Anorexic patients can waste about 50% of the energy of
their food due to this inefficient metabolism at the start of refeeding, making
the maintenance of any gain in weight difficult (Moukadden, 1997). Another study
concluded that even with weight gain after 3 months to a year, it was not enough
to maintain a desirable nutritional status. This was because patients did not
reach an adequate body mass index and their immunological indexes were lower
than in control subjects during an entire one year follow-up (Marcos, 1997).

Conclusions From the information presented, one can only imagine just how
complex the issues really are that the anorexic attempts to deal with via
dieting. The anorexic may be dealing with substance abuse, depression, sexual
abuse, confusion about their sexual orientation, or bodily dissatisfaction to
name a few. The individual anorexic may be suffering from a combination of such
issues in varying degrees. To what extent, psychological, societal, and
biological factors affect the onset of the disorder is, as of yet, too complex
to determine. It appears to vary from individual to individual, although there
are some features seen more commonly than others. The variability seen with the
disorder on an individual basis is why the anorexic sufferer can not be
categorized into a particular stereotypical group. It is not just the white
adolescent girl who is affected. The disorder affects various other groups as
well and is being seen more frequently in groups it did not typically affect. It
has been mentioned how the disorder is becoming more prevalent among immigrants
who move to westernized cultures; yet, the disorder is rarely ever seen in less
developed countries. Males also are being seen more frequently to be sufferers
of this traditionally female disorder. This data seems not to point to a
particular group as being more prone to developing anorexia, but instead points
to society=s unrealistic and unachievable ideals, as encouraging more sensitive,
insecure, or emotionally disturbed individual members of society to lose weight.

Weight loss often provides these people with short lived confidence, and for a
while they feel good about their weight loss and in control of something in
their life. They inevitably desire to feel like this again so they set out to
lose more weight. This cycle continues until someone steps in and helps the
sufferer by convincing them to seek help. This can be hard as the anorexic is
usually so far in denial that they are the last to realize just what shape they
are in. The road to recovery is difficult and the body seems to resist any
weight gain during the initial refeeding period. Even after an entire year of
treatment, evidence suggests that recovery has not been achieved and many
anorexics still continue to suffer from their disorder. There are so many
complications that anorexia can be attributed to that it would appear that the
quicker a person complies with treatment and can be recovered, the better. It is
quite obvious that anorexia is a complex disorder that partly involves how one
perceives his or her self and what physical standard society dictates they
should live up to. The topic has many areas that require further research as
society has been shown not to be the entire causative factor for the development
of the disorder. It has been shown to be one of them however; so until society
becomes more realistic in the ideals it endorses, it is responsible, at least in
part, for the prevalence of this disorder.

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Monthly, July/August, 1996 (or see

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