Anorexia
Nervosa Introduction: 95% or more afflicted with this eating
disorder are young
females. The onset is usually during adolescence. These patients have
an abnormal sense of body image, where they think of themselves as overweight,
when they are actually below normal weight. They are terrified of becoming obese.
They refuse to maintain a normal body weight. In women one of the hallmarks is
that they have no menstrual periods (amenorrhea). All of the body functions are
"put on spare flame" and one such function is the gonadotropin hormone.
Reduced production of this hormone leads to ovarian malfunction(amenorrhea). About
1 to 3% of the 15 to 20 year female age group suffer from anorexia nervosa. There
is a significant number of anorexia nervosa cases, where childhood molestation
likely was the triggering factor (see Ref. 2). This
study from the North Dakota School of Medicine and Health Sciences compared the
eating behavior of a group of sexually abused children aged 15 to 20 with a control
group of nonabused children. The study showed that the abused children developed
a dissatisfaction about their weight and in particular they were desiring a leaner
body weight. At times of emotional upsets they would eat less and use methods
of purging to loose even more weight.There are likely other factors such as
perhaps a genetic tendency for depression. Depression, by the way, is present
in 85% of anorexia nervosa patients. This was documented again in a Swedish study
(Ref. 3), where 50 teenagers with anorexia nervosa were compared with 51 normal
teenagers as control group. This was a longitudinal study where the same
persons were followed up and intensely interviewed at the ages 16, 21 and 24 years
for 10 years. The findings were that mental illness(mostly depression) was part
of anorexia nervosa and that the outcome of this eating disorder is dictated to
a large extent by how well this is controlled. Conversely, the mental illness
cannot be stabilized, if the anorexia nervosa is not addressed.
Leptin and restlessness: The
fat cells produce a hormone called leptin, which is produced less when starvation
sets in. Normally a lack of this hormone stimulates the appetite center to increase
appetite. A lack of leptin in the system leads to a restlessness similar to hyperactivity
syndrome. Ref.4 studied this phenomenon in rats as well as in a group of anorexia
nervosa patients. Infusion of leptin in starved rats lead to significant reduction
of a hyperactivity score. Similarly a hyperactivity score in treated anorexia
nervosa patients normalized as the low leptin levels came up to normal levels
with weight gain. It is unclear at this time whether the change in leptins is
part of the cause of anorexia nervosa or whether it is simply another internal
symptom of anorexia nervosa. | Symptoms:
As this is mainly a psychological disorder, the earliest symptom is an obsession
about body weight, even when the weight is normal or already below the normal.
Patients may complain about other health problems such as bloating, constipation
or abdominal symptoms. Patients have a normal appetite, but they are preoccupied
with food and diets. They may collect recipes and prepare elaborate meals for
others, but will refrain themselves from eating it. Anorexia nervosa patients
deny that they have a disorder. They also resist treatment. They are often manipulative
and are lying about their true food intake. They are also concealing that they
are inducing vomiting or binge eating followed by vomiting. They also conceal
their use of laxatives(constipation pills) or diuretics(water pills). About 50%
of anorexia nervosa patients have the binge/purge behavior that is typical for
bulimia nervosa patients. Often anorexia nervosa patients engage vigorously in
exercise programs as another means to control weight. Due to hormone changes
there is a loss of sex drive and as I mentioned before a lack of menstrual periods
(called amenorrhea) in females. Other physical symptoms are a slow heart beat,
low body temperature (hypothermia) and low blood pressure. Due to a lack of female
hormones in females there is a male body hair growth pattern and a fine hair growth
all over the body (lanugo hair). Due to a lack of protein there is a development
of edema (water retention in the tissues). Depression as mentioned above is common.
Apart from the above mentioned hormone changes these other hormone changes tend
to occur: low thyroid hormones, low luteinizing hormones, high cortisol levels.
When the body weight is reduced to less than 15% below ideal body weight, virtually
every organ system malfunctions. The most dangerous among these are cardiac disorders
as well as fluid and electrolyte disorders. Heart size and cardiac output decrease.
The induced vomiting and use of laxatives and diuretics leads to severe dehydration
and a metabolic alkalosis. This is diagnosed by blood tests, which show a dysbalance
in the electrolytes and a low potassium level. These electrolyte changes can lead
to dangerous fast irregular heart beat patterns, which will cause sudden death. Diagnosis:
The physician will take a thorough history and ask pertinent questions surrounding
the above mentioned symptoms. The weight that is 15% or more below the ideal body
weight for the person is a powerful pointer as to the diagnosis.
However, other physical conditions such as a brain tumor, Crohn's disease, a hidden
cancer or another mental illness such as schizophrenia has to be excluded by doing
appropriate tests. In females one of the requirements of the diagnosis of anorexia
nervosa is that there are no menstrual periods despite them having been normal
in the past. The hallmark for the diagnosis is the over consuming fear of being
or becoming overweight, which is not diminished by the actual weight loss. Associated
with this condition is the presence of a major depression, which has symptoms
of its own such as sleep disorder, mood disturbance, loss of weight and suicidal
thoughts or behavior. Between cardiac death and death through successful suicide,
anorexia nervosa has a mortality rate of 10 to 20%. Treatment:
This consists of an immediate therapy and a long-term therapy. The first
step is to normalize the body chemistry and induce weight gain well above the
cutoff line of 75% of ideal body weight. This is best done in the hospital setting.
Then there is the long-term therapy consisting of a psychiatric assessment
and treatment. This usually involves behavioral-cognitive and/or psycho-dynamic
treatment methods. If a specialist in eating disorders is available, a referral
to that resource person should be done. Family therapy for younger persons
is also helpful, as the family provides the support when the patient returns to
the old environment. Often family members say exactly the wrong thing, which triggers
the patient to return to the anorexia nervosa behavior pattern. Family therapy
addresses that issue. Often fluoxetine(brand name: Prozac) is used alongside the
other psychotherapeutic treatment modalities. Fluoxetine lifts the depression
and helps to control the phobia associated with eating disorders. It is safe to
take this antidepressant medication for several years until the person has stabilized
and adopted healthy living habits. Contrary to popular believe fluoxetine is NOT
addicting. More info
on anorexia nervosa through this link.
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