By the time I saw her in consultation two weeks later, Andrea weighed barely 74 pounds.
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She sat rigidly upright in her chair, dressed in multiple layers of clothes, and refused to remove her winter jacket in the warm room when invited to do so. Her face was pallid and her face and hands appeared emaciated, showing the outlines of her bones beneath the skin. Her hands were cold and blue.
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I never used to talk to my Mom. Before Christmas I used to exercise really a lot—a couple of hours a night. Then I got really mad. I used to have goals of exercising. I began to see her as an outpatient once a week for a month. She continued to be extremely tense and inhibited, and she worried incessantly about eating and about school. She complained that it was cold at school, particularly in swimming class. Despite her shivering she insisted on how does anorexia nervosa evolve?
She was encouraged to eat more and increased her intake somewhat, but she was unable to gain any weight. She withdrew even more. One evening her mother found her curled up in her closet, crying hysterically. She complained of headaches before and of stomachaches after each meal. It became necessary to admit her to the hospital on a pediatric unit, where her meals could be monitored.
Her weight stabilized in the hospital and her mood improved over the next three weeks. She was instructed in a meal plan and for the first time expressed her willingness to eat the necessary quantities. Because she was able to do this she was discharged home and continued to be seen by me together with a dietitian who monitored the meal plan. Andrea became less frightened and was able to gain two pounds in the next two weeks. Although she was now eating adequately, she resisted recording her meals in the food diaries the dietitian had given her.
During the next month she became more talkative and spontaneous at home, and was even beginning to reach out to some of her friends. In another month her weight had increased to just over 86 pounds. She was unwilling to talk about her worries with me but was expressing them to her mother. When she saw a picture of a malnourished child in a newspaper she told her mother that she felt bad because we have too much, while other people all over the world have too little.
Grudgingly she ate the amounts prescribed but balked increasingly at coming to appointments with me. I told her that I would strike a deal with her. If she would continue to gain weight adequately, I would see her less frequently; but if she did not, I would need to see her weekly again. We set a goal of 90 pounds for three weeks. When she returned she weighed Her weight was above 93 pounds. She was to return in two months, and I kept telephone contact with her mother.
Because Andrea was now eating without apparent worry and was again interacting well with her family and friends at school, we stretched the next appointment out to three months. She was no longer studying excessively, was going out for basketball, and tried out for her school play. For the first time she was fighting with her sisters, which both annoyed and pleased her mother.
She appeared healthy and robust, weighing pounds, which was near the 50th percentile for her age. Andrea had recovered fully from her anorexia nervosa in a relatively short period of time—two years from the onset of her weight loss. She had received outpatient treatment for just over a year. Andrea displayed both depression and obsessive-compulsive behavior, which was characterized by obsessive thoughts about her appearance and about eating, and she exercised excessively.
All of these symptoms resolved remarkably as her nutrition improved. She did not have intensive psychotherapy but rather a supportive approach, which emphasized the resumption of good health and age-appropriate behavior. Initially, when Andrea reluctantly participated in the treatment, I spent considerable time educating her about the physical effects of starvation, explaining the symptoms that she had developed.
Whether she really understood or accepted the explanations was difficult to know. At least she seemed to listen. At any rate, my discussions showed her that I was interested in her perceptions and feelings, and they helped us to establish a sense of trust. The treatment included nutritional counseling by a dietitian emphasizing the restoration of healthy eating patterns. At first Andrea really had no idea why she was not eating.
It is quite possible that her fear of eating and of becoming fat was grounded in a fear of growing up. But once she got past the hurdles of eating adequately, gaining weight, and continuing to mature physically, she began coping with the tasks of adolescence. The biological and psychological changes of adolescence were set into motion and there was no way of holding them back. She even began to lose some of her shyness and inhibition, and she joined in the activities of her friends.
I had allowed her to make her own decisions about eating while she remained at home. Had she been forced to eat, her resistance to treatment would how does anorexia nervosa evolve? Andrea was fortunate to be able to respond to the biological drive of growing up. Others tenaciously hold on to their desire to be thin and require more intensive psychotherapy. Still other patients require much longer periods of hospitalization in order to recover. Andrea basically had a very satisfactory relationship with her parents.
She was much more dependent on her mother than most year-olds, but as her illness improved, this dependence lessened. She was later than most of her classmates in seeking adolescent independence. Part of this delay was due to her illness, and part of it was due to her inherent temperament. Her mother and the adult women she knew exposed her to constant dieting and preoccupation with their appearances. She was bombarded with the message that women eat less than men and boys.
Her father and brother always were encouraged to eat more. The discussions among her friends and the magazines she read gave her the message that she should look sexy. That meant having breasts, but to be thin. Certainly not to have thunder thighs. Lori began reading diet books but was frustrated by learning that each book had different rules. The one thing they had in common was that a person had to be very committed to lose weight.
She protested that her parents were making a big deal over nothing. She was just trying to eat healthily. Eventually, she was hospitalized but persisted in fighting the efforts to make her fat. Her book is 18 demystifying anorexia nervosa valuable and unusual in describing her thoughts and feelings and revealing great self-insight.
Young girls growing up on farms in Iowa and in small towns in Minnesota are exposed to similar media influences, and they acquire many of the same thoughts and ideas that Lori did. They read the same magazines and view the same images of thin models and emaciated waifs in brand-name underwear. The individual manifestations may differ, but their goals are the same—to be the best at dieting. Local influences may color the way in which food restriction is carried out. A girl living on a farm in Iowa refused to eat corn. She rationalized that corn was fed to calves to make them fat, and she was not about to become a fat cow.
Her expectations have been for perfection in all of her pursuits. Her academic grades have been at the highest level because of her conscientious hard work. She played a musical instrument and practiced diligently. She participated in a sport and worked at it. And she had been active in clubs, church, and other activities. In elementary school she shone in all of these tasks and carried them off easily.
As she entered junior high school or high school, she became more challenged in one or more areas. She noted that other people were as good as or better at some of them than she. That made her study harder and work harder at her lessons and activities. Moreover, she may have found that others were making more friends and were achieving more social recognition. Perhaps not surprisingly, she began looking to herself to find reasons for why she was no longer among the most popular girls. Did she need to study harder and for longer hours? Was there something wrong with the way she looked?
Was she getting too fat and lazy? There might be an event that would confirm her fears: an undesirable test grade, a slight from her best friend, a comment that her hips are becoming heavy or that her stomach is too big. This is how the stage is often set for a girl to begin dieting. It may begin quite innocently and unnoticed. She may also begin exercising more and more. A whole host of situa- how does anorexia nervosa evolve? The common thread in the process is the inexorable weight loss. Once it reaches a critical point, characteristic physiological and psychological changes take place that define and perpetuate anorexia nervosa.
Just how common is anorexia nervosa? The answer depends on how we define the disorder. I believe, as does George Hsu, that dieting and anorexia nervosa are on a continuum; therefore the point at which harmless dieting ends and anorexia nervosa begins is arbitrary. Studies that have asked individuals to rate themselves with regard to attitudes about eating and body image and about dieting behaviors have come up with very high rates of concern about eating and body image among females and somewhat lower rates among males.
To my mind, this does not represent anorexia nervosa, nor does it represent an eating disorder. Rather, it reflects common societal attitudes about eating and self-concept. For anorexia nervosa to occur, physiological and psychological function must be impaired. The criteria for its diagnosis must be clearly defined. The best ones we have are those defined in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. They are now generally accepted throughout the world and are used in most research studies.
Diagnosis of anorexia nervosa is discussed more fully in Chapter 8. Accurate diagnosis is nec- how common is anorexia nervosa? An aim of epidemiology is to determine the number of cases of a disease in a population. Broader or narrower definitions of the disease will yield more or fewer cases. Anorexia nervosa once was thought to be very rare but is now quite common. It is, in fact, the third most common chronic disease among teenage girls. In the distant past it often was unrecognized for what it was. Therefore, reports in the medical literature were limited, creating the impression of rarity.
Not until the s did anyone try to determine the frequency of the disorder in the population. Sten Theander, at the University of Lund in southwestern Sweden, studied the medical records of women who had been treated for anorexia nervosa between and Theander found an increase in the numbers during that time, but cautioned that the increase might be more apparent than real because of better identification of the disorder.
Other studies, in northeast Scotland and in Monroe County, New York, also suggested increases over time. These studies were based on psychiatric case registers, rosters of individuals who had been seen by psychiatrists in those communities. A study in Zurich, Switzerland, counted patients who had been hospitalized. Thus, the patients were not drawn from a defined geographic area, and the results represented estimates of incidence. Additionally, a requirement of the studies was that the patients had received treatment for their disorder either in a hospital or by a psychiatrist.
Individuals in the surrounding communities who were treated by nonpsychiatric physicians and those who had received no hospital treatment would not have been included. In my own studies in Rochester, Minnesota, my colleagues and I used a different methodology and produced quite different results.
We did this by reviewing many thousands of records of women and men 22 demystifying anorexia nervosa who had weight loss from any cause, and of women who had menstrual irregularities. The time span we studied was considerable: from through We applied standard criteria for diagnosing the disorder to the information gleaned from the medical records and identified individuals who had definite, probable, and possible anorexia nervosa. Thus, we came up with numerous individuals who had never been formally diagnosed with anorexia nervosa but who had all the characteristics of the disorder that are now recognized.
Most of these people had never been hospitalized for the disorder, and many had never seen a psychiatrist. Thus, they would have been lost to a study that depended on hospital records or psychiatric case registers. Some earlier diagnostic criteria had set an upper age limit at 25 years. We used no age limits in searching for these individuals. Thus, we identified persons in the community from a broad age range. The youngest girl was 10 and the oldest woman was 59 when her disorder began. As expected, however, by far the largest numbers were girls and women between the ages of 15 and 24 years; one in 10 subjects was male see Figure 1.
Distribution of age at diagnosis of anorexia nervosa. Females, open bars; males, cross-hatched. Adapted from Lucas, AR, et al. In the typical age group, however—the females between 15 and 24 years of age—there was a significant increase from through The occurrence of anorexia nervosa in older women had remained the same over time, and the occurrence in males had also remained constant see Figures 2 and 3.
We found the overall incidence rate new cases occurring per year to be 8. For females it was Among through year-old females it rose from about 15 per , in to about 60 per , in Our study showed higher incidence figures than other studies because we screened the entire community, regardless of whether the subjects had previously been diagnosed or treated.
The incidence figures derived by Hoek and Brook, who surveyed general medical practitioners in Holland for possible cases of anorexia nervosa, came closest to ours. Incidence rates for anorexia nervosa in residents of Rochester, Minnesota, — From Lucas, AR, et al. Incidence rates for anorexia nervosa in 15 to year old female residents of Rochester, Minnesota, — We found the prevalence of the disorder number of cases in the community at any given time to be about 1 in older teenage girls. It is likely that the rates for anorexia nervosa are similar throughout North America and Europe.
In South America, particularly in Brazil and Argentina, the disorder is not uncommon. Reports of many cases have come from Australia and New Zealand as well. It is said that the disorder has become more frequent in Japan. Young women in countries that have become how common is anorexia nervosa?
Increasing globalization and the homogenization of cultures worldwide have hastened the spread of the disorder. In contrast, it is still rare in the Middle East, with the exception of Israel. It is nearly unheard of in Africa except in South Africa and Egypt. Although there are some case reports of anorexia nervosa in African American women, most of the reports are not of typical anorexia nervosa. The disorder is still very rare in this ethnic group. What makes for the differences in prevalence among different cultural and ethnic groups? First, the disorder is more frequently recognized in developed countries that have sophisticated medical care than in those countries with more primitive medical care systems.
Second, the attitudes toward body shape and dieting differ among cultures. Western European and North American cultures place high value on slimness in women whereas Middle Eastern, African, and Polynesian cultures value adiposity. In such cultures anorexia nervosa is unlikely to occur. But there must be other factors. Starvation occurs with great frequency in underdeveloped countries. When food becomes available they will eat eagerly, despite the physical discomfort that comes from distending a shrunken stomach. They may even gorge themselves when given enough food to do so. On an episode of the TV show Survivor in April , Cody, who with his fellow competitors had been starving in the Australian Outback for many days, won the opportunity to spend a day and night with ranchers on the range.
They ate a hearty supper of beef stew and beans. He stuffed himself. Despite being sick throughout the night from overeating, he awakened in the morning and treated himself to a full breakfast including eggs and bacon. When there is no food, victims of famine continue to starve, and eventually they become indistinguishable from a person with chronic anorexia nervosa who has refused treatment and has given up hope. Knowing the circumstances makes the cause obvious. Another difference is that individuals with anorexia nervosa starve selectively. They make restricted food choices while surrounded by plenty.
Their restriction of essential nutrients is not as complete as that imposed on vic- 26 demystifying anorexia nervosa tims of famine. This is why patients with anorexia nervosa do not often develop specific vitamin and mineral deficiencies. It is quite likely that some individuals and perhaps some ethnic groups have genetically determined protective factors that prevent them from developing the symptoms of anorexia nervosa after dieting.
I suspect that this is true for nonwhite populations, among whom anorexia nervosa is rare. Scientific studies have not yet confirmed this hypothesis. Our incidence figures for the s suggest a leveling off in the frequency of anorexia nervosa. As the century drew to a close, this certainly seemed to be so for the form of the disorder in which adolescent girls strictly curtail their eating without resorting to binge-eating or purging.
In its place we have seen more teenage girls and young women who have a mixed symptomatology manifested either by intermittent starving and binge-eating behavior, or binge-eating and purging behaviors known as bulimia nervosa. Our study of the incidence of bulimia nervosa in Rochester showed a sharp rise in incidence among females in the early s see Figure 4. Incidence rates for bulimia nervosa among female residents of Rochester, Minnesota, —, adapted from Soundy, TJ, et al. He noted that they had a morbid fear of becoming fat, much like typical anorexic patients.
But they also had intractable urges to overeat, and they avoided the fattening effects of food by vomiting or abusing purgatives. Many of them had a previous episode of anorexia nervosa with weight loss. Before her 13th birthday Ynez had been of average height and weight. She weighed 98 pounds. A very pretty brunette with luxuriant, wavy hair, she was the most popular girl in her elementary school because of her outgoing, fun-loving nature.
She became infatuated with a boy in her class and wanted to make herself attractive to him. Consequently she spent much time scrutinizing herself in the mirror, brushing her long hair, and noticing small blemishes. The following year she attended a much larger school, housing both the junior high and high school grades. She felt overwhelmed by the prospect of being in this school and she feared failure, even though she was an excellent student.
Moreover, she feared that she would not be accepted socially. She strove to become more beautiful, hoping that this would ensure her popularity. As her breasts developed and her hips and thighs grew larger, she became concerned that she was getting fat. Noticing that her waistline was increasing was particularly distressing. She studied fashion magazines and envied the slender appearance of supermodels, comparing her measurements to theirs.
She wanted to look like these models. Thus she began to diet and rather quickly was able to lose some weight. Her friends envied her because they failed in their attempts to diet. Ynez persisted even though her friends were baffled because she had never been overweight. Her success at dieting heightened her resolve to continue. Occasionally she gave in to hunger pangs and overate.
She tried to vomit unsuccessfully. Eventually she learned to gag herself with a what causes anorexia nervosa? She abhorred the idea of vomiting but it gave her a feeling of control. She could now occasionally eat more because she knew she could rid herself of the food. Her vomiting was followed by mixed feelings of guilt and mastery. She had never menstruated. Her hair began falling out in bunches when she brushed it.
Her skin became dry and scaly, and her fingers became bluish and cold.
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Her clavicles and shoulder blades stood out sharply. When she pinched the loose skin around her waist she believed it to be fat. Her father spent long hours at work managing an automobile dealership and her mother taught in the elementary school. They had hoped that her problem would go away. When it became only too apparent that Ynez was starving herself, her parents finally insisted that she have a medical evaluation.
She appeared emaciated and had a slow pulse and low blood pressure. Fine, downy hair had appeared on her back. Because of a heart murmur she was referred to a pediatric specialist for an evaluation. The heart murmur proved to be benign. The remaining findings were all manifestations of starvation. It was noted that there was erosion of her dental enamel from vomiting. The pediatrician then referred her to me for treatment. Ynez seemed motivated for treatment because she understood intellectually that she had carried her dieting too far.
She was ready to admit that she felt miserable, being cold all of the time. She tired easily and found it difficult to carry out the many activities she was involved in. Concentrating on her schoolwork had become a problem and she was sleeping poorly. Ynez was able to increase what she ate, but she was unable to stop vomiting. Thus, after a period of outpatient treatment she required more intensive treatment in the hospital. Her vomiting was controlled in the hospital because her meals were regular, but it recurred after she returned home. Her course was rocky and protracted, with weight fluc- 30 demystifying anorexia nervosa tuations over the next several years since she was unable to maintain the regular eating habits that were established in the hospital.
Periodically she overate. This triggered further vomiting, which had become easier for her to do. Eventually, at age 17 years, her weight reached pounds and she had her first menstrual period. However, she continued to struggle with her disorder into her early twenties. Kirsten was a rather quiet year-old ninth grader who strove to participate in all the sports at her small rural school. Her older sister was an honor student and a standout basketball player on a team that had consistently been the champions in their league.
They had often won their regional competition. That year they were to compete at the state tournament. Kirsten pushed herself to compete athletically with older girls and made the varsity volleyball team, the only one in her class to accomplish this. She rose early each morning to do her schoolwork, and she ran extra miles after school to improve her physical condition.
During the winter she participated in basketball but was disappointed not to make the varsity team. It was little consolation to her that the team was among the best in the state, and its members, including her sister, were all eleventh and twelfth grade students. From August to December she had lost 10 pounds, her weight dropping from to 96 pounds. She had become listless and irritable. Her mother, a bookkeeper at a nursing home, brought Kirsten to her pediatrician in the nearby city.
The pediatrician found no illness to account for the weight loss and encouraged Kirsten to eat more, arranging to see her again in a month. By January Kirsten had lost even more weight, now weighing 93 pounds, and she had missed two menstrual periods. Kirsten was selecting foods low in calories, had virtually eliminated fats from her diet, and was skipping her lunches. She insisted that she was eating a healthy diet, pointing out that she had studied the American Heart Association guidelines. What she was unaware of is that her diet was woefully inadequate for a growing, rapidly developing adolescent who was physically very active.
She was consuming virtually no fats, very little protein, and the total number of calories in her diet was far below what her body needed. Another month elapsed without progress. Her pediatrician asked me and a dietitian knowledgeable about the treatment of eating disorders to participate in the treatment. Working closely with the dietitian, I reviewed the situation and spent some time educating Kirsten about her growth and nutritional needs.
She had now lost a total of 16 pounds and had missed three menstrual periods. Although eating more, she was exercising excessively.
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Her hands were cold and blue, the palms of her hands had an orange tint, and her resting pulse rate was 44 beats per minute. She was very tearful, protesting that she had been trying to eat more. I told Kirsten that in order to maintain her health, she must not lose any more weight, and she needed to consume enough food to accomplish that. Since she was expending too much energy, I told her that she could not participate in physical education or in competitive sports for the time being.
I arranged to see Kirsten again, setting up twice weekly appointments in order to keep very close track of her progress or lack of it. The dietitian would see her once a week. Kirsten was upset about having to miss school for appointments. Her mother nevertheless brought her to the appointments faithfully.
Within a week her weight loss had abated. We reduced the frequency of appointments to weekly. Kirsten said little at first, but was willing to go through the motions of following the meal plan prescribed. She knew that she could not participate in sports until she had gained an adequate amount of weight. As we educated her about nutritional principles and the physiological effects of weight loss and weight gain, she began to ask the dietitian questions about foods.
She continued to be reluctant to discuss any concerns with me. When I asked her about her schoolwork, her friends, her interest in sports, and her interaction with her sister, her responses usually were brief and matter-of-fact. Some of our conversations focused on the physical changes taking place in her body that resulted from the weight gain. Her fears and anxiety about this process also had to be addressed. Her nutritional state improved as her weight slowly increased. By the beginning of August, her weight had reached pounds, and by the time school began it was more than pounds.
She was now 5 feet 7 inches tall. She again looked healthy and perky. Her mother said that she had regained her spark. I felt comfortable about having her resume sports, and she again joined the volleyball team during her sophomore year. While Kirsten had been gaining some weight with a period of reduced physical activity through the summer, she would need to eat considerably more to continue gaining weight while actively involved in sports.
I pointed out that it is relatively easy to eat enough to maintain weight, but to continue gaining, as was necessary at her age, she would have to push herself to eat more, even after feeling full. Her mother commented that before she was seeing the dietitian and me regularly, Kirsten was encouraged to change her eating habits and was given emotional support, but she had not been given specific guidelines about what to eat.
Moreover, no goals had been set for her. We were very specific about what she had to do, emphasizing the seriousness of the situation. Her mother also noted that Kirsten had regained some of her energy and seemed more cheerful around home. She was also beginning to seek out her friends again. Her participation in volleyball proved to be beneficial. Kirsten ate her prescribed lunches at school. When she came home after practice she seemed genuinely hungry for the first time since the previous winter and ate a substantial dinner.
We were able to reduce the frequency of her clinic visits to once every two weeks and later during the school year to once a month. Kirsten participated in basketball during the winter. She remained enthusiastic about her studies and showed renewed interest in her social life. By February of the next year her weight had stabilized at pounds. Altogether the dietitian and I had each seen her a total of 22 times. Her mother kept me apprised of her good progress during her final year of high school.
Kirsten had continued to gain a moderate amount of weight and had come into her own socially what causes anorexia nervosa? Kirsten had developed as a star in her own right, both in volleyball and basketball. Unlike Ynez, Kirsten was not so much fearful of getting fat as she was driven to compete with her sister and older peers. If she had thoughts about wanting to be thin, she did not reveal them. She placed herself on a reducing diet believing that eliminating fats was the healthy thing to do. Her intentions were good, and she did not realize that she was, in fact, starving herself.
Clinicians have struggled to understand the causes of eating disorders for more than a century, ascribing them variously to biology, psychology, or culture over the years, depending on the currency of the day. One or another of these theories has been favored at any given time. But any such concept of the illness is too simplistic. It ignores history and clinical experience.
The latest vogue is to suggest that the cause lies in changes in the body chemistry. Yet ascribing everything to biology alone has as little value as ascribing it all to culture. Although patients with anorexia nervosa look and behave very much alike once their starvation is well advanced, there is no single cause.
The antecedents of the illness—the ways it begins —vary enormously. What underlies the problem often may not be discerned at the time of crisis but may come to light much later. Sometimes the precipitant is never known. As with many other illnesses, a combination of vulnerabilities and circumstances is necessary for it to become manifest. In attempting to understand the cause when I was seeing many patients in the s, I tried to develop a working hypothesis to make sense of the disease.
It seemed clear to me that quite different circumstances led to the disorder in different individuals. In some, significant life events seemed to trigger the disorder; in many others, there were none. While some families had focused excessively on issues of food 34 demystifying anorexia nervosa and body image, many others had not. In contrast with descriptions in the literature, most of the parents I encountered were not overcontrolling, and they were not excessively enmeshed with their children.
While the patients, once they had anorexia nervosa, often had personality characteristics in common with each other, the stories leading up to the beginning of the disorder varied, and the family constellations and parental attitudes differed one from another. Most children in our society are exposed to similar societal pressures but they do not react alike. It seemed that in order to develop anorexia nervosa one needed to be vulnerable in some special way. Risk factors and vulnerability were not well understood at that time, but clearly some individuals were more susceptible than others.
Once the illness began, the patients looked and behaved remarkably alike. They demonstrated profound physical and emotional changes. Their parents understandably became increasingly concerned, and this often led to conflicts. More often than not these conflicts were the result, not the cause, of the illness. I speculated that there was a genetically determined metabolic predisposition that interacted with early life experiences within the family environment.
Triggered by pubertal changes, this predisposition could lead to dieting. A vicious circle would ensue, leading to undernutrition, physiological changes, and changes in thinking that constituted anorexia nervosa. In a psychiatrist, George Engel, working at the University of Rochester, New York, published what was to become a classic paper in Science. In it he elaborated the biopsychosocial model of disease. He proposed that all diseases should be viewed within the 2 framework of multiple factors: biological, psychological, and social.
If dieting occurred at the time of pubertal endocrine changes, when girls rapidly acquire body fat, a vicious circle leading to weight loss, undernutrition, and physio- what causes anorexia nervosa? Biological Vulnerability Genetic, physiological predisposition Psychological Predisposition Early experience Family influences Intrapsychic conflict Pubertal endocrine changes Ameliorating Weight loss Personality change Dieting Undernutrition Mental changes Social climate 35 Physiological changes Sustaining Societal influences and expectations Figure 5.
Biopsychosocial model for anorexia nervosa. Adapted from Lucas, AR, Toward the understanding of anorexia nervosa as a disease entity. Mayo Clin Proc, ; Almost certainly, a biological vulnerability is necessary for an individual to develop anorexia nervosa. In addition, certain psychological characteristics and environmental experiences can reinforce the biological vulnerability, as I 3 further expanded in a theoretical model of the disease.
This interactional model suggests that three factors—biological, psychological, and social—lead to inappropriate dieting at the time of pubertal changes, when girls are rapidly gaining body fat. Each of these three factors has a greater or lesser impact on particular individuals in whom anorexia nervosa develops. Some girls have a strong innate tendency to develop the disorder, but the genetic predisposition must be necessary for the disorder to occur.
Most individuals those who do not have the genetic predisposition will never develop anorexia nervosa, even though exposed to the same environmental stresses and social pressures that influence vulnerable persons. Many environmental influences reinforce the vulnerability to the disorder and lead to dieting. Certain parent-child relationships are more conducive to the development of the disorder, but in and of themselves they do not cause 36 demystifying anorexia nervosa it. Events as diverse as an illness, a sexual assault, or performance in sports can trigger weight loss and thus play a role in the developing disease.
The social climate, where high value is placed on extreme thinness, reinforces any tendency to diet and to lose weight. And overzealous attention to preventive health practices that promote dietary restrictions or exercise also may reinforce this tendency. Even though researchers believe that there is a genetic influence in anorexia nervosa, the particular genetic link has not been discovered.
This connection will have to await results of the ongoing study of the human genome. Containing at least 30, genes, the human genome constitutes the genetic information present in every cell of the body. Individual genes are long sequences of four nitrogenous bases adenine, cystosine, guanine, and thymine that make up the double helical structure of DNA. The DNA chains are situated on 23 pairs of chromosomes that are present in the nucleus of every one of the trillion human cells in each body.
The function of genes is to produce proteins that have a particular physiological action. The elucidation of nearly percent of the human genome in has opened the door to a new world of possibilities. As the genes associated with particular diseases are identified, diagnosis and treatment may be facilitated.
However, the practical application of this new knowledge will take time. Genes responsible for numerous diseases have now been identified. Some diseases are caused by single mutant genes. Examples of these are cystic fibrosis, sickle cell anemia, and phenylketonuria. These can easily be understood and some can be effectively treated. In phenylketonuria the errant gene fails to produce the protein enzyme that metabolizes what causes anorexia nervosa?
The disease is treated by restricting dietary phenylalanine. In the future, genetic engineering may allow the defective gene to be replaced with a healthy one. Other diseases such as Down syndrome trisomy 21 are the result of the addition or deletion of entire chromosomes. This results in a broad range of physical, developmental, and mental abnormalities.
Finally, there are diseases that result from the interaction of multiple genes. These include common diseases such as coronary artery disease, hypertension, and diabetes mellitus, as well as psychiatric disorders. In these diseases the effects of several or many genes interact to create the predisposition to the disease. Environmental triggers then make the disease manifest. This is very likely the way in which anorexia nervosa is caused. Most likely, a number of genes that influence specific physiological and personality characteristics are necessary for anorexia nervosa to develop.
The way genes interact to determine personality and temperament is highly complex and poorly understood. The same characteristics that play a role in anorexia nervosa may have beneficial qualities. For example, anorexic patients display a great deal of persistence and compulsivity. These traits may reinforce the illness but the same traits can have a positive influence under other circumstances.
Particular genes may enhance or protect against the effects of starvation. Just how our genes and environment interact to result in anorexia nervosa is still speculative. It is likely that multiple genes interact to influence behavioral and temperamental characteristics. Genes also are 38 demystifying anorexia nervosa undoubtedly involved in how the body responds to starvation and to treatment interventions.
Once we begin to know our genes and mental processses more intimately, these interactions will begin to become clear. Thus, there is no single gene that causes anorexia nervosa, but many genes involved in a dynamic process—the interaction of fundamental biological processes and environment—ultimately resulting in the disease. Genes and environment also determine how each individual responds to her disease.
Despite the similarities in starvation effects, each person with anorexia nervosa differs from all others in just how the illness began and in how she deals with it. Tolstoy was right in saying that each individual has his own personal disease, although he did not have the benefit of the scientific advances of the twentieth century. Environment People create their own environments to a great extent, and the personalities of individuals tend to determine how others react to them.
Children do not merely play a passive role in selecting from and responding to their environment. Their own genetically determined pro8 clivities will have a further effect on their environment. Once dieting and weight loss have progressed to the point that starvation has set in, it becomes difficult for vulnerable individuals to stop dieting. Profound biological and psychological changes occurred among these people, similar to those observed among patients with anorexia nervosa.
The vicious circle that is set in motion is relentless and becomes self-perpetuating. It may be extremely pernicious and lead to chronic anorexia or even death, or the circle may be interrupted and turn to recovery see Figure 6. There are innate and environmental factors that what causes anorexia nervosa? Outcomes of anorexia nervosa. From Lucas, AR, Toward the understanding of anorexia nervosa as a disease entity.
Among the sustaining factors are a severe form of the illness itself, personality factors conducive to maintaining unhealthy eating habits, certain family and interpersonal interactions, the social pressures that value excessive thinness, and inappropriate treatment. On the other hand, a mild form of the illness, effective coping skills, positive family and environmental support, and appropriate treatment may lead to improvement and recovery.
The biopsychosocial model emphasizes that the causative factors interact and synergistically reinforce each other. For each individual they interact in an unique way, but result in a clinical picture that has common features for all those affected.
Adding to the background of anorexia
The course of the illness will vary, depending on the sustaining and ameliorating factors described. Outcome may depend very much on the experiences and opportunities in the environment. Some individuals recover spontaneously, or at least without formal treatment. A review of medical records in our community epidemiological study has taught me that it is not unusual for a teenager to lose sufficient weight to qualify for a diagnosis of anorexia nervosa but recover without formal intervention.
For these individuals, parents or another influential individual may have provided advice 40 demystifying anorexia nervosa that the teenager was able to accept. At other times, the teenager herself may have realized that what she was doing was irrational and was able to begin eating normally again. Still others may not have had a strong genetic predisposition to develop anorexia nervosa and their natural hunger allowed them to overcome their desire to diet and remain thin. For other individuals, the illness is so severe, and they cling so tenaciously to their distorted ideas that the illness continues, despite the best attempts of family members and professionals to intervene.
Some of these become chronic anorexics, doomed to a lifetime of marginal existence, dominated by their chronically starved state. Arthur Crisp, 10 in his book, Anorexia Nervosa, Let Me Be, implied that some patients were untreatable and pleaded that they should be allowed to live with their disease in dignity. Oftentimes the onset of dieting can be unconsciously or consciously motivated by circumstances in the family. The dieting may cease when the precipitating circumstances are resolved, or it may become more extreme when the individual has the biological vulnerability for severe anorexia nervosa.
The severity of starvation may trigger that vulnerability, rendering the condition difficult to reverse. She and her younger brother remained with their mother. Penny had always been close to her father, but after the divorce he visited infrequently. Penny began to diet and rapidly lost weight. When she went to visit her father during summer vacation he was alarmed by her appearance and sought help for her.
She also harbored the unrealistic hope that her parents would be reunited. Because her illness was not far advanced it was possible in treatment to deal with her family issues and help her come to a satisfactory conclusion. Penny no longer had the psychological need to diet and gave up her harmful behavior. Annette, age 16 years, became preoccupied with counting calories, reading food labels, and avoiding foods containing fats and choles- what causes anorexia nervosa? Although she was still growing, she lost weight and her menstrual periods ceased.
The history revealed that her grandfather had recently died of coronary heart disease. His cholesterol level had been elevated and there had been much talk in the family about the consequences of his unhealthy lifestyle. When we discussed her concerns, Annette revealed that she was very worried about her intake of fats and cholesterol in her diet, and she feared that she might develop heart disease like her grandfather.
Her serum cholesterol level was measured and was found to be perfectly normal. Her treatment involved working with a dietitian who instructed her in a healthy but sufficient meal plan appropriate for her growth needs and activity during mid-adolescence.
Demystifying Anorexia Nervosa
Other girls, and some boys, who have elevated cholesterol levels need careful counseling by a dietician and sometimes by a psychiatrist so they do not inappropriately undernourish themselves during adolescence. Some of these teens may inadvertantly develop anorexia nervosa if they are excessively compulsive and fastidious about their diets. The more intense the dieting behavior, the greater is the risk of developing an eating disorder. We have already seen that most adolescent girls who start a diet do not develop anorexia nervosa.
Hsu further hypothesized that genetic, psychological, biological, personality, and family factors increase the vulnerability to an eating disorder in individuals who diet. He then reviewed the literature pertaining to sociocultural factors, development in adolescence, and identity formation in the female that support the hypothesis. The emphasis on slimness, he says, is intensifying. Even young girls 7 or 8 years of age have concepts about physical attractiveness that are similar to those of adolescents.
Girls who are insecure about themselves are most vulnerable to the environmental pressures to diet. While the disorder begins most often in young people in whom puberty has begun, it can occur in older individuals as well. Not infrequently it starts in young people beyond high school age, often at the time they are separating from home and family.
Our community epi- 42 demystifying anorexia nervosa demiologic study has shown that much less commonly it can begin even later in life. When it begins during the adult years, there often is an identifiable precipitant, which may be marriage or the occurrence of an illness. It has manifested in individuals who have had a drinking problem that has led to poor nutrition.
In adult life it is frequently associated with a depressive illness. The oldest individual in our community study had onset of the disorder at age 59, an unusually late time for it to begin. This patient did not have a depression and the reason for developing anorexia nervosa was obscure. Thus, there are many pathways that lead to anorexia nervosa. The illness itself is never fleeting. Once it takes hold it rarely lasts less than six months.
More often it continues for several years, either in a mild or severe form. It may last for many years, it may recur at a later time, or it may persist for a lifetime. The outcomes are extremely variable. There are still no ways to predict what the course and outcome will be for a particular individual.
My experience has been that most teenagers with the disorder will recover. They tend to miss out on their adolescence, but most make up for their loss and are able to go on with their lives. The follow-up studies that have been done also indicate that most recover, but it often takes a very long time for recovery to occur. These studies are discussed in Chapter 13 on outcome. One must remember that these studies included only patients very severely ill with anorexia nervosa. The less severely ill individuals—those who are seen as outpatients and some of those who may never have come to medical attention—often have a briefer duration of illness.
It is after recovery that the diverse personalities of patients with anorexia nervosa assert themselves again. Just as many roads lead to anorexia nervosa, the roads traveled diverge and go in many directions once the illness is over. Once freed of the constraints of starvation and delayed development, new personality characteristics emerge, and individual skills and capacities become manifest.
Culture Many cultural forces in our society have a profound effect on girls and young women. Large numbers of young girls are unduly influenced by the ubiquitous media messages to be thin. These influences are perva- what causes anorexia nervosa? Girls of younger and younger age are constantly influenced by images, models, and performers who are incredulously thin. They emulate these idols by curtailing their nourishment and scrutinizing their own shapes in the mirror. Pre-teens normally have a protuberant abdomen, and this can become an object of abhorrence and disgust to the girl as she matures.
Fortunately, most young girls who attempt dieting yield to the biological drive to grow and develop, and they give up their dieting after a short while. Those who persist because of their strong will and determination become anorexic. The social pressures on women to be thin have been greater than ever in the latter part of the twentieth century, and have not abated.
On the contrary, they have become institutionalized in Western culture and have spread to other countries as a result of globalization. The impact of media messages is greatest on girls in their teens. The message glorifying thinness is now widespread. Little wonder that the incidence of anorexia nervosa has steadily been climbing.
Teen Vogue in the year is replete with lanky, long-legged models. Their arms and legs are spindly and their abdomens flat. Not one of them sports an average figure. They wrote personal reflections and poems. The most ubiquitous theme was their body consciousness. More than any other topic, eating disorders appeared in their writing, with 50 of the pieces dealing with their unhealthy relationships with food. One girl has pinups of boys on the walls of her room. They are my aspirations.
And then I wonder why I hate myself. We lust for the perfect body. We crave control over our lives. In those examples there were the common themes of fear of fatness and the relentless pursuit of thinness. All were girls or young women who strove for perfection but who had impaired self-esteem. Because it occurs most frequently in girls, anorexia nervosa may be overlooked when it occurs in a boy. Only one in ten anorexics is a boy. Those who develop anorexia nervosa may have a fear of fatness just as girls do.
And just as in girls, these boys may begin dieting after their classmates tease them. Some have uniquely false ideas that contribute to their illness. Such was the case of Robert, a year-old eighth grader. Colouring Contest. More info. Small Business. New in the library. Vertical Gardening. Loving someone with an eating disorder. The Math Book. How to not wear black. To feel the music.
American Carnage. From the Ashes. Do Dice Play God? One-Pot Vegetarian. Anthony Bourdain : The Last Interview. Everything About You. Caging Skies. The Hat Shop on the Corner. The Chrysalids. Lives of Girls and Women. The Rosie Result. Elon Musk.
The Bridge Test. Eat to Feed. DIY Mushroom Cultivation. Perception: a photo series. Tokyo Ghoul re: I Know You.
Related Demystifying Anorexia Nervosa: An Optimistic Guide to Understanding and Healing
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