Psychological of Anorexia Nervosa
Anorexia nervosa is an eating disorder characterized by immoderate food restriction and irrational fear of gaining weight, as well as a distorted body self-perception. It typically involves excessive weight loss and usually occurs more in females than in males. Because of the fear of gaining weight, people with this disorder restrict the amount of food they consume. This restriction of food intake causes metabolic and hormonal disorders. Outside of medical literature, the terms anorexia nervosa and anorexia are often used interchangeably; however, anorexia is simply a medical term for lack of appetite, and people with anorexia nervosa do not in fact, lose their appetites. Patients suffering from anorexia nervosa may experience dizziness, headaches, drowsiness and a lack of energy.
Anorexia nervosa is an eating disorder characterized by refusal to stay at even the minimum body weight considered normal for the person’s age and height. Other symptoms of the disorder include distorted body image and an intense fear of weight gain. Inadequate eating or excessive exercising results in severe weight loss. Eating disorders frequently develop during adolescence or early adulthood, but some reports indicate their onset can occur during childhood or later in adulthood. Anorexia nervosa is one of the two major types of eating disorders; the other is bulimia.
People with anorexia see themselves as overweight even though they are dangerously thin. The process of eating becomes an obsession to them. Unusual eating habits develop, such as avoiding what they perceive as high caloric food and meals, picking out a few foods and eating only these in small quantities, or carefully weighing and portioning food. People with anorexia may repeatedly check their body weight and many engage in other techniques to control their weight, such as intense and compulsive exercise or purging by means of vomiting and abuse of laxatives, enemas, and diuretics. Girls with anorexia often experience a delayed onset of their first menstrual period.
Anorexia nervosa is characterized by low body weight, inappropriate eating habits, obsession with having a thin figure, and the fear of gaining weight. It is often coupled with a distorted self image which may be maintained by various cognitive biases that alter how the affected individual evaluates and thinks about her or his body, food and eating. Those suffering from anorexia often view themselves as “too fat” even if they are already underweight. They may practice repetitive weighing, measuring, and mirror gazing, alongside other obsessive actions to make sure they are still thin, a common practice known as “body checking”.
Anorexia nervosa most often has its onset in adolescence and is more prevalent among adolescent females than adolescent males. However, more recent studies show the onset age has decreased from an average of 13 to 17 years of age to 9 to 12. While it can affect men and women of any age, race, and socioeconomic and cultural background, anorexia nervosa occurs in ten times more females than males.
People with anorexia nervosa continue to feel hunger, but they deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known. It is a serious mental illness with a high incidence of comorbidity and similarly high mortality rates to serious psychiatric disorders. People suffering from anorexia have extremely high levels of ghrelin (the hunger hormone that signals a physiological need for food) in their blood. The high levels of ghrelin suggests that their bodies are desperately trying to make them hungry; however, that hunger call is being suppressed, ignored, or overridden. Nevertheless, one small single-blind study found that intravenous administration of ghrelin to anorexia nervosa patients increased food intake by 12–36% over the trial period.
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: an- (ἀν-, prefix denoting negation) and orexe (όρεξη, “appetite”), thus meaning a lack of desire to eat. However, while the term “anorexia nervosa” literally means “neurotic loss of appetite”, the literal meaning of the term is somewhat misleading. Many anorexics do enjoy eating and have certainly not lost their appetites as the term “loss of appetite” is normally understood; it is better to regard anorexia nervosa as a compulsion to fasting, rather than a literal loss of appetite.
Psychological of Anorexia Nervosa
Eating disorders frequently co-occur with other psychiatric disorders, such as depression, substance abuse, and anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure, that may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is critically important.
Not only does starvation result in physical complications, but mental complications as well. P. Sodersten and colleagues suggest that effective treatment of this disorder depends on re-establishing reinforcement for normal eating behaviours instead of unhealthy weight loss.
Anorexia nervosa is classified as an Axis I disorder in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV), published by the American Psychiatric Association. The DSM-IV should not be used by laypersons to diagnose themselves.
DSM-IV has now been replaced by DSM-5 . There are important changes to the criteria for anorexia nervosa and other eating disorders. Note that the following discussion concerns DSM-IV.
- DSM-IV-TR: diagnostic criteria for AN includes intense fear of gaining weight, a refusal to maintain body weight above 85% of the expected weight for a given age and height, and three consecutive missed periods and either refusal to admit the seriousness of the weight loss, or undue influence of shape or weight on one’s self-image, or a disturbed experience in one’s shape or weight. There are two types: the binge-eating/purging type is characterized by overeating or purging, and the restricting type is not.
- Criticism of DSM-IV There have been criticisms over various aspects of the diagnostic criteria utilized for anorexia nervosa in the DSM-IV. Including the requirement of maintaining a body weight below 85% of the expected weight and the requirement of amenorrhea for diagnosis; some women have all the symptoms of AN and continue to menstruate. Those who do not meet these criteria are usually classified as eating disorder not otherwise specified; this may affect treatment options and insurance reimbursments. The validity of the AN subtype classification has also been questioned because of the considerable diagnostic overlap between the binge-eating/purging type and the restricting type and the propensity of the patient to switch between the two.
- Criticisms of DSM-IV and Diagnosing Adolescents with Anorexia Nervosa – There have been criticisms over the diagnostic criteria utilized for anorexia nervosa in the DSM- IV and its applicability in diagnosing adolescents with anorexia nervosa. Several criticisms of the DSM-IV in diagnosing adolescents with anorexia nervosa are:
- Fulfillment of DSM- IV criteria B and C for anorexia nervosa are dependent on complex abstract reasoning, the capacity to describe internal experiences, and the ability to perceive risk. While formal thought emerges between ages 11–13, complex abstract reasoning continues to develop late into adolescence. The ability to perceive risk also continues to develop through adolescence, as some preadolescents have difficult perceiving the relative risk of alternative outcomes. Adolescents and children must first develop these internal thought processes in order to then endorse fear of weight gain or distortion of body image, and deny the seriousness of low body weight despite their behaviors that contribute to harmful weight loss, which are necessary to fulfill criteria B and C. These developmental factors may impede an adolescent or child from receiving a diagnosis of anorexia nervosa. It is the hope of certain professionals that the DSM-V will take the unique developmental stages of children and adolescents into account when revising the current criteria. One proposed amendment would be to allow behavioral indicators as a means of substituting internally referenced cognitive criteria.
- Another criticism focuses on the current weight criteria specified to receive a diagnosis of anorexia nervosa. Critics state that there is wide variability in the rate, timing and magnitude of both height and weight gain during normal puberty. Physical development varies greatly during puberty, making it a challenge to define an optimal weight range for a growing child or adolescents.
- ICD-10: The 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).
- If onset is before puberty, that development is delayed or arrested.
- Certain physiological features, including “widespread endocrine disorder involving hypothalamic-pituitary–gonadal axis is manifest in women as amenorrhoea 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”.
- Self-evaluation based largely or entirely in terms of weight and appearance
- Pre-occupation or obsessive thoughts about food and weight
- Refusal to accept that one’s weight is dangerously low despite warnings from family, friends and/or health professionals
- Low self esteem
- Mood swings
- Clinical depression
- Withdrawal from interpersonal relationships in favour of social isolation
Psychological Anorexia Causes
Psychologically, certain personality traits increase the risk of anorexia. People with anorexia nervosa often have low self-esteem, and suffer from feelings of insufficiency. They may have rigid thought patterns, and have an almost compulsive need to control their lives. Externally, anorexics may appear as effective people going all-out in all areas of their lives, and striving to overachieve in careers, sports, or schoolwork as well as weight loss.
People with anorexia nervosa are often perfectionists, who are overly critical of themselves. Anorexics also tend to socially isolate themselves, and to avoid conflict when possible.
Anorexia nervosa often arises alongside other mental health disorders, including clinical depression, anxiety, and symptoms of obsessive compulsive disorder. Whether depression and other mental health disorders trigger anorexia or not is difficult to determine. Starvation results in a number of psychological health complications, including depression, anxiety, social isolation, mood and personality changes, an obsessive thinking. Mental health disorders in anorexics may be a result of anorexia nervosa, rather than the cause of the eating disorder.
Traumatic life changes have also been known to trigger anorexia nervosa, although this is only thought to occur if the individual is already “pre-disposed” to developing the eating disorder. Such life changes may include:
- grieving a death
- beginning adolescence
- beginning a new job
- losing a job
- entering a new school
- failing at schoolwork
- ending a relationship.
Many people experience these life events for the first time in their teen years, which may partially explain why anorexia affects teens more often than adults.
Once anorexia nervosa develops, the eating disorder tends to reinforce itself. Positive comments on weight loss by peers or family members in the initial stages of anorexia may reinforce the desire to continue losing weight. The eating disorder may give the anorexic a feeling of power, self-control, or virtue.
- American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders.
- American Psychiatric Association Work Group on Eating Disorders (APAWG). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 2000; 157(1 Suppl): 1-39.
- Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. New England Journal of Medicine.
- American Journal of Psychiatry , 1999; 340(14): 1092-8.
- National Institutes of Health, National Library of Medicine, MedlinePlus, 2006. http://www.nlm.nih.gov/medlineplus/ency/article/000362.htm
- Westen D, Harnden-Fischer J (2001). “Personality profiles in eating disorders: rethinking the distinction between axis I and axis II”. The American Journal of Psychiatry 158 (4): 547–62. doi:10.1176/appi.ajp.158.4.547. PMID 11282688.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th, text revision (DSM-IV-TR) ed. 2000.
- Gendall KA, Joyce PR, Carter FA, McIntosh VV, Jordan J, Bulik CM (2006). “The psychobiology and diagnostic significance of amenorrhea in patients with anorexia nervosa”. Fertility and Sterility 85 (5): 1531–5.
- Smith, A. T.; Wolfe, B. E. (2008). “Amenorrhea as a Diagnostic Criterion for Anorexia Nervosa: A Review of the Evidence and Implications for Practice”. Journal of the American Psychiatric Nurses Association 14 (3): 209–15.
- Eddy KT, Dorer DJ, Franko DL, Tahilani K, Thompson-Brenner H, Herzog DB (2008). “Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V”. The American Journal of Psychiatry 165 (2): 245–50.
- Marlene Busko Diagnostic Criteria for Eating Disorders May Be Too Stringent. Medscape.com (2007-05-30). Retrieved on 2012-02-04.
- Workgroup for Classification of Eating Disorders in Children and Adolescents. “Classifications of Eating Disturbance in Children and Adolescents: Proposed Changes for the DSM-V”. European Eating Disorders Review, 2010,p.81
- Knoll, S., Bulik, C., & Hebebrand, J. “Do the currently proposed DSM-5 criteria for anorexia nervosa adequately consider developmental aspects in children and adolescents?”. Early Adolescent Psychiatry, 2011,p.96
- Journal of Adolescent Health. “Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine”. 2003,33,p.496
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