Eating+Disorders-Anorexia

**Anorexia** Anorexia nervosa means ‘nervous loss of appetite’ but most anorexic people retain an appetite for food but deny themselves all but small quantities of low calorie food. The typical calorific intake of a person suffering from anorexia is in the region of 600-800 calories, but in some cases the starvation is even more extreme. Anorexia is associated with a large number of physical and psychological symptoms, and in some cases the self-starvation proves fatal. In the highest risk group (young women between15 to 25) the prevalence is between 0.5 and 1%. Many more women than men develop anorexia, and in most cases the age of onset is during middle-to-late adolescence. There appears to be a higher risk of anorexia developing in middle-class white women from Western cultures. In 1992, The Royal College of Psychiatrists suggested that just under 1 % of women aged 15 to 25 were anorexic, but that the eating habits of many more young women could be described ‘as seriously disturbed’. It is generally agreed that anorexia nervosa has become more common in recent decades. **Sex and age:** Many more women than men develop anorexia in that they comprise around 90% of those cases in which the age of onset is during middle-to-late adolescence, or during adulthood. In most cases the onset of anorexia occurs during adolescence, although the condition can begin much later, or earlier. In recent years it has become more widely recognised that children may also suffer from the condition.Social class, race and culture: there appears to be a higher risk of anorexia developing in middle-class women than in those of the working class background (Andersen, 1983). The highest rates of anorexia occur in white women within Western Cultures but in recent years it appears that there has been a considerable rise in the rate of anorexia in Japan. **Dignosis of anorexia:** Low body weight or weight loss is a necessary element for a diagnosis of anorexia. DSM-IV uses the criterion of 15% or more below the normal weight for age and height. In addition to physical weight, criteria include: an intense fear of becoming obese, avoidance of ’fattening’ foods and perceptual disturbances of body weight, size or shape. In female patients, disturbances of the menstrual cycle may also be an additional criterion for diagnosis of anorexia nervosa. According to DSM-IV, a diagnosis of anorexia requires that there be an absence of periods over at least three consecutive menstrual cycles. In males, loss of sexual interest and potency may also be considered diagnostic signs.
 * Eating disorders – anorexia nervosa.**

DSM-IV criteria
= Behavioural abnormalities = Most of the unusual and disturbed behaviours associated with anorexia are related to the pursuit of thinness. The principal behavioural change is a severe restriction of eating, which amounts to self-starvation. Anorexic patients also use various additional strategies to ensure that they will not put on weight. Many make themselves vomit after they have eaten, or abuse laxatives or diuretic drugs in the bid to bring about weight loss. A relatively high proportion engage in activities such as running or gymnastics which demand a high expenditure of energy. Exercise can become compulsive for those who suffer from an eating disorder. **Physiological factors related to anorexia** Self-starvation and weight loss eventually produce severe effects on physical health, and some harmful effects may persist even when there has been a substantial recovery of lost weight (Sharp & Freeman, 1993). Amenorrhoea (stop of menstruation) is often one of the earliest physical effects of self-starvation, and after several successive menstrual periods have been missed there may be long-term disruption of the menstrual cycle. Hormonal treatment is sometimes necessary, but in rare cases even this is not effective and the cessation of menstruation appears to be permanent. A reduction in food intake lowers the basal metabolic rate and has serious adverse effects on the functioning of the circulatory system. Low blood pressure and a low heart rate tend to give the person a pale look and may lead to dizziness and fainting. Other physical changes include nausea, severe constipation, brittle nails and a dry skin which is prone to ‘cracking’. The hair on the scalp may become very thin, and fine hair may start to grow, particularly on the back and face (Garfinkel & Garner, 1982). Severe weight loss is also associated with the bone condition osteoporosis, a reduction in bone tissue due to oestrogen deficiency and an excess of naturally produced steroids leads to the bones becoming excessively porous and easily fractured. Several of the physical complications of anorexia nervosa can be life threatening. In some cases of self-starvation leads to kidney failure. More frequently, fatalities result from the effects of starvation on the cardiovascular system. Frequent vomiting, purging or the abuse of diuretic drugs can lead to severe disturbances in the balance of electrocutes, and such imbalances can lead to cardiovascular complications that result in the death of the patient. = = = Mental health = The majority of anorexic patients are emotionally disturbed in some way. Anxiety and depression are very common, and many patients experience rapid mood-swings. Many of the mood changes appear unrelated to the external situation, but some may be identified as responses to weight gain or to attempts by family members or health professionals to encourage eating. Anorexic patients have an intense fear of becoming fat and many develop strong aversions towards high calorie foods. Anxiety levels are often high, but the major emotional problem associated with anorexia is depression, and it is generally found that around half of all anorexic patients meet the criteria for clinical depression. Associated with the depression are thoughts and feelings relating to insecurity, loneliness, guilt, inadequacy and helplessness. Few patients have any thoughts of, or any interest in, romantic or sexual relationships and many develop revulsion towards sex. **Low self-esteem**: many anorexic patients have a low level of self-esteem, lack of self-assurance and feel inadequate despite a high level of intelligence and a history academic success. Their tendency towards obsessionality may show itself in ‘perfectionism’, and by setting themselves the highest (often unattainable) standards they may set themselves up for failure. **Effect on social behaviour**: Many anorexic patients withdraw from family and friends. This self-imposed isolation appears to be a response to what the patient regards as a constant ‘nagging’ by other people about the need to eat. In a bid to deflect unwanted concern and attention, the patient may go to great lengths to conceal her avoidance of food or to hide her true body shape. She may pretend that she often has meals away from home, for example, and take to wearing oversized baggy clothing. = Psychological explanations including the role of culture on cognitions =
 * The individual has a bodyweight less than 85% of that expected.
 * There is an intense fear of becoming fat in spite of being considerably underweight.
 * The individual's thinking about his/her body weight is distorted, either by exaggerating its importance to self-evaluation or by minimising the dangers of being considerably underweight.
 * In females, the absence of three or more consecutive menstrual cycles (amenorrhoea).

Cultural explanation: The cultural demand for thinness
Many eating disorders begin when a young woman who is not substantially overweight comes to believe that she ‘needs’ to go on a diet. Aspects of the woman’s personal history undoubtedly contribute to her dissatisfaction with her body shape, but the desire to be thin is often powerfully influenced by media images and messages. The media both reflect and help to shape a strong cultural pressure towards thinness, and the rise in the incidence of eating disorders which has become evident in recent years throughout Europe, in North America and in Japan is frequently attributed to an increase in this cultural emphasis on thinness as an ideal body shape. The cultural pressure towards thinness may have intensified in the 1960s, when many leading fashion models appeared pre-pubescent, boyish and rather emaciated. However, there had been a distinct tendency for thin women to be chosen as fashion models since at least the 1920s, and even in the Victorian period some women were persuaded to use extremely tight corsetry in order to achieve a desirable ‘wasp waist’. The fact that at other times, and in other cultures, a more rounded figure has been considered ideal suggests that the current position might be open to change. Indeed, there is already evidence of a backlash, with organised groups of women challenging the prevalent view and identifying ‘sizism’ as an oppressive set of attitudes having direct parallels with sexism and racism. Women are much more likely than men or children to be the target for the media propaganda that exalts thinness, but no group is immune. The representation of the ideal female as thin is apparent in the media coverage of children’s fashion and also in the design of dolls, so that even very young girls are subjected to distorted models of the ideal body shape. Sanders and Bazalgette (1993) analysed the body shape of three of the most popular dolls available for young girls (Barbie, Sindy and Little Mermaid), measuring their height, hips, waist and bust. They then transformed these measurements to apply to a woman of average height and found that, relative to real women, the dolls all had tiny hips and waists, and greatly exaggerated inside leg measurements. Distorted ideas about what is normal and acceptable mean that many children (especially girls) become dissatisfied with their own shape even though it might be well within the healthy range. Studies indicate that by the age of 12 food and eating are often regarded as moral issues and that body shape is often a major criterion in self-evaluation of others (e.g. Hill, 1993). Furthermore, many parents of young children are unhappy with their child’s body shape, and many children are aware of their parents’ dissatisfaction. When we consider the numerous sources of social pressure that coerce even young children towards being thin, it may seem unsurprising that as may as one-third of 9-years old girls are dissatisfied with their body shape, and that by this age many have already started dieting. Men, too, are now coming under pressure to conform to an ‘abnormal’ ideal. There is a growing emphasis on the ‘worked-out’ male figure, and many men feel a strong demand to ‘get in shape’. A 1993 MORI survey of adult males in the UK indicated that one-third of men had been on a diet and that nearly two-thirds believed that a change in shape would make them more sexually attractive. It remains to be seen whether the growing emphasis on an ideal male shape will lead to an increase in the number of men who suffer from eating disorders. **Distorted cognitions** A number of cognitive distortions and irrational beliefs are commonly associated with anorexia. Some of these relate to eating (the person may be constantly preoccupied with thoughts about food and calories) and others relate to health. According to the body-image distortion hypothesis (Bruch, 1962), many anorexic patients suffer from the delusion that they are fat. Many clinicians are familiar with patients who continue to insist that they are too fat even when they are, in fact, emaciated, and when relatives try to convince such people of the reality of their physical state, perhaps by pointing to the degree of weight loss or showing photographs, they often meet with a response of firm denial or of extreme hostility. Over thirty experimental studies have now examined the way in which people who suffer from an eating disorder perceive their own body shape and size. These studies have employed a variety of size estimation and image distortion techniques. Overall, the research has confirmed that many eating disordered patients do indeed overestimate their body size. However, the studies have also shown that the degree of distortion varies considerably with contextual factors, including the precise nature of the instructions given to subjects. It appears that at least some of the reports given by patients reflect their emotional appraisal rather than their perceptual experience. In their reformulation of the body-image distortion hypothesis, Slade and Brodie (1994) suggest that those who suffer from an eating disorder are in fact uncertain about the size and shape of their own body, and that when they are compelled to make a judgement they err on the side of reporting an overestimation of their body size. **Genetic explanation** Some twin studies suggest that around 60% of MZ twins are concordant for the condition (Holland et al. 1988). Research as also indicated that other relatives may be at slightly increased risk, although this does not necessarily implicate genetic factors. Such a family link might well be explicable in terms of environmental or social interactional factors rather than the genetic similarity between blood relatives. Evaluation: Some of the twin studies have not controlled for the effect of similar shared environments (e.g. by using adoption studies) or have found more environmental than genetic influences in eating disorders. Since concordance rates are nowhere near 100% for twins, it must be assumed that environmental factors are also involved. It is not clear what is actually inherited. It could be a trait like perfectionism, or it could be a predisposition to inherit a mental disorder in general. It is difficult to determine the biological cause and effect of eating disorders because it is difficult to determine since the physical disorders found in anorexia and bulimia may be an effect of starvation and purging rather than a cause. **Treatments of anorexia** Treatment involves both medical and psychological help. A major focus in treatment is the implementation of a reasonable eating pattern. If the patient’s weight is very low, and the weight loss is continuing, it will be necessary to achieve a substantial weight gain within the shortest possible time. There is no pharmacological cure for anorexia, but various drugs may have a place in treatment. In conjunction with a strict dietary regime and psychotherapeutic interventions, anti-depressant drugs often prove useful. Tranquilizers may also be prescribed if there is a high level of anxiety. Hormones and drugs which stimulate the production of certain hormones may also be used to aid the re-establishment of menstruation if this does not occur naturally after a reasonable weight gain has been achieved. Treatments that involve a dietary regime is also likely to include an intensive educational component, in which the patient is informed with the dangers of self-starvation and encouraged to discuss dietary health issues, eating habits and attitudes to food. Various cognitive therapy programmes have been developed with a view to challenging anorexic patient’s unrealistic beliefs about body shape, food and eating. Since eating disorders are commonly described as problems in which eating (or dieting) is out of control, a detailed exploration of these issues of control is often central to cognitive therapy programmes used to treat these patients. If excessive weight loss is regarded as resulting from extreme self-control over eating, therapy will try to establish appropriate self-control. There is a danger that programmes that implement a strict externally controlled dietary regime might actually undermine a patient’s attempt to exercise appropriate self-control. The control issue is addressed directly in Freeman’s (1992) model for outpatient treatment of patients with severe anorexia. His programme aims to promote autonomy and to encourage patients to gain the necessary control over eating. Daily outpatient group sessions provide and opportunity for patients to discuss eating-related issues and other problems, and to express their feelings. Evaluation studies have demonstrated that this approach to treatment is at least as effective as the traditional form of inpatient treatment for such patients. Those who suffer from anorexia are often reluctant patients. Most forms of psychotherapy, however, emphasize on a good relationship between the client and the therapist. It is particularly challenging to work with anorexic patients but if a good relationship can be established, psychotherapy may be effective although many authorities recommend a directive rather than a client-centred approach. Psychotherapy focuses on the patient’s current problems and attitudes and on aspects of the personal history. Most psychotherapists try to encourage healthy eating patterns and to reinforce weight gain, and in some sessions the conversation may focus mostly on eating and body shape but most of the time the focus is somewhere else. The patient will be encouraged to explore and express her feelings towards a wide spectrum of concerns. The themes that are explored include family relationships, attitudes to success and failure, sexual feelings and issues related to control. In many cases it will become apparent that the patient has very low self-esteem, and the therapist may work towards increasing the patient’s self-confidence and positive self-evaluation. Crisp et al. (1991) conducted a controlled study in which anorexic patients who received psychotherapy were compared to those in a control group (these patients were referred back to primary care services). There were three treatment groups. One group of patients received therapy while they were hospitalized. Another received individual psychotherapy on an outpatient basis, and the third received group psychotherapy on an outpatient basis. Patients in all the treatment groups increased in weight significantly more than patients in the control group, and there were no significant differences between any of the treatment groups. This indicates that psychotherapy is a better than no therapy. **Cognitive behaviour therapy** Early on in a treatment programme, cognitive therapy is often used as a means of encouraging the patient to resume a reasonable eating pattern. At that stage, the therapist will usually examine, explore, challenge and restructure cognitions that relate to food and to eating. The focus of cognitive therapy used in a later stage is likely to be more fundamental beliefs about the self, about control and about personal attractiveness or acceptability in the eyes of others. At this stage the cognitive programme may be less behavioural in style and more psychotherapeutic. Thus a cognitive approach may be used to encourage patients to end self-starvation and to modify beliefs which may have played a part in establishing an anorexic condition. **Family-based approaches** Family therapists suggest that anorexia should be understood as a condition generated and maintained within a family system. They point to enmeshment, over-protectiveness, rigidity or the avoidance of conflicts as characteristics of anorexic families, and emphasize the threat to the family façade which may arise when a girl reaches adolescence. Anorexia is seen as the family’s solution to a critical whole-family situation, and family therapy therefore seek to address the underlying dysfunction so that the anorexia is no longer ‘needed’ by the family and can therefore be safely discontinued (Minuchin et al. 1978). The effectiveness of family therapy as a treatment for anorexia has been studied by ** Dare et al (1995) ** with patients from a hospital in London. All the studies have taken form of controlled trials in which families have been assigned at random to one of a number of treatment conditions. To control for variation between therapists, the same therapists give the different treatments. After patients have been admitted to the hospital for weight restoration, they are assigned to a particular form of psychotherapy. The first trial involved a comparison of conjoint family therapy where all family members participate together and supportive individual psychotherapy. Family therapy was shown to be more effective, especially if the anorexia had an early onset, i.e. before the age of 19 and when the condition was of relatively short duration (less than 3 years). After five years, 90% of the patients treated with family therapy were judged to be well, whereas half of those who had received individual therapy were still suffering from an eating disorder. In the second trial, family therapy was compared to individual supportive therapy and individual psychoanalytic therapy. Again, family therapy was shown to have greater therapeutic effect than either of the comparison treatments. In a third trial, conjoint family therapy was compared to ‘family counselling’, in which the therapist worked separately with the parents and with the adolescent patient. Overall, these two forms of treatment proved equally effective, with around two-thirds of the patients either ‘well’ or ‘considerably improved one year after treatment began. However, the third study suggests that it is perhaps not necessary to use the ‘whole family therapy’ approach as originally suggested by family therapist. **Outcome.** The longer-term outcome for anorexia nervosa is highly variable. Some people with a history of anorexia are eventually able to maintain a safe and relatively stable weight. Some follow an oscillating pathway of recovery and relapse. And up to a half go on to develop bulimia (Kreipe et al. 1989). The prognosis is very poor for those who remain untreated and for those who are identified only after their weight has dropped to a dangerous level. The outcome for those who receive treatment at a reasonably early stage in their illness is sometimes said to conform to a rule of thirds, i.e. one-third make a good recovery, one-third recover to some extent and the remaining third show little improvement and remain chronically ill. Certain factors have been identified as predictive of a relatively good outcome. These include the anorexia being relatively ‘mild’, i.e. a short-term illness with comparatively little weight loss, good social relationships during childhood and adolescence (especially within the family), the absence of self-induced vomiting and purging and the ability to eat in front of other people without undue anxiety. It also seems that the outcome may be more favourable for female anorexic patients than for males. // Based on Frude, Neil (1998) Understanding Abnormal Psychology. Blackwell Publishers. // // See also here [] //