Anorexia Nervosa

Background: Richard Morton first described anorexia nervosa more than 300 years ago, in 1689, as a condition of "a Nervous Consumption" caused by "sadness, and anxious Cares." In 1873, 2 prominent physicians separately described anorexia nervosa; Charles Laségue described it as "a hysteria linked to hypochondriasis," and Sir William W. Gull described it as "a perversion of the ego." This was the same year the disorder received its current name. In the first half of the 20th century, a variety of views of the disorder emerged. Pierre Janet considered anorexia to be a purely psychological disorder. Morris Simmonds proposed that pituitary insufficiency led to weight loss in some patients. Berkman viewed physiological disturbances as secondary to the psychological etiology of the disturbance.

Additional formulations of and insights into anorexia were developed in recent times by several modern pioneers. Bruch viewed self-starvation as a representation of struggle for autonomy, competence, control, and self-respect. Failure of the mother to recognize and confirm the child's independent needs was purported to produce inner confusion in 3 overlapping areas. These areas include a tendency to overestimate body size; an inability to correctly identify internal sensations such as hunger, satiety, affective states, and sexual feelings; and a sense of ineffectiveness characterized by feelings of loss of control.

Mara Selvini Palazzoli developed a view similar to Bruch’s, but Palazzoli postulates that patients with anorexia experience the body as "the maternal object, from which the ego wishes to separate itself at all costs."

Crisp proposed a developmental model, with the psychopathology of anorexia stemming from biological and psychological experiences surrounding the achievement of adult weight. Conflicted about attaining psychological maturity, patients with anorexia use dieting and subsequent starvation as a means to regress back to prepubescent size, hormonal status, and life experience.

Although anorexia historically has been defined by self-imposed starvation, binge eating has been reported as part of the clinical picture over the years. DaCosta and Halmi reviewed 14 studies in which they divided patients with anorexia nervosa into bulimic and nonbulimic subtypes. Patients with bulimia and anorexia nervosa were found to report greater impulsivity, social involvement, sexual activity, family dysfunction, depression, and conspicuous emotional disturbance in general.

Purging behaviors associated with binge eating (ie, induced vomiting and/or laxative use), rather than binge eating, have been viewed to be better indicators for subclassifying anorexia nervosa. Garner et al found that the psychopathology of patients with anorexia who engage in purging behavior is distinguishable from the psychopathology of patients with anorexia who do not purge.

In an effort to describe the "essence" of anorexia nervosa, Sten Theander outlines the common traits of the disorder. These traits include "the marked preponderance of females and young people among the patients; food refusal; the extreme, often life-threatening emaciation, but also the tendency to recovery, and the denial of illness."

Gerald Russell contends the disorder has changed over the last 30-50 years or more. Specifically, Russell notes that the psychological content of anorexia nervosa has shifted to a dread of fatness, which is congruent with the high value society affords thinness in women. Russell also notes that the incidence of the disorder has risen since the late 1950s, likely due to adverse sociocultural factors.

One of the great challenges of the day, and of the future, is how to effectively treat this complex multidimensional psychiatric disorder in the era of managed care.

Pathophysiology:

Definition of problem

Anorexia nervosa is characterized by the individual's refusal to maintain minimally normal body weight, an intense fear of gaining weight, and significant disturbance in the perception of the shape or size of the body. Additionally, postmenarchal females with this disorder are amenorrheic (ie, exhibit the absence of at least 3 consecutive menstrual cycles).

Once the diagnosis has been made, mutually exclusive subtypes can be used to specify the presence or absence of binge-eating/purging behavior. Patients with the restricting type accomplish weight loss primarily through dieting, fasting, or excessive exercise. Regular binge-eating or purging does not occur. Patients with the binge-eating/purging type regularly engage in binge-eating or purging behavior (eg, self-induced vomiting, or misuse of laxatives, diuretics, or enemas). Most individuals in this category engage in these behaviors at least weekly.

Individuals with anorexia who binge or purge have been found to be more likely than those with the restricting type to show problems with impulse control (eg, substance use disorder, emotional lability, sexual activity), have had the illness longer, and are somewhat heavier. Patients with the restrictive type are more likely to be more obsessional, more socially awkward, and more isolated than those with the binge-eating/purging type.

Associated features and disorders may include depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Obsessive-compulsive features related to and unrelated to food also may be present. Additional features may include concerns about eating in public, feelings of ineffectiveness, a strong need to control one's environment, inflexible thinking, limited social spontaneity, and overly restrained initiative and emotional expression.

Frequency:

• In the US: Anorexia nervosa, meeting full Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) criteria, has been found to occur in 1 out of 100-200 females in late adolescence and early adulthood. Individuals who are subthreshold for the disorder are encountered more commonly. Incidence rates have increased in recent years. A familial pattern has been noted.

Age: Although more commonly the illness begins between early adolescence (13-18 y) and early adulthood, earlier-onset and later-onset are encountered. In some patients with early-onset (ie, age 7-12 y), obsessional behavior and depression are common. In a few cases, exacerbations of anorexia nervosa and symptoms similar to obsessive-compulsive disorder have been associated with pediatric infection-triggered autoimmune neuropsychiatric disorders.

• Be aware that illness denial is common. Persons who are anorectic are notoriously unreliable informants.

• Screening for comorbid psychiatric factors, including substance abuse/dependence, mood disorders, social phobia, obsessive-compulsive disorder, and personality disorders (most commonly cluster C) is necessary.

• Be aware that eating disorders are more common among competitive athletes. Female athletes are especially at risk in sports such as gymnastics, ballet, figure skating, and distance running. Males in sports such as bodybuilding and wrestling also are at greater risk. Extreme exercise appears to be a risk factor for developing anorexia nervosa, especially when combined with dieting.

• Treatment ambivalence is common, so acceptance and compassion from the interviewer is important.

• Data may be gathered from collateral sources.

• Structured interviews may assist in information gathering for assessment purposes. Examples include the following:

• Clinical Eating Disorder Rating Instrument (CEDRI)

• Eating Disorder Examination (EDE)

• Interview for Diagnosis of Eating Disorders (IDED)

• Structured Interview for Anorexia and Bulimia Nervosa (SIAB)

• Self-report questionnaires provide a method for obtaining more detailed information regarding various dimensions of eating-related symptomatology and more general psychopathology.

• These serve as screening instruments for the presence/severity of symptomatology.

• The findings help guide treatment planning by identifying issues that require attention.

• Responses may reveal other psychiatric symptomatology.

• They may be repeated, thus helping to assess progress.

• Dimensions for self-report questionnaires and related tools are as follows:

• Body image disturbance

• Body dissatisfaction subscale of the Eating Disorder Inventory (EDI)

• Body Shape Questionnaire

• Maladaptive eating attitudes, behaviors, and cognitions can be elicited using the following:

• Eating Attitudes Test

• Eating Disorder Inventory

• General psychopathology can be assessed using the following:

• Symptom checklist

• Beck Depression Index

• Self-monitoring may involve recording such things as daily times of consumption, what was consumed, and in what quantities.

• Patients need to be encouraged to participate in this activity and to record accurately and immediately after eating (ie, an eating diary).

• Clinicians may develop their own forms or use established forms (eg, IDED).

• Family members and roommates can check reliability.

• Two weeks of monitoring often is recommended before beginning psychotherapy. This can be modified, according to the clinician’s judgment.

• Expect some initial resistance.

Physical:

Table 1. Physical Complications of Anorexia Nervosa

Organ System	Symptoms	Signs	Laboratory Test Results
Whole body	Weakness, lassitude	Malnutrition	Low weight/body mass index, low body fat percentage per anthropometrics or underwater weighing
Central nervous system	Apathy, poor concentration	Cognitive impairment; depressed, irritable mood	CT scan: Ventricular enlargement; MRI: Decreased gray and white matter
Cardiovascular and peripheral vascular	Palpitations, weakness, dizziness, shortness of breath, chest pain, coldness of extremities

• Physical examination

• Along with the physical complications noted, physical examination of patients with anorexia may reveal a number of important issues.

• Appearance may be marked by significantly reduced weight, which, in some cases, may be to the point of emaciation.

• Skin in many patients with anorexia may develop lanugo, characterized by downy soft body hair on the face, volar forearms, and other surfaces of the body. This may be accompanied by a loss of scalp hair. Brittle nails and dry skin may be present with a yellowish discoloration, probably secondary to carotenemia.

• Bone may be affected with osteoporosis and decreased calcium, decreased phosphorus, and decreased magnesium.

• Teeth in patients who engage in purging may have decalcification of the lingual, palatal, and posterior occlusal surfaces due to the effects of the acidic gastric contents of vomit. The amalgams, which are resistant to acid, may end up projecting above the surface of the teeth.

• Cardiovascular
  • Starvation frequently is accompanied by bradycardia and low blood pressure. The bradycardia can be profound at times, despite restricted fluid volume.

  • Conduction abnormalities occasionally are present, possibly resulting from hypokalemia and less frequently resulting from other fluid and electrolyte abnormalities (ie, hypomagnesemia, hypocalcemia, and hypophosphatemia).

  • Cardiomyopathy can result from excessive, aggressive refeeding. The use of ipecac may aid the development of cardiomyopathy.

  • Weight loss also can be associated with the development of mitral valve prolapse.

  • ECG abnormalities may occur, including prolongation of QT interval, which may predispose patients with anorexia to life-threatening arrhythmias, decreased QRS amplitude, nonspecific ST segment changes, and T-wave changes.

• Pulmonary: Spontaneous pneumothorax and pneumomediastinum have been observed, although the pathophysiology of this is not clear.

• Fluid and electrolyte abnormalities may include dehydration, rebound peripheral edema, low sodium, low potassium, low chloride, metabolic alkalosis, low magnesium, and low phosphate.

• Gastrointestinal complications
  • These may include reduced taste, parotid enlargement, esophageal trauma and/or dysfunction, delayed gastric emptying, peptic ulcers, gastric dilatation, superior mesenteric artery syndrome, malabsorption, duodenal dilation, jejunal dilation, damage to the mesenteric plexus due to laxative use, pancreatitis, and liver hepatitis.

  • Metabolic concerns may include impaired glucose tolerance, increased cholesterol levels, beta-hydroxybutyric acid increase, protein deficiency (rare), increased carotene, zinc deficiency (rare), impaired temperature regulation, and sleep deficiencies (less deep sleep, more disrupted sleep).

• Renal system concerns may include prerenal failure (dehydration), dyscontrol of antidiuretic hormone secretion, hypokalemic nephropathy, and renal stones.

• Endocrine system concerns may include abnormal hypothalamic-pituitary-gonadal axis, abnormal hypothalamic-pituitary-adrenal axis, abnormal menses, and delayed puberty.

• Hematological system concerns may include anemia, leukopenia, thrombocytopenia, and abnormal cytokines.

• Neurological system: Electroencephalogram, CT scan, and MRI generally demonstrate enlarged ventricles and increased ventricle-brain ratios in patients with anorexia when compared to age-matched and sex-matched controls. These abnormalities generally normalize with weight gain.

• Mental status

• Importantly, note that anorexia nervosa is a multifaceted disorder that requires comprehensive multidimensional assessment. Furthermore, anorexia nervosa is characterized by considerable heterogeneity in symptomatology and comorbid psychopathology (ie, mood disorders, anxiety disorders, personality disorders, and substance abuse disorders). Nevertheless, some general comments may be made about what to observe for when evaluating the mental status of these patients.

• Orientation: Generally speaking, patients with anorexia typically are well oriented to time, person, and place and usually have reasonably good reality testing.

• Affect often is depressed.

• Appearance usually is characterized by being well-groomed and appropriately dressed. Commonly, females wear loose clothing designed to disguise their emaciation, despite the fact that the patient is convinced she is overweight.

• Hallucinations and formal delusions are not commonly present. However, body image disturbance frequently is present and, in some cases, may border on delusional. Multiple facets of body image disturbance may include body image distortion (ie, weight over estimation), body image dissatisfaction, and body image avoidance. Delusional thinking about appearance may be present when the person has complete conviction about distortions of the reality of her or his actual appearance. Delusional thinking in patients with anorexia usually is confined to situations that draw attention to appearance.

• Suicide may occur in patients with anorexia. Depression, which is an obvious risk factor, commonly is associated with the disorder. Death may result from increasing malnutrition due to neglect or active suicide. Follow-up studies report that half the mortality observed in this population is the result of suicide.

Causes: The etiology of anorexia nervosa is thought to be a combination of genetic, neuroendocrine, physiological, and psychosociological influences.

• Genetic: Specific genetic factors appear likely to be important in the etiology of anorexia nervosa; however, what this trait may be is unclear.

• Twin studies have shown the disorder to run in families.

• Additional abnormalities in 5-hydrocytryptamine (5-HT), noradrenaline, and corticotropic-releasing hormone (CRH) function have been observed in patients who have recovered from anorexia.

• Neuroendocrine: A substantial number of abnormalities of hormone regulation have been described in patients with anorexia nervosa.

• One hypothesis postulates that hypothalamic abnormalities (eg, neurotransmitter disturbances) are a primary cause of dysfunctional eating and neuroendocrine dysregulation in anorexia. This theory has not been substantiated.

• The starvation hypothesis postulates that abnormal hormone and neurotransmitter regulation result from reduced caloric intake, suggesting neurotransmitter and neuroendocrine changes in patients with anorexia appear to be an adaptation to a state of starvation.

• Physiological: Some physiological features have been proposed to act to sustain fasting in persons who are anorectic, although these starvation consequences are not viewed to precipitate the disorder. Several hypotheses have been proposed.

• Gastric emptying is delayed in persons who are anorectic and who are restricting their diet.

• Levels of cholecystokinin (CCK), a brain-gut peptide with established roles in the modulation of both food intake and gastric emptying, differ in the plasma of patients with eating disorders and in controls.

• Patients with anorexia rate satiety higher whether gastric emptying is prolonged or not.

• Implications: Altered gastric emptying sets off a pathophysiologic reaction in patients with anorexia, which helps sustain a psychosocially induced commitment to dieting. Renourishment may be an important first step in treatment.

• Psychological: A variety of psychological, sociological, and family influences have been hypothesized to influence the development of anorexia nervosa.

• Psychodynamic theories view anorexia as a failure to separate, individuate, and develop autonomy from the primary caregivers. Research on normal female development proposes that the female personality develops through attachment to others. The female confirms her worth through interpersonal relationships. Cultural changes have led women to devalue relationships in favor of autonomy and independence. Steiner-Adair proposes that the incidence of eating disorders has erupted due to an unrealistic emphasis on autonomy in women. The well-rounded mother is associated with mothering and interdependence. Thus, a person with anorexia, by rejecting symbolic parts of her body, is colluding with the current cultural norm.
  • Self-psychology theories: Geist proposed the mother of a child with anorexia allowed identification by the daughter but was unable to express any thoughts or feelings different from her own. Subordinating her self-needs to her mother's needs, the child turns to the father for mirroring and empathy. This bond becomes threatened by sexual maturation, which explains, in part, the onset of symptoms in adolescence.

  • Psychoanalytic theory adheres to the notion that symptoms serve as a defense, which masks an underlying core set of more primitive issues and dynamics. One such central issue is a fear of and resistance to growing up. Beneath this issue, psychoanalytic folklore describes an even more primitive core dynamic known as oral impregnation. In oral impregnation, the female believes if semen is swallowed she will become pregnant. In fact, fear of fatness has been viewed as a rejection of any possible pregnancy. Once the underlying core dynamics are recovered and made conscious (ie, the return of the repressed), the anorexic symptoms reportedly dissipate.

• Family theories view eating disorders as a method used by the female patient as a cry for help for a conflicted and dysfunctional family. Anorectic families have been described as enmeshed, vacillating between overprotectiveness and abandonment. Minuchin noted that the maintenance of the symptomatic child often defused parental conflicts, and when the symptomatic child matured, the balance of the family became disrupted.

• Cognitive-behavioral theories: Anorexia nervosa is conceptualized as a learned behavior maintained by positive reinforcement. The individual utilizes excessive dieting to lose weight and, subsequently, is reinforced by peers and society. Being overweight receives negative reinforcement, disapproval, and sometimes ridicule. Reinforcement for weight loss can become so powerful that the individual maintains the anorexic behavior despite threats to health and well-being.

• Media influences: Brumberg (1988) reports that a multitude of social pressures have been promoting dietary restraint, ie, books and magazines touting keys to caloric counting, the fashion industry promoting slimness, the television and film industry's message that thinness is associated with sexual allure and professional success, and the emphasis on physical fitness and athleticism. Anorexia has been, in fact, arguably described as an extension of determined dieting.

• Complete blood count

• Chem-7 (chlorine, carbon dioxide, potassium, sodium, BUN, creatine, glucose, calcium)

• Beta human chorionic gonadotropin (bHCG)

• Consider extended chemistries to include total protein, liver function tests, and creatine kinase (CK)

• Urinalysis

• Fecal occult blood

• Ethanol and dangerous drug screen

• Serum erythrocyte sedimentation rate (ESR) and thyroid function tests - Unlikely to alter emergency department management but may be sent from that department

Imaging Studies:

• Brain imaging - Increase in ventricular-brain ratio secondary to starvation often observed

• Chest and abdominal x-rays - May be indicated

• Electrocardiogram

Consultations: An important prognostic indicator is an individual’s ability to develop a constructive attachment to the therapist.

• Societal concerns with thinness

• Providing knowledge to the general public about the dangers of dieting and anorexia nervosa

• Emotional problems of female adolescents and young adults (because they are the high-risk group)

• Secondary prevention objectives are the following

• Successful early recognition

• Effective early intervention

Patient Education:

• Providing knowledge to the public about the dangers of dieting and anorexia nervosa may help in prevention.

• Eating disorders are multifaceted behavior problems that require a multidimensional approach. Assessment of the family is important whenever possible to include education about the disorder. Interviews, self-report questionnaires, and self-monitoring may prove useful for providing an organizational framework to guide the assessment process.

Medical/Legal Pitfalls:

• Patients who have been sexually abused or who have otherwise been the victims of boundary violations are prone to stir a profound need to rescue the patient, which can occasionally result in a loosening of the therapeutic structure, loss of therapeutic boundary-keeping, and a sexualized countertransference reaction. In some cases, these countertransference responses have led to overt sexual acting out and unethical treatment on the part of the therapist, which may compromise treatment and also severely harm the patient. Clear boundaries are critical in the treatment of all patients with eating disorders, not only those who have been sexually abused, but also those who may have experienced other types of boundary intrusions regarding their bodies, eating behaviors, and other aspects of the self by family members and others.

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