Anorexia
By Patrice Scinta
Summer Discovery Program: Exploring Careers in Medicine
Instructor: Steve Anisman
Summer, 1998
In our weight obsessed times, the average adolescent female worries about the size of her thighs, eats food that is low in fat and calories, and exercises frequently to tone her body. Although most people applaud our nation's attempts to become more healthy and physically fit, others are worried about the messages we are sending to our children. They think that celebrities like Pamela Anderson and Tori Spelling have created an unattainable perception of beauty that has resulted in a growing epidemic amongst teenage girls of the eating disorder anorexia nervosa The DSM - IV diagnostic criteria for this illness involves several factors. The first is an outright refusal to maintain a normal body weight for his/her age and height. The body weight they do maintain is 85% or less of their optimal weight. The second factor is an intense fear of gaining weight even though the sufferer is already underweight. They are mentally disturbed and their self esteem is affected by their body weight, size, or shape. The last factor is an absence of three or more consecutive menstrual cycles in postmenarcheal females. If this disorder goes untreated it can result in many severe medical problems such as an irregular heart beat, destruction of teeth, loss of muscle mass, a weakened immune system, permanent loss of bone mass, and even death. Although this disorder is widely reported on and frequently witnessed in our society, there is a great deal of dissention in the medical field as to what the exact causes and proper treatments are. The disorder remains a mystery that baffles and frustrates the family and often the general practitioner of the patient. The purpose of this paper is to discuss some of the currently held theories on the environmental and genetic factors that cause an individual to develop anorexia . The efficacy of the most predominantly accepted treatments will also be reviewed.
Anorexia was first identified in 1873, and even then doctors reasoned that familial factors were important in the development of anorexia nervosa in an individual. Today, it is thought that female, first - degree relatives of patients with anorexia nervosa are five times more likely to develop anorexia than people with no family history of this disorder. It has also been found that patients with a family history of anorexia experience a more severe type of anorexia, which includes a greater amount of weight loss (14.2 kg per meter 2 vs. 15.6 kg per meter 2 ) Clinical research has shown that the genetic contribution to acquiring restricting anorexia only occurs at a young age. Researchers have narrowed the genetic factors down to a few specific components that they believe predispose an individual for developing anorexia. One of the proposed genetic features is a decrease in the functioning of the hypothalamus. It has been shown in studies that the pharmacological blockade of the a - noradrenergic system in the hypothalamus stimulates loss of appetite and weight loss. Research has also discovered that anorectics who have brought their weight back to the average expected body weight (AEBW) but who still exhibit symptoms such as reduced calorie intake maintain a 50 % reduction of norepinephrine levels in their cerebrospinal fluid. However, this idea is considered arbitrary by some investigators because it fails to account for other feeding regulating substances such as insulin, glucagon, endorphins, and estrogen. The relationship between the percentage below ideal body weight and the delay in thyroid hormone peak after the injection of thyroid releasing hormone suggests that the malfunctioning of the hypothalamus is a result of severe weight loss rather than the opposite. Another proposal is a tendency to a high growth rate or obesity factors into the development of anorexia. The whirlpool theory suggested by Marilyn Duker and Roger Slade states that once these certain biological factors cause a person to make the decision not to eat, a downward spiral begins. The whirlpool effects include biological changes that are connected with starvation and progressively reduce the mental capacity of the sufferer. It is this reduction in mental capacity that maintains the decision not to eat. Along with these hypotheses, it is thought that weight loss in individuals who are genetically vulnerable to anorexia triggers the release of certain opiates. The release of these opiates results in an increase in activity and bright - eyed alertness in patients with anorexia nervosa that is contradictory to the sluggishness and retardation experienced by most people during starvation.
There is a general consensus amongst the investigators of anorexia nervosa that certain environmental factors are needed to induce anorexia in an individual who is genetically susceptible to the disorder. Anorexics tend to be perfectionists who have unrealistic expectations of themselves. To them, every action is either a complete success or failure. They are generally very intelligent; and contrary to the belief that anorexics are people who are unable to get a grip on themselves they have more will power, determination, perception, and awareness than most people. Anorexics also tend to come from families that have high expectations for success and little tolerance for failure. They often feel smothered by their families, and think that food is the only aspect of their life that they can control. Parents who put a high value on physical beauty can also contribute to anorexia in their daughters. Social factors have come under fire lately as the predominant cause for eating disorders. Kristin Harrison did a study to investigate if an exposure to thin celebrities causes eating disorder symptomatology. She predicted that an interpersonal attraction to thin media personalities promotes the body dissatisfaction, drive for thinness, perfectionism, and feelings of ineffectiveness that leads to and is a part of anorexia. An interpersonal attraction was defined as a combination of three responses to a character: a feeling of similarity to the character, a longing to be like the character, and actually liking the character. The subjects of the study were two hundred - thirty two female undergraduate students from a large Midwestern university. They were asked to answer on a scale of 0 = never to 4 = regularly how often they watched six popular TV shows at that time (1994): Beverly Hills 90210, Melrose Place, Seinfeld, Northern Exposure, Designing Women, and Roseanne. The research team designated characters from the shows that were thin, fat, and average. A character was considered average if their weight was inconspicuous and not a part of their character makeup. The subjects were given pictures of the six characters chosen from the shows to represent the weight categories along with three pictures of well known models from each category. After reviewing the photos, the subjects were asked to answer on a scale of one to five the following questions, " 1. How much do like this character/model? 2. How similar do you feel to this character/model? 3. How much do want to be like this character/model?" These women were also given the Eating Attitudes Test (EAT) and the Eating Disorders Inventory (EDI), which can assess a wide range of behaviors and attitudes associated with anorexia nervosa. The results showed that most of the respondents were interpersonally attracted to the average sized media personalities, and the attraction to the thin personalities was only slightly greater than that to the heavy personalities. As predicted, it was observed through the EAT and EDI that only the respondents who were interpersonally attracted to thin personalities qualified as anorexics or had general eating disorder symptomatology. Kristin Harrison also suggests that continual exposure to extremely thin models, such as the ones in Calvin Klein advertisements, only causes annoyance in most women. It is only when the media consumer begins to find the personality interpersonally attractive that the real danger begins. Once the girl begins to lose weight, the whirlpool goes into effect and her own body image becomes distorted.
However, not all women with perfectionist tendencies or who are interpersonally attracted to thin media personalities become anorexic. The development of the disorder requires the interaction and timing of a specific combination of several factors. Many researchers believe that a circumstance that rises the mental arousal of someone who is predisposed for anorexia triggers the initiation of this disorder. They often involve a transition period where these already unstable individuals are given increased demands, such as beginning a new school or job. The trigger could also be the breakup of a meaningful relationship and the loneliness that goes along with it.
Once an anorexic's body weight drops below 60% of her average expected body weight (AEBW) she is no longer medically safe. At 50 % of her AEBW, she only has a few days to live because of the dangerous combination of electrolyte imbalance, dehydration, and malnutrition that is occurring in her body. Most doctors would agree that when a patient is in either one of these situations they must be placed in a hospital and started on a refeeding program. This involves the intake of anywhere from 3,000 to 5,000 calories a day and bed rest so that the energy expenditure is kept to a minimum. The food can be given to the patient in several different ways. Nasogastric tube feeding places a tube into the nostril far enough so that the tip is at the back of the throat. After swallowing a large mouthful of water, the end of the tube will curve and slide down the esophagus under its own weight. Liquid diets are generally used for patients who are further along the healing process. This stage requires a great amount of nursing to make sure the patient doesn't hide the drink in some way. An anorexic generally can not or will not eat three normal meals at this time.
After the individual's weight has become 70% of their AEBW, the doctor must make an important decision about how the anorexic's weight will be gained back. They can either try to overcome the anorexic's willful refusal to eat and use whatever medical techniques that they see as necessary, or they can gain the cooperation of the anorexic and attempt to get her involved in organizing her own nutritional recovery.
The first route requires inpatient treatment and generally continues the 3,000 - 4,000 calorie a day diet and bed rest system that was employed while the patient was close to death. This is done as a prerequisite to psychotherapy. The method generally leaves the anorexic feeling abused and causes them to have a general unwillingness to participate in psychotherapy. They want no further contact with the people who forced them to gain weight. This method is also employed in centers called total institutions because they regulate all aspects of an individual's life. The patient is separated from home and their possessions. Their clothes are often taken away so that they won't try to escape. Amenities such as phone calls, letters, reading material, and TV are given only when the patient eats. Both of these coercive methods have a high rate of failure because the patient often does not learn why starving herself is wrong, or if she realizes this she doesn't know how to change her behavior. She merely gains weight, which she can take off again later, and when she is told by friends and family that she looks better it only further assures her that her experience is separate from others. She feels that her control over food makes her special.
When psychotherapy is given along with weight gain, the effects are much more satisfactory. The doctor gives the girl the opportunity to regulate the weight gain herself, so the process may take years to complete. The anorexic must first learn to hold her weight stable, and then she can gradually begin gaining weight at a pace of about one pound per week. The goal of this out patient treatment is not only to make the anorexic gain weight, but also to maintain a sense of personal autonomy.
While many experts on anorexia contend that the only cures for anorexia are food and psychotherapy, there are currently several drugs that are being used in the treatment of the disorder. The most widely used drugs in attempts to generate weight gain are phenothiazines and antidepressants. A.H. Crisp stated that phenothiazine can assist in weight gain during refeeding treatments, especially when the disorder is close to schizophrenia. He also believes that antidepressants are of little use in the treatment of anorexia. Many experts in the field of anorexia would agree with these claims. The drug naloxone was shown to increase weight gain without a change in food intake by inhibiting lipolysis. This drug however does not extinguish the memory of the behaviors associated with anorexia. They are imprinted in the memory mechanism and the "recovered" anorexic can relapse when under the stress of an open - ended agreement.
At the present, anorexia nervosa remains an enigma for the medical field. It seems strange that otherwise extremely intelligent people would make a conscious decision not to eat, but no conclusive evidence has been found that proves this disorder is a physical illness either. Even though doctors are unsure of the causes of and proper ways of treating this disorder, it is vital that a person suffering from anorexia nervosa receives medical attention. The counseling and refeeding techniques that are known today can prevent an individual from dying to be thin.