ANOREXIA NERVOSA  DSM IV 307.10

EXPLANATION

Anorexia Nervosa is an unrealistic fear of becoming fat.  It is much more prevalent among females than males, and particularly among adolescent girls.  Early signs include excessive dieting, exercise usually beyond any normal reasonable level, and significant weight loss.  It may also be first evidenced when there is a failure to gain weight during a period of growth in adolescents.  There is usually an excessive preoccupation with food, calories, and food preparation.  In young adolescent girls, excessive dieting can also lead to severe menstrual irregularity. While it is common for teenagers to diet, they will usually give up the diet after a few days or weeks.  Those who go on to develop anorexia usually persist to the point of emaciation and ignore warnings from family and friends.  The disorder almost always occurs in adolescent girls and young women (less than 10% of the cases occur in males).  In a typical case, an adolescent who is normal weight or slightly overweight will begin to eliminate snack foods and high calorie foods from her diet.  Eventually, her food restrictions expand until they become increasingly stringent.  Very often, fanatic exercise, obsessive calorie counting, and going for very long periods accompany the dieting without eating.  In many cases, the individual may encourage others to eat, but avoid eating herself.  This food restriction results in a progressive loss of body fat.  In more serious cases self-induced vomiting, inappropriate use of laxatives and diuretics are commonly used to speed up the weight loss.  The specific cause of anorexia nervosa is not clearly understood.  It is currently believed that multiple factors play a role.  Psychological factors such as fear of sexuality, family pressures, and past negative experiences may also be a factor.  Often these girls have some compulsive personality characteristics and may have been at least slightly overweight during some period of childhood.  They tend to be strongly influenced by social pressures that emphasize the desirability of extreme thinness and encourage the dieting process. Psychoanalytic theory suggests that these individuals may have a developmental arrest at a very early childhood years.  The issues of trust, autonomy, and separation vs. individuation may be unfulfilled and the individual remains in the independent position.  The symptoms are thought to be associated with the perceived loss of control in some aspect of life.  This issue of control becomes the overriding factor in the family of the patient with an eating disorder.  The typical family consists of a passive father, a domineering mother, an overly dependent child.  There is a high value placed on perfectionism in this family and the child believes she must satisfy the standard. Some therapists feel that the issue in females centers on the father-daughter relationship and that anorexic girls have an extreme need to obtain approval from their fathers.  Some biological theories suggest that the causes of these disorders may arise from neuro-endocrine problems within the hypothalamus gland.  There is some evidence to suggest that some individuals may have a genetic predisposition that usually becomes apparent at the time of puberty.  Therapists report that these individuals tend to find an unrealistic pleasure in weight loss and also tend to deny self-pleasure in other areas.  They may have a hysterical or obsessive personality style, tend to have a distorted or unrealistic body image. Usually, they report that they are fat regardless of weight, tend to perceive themselves at fat even when they are significantly below normal body weight for their size. These individuals tend to be intelligent, usually were good students, and often from an upper middle class family.  They usually have a history of being quiet and cooperative as children. Disturbed sleep patterns are also commonly reported, especially early morning insomnia. Complaints include feelings of fatigue, feelings of being hyper and/or anxious, feelings of being cold even when the room is obviously warm, denial or loss of sexual interests. These individuals may also experience frequent infections, which usually is indicative of a depressed immune system.

TREATMENT

In most instances psychotherapy, diet counseling, and counseling for the parents all are recommended while the adolescent with anorexia remains at home.  When the weight loss is out of control and dangerous practices, such as vomiting, use of laxatives, and use of diuretics begin to show signs of physical harm hospitalization becomes necessary for more intensive treatments.  In individual therapy these individuals tend to be very resistant to initiating change and need to explore underlying issues, which cause them to distort their body image and cause excessive concern with body weight.  In addition, they also need to lessen their need to be “in control” and develop a more relaxed and less perfectionist and obsessional orientation.