FREE ESSAY ON ANOREXIA NERVOSA: A COMPLEX DISORDER BOTH

ANOREXIA NERVOSA: A COMPLEX DISORDER BOTH

Anorexia Nervosa: A Complex Disorder Both
Psychologically and Nutritionally
by
Jamie Stone
Introduction
Eating disorders are a cause for serious concern from both a psychological and a
nutritional point of view. They are often a complex expression of underlying problems
with identity and self concept. These disorders often stem from traumatic experiences and
are influenced by society=s attitudes toward beauty and worth (Eating Disorder Resource
Center, 1997). Biological factors, family issues, and psychological make-up may be what
people who develop eating disorders are responding to. Anyone can be affected by eating
disorders, regardless of their socioeconomic background (Eating Disorder Resource Center,
1997). Anorexia nervosa is one such disorder characterized by extreme weight loss. It is
the result of self imposed and severe restrictions of food and fluid intake, a distorted
body image, an intense fear of becoming fat, and a poor self esteem. Besides dieting to
extremes, anorexics often over exercise to lose weight. Anorexics themselves are often
the last to realize how undernourished and underweight they are. Even after reaching a
weight that is dangerously low, they feel good initially, about losing the weight. No
matter how much is lost, anorexics continue to feel fat and desire to lose more weight.
It is this denial that makes it so hard to convince anorexics to seek help (Eating
Disorder Resource Center, 1997). This paper=s focus is to look in more detail at the
psychological and societal factors contributing to anorexia nervosa, as well as the
nutritional and physiological complications that arise for people on such severely
restrictive diets.
Psychological and Societal Contributions
Anorexia Nervosa was first described by an English physician by the name of Richard
Morton in 1689. Until 1914, it was considered a disease that arose from a morbid mental
state and a disturbed nerve force. That year, Dr. Simmonds, a pathologist, found one
woman=s refusal to eat to be the direct result of an anterior pituitary lesion. This
shifted the focus away from the emotional aspects of the disorder to more physiological
and endocrinological terms. It was not until 1938 that anorexia nervosa was once again
considered a largely emotional disorder (Blackman, 1996). In fact, one of the criteria
for the diagnosis of anorexia nervosa according to the manual of The American Medical
Association (DSM IV) is an intense fear of gaining weight or becoming fat, even though
underweight. Another clearly psychological requirement for diagnosis, is a disturbance in
the way in which one=s body weight or shape is experienced, undue influence of body
weight or shape on self evaluation, or denial of the seriousness of the current low body
weight (Blackman, 1996).
Anorexia nervosa may be a primary disorder in which other psychiatric conditions are
secondary, such as depression. It may also be secondary itself to a disorder such as
schizophrenia or co-morbid with obsessive compulsive disorder. As well, it can also be a
component of a personality disorder (Blackman, 1996; Carlat, 1997). The anorexic sufferer
is typically female. Ninety-percent of all cases occur among adolescent girls or young
women but the number of males with the disorder is on the rise (Blackman, 1996; Carlat,
1997; Kinzl, 1997). It is estimated that 1% of girls ages 12-18 meet the criteria for
full blown anorexia and as many as 5-10% have milder forms of such eating disorders if
the criteria is applied less stringently (Blackman, 1996). Anorexics are usually high
achieving youngsters who may be heavily involved in sports (e.g. gymnastics, swimming,
cheer leading, ballet, etc.). These people are often competitive, perfectionistic, with
obsessive compulsive personality features. Fears of growing up or discomfort toward
sexuality may also be precipitating factors (Blackman, 1996). Studies have shown that 75%
of American Women are dissatisfied with their appearance and as many as 50% are on a diet
at any one time. Even more alarming is that 90% of high school junior and senior women
regularly diet, even though only between 10%-15% are over the weight recommended by the
standard height-weight charts (Council on Size and Weight Discrimination, 1996). The
majority of these women do not develop eating disorders; however, 1% of teenage girls and
5% of college-age women do become anorexic or bulimic (Council on Size and Weight
Discrimination, 1996). Perhaps these figures represent the women who are less able to
cope with their bodily dissatisfaction and thus are the ones who take dieting to the
extreme.
The disordered eating behavior usually starts out with a pattern of dieting or particular
food choices, such as avoiding certain foods which are seen as fattening. As the disorder
progresses, anorexics become resourceful in hiding their troublesome behavior and may
start to avoid eating with their families. They may also attempt further weight loss by
compulsive exercising. The condition can become well advanced before parents even notice,
as anorexics may wear many layers of clothes to conceal their thinness. Often the
diagnosis is not made until the person is brought to a clinic for problems such as
physical weakness, lack of energy, excessive sleepiness, and recent poor performance in
school (Blackman, 1996). 
Actually, certain familial relationships seem to be more prevalent among anorexic
sufferers. Studies have shown many anorexic families are enmeshed, overprotective,
conflict avoidant, and as co-opting the anorexic in destructive alliances with one parent
or another. The parents themselves tend to be more affectionate and neglectful than
parents of non anorexic children. The father in particular is often controlling
(Blackman, 1996). Physical and/or sexual abuse are also not uncommon features in families
with anorexics (Carlet, 1996; Kinzyl, 1997). Even though these trends are trends often
seen, there are many anorexic families that do not fit this profile. 
One of the other major contributors to the disorder is society and its values. Anorexics
are sensitive to society=s approval of what is an acceptable weight or body size
(Blackman, 1996). Self worth is equated with a desirable slim appearance. This creates a
vulnerability to eating disorders for people who are especially concerned with meeting
this ideal. Western culture in particular has an obsession with looks. Slim, attractive
people are linked to beauty, success, and happiness. Our society teaches us to value such
superficial standards and bombards us with images of the idealized female body through
mediums such as magazines, films, and television (Blackman, 1996). One only has to watch
television or read the latest magazines and take note of just how few overweight or
average looking people there are appearing in advertisements to verify this fact.
Anorexia nervosa in fact predominates in industrialized developed countries; yet is
extremely rare in less industrialized and non western countries (Blackman, 1996). As
well, immigrants who have migrated to a westernized country have been found to become
more prone to develop eating disorders (Blackman, 1996).
For the sufferer of anorexia, the onset of the disease often begins with a chance remark
by someone important to them, possibly a coach or a friend. They may suggest that they
are getting fat, big, clumsy, or that their performance (if they are athletes) is
suffering (Blackman, 1996). These remarks, as unintentional or innocent as they may seem
to the person making them, only serve to reinforce society=s attitude that gaining weight
is unacceptable. For others, it may will be the media itself that precipitates the
development of the disorder. Some patients cite wanting to look like a favorite film star
or model as their initial motivation to lose weight (Blackman, 1996).
Males With Eating Disorders
Typically, dieting and eating disorders such as anorexia nervosa are associated with
females at or near adolescence. A group that often gets overlooked in the studies are
males. Eating disorders are not rare among males; 10-15% of all bulimic patients are
male, while 0.2% of all adolescent and young males meet the stringent criteria for
bulimia. These figures are similar for anorexia nervosa (Carlat, 1997). Males are now
being studied more frequently to determine whether or not they differ significantly from
females with respect to eating disorders. If males are found to not differ significantly
from females in this respect, then those who support a more biologically based view of
the disease, gain support. Things such as schizophrenia or depression for instance could
then be seen as major determining factors. If however, it is found that certain cultural
and psychological risk factors are the same for both males and females, then the
sociocultural view of eating disorder etiology gains support (Carlet, 1997). Males in
fact do share some similar central features as females who suffer from anorexia; but they
also have their own unique issues with regard to social pressures and vulnerabilities
(Carlet, 1997). Unlike females who typically Afeel fat@, males are often obese to begin
with. Males are more likely to diet to attain goals in a particular sport like wrestling
or swimming. Males also diet to prevent themselves from developing medical complications
witnessed in other family members such as cardiovascular disease and diabetes (Blackman,
1996). In several cases involving males, their profession was found to be clearly related
to the onset of the eating disorder (Carlat, 1997). One patient studied by Carlat et al.
reported taking appetite suppressing pills in an effort to keep slim for acting roles and
within several months he began a pattern of binge eating and self-induced vomiting. In
the same study, which involved 135 males with eating disorders, 22% had anorexia nervosa,
73% were single and 131 were Caucasian. The average age of onset was 19.3 years. The
average education level was 1.6 years of college at the time of their first treatment
(Carlat, 1997). This does not necessarily mean that this group is more susceptible to
developing eating disorders as these results could have been influenced by how the sample
was taken.
With regard to the core concerns about body image and weight, it appears that males with
anorexia may be more similar to their female counterparts than to male bulimic patients
(Carlat, 1997). Like females, Carlat et al. found that male anorexics clearly feared
weight gain and desired a body weight of only 75% of their ideal body weight (Carlat,
1997). Perhaps the biggest finding with males is the high prevalence of
homosexuality/bisexuality in those with eating disorders as compared to the general
population. Recent data estimates 1%-6% of healthy males are homosexual and that only 2%
of females with eating disorders are homosexual (Carlat, 1997). Homosexuality was found
to have a 27% prevalence among male patients with eating disorders however. Anorexic
males in particular were also found more likely to be asexual (defined as having a lack
of interest in sex for a year prior to assessment). This is also a common finding in
females (Carlat, 1997; Murnen, 1997). With anorexia, it is thought to be to due to the
testosterone lowering effect of protein-calorie malnutrition, combined with active
repression of sexual desire (Carlat, 1997). The high rate of homosexuality and
bisexuality among males with eating disorders can serve as evidence for both psychosocial
and biological views of the etiology of eating disorders. Psychosocially, homosexuality
can be seen as a risk factor that puts males in a subculture system that places the same
importance on looks and appearance in men as the larger culture places on women (Carlat,
1997). It is these similar cultural pressures toward thinness that cause eating disorders
(Carlat, 1997). From a biological point of view, it can be argued that brain structure
between homosexual men and heterosexual women are similar (Carlat, 1997), particularly a
tiny precise cell cluster known as the third interstitial nucleus of the anterior
hypothalamus or INAH3. This cluster of cells in gay men was found to be about half the
size of the cluster in straight men which puts them in the same size range as
heterosexual women. This particular part of the hypothalamus has been strongly implicated
in regulating male-typical sexual behavior (Nimmons, 1994). It may be argued then that
homosexual men react to environmental stressors in a biologically feminine way,
increasing their risk of eating disorders (Carlat, 1997). Males, like the females studied
by Carlat et al. , were shown to have high rates of co-morbid major depression, substance
abuse, anxiety disorders, and personality disorders. One year after initially being
treated, 59% still suffered from their eating disorder. (Carlat, 1997). This is a cause
for concern as there are so many concurrent complications that can arise from eating
disorders, especially anorexia nervosa.
Adverse Effects of Anorexia Nervosa
Anorexic patients are often found to suffer from osteoporosis, anemia, and hypotension
(Carlat, 1997). Chronic starvation due to anorexia has also been linked to seizure
activity and fainting attacks (Blackman, 1996). The anorexic often looks pale, tired,
wasted, bradycardia (slow heart rate) may be present, and the skin is cold to the touch.
Another common feature is the presence of fine downy hair on arms and torso. Laboratory
results often reveal quite abnormal values. These values are often caused by dehydration
and severe electrolyte imbalances which can be life threatening. Amenorrhea, or absence
of menstruation occurs in post menarchal girls who lose more than 20% of their expected
body weight (Blackman, 1996; Rock, 1996). Amenorrhea, in fact is another one of the
diagnostic criteria for anorexia nervosa (for females) according to the DSM IV (Blackman,
1996). The absence of menarche is related to the bodies reaction to extreme fat loss and
the non viability of pregnancy under these conditions (Blackman, 1996). Starvation itself
as been shown to induce many hormonal changes in the body as well as inducing mental
states such as anxiety, depression, and even psychosis (Kershenbaum, 1997).
These are just a few of the consequences associated with anorexia nervosa. There are many
others ranging from things as obscure as bilateral foot drop, which was observed in one
15 year old girl (Kershenbaum, 1997), to something as serious as sudden death and even
suicide (Neumarken, 1997). Sudden death is defined as the sudden, unexpected, and
unexplainable occurrence of death. Some of those who died suddenly, did show
abnormalities in ECG recordings days prior to death. As well, upon autopsy, changes in
brain structure and cardia muscles (such as atrophy) were sometimes found (Neumarken,
1997). 
One would question with all of the adverse consequences, why anorexics still diet.
Anorexia produces a *runners high= as does exercise. This is a result of opiate release
in the brain which in turn suppresses appetite and promotes increased levels of activity.
Once anorexic behavior begins and becomes established, it promotes this endorphin
secretion and becomes pleasurable and self reinforcing. The sufferer then is bound to
self starve and the established cycle is no longer deliberate or easily stopped
(Blackman,1996).
Treatment
Treatment comes in the form of psychotherapy, nutritional education, and refeeding.
Nutritional education takes time however as the farther a person is below their healthy
weight, the more their cognitive ability is impaired (Merriman, 1996). The first of the
higher mental functions to be lost is the capacity for abstract thinking. As the
condition progresses, the anorexic may not even be able to assimilate information
(Merriman, 1996). The nutritionist then must carefully plan nutrition education sessions
to make them as meaningful to the person as is possible.
Refeeding is also not a straightforward process as anorexics often find it quite
difficult to gain weight. This is due to an increased diet induced thermogenesis and a
lower metabolic efficiency. Anorexic patients can waste about 50% of the energy of their
food due to this inefficient metabolism at the start of refeeding, making the maintenance
of any gain in weight difficult (Moukadden, 1997). Another study concluded that even with
weight gain after 3 months to a year, it was not enough to maintain a desirable
nutritional status. This was because patients did not reach an adequate body mass index
and their immunological indexes were lower than in control subjects during an entire one
year follow-up (Marcos, 1997). 
Conclusions
From the information presented, one can only imagine just how complex the issues really
are that the anorexic attempts to deal with via dieting. The anorexic may be dealing with
substance abuse, depression, sexual abuse, confusion about their sexual orientation, or
bodily dissatisfaction to name a few. The individual anorexic may be suffering from a
combination of such issues in varying degrees. To what extent, psychological, societal,
and biological factors affect the onset of the disorder is, as of yet, too complex to
determine. It appears to vary from individual to individual, although there are some
features seen more commonly than others. The variability seen with the disorder on an
individual basis is why the anorexic sufferer can not be categorized into a particular
stereotypical group. It is not just the white adolescent girl who is affected. The
disorder affects various other groups as well and is being seen more frequently in groups
it did not typically affect. It has been mentioned how the disorder is becoming more
prevalent among immigrants who move to westernized cultures; yet, the disorder is rarely
ever seen in less developed countries. Males also are being seen more frequently to be
sufferers of this traditionally female disorder. This data seems not to point to a
particular group as being more prone to developing anorexia, but instead points to
society=s unrealistic and unachievable ideals, as encouraging more sensitive, insecure,
or emotionally disturbed individual members of society to lose weight. Weight loss often
provides these people with short lived confidence, and for a while they feel good about
their weight loss and in control of something in their life. They inevitably desire to
feel like this again so they set out to lose more weight. This cycle continues until
someone steps in and helps the sufferer by convincing them to seek help. This can be hard
as the anorexic is usually so far in denial that they are the last to realize just what
shape they are in. The road to recovery is difficult and the body seems to resist any
weight gain during the initial refeeding period. Even after an entire year of treatment,
evidence suggests that recovery has not been achieved and many anorexics still continue
to suffer from their disorder. There are so many complications that anorexia can be
attributed to that it would appear that the quicker a person complies with treatment and
can be recovered, the better. It is quite obvious that anorexia is a complex disorder
that partly involves how one perceives his or her self and what physical standard society
dictates they should live up to. The topic has many areas that require further research
as society has been shown not to be the entire causative factor for the development of
the disorder. It has been shown to be one of them however; so until society becomes more
realistic in the ideals it endorses, it is responsible, at least in part, for the
prevalence of this disorder. 
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