Anorexia Nervosa
Popular culture and body image
Some of you may recall the emaciated image of Nicole Richie on the cover of several tabloids awhile ago. Of course, that led to speculation that she may have anorexia nervosa. But is it not uncommon for many of our female celebrities, whether actresses or models, to be super-thin. It is not surprising, given the undue value that is placed on thinness in the western cultures.
How common are eating disorders?
Anorexia nervosa is one of the three most common eating disorders in the U.S.A. The other two are: bulimia nervosa and binge-eating disorder. The symptoms of anorexia nervosa appear early, usually between the ages of 11 and 13. In this country 1 or 2 out of every 100 kids struggle with some form of eating disorder. It is also estimated that 42% of first-to third-grade girls want to be thinner and 81% of 10 year olds are afraid of being fat. More than 90% of those with eating disorders are women.
The story of Gabriella
I first met Gabriella* when she was 19 and under my care at the psychiatric ward of a local hospital. She was admitted to the hospital because she had become depressed and suicidal over the last several months. At 5’ 3” and weighing just 80lbs, Gabby believed she was fat! Gabby came from a close-knit family – her parents were first generation Italians and she had one younger sister, age 16. She had just moved from home to attend college and had started dating for the first time. The pressure of school, social life and being away from her family for the first time intensified her insecurity about her body image. Although she kept restricting her diet and increasing her exercise time, she remained concerned about her appearance. She became withdrawn and her academic performance suffered. A feeling of dejection set in and Gabby was suddenly thinking about ways to end her life. Fortunately, her roommate at college called her parents who brought her back home. She was taken to her internist who was alarmed by her level of malnutrition and referred her for inpatient psychiatric treatment.
Gabby described herself as a perfectionist ever since she was 6 or 7 years old. She believed her parents wanted her to be ‘perfect’ as she was the older of the two sisters. She also stated that between her two parents, her father was the most demanding. Around age 10, Gabby began ‘feeling fat’. She recalled her family religiously ate supper together, but often she would make excuses not to eat with them. She also joined the gymnastic team at school, so she could exercise regularly. She was able to hide her obsession with her body image until she was a sophomore in high school when her parents noticed Gabby was often fasting and not eating much. Despite family concerns and insistence, Gabby refused to see a health professional.
While in the hospital, Gabby was found to be in poor physical condition. She seemed to be in mild heart failure, and she had also developed swollen joints, anemia and dry skin. A team of internists, dieticians, therapists and psychiatrists provided concerted treatment for several weeks before Gabby began to recover both physically and emotionally.
So, how can we recognize anorexia nervosa in someone?
The following are some of the tell-tale signs of anorexia nervosa:
Intense fear of gaining weight.
Distorted view of body size and/or shape.
Unusual eating habits such as avoiding meals, dieting, fasting, sticking to only a few food items, eating very small meals, weighing food before eating, counting calories on anything eaten, etc.
exercising excessively.
In addition to the above symptoms, for somebody to be diagnosed with anorexia nervosa, he/she must:
Weigh at least 15% below for age and height.
Show refusal to maintain minimum normal body weight.
Miss at least 3 consecutive menstrual cycles, if a female of child-bearing potential.
Co-morbid psychiatric conditions
It is important to realize that people with anorexia nervosa often have other emotional disorders which need to be treated as a part of overall treatment strategy. The most common co-occurring conditions include major depression, obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, etc.
Medical complications of anorexia nervosa
Slow heart rate
low blood pressure
Heart Failure
Brittle hair and nails
Dry and yellow skin
Anemia
Swollen Joints
Reduced muscle mass
Loss of Bone density (Increased risk of fractures)
What is the Best way to treat anorexia nervosa?
The most important goal is to restore a healthy body weight. The best approach in treatment is a multi-disciplinary approach i.e. treatment team should consist of psychiatrists, therapists, internists and nutritionists. The first step in treatment, depending on the severity of symptoms may be hospitalization (as was the case with Gabriella). Individual and family psychotherapy, cognitive-behavioral therapy, supportive group therapy and self-help groups are all useful. Psychotropic medications are typically not very effective in treating anorexia nervosa, but sometimes selective serotonin reuptake inhibitors (SSRI’s) may be useful. Any co-occurring psychiatric condition should be properly treated.It is known that the earlier the treatment is offered the better the long-term outcome.
* Name has been changed to protect patient’s privacy.
The purpose of this article is for educational purposes only. It is not intended to diagnose or treat any medical or psychiatric issue. Dr. Rakesh Ranjan is a practicing psychiatrist and a researcher. He is a recipient of several research awards and has authored several peerreviewed journal articles and book chapters on psychiatric illnesses and their treatments. He is a national speaker for several organizations and serves on the medical advisory board for the NAMI of Greater Cleveland. If you or a loved one is experiencing any symptoms that would lead you to believe that there could be a mental imbalance, please email your questions to Dr. Ranjan at askthedoctor@charakresearch.com. Each Wednesday, Dr. Ranjan will address some of these questions in this column. All contact info will be kept confidential.