Anorexia is a mental disorder that belongs to the group of eating disorders, characterized by non–acceptance of the body image, refusal of food, the creation of obstacles to its assimilation and stimulation of metabolism in order to reduce weight. The main symptoms are avoidance of eating, limiting portions, exhausting physical exercises, taking drugs that reduce appetite and accelerate metabolism, weakness, apathy, irritability, physical ailments. Diagnosis includes clinical interview, observation, and psychological testing. Treatment is carried out by methods of psychotherapy, diet therapy and drug correction.
Translated from ancient Greek, the word “anorexia” means “lack of appetite for food.” Anorexia nervosa often accompanies schizophrenia, psychopathy, metabolic diseases, infections and gastrointestinal diseases. It may be a consequence of bulimia or precede it. The prevalence of anorexia is determined by economic, cultural, and individual-family factors. In Europe and USA, the epidemiological indicator among women aged 15 to 45 reaches 0.5%. Worldwide figures range from 0.3 to 4.3%. The peak incidence is observed among girls 15-20 years old, this group of patients is up to 40% of the total number of patients. Anorexia is rare among men.
Causes of anorexia
The etiology of the disease is polymorphic. As a rule, the disease develops with a combination of several factors: biological, psychological, micro- and macrosocial. Girls from socially prosperous families, distinguished by the pursuit of perfection and having a normal or increased BMI, are at high risk. Possible causes of the disease are divided into several groups:
- Genetic. The likelihood of illness is determined by several genes regulating neurochemical factors of eating disorders of behavior. To date, the HTR2A gene encoding the serotonin receptor and the BDNF gene affecting the activity of the hypothalamus have been studied. There is a genetic determinism of certain character traits predisposing to the disease.
- Biological. Eating behavior is more often disturbed in people with overweight, obesity and early onset of menarche. It is based on the dysfunction of neurotransmitters (serotonin, dopamine, norepinephrine) and excessive production of leptin, a hormone that reduces appetite.
- Microsocial. An important role in the development of the disease is played by the attitude of parents and other relatives to nutrition, overweight and thinness. Anorexia is more common in families where relatives have a confirmed diagnosis of the disease, where neglect of food, refusal to eat is demonstrated.
- Personal. Individuals with obsessive-compulsive personality type are more susceptible to the disorder. The desire for thinness, starvation, exhausting loads are supported by perfectionism, low self-esteem, insecurity, anxiety and suspiciousness.
- Cultural. In industrially developed countries, thinness is proclaimed one of the main criteria of a woman’s beauty. The ideals of a slim body are promoted at different levels, forming the desire of young people to lose weight in any way.
- Stressful. The death of a loved one, sexual or physical violence can be a trigger for anorexia. In adolescence and at a young age, the reason is uncertainty about the future, the inability to achieve the desired goals. The process of losing weight replaces the areas of life in which the patient fails to realize himself.
The key mechanism for the development of anorexia is a painful distortion of the perception of one’s own body, excessive concern about an imaginary or real defect – dysmorphic phobia. Under the influence of etiological factors, obsessive, delusional thoughts about excess weight, one’s own unattractiveness, ugliness are formed. Usually the image of the bodily “I” is distorted, in reality the patient’s weight corresponds to the norm or slightly exceeds it. Emotions and behavior change under the influence of obsessive thoughts. Actions and thoughts are aimed at weight loss, achieving thinness.
Strict nutrition restrictions are introduced, the food instinct and the instinct of self-preservation are inhibited. The lack of nutrients activates physiological defense mechanisms, metabolism slows down, the secretion of digestive enzymes, bile acids and insulin decreases. The process of digesting food first causes discomfort. In the later stages of anorexia, the assimilation of food becomes impossible. There is a state of cachexia with a risk of death.
During anorexia, there are several stages. Not the first, initial, patient’s interests are gradually changing, ideas about the beauty of the body and its attractiveness are distorted. This period lasts for several years. Then comes the stage of active anorexia, characterized by a pronounced desire to lose weight and the formation of appropriate behavior. At the final, cachectic stage, the body is exhausted, the critical thinking of the patient is disrupted, and the risk of death increases. Depending on the clinical signs , there are three types of the disease:
- Anorexia with monothematic dysmorphophobia. The classic variant of the disease is a persistent idea of losing weight supported by appropriate behavior.
- Anorexia with periods of bulimia. Periods of fasting, severe food restriction alternate with episodes of disinhibition, decreased focus, in which gluttony develops.
- Anorexia with bulimia and vomitomania. Fasting is periodically replaced by gluttony and subsequent provocation of vomiting.
Symptoms of anorexia
A mandatory symptom of the disease is a conscious restriction of the amount of food consumed. It can manifest itself in different forms. In the early stages of the disease, patients lie to others about the feeling of fullness before it occurs, chew food for a long time to create the appearance of its prolonged and abundant consumption. Later, they begin to avoid meetings with relatives and friends at the dinner table, find a reason not to attend family dinners and lunches, talk about an alleged disease (gastritis, stomach ulcer, allergies) that requires a strict diet. At a late stage of anorexia, complete cessation of nutrition is possible.
To suppress appetite, patients resort to taking chemicals. Psychostimulants, some antidepressants, tonic mixtures, coffee and tea have anorexic effect. As a result, addiction and addictive behavior are formed. Another widespread sign of anorexia is attempts to boost metabolism. Patients train a lot, actively visit saunas and baths, wear several layers of clothing to increase sweating.
To reduce the absorption of food, patients artificially induce vomiting. They provoke an emetic act immediately after eating, as soon as it is possible to get into the toilet room. Often, this behavior occurs in social situations when it is impossible to refuse to eat with other people. At first, vomiting is induced mechanically, then it occurs independently, involuntarily when it gets into a suitable environment (in a toilet, a secluded room). Sometimes, to get rid of fluids and food as soon as possible, patients take diuretics and laxatives. Diarrhea and diuresis can gradually become the same involuntary acts as vomiting.
A common manifestation of behavioral disorder is a food excess, or a food “binge”. This is an uncontrolled attack of consuming a large amount of food in a short period of time. With a food excess, patients cannot choose products, enjoy the taste and regulate the volume of what they eat. The “binge” takes place alone. It is not always associated with a feeling of hunger, it is used as a way to calm down, relieve tension, relax. After gluttony, feelings of guilt and self-hatred, depression and suicidal thoughts develop.
Without psychotherapeutic and medical assistance, anorexia leads to a variety of somatic diseases. Most often, young people experience growth retardation and sexual development. Pathologies of the cardiovascular system are represented by severe arrhythmias, sudden cardiac arrest due to a deficiency of electrolytes in the myocardium. Patients’ skin is dry, pale, pasty and edematous due to a lack of proteins. Complications from the digestive system are chronic constipation and spastic abdominal pain. Endocrine complications include hypothyroidism (hypofunction of the thyroid gland), secondary amenorrhea in women, infertility. Bones become brittle, fractures become more frequent, osteopenia and osteoporosis develop. Substance abuse and depression increase the risk of suicide (20% of all deaths).
Anorexia is an independent nosological unit and has clear clinical signs that are easily recognized by psychiatrists and psychotherapists. Diagnosis is characterized by a high level of consistency between clinicians, reliable, but can be complicated by patients’ dissimulation – conscious concealment, concealment of symptoms. Differential diagnosis involves the exclusion of chronic debilitating diseases and intestinal disorders, sharp weight loss against the background of severe depression.
The diagnosis is established on the basis of the clinical picture, in some cases psychodiagnostic questionnaires (Cognitive behavioral patterns in anorexia nervosa) are used. Anorexia is confirmed in the presence of the following five signs:
- Body weight deficiency. Patients’ weight is less than normal by at least 15%. The BMI is 17.5 points or lower.
- Patient initiative. Weight loss is caused by the active actions of the patient himself, and not by somatic diseases or external situational conditions (forced hunger). Avoidance, avoidance of meals, open refusals to eat, provocation of vomiting, taking medications and excessive physical exertion are revealed.
- Obsession and dysmorphic phobia. With anorexia, there is always dissatisfaction with the patient’s body, an inadequate assessment of weight and appearance. The fear of obesity and the desire to reduce weight become super-valuable ideas.
- Endocrine dysfunction. Hormonal disorders affect the hypothalamus-pituitary-gonadal axis. In women, they are manifested by amenorrhea, in men – loss of libido, decreased potency.
- Delayed puberty. At the onset of anorexia at puberty, secondary sexual characteristics are not formed or are formed late. Growth stops, the mammary glands do not increase in girls, the genitals remain juvenile in boys.
The intensity and duration of therapy depends on the severity of the pathology, its causes, the age of the patient, his mental and physical condition. Treatment can be carried out on an outpatient or inpatient basis, sometimes in an intensive care unit, aimed at restoring somatic health, forming an adequate opinion about one’s own body, normalizing the diet. Comprehensive care for patients includes three components:
- Diet therapy. The nutritionist tells the patient and his relatives about the importance of sufficient intake of nutrients, explains the needs of the body and the consequences of fasting. The medical menu is compiled taking into account the taste preferences of the patient. To restore normal nutrition and weight gain, the caloric content of the diet increases gradually over several months. In severe cases, glucose solutions are first administered intravenously, then the patient begins to consume nutritional mixtures and only after that goes to regular food.
- Psychotherapy. The most effective direction is cognitive-behavioral psychotherapy. At the initial stage, conversations are held during which the features of the disease, its possible consequences, and the patient’s choice are discussed. A positive perception of personality and body image is formed, anxiety is reduced, internal conflict is resolved. At the behavioral stage, techniques are being developed and mastered to help restore a normal diet, learn to enjoy food, movement and communication.
- Medical correction. To accelerate puberty, growth and strengthening of the bones of the skeleton, replacement therapy with sex hormones is prescribed. H1 histamine blockers are used for weight gain. Neuroleptics eliminate obsessive-compulsive symptoms and motor arousal, contribute to weight gain. Antidepressants are indicated for depression, SSRIs are used to reduce the risk of relapse in patients with restored nutrition and weight gain.
Prognosis and prevention
The outcome of anorexia is largely determined by the time of the start of therapy. The earlier treatment is started, the more likely a favorable prognosis is. Recovery is more likely to occur with a comprehensive therapeutic approach, family support and elimination of factors that provoke the disease. Prevention should be carried out at the level of the State, society and family. It is necessary to promote a healthy lifestyle, sports, balanced nutrition and normal weight. In the family, it is important to maintain the traditions of sharing food associated with positive emotions, teach children how to cook balanced meals, and form a positive attitude to appearance.
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