Anorexia nervosa : Symptoms & Treatment

Anorexia nervosa is a type of eating disorder (ED), just like bulimia and binge eating.

The person who suffers from anorexia nervosa fights a fierce and dangerous battle against weight gain. They are the victims of many unreasonable fears that can be likened to true phobias related to the consequences of eating, such as gaining weight or becoming obese. The result is an obstinate and often dangerous food restriction.

The control that the anorexic person has over her food is excessive and permanent. Most of the time, the appetite is preserved but the person fights against the need and desire to eat. She imposes on herself a gradual weight loss that can go as far as emaciation (extreme thinness).

At the heart of anorexic behaviours, there is a real phobia of weight gain, so intense that it pushes the person to avoid situations or behaviours that could lead to weight gain: eating unfamiliar foods, eating without physical exercise, etc. As a result, the person gradually loses weight, but the satisfaction they feel is short-lived and they quickly seek to lose weight again.

The person’s perception of his or her body is distorted; this is called dysmorphophobia. These maladaptive behaviors will lead to more or less serious medical complications (malaise, panic attacks, amenorrhea….) and will cause the person to become socially isolated.

Anorexia or anorexia nervosa?

The term anorexia is abused to refer to anorexia nervosa but anorexia nervosa is a medical entity in its own right. Anorexia is a symptom that can be found in many pathologies (gastroenteritis, cancer, etc.) that corresponds to the loss of appetite. In anorexia nervosa, the appetite is preserved but the person refuses to eat.

Causes


Anorexia nervosa is a widely studied eating disorder. The exact causes of the disorder are complex and often interrelated.

Researchers agree that many factors are involved in the development of anorexia nervosa, including genetic, neuroendocrine, psychological, familial and social factors.

Although no gene has been clearly identified, some studies point to a family risk. If a female member of the family suffers from anorexia, there is a 4-fold greater risk11 that another woman in that family will suffer from the disorder than in a “healthy” family.

Another study conducted on identical twins (monozygotic) showed that if one of the twins suffers from anorexia, there is a 56% chance that her twin will also be affected. This probability decreases to 5% if they are different twins (dizygotic)1.

Endocrine factors such as hormone deficiency seem to be at play in this disease. The decrease of a hormone (LH-RH) involved in the regulation of ovarian function is put forward. However, this deficit is observed when there is a loss of weight and the LH-RH level returns to normal with the regaining of weight. This disorder would therefore seem to be a consequence of anorexia rather than a cause.

At the neurological level, numerous studies point to a serotonin dysfunction. Serotonin is a substance that ensures the passage of the nervous message between neurons (at the synapses). It is notably involved in the stimulation of the satiety center (area of the brain that regulates appetite). For many reasons that are not yet understood, there is a decrease in serotonin activity in people with anorexia2.

Psychologically, many studies have linked the onset of anorexia nervosa to negative self-esteem (feelings of inefficiency and incompetence) and a strong need for perfectionism.

Hypotheses and analytical studies find certain constants in the personality and feelings experienced by anorexic people. Anorexia often affects young people who avoid situations of even slight danger and who are very dependent on the judgment of others. Psychoanalytical writings often evoke a rejection of the body as a sexual object. These adolescents would unconsciously like to remain little girls and would have difficulties to build an identity and to acquire autonomy. The disorders caused by eating disorders affect the body which “regresses” (absence of menstruation, loss of shape with weight loss, etc.).

Finally, studies carried out on the personality of people affected by anorexia, find certain types of personality more affected by this pathology such as: avoidant personality (social inhibition, feeling of not being up to the task, hypersensitivity to negative judgment of ‘others …), the dependent personality (excessive need to be protected, fear of separation, …) and the obsessive personality (perfectionism, control, rigidity, attention to detail, scrupulous attitude, …). 

At  the cognitive level , studies highlight automatic negative thoughts leading to false beliefs often present in anorexics and bulimics such as “thinness is a guarantee of happiness” or “any fat gain is bad”.

Finally, anorexia is a pathology that affects the population of industrialized countries more. Sociocultural factors therefore play an important place in the development of anorexia. The social criteria of beauty conveyed by young models with particularly thin and almost asexual bodies largely influence our adolescents in search of identity. The cult of thinness is omnipresent in the media which “sells” us endlessly a profusion of miracle diets and often advocates weight control for the length of a magazine cover before, during and after the holidays and the summer holidays.

 Associated disorders

There are mainly psychopathological disorders associated with anorexia nervosa. However, it is difficult to know if it is the onset of anorexia that will lead to these disorders or if the presence of these disorders will lead the person to become anorexic.

According to some studies , 4,5 , the main psychological disorders associated with anorexia are:

  • obsessive-compulsive disorder (OCD) which affects 15 to 31% of anorexics
  • social phobia 
  • depression that would affect 60 to 96% of anorexics at some point in the illness 
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Extreme periods of fasting and compensatory behaviors (purges, use of laxatives …) lead to complications that can cause serious kidney, heart, gastrointestinal and dental problems.

 Prevalence

Described for the first time with a case study in 1689 by Richard Morton, it was not until the 1950s to have a more detailed description of anorexia nervosa thanks to the important work of Hilde Bruch on this subject. 

Since then, the incidence of the disease has steadily increased. According to recent studies, 

the global prevalence of anorexia in the female population is estimated at 0.3%, with high mortality (between 5.1 and 13%). It would affect women 10 times more than men , 7,8 .

 Diagnostic

Psychopathological Assessment
To make a diagnosis of anorexia nervosa, various factors must be observed in a person’s behavior.
In North America, the usual screening tool is the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) published by the American Psychiatric Association. In Europe and elsewhere in the world, healthcare professionals generally use the International Classification of Diseases (ICD-10).
In summary, to evoke an anorexic disorder, it is necessary to assess the presence of several criteria, the main one being a refusal to maintain a normal weight.. Usually, the anorexic person refuses to stay at 85% of their ideal weight (obtained from height and bones). There is also an intense or even phobic fear of gaining weight associated with a significant disorder of the body diagram (distorted vision concerning weight, size and body shapes). Finally, different behaviors related to food are typical for people with anorexia, such as hiding food or encouraging others to eat . Each food intake is followed by a feeling of guilt which invades the anorexic person and leads him to adopt compensatory behaviors (intensive sports practice, taking purgatives …).

Somatic assessment
In addition to the psychopathological assessment, a complete physical examination is necessary in order to make the diagnosis of anorexia nervosa and to assess the state of undernutrition and the consequences of food deprivation on the physical health of the person.

In children under 8 years of age, the doctor will look for clues that may suggest anorexia. A slowing of the growth of stature, a stagnation or a fall in the BMI, the presence of nausea and unexplained abdominal pain will be sought.  

Faced with a teenager likely to present anorexia nervosa, the specialist will look for delayed puberty, amenorrhea, physical and / or intellectual hyperactivity.

In adults, several clues may direct the doctor to a diagnosis of anorexia nervosa. Among the most common, the doctor will be vigilant in the face of weight loss (greater than 15%), a refusal to gain weight despite a low body mass index (BMI), a woman with secondary amenorrhea, a man with marked decrease in libido and erectile dysfunction, physical and / or intellectual hyperactivity and infertility.

The behaviors put in place by the person aimed at reducing food intake have more or less serious repercussions on health. The doctor will carry out a clinical and paraclinical examination (blood tests, etc.) in search of problems:

  • heart problems such as heart rhythm disturbances
  • dental, including erosion of tooth enamel
  • gastrointestinal disorders such as bowel movement disorders
  • bone, including a decrease in bone mineral density
  • kidney
  • dermatological

EAT-26 screening test
The EAT-26 test is used to screen people likely to suffer from eating disorders. It is a 26-item questionnaire that the patient fills out on his or her own and then gives to a professional who analyzes it. The questions ask about the presence and frequency of diets, compensatory behaviors and the control that the person has over his or her eating behavior.

Complications

The main complications of anorexia are the more or less serious physiological disorders induced by weight loss.

In children suffering from anorexia, severe weight loss can cause growth retardation.
The main complications of anorexia are physiological disorders of varying severity induced by restrictive eating behaviors and purging compensations.

Dietary restrictions can lead to muscle wasting, anemia, hypotension, cardiac slowing and a decrease in calcium levels that can lead to osteoporosis. In addition, most people with anorexia are in amenorrhea (absence of menstruation) but this often goes unnoticed, hidden by the artificial menstruation created by taking birth control pills.

Repeated vomiting can lead to various problems such as: erosion of tooth enamel, inflammation of the esophagus, swelling of the salivary glands and a drop in potassium levels that can cause rhythm disorders or even heart failure.

Taking laxatives also causes numerous problems, including intestinal atony (lack of tone in the digestive tract) leading to constipation, dehydration, oedema and even a drop in sodium levels that can lead to renal failure.

Finally, the most serious and tragic complication of anorexia nervosa is death by complications or suicide, which mainly affects chronic anorexics. The earlier anorexia is detected and treated, the better the prognosis. When treated in this way, the symptoms disappear in most cases within 5 to 6 years after the onset.

The symptoms of anorexia nervosa

The symptoms of anorexia will revolve around the refusal to maintain a normal weight, the fear of gaining weight, the distorted vision that in the anorexic person of his physical appearance and the negation of the severity of the thinness. 

  • Food restriction 
  • Obsessive fear of gaining weight
  • Significant weight loss
  • Frequent weighings
  • Taking diuretics, laxatives or enemas
  • Missing periods or amenorrhea
  • Intensive sports practice
  • Isolation
  • Vomiting after eating 
  • Scrutinize in the mirror the parts of his body perceived as “fat”
  • Lack of awareness of the medical consequences of losing weight
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 In the literature, we often find two types of anorexia nervosa:

Restrictive type anorexia:

This type of anorexia is mentioned when the anorexic person does not resort to purgative behaviors (vomiting, taking laxatives, etc.) but to a very strict diet with intensive physical exercise. 

Anorexia with binge eating:

Some people present both symptoms of anorexia nervosa and bulimia, in particular compensatory behavior (taking purgatives, vomiting). In this case, we are not talking about bulimia but anorexia with binge eating.

People and risk factors for anorexia nervosa

People at risk

Anorexia would often start during adolescence. The age of onset of anorexia is between 14 and 18 years, but in 10 to 20% of cases, the disease appears before 12 years, and for a smaller percentage, after 25 years. 

It would affect girls more frequently than boys (boys affected for every 1 girls). Anorexia nervosa like other eating disorders affects populations in industrialized countries more.

Certain professions which require physical performance (athlete, actor, model, dancer 10 , sportsman) for which it is important to have a certain control of his weight and his body image, would have more people suffering from eating disorders than other trades.

Finally, people suffering from chronic pathologies involving a strict diet (type 1 diabetes, familial hypercholesterolemia, etc.) are more likely to develop anorexia nervosa.

Risk factors

A dramatic event (divorce, bereavement …) or a change in daily life can be the cause of the onset of anorexia in an already fragile person.

Prevention of anorexia nervosa

While there is no sure way to prevent the onset of this disorder, there may be ways to detect it earlier, contain its progress, and prevent this disorder from becoming chronic.

For example, the pediatrician and / or the general practitioner can play an important role in identifying early indicators that may suggest an eating disorder. During a medical visit, do not hesitate to tell him or her about your concerns about the eating behavior of your child or teenager. Thus warned, he will be able to ask him questions about his eating habits and whether or not he is satisfied with his body appearance. In addition, parents can cultivate and strengthen a healthy body image of their children, regardless of their size, shape and appearance. It is important to be careful to avoid any negative jokes about this.

Medical treatments for anorexia nervosa

It is difficult to recover from anorexia nervosa without support. The prescription of drugs, the establishment of nutritional care and the proposal to undertake psychotherapy can then be considered to treat anorexia nervosa. Sometimes, specialized hospitalization may be necessary.

Medication management

Studies have shown that fluoxetine (Prozac®), an antidepressant, is effective in combating depression often associated with anorexia but also in helping anorexics maintain a normal weight obtained after hospitalization.

Des anxiolytiques (benzodiazépines) peuvent être prescrits dans certains cas notamment pour diminuer l’anxiété qui envahit les personnes anorexiques avant les repas.

Finally, other drugs may be prescribed after medical evaluation on the physiological consequences of undernutrition and purging lines (deficiencies, digestive, renal, cardiac, endocrine disorders, etc.).

Nutritional care

This support is very important and effective in addition to drug treatment and psychotherapy. The coordinating doctor of the multidisciplinary team that accompanies the person suffering from anorexia nervosa will set many objectives to be achieved, including weight gain via a renitrution program adapted to the person’s needs and in which the latter will be invited to invest. .

Nutritional therapy will allow the anorexic person to relearn how to eat: resume a balanced diet, understand taboo foods (sugar, butter, etc.), eat slow sugars again to avoid crises, get used to sit-down meals again. table, 4 per day, in reasonable quantities. Information related to weight and diet will be provided and explained, such as the theory of natural weight. With this therapy, we try to change the relationship that the patient has with food. Finally, this method is also interested in the compensatory bleeding behaviors that the patient used to use.

Psychotherapeutic support

Psychotherapies are offered for the most part, individually or in groups, but they all have the objectives: to improve the perception and self-esteem of the anorexic person and to work on certain conflicts. 

Most of them concern the person who suffers from anorexia but they can also be addressed to the family (parents, spouses, siblings) of the patient, directly affected by this disease.   

Behavioral and Cognitive Therapies (CBT)

They are very effective in treating the symptoms of anorexia since it involves getting the person to observe their pathological behaviors (purging behaviors) and their dysfunctional thought patterns concerning diet, weight, self-esteem. self and body image. The goal of TBI is not to find the causes or the origin of the disorder but to act on it.

Systemic family therapy

This therapy is called “systemic” because it considers the family group as a system and a set of interdependent elements. In this case, the family would not be made up of independent elements (parents / children), but of entities which influence each other.

Systemic family therapy studies the modes of communication and the different interactions within the family in order to subsequently try to improve internal relationships. When one member of a family is affected by a disease like anorexia, the other members will be affected. For example, meal times can be particularly difficult for the family to manage. The actions and words of each other can be helpful or on the contrary harmful for the patient. It is not a question of making each other feel guilty, nor of making them guilty of anorexia, but of taking into account their suffering and making everyone move in the right direction for them but also for the patient.

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Psychodynamic psychotherapy

This psychotherapy is inspired by psychoanalysis. It is widely used to support the person in the search for conflicts (personal, interpersonal, conscious and unconscious, …) that may be at the origin of the appearance of eating disorders.

Interpersonal psychotherapy

This short therapy, mainly used to treat depression, has been proven to help people with eating disorders. During interpersonal psychotherapy, the subject will not be food but the person’s current interpersonal difficulties which inevitably have consequences on his eating behavior.

Hospitalization

Sometimes, specialized hospitalization may be necessary to increase the chances of recovery of the patient, after failure of outpatient treatment, in cases of severe weight loss and when significant health problems are detected.

Depending on the establishment, conventional specialist hospitalization or day hospitalization may be offered. For the latter, the person will go to the hospital every day of the week for treatment and will return to their home in the evening.

In a service specializing in the management of eating disorders, the patient receives care provided by a multidisciplinary team (doctor, nutritionist, psychologist, etc.). Treatment often includes refeeding, nutritional rehabilitation, psycho-educational support and psychotherapy follow-up. 

In some cases, the most serious, the medical team may decide to use nasogastric tube feeding (tube that allows entry through the nasal cavities into the stomach) or intravenous hyperalimentation. 

Our specialist’s opinion

“Very often people with anorexia are suffering, depression very often accompanies this disorder. Curing anorexia is possible but the family and loved ones must be there to bring their loved one with anorexia to awareness of their disease. Psychotherapy follow-up can be beneficial for the whole family, which is often harmed by the disease. »  

Céline BRODAR, Psychologist

Complementary approaches to anorexia

There are many dietary supplements and herbal products aimed at reducing appetite and promoting weight loss. People with eating disorders know about them and often abuse them. These products can have potentially dangerous interactions with other drugs, such as laxatives or diuretics, which are commonly used by people with anorexia and bulimia. In addition, the weight loss caused by the absorption of supplements or herbs can have serious side effects on their health. Among the most common, the person may suffer from heart rhythm disturbances (irregular heartbeats), tremors, hallucinations, insomnia, nausea, dizziness and nervousness.

Do not hesitate to discuss the potential risks of using dietary supplements or herbs with your doctor.

Processing

Yoga. Some researchers agree that yoga could have beneficial effects as a complementary treatment for eating disorders. Yoga can help these people by increasing their sense of well-being and promoting their access to relaxation.

A recent study carried out on 54 adolescents suffering from eating disorders demonstrated a better effectiveness of standard treatment when it is coupled with supervised practice of yoga at the rate of 2 sessions per week for 8 weeks 8 .

 Art therapy. This form of therapy uses different forms of art (dance, theater, plastic and visual arts, …) as mediator and means of expression. Art therapy allows the patient to come into contact with the other by means other than by speaking. It is a new way of communication to express your emotions and your experiences.

Most people with bulimia have difficulty expressing their emotions and may resort to excessive behavior. The art therapist will be able to accompany the person to express himself, but it can also bring him a broader vision of his personality and the possibility of renewing, by the means of the creation, a living relationship with himself.

 Hypnosis. Current research, still in progress, would show some interest in the use of hypnotherapy for the treatment of eating disorders. Further studies are needed to validate its effectiveness.


References

Notes
1. Holland, AJ, Sicotte, N. and Treasure, J., 1988, “Anorexia Nervosa: Evidence for Genetic Basis ”, Journal of Psychosomatic Research, vol.32, # 6, p.561-571.
2. Diaz-Marsa, M., Carrosco, Jl, Hollander, E., Cesar, J. and Saiz-Ruiz, J., 2000, “Decreased Platelet Monoamine Oxidase Activity in female Anorexia Nervosa”, Acta Psychiatrica Scandinavia, vol. 101, n ° 3, p. 226-230.
3. Halmi, KA, Ecpert, E., Marchis, P., Sampugnaro, V., Apple, R. and Cohen, J., 1991, “Comorbidity of Psychiatric Diagnosis in Anorexia Nervosa”, Archives of General Psychiatry, vol. 48, n ° 8, p. 712-718.
4. Rastam, M., Gillberg, C. and Gillberg, IC, 1996, “A Six-Year Follow-up Study of Anorexia Nervosa Subjects with Teenage Onset”, Journal of Youth and adolescence, vol.25, p. 439-453  
5. Sullivan, PF, Bulik, CM, Fear, JL, and Pickering, A., 1998, “Outcome of Anorexia Nervosa: A Case-Control Study”, American Journal of Psychiatry, vol.155, n ° 7 , p.939-946.
6. Herzog DB, Greenwood DN, Dorer DJ, et al. Mortality in eating disorders: A descriptive study. Int J Eat Disord 2000: 28: 20-6.
7. Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003; 34: 383-96
8. Zipfel S, Lowe B, Reas DL, Deter HC, Herzog W. Long-term prognosis in anorexia nervosa: Lessons from a 2 1 year follow-up study. Lancet 2000; 355: 721-2.
9. Leichner, P., Steigher, H., Puentes-Neuman, G., Perreault, M., & Gotheil, N. (1994) Validation of a dietary attitude scale with a French-speaking Quebec population. Canadian Journal of Psychology 39,49-54. (In French).
10. Garner, DM and Garfinkel, PE, 1980, “Socio-Cultural Factors in the Development of Anorexia Nervosa”, Psychological Medicine, vol. 10, n ° 4, p. 647-656.
11. Carei TR, Fyfe-Johnson AL, Breuner CC, et al. Randomized controlled clinical trial of yoga in the treatment of eating disorders. J Adolesc Health. 2010 Apr; 46 (4): 346.