Anorexia nervosa

Anorexia nervosa is an eating disorder characterized by severe weight loss, a dangerously low body weight, and a distorted body image that drives an otherwise high-functioning person—usually a young woman—to starve herself. Anorexics keep themselves underweight by eating sparsely and infrequently, as well as purging—voiding food by induced vomiting, laxative use, etc.—and exercising intensely, often without recognizing that their actions are unhealthy or that their perceptions of their bodies are not normal.

Anorexia is diagnosed overwhelmingly among females and usually manifests during adolescence though 5 to 15% of those diagnosed are male and the actual prevalence could be higher as symptoms of starvation in young men are less obvious than in young women. Adolescents and young adults with anorexia are often high-achievers and perfectionists—successful in school and popular with peers—making it difficult for parents and other adults to see how troubled they are. But anorexia is extremely serious condition—a life-threatening psychiatric disorder that, untreated, leads to fatal medical problems and a high rate of suicide. The earlier it is treated, the better the odds of the patient recovering, and avoiding future relapse.

Behavioral signs that a child might be anorexic include rejection of a healthy amount of food, dramatic dieting, compulsive exercise, and a gross overvaluing of shape and weight as components of her identity. Visible signs that she is starving herself include extreme weight loss, abnormal thinness, brittle nails, hair loss, constipation, irregular menstruation, and swelling. Still, in growing children and adolescents what constitutes a normal weight is very difficult to ascertain; a failure to keep up with normal growth and weight gain that might be perceived as being a “late bloomer” could be a sign of anorexia. But experts agree that the defining characteristic of anorexia is body image distortion—what the child sees in the mirror as unacceptably fat is, to anyone else, disturbingly thin.

Researchers are unsure about the root causes of anorexia, but the consensus is that the disorder likely stems from a combination of biological, genetic, and social factors. Research has tied anorexia to abnormalities in the expression of one or more genes, which may emerge as a result of environmental factors—a so-called epigenetic change. But genetics and brain chemistry alone do not cause anorexia—in all sufferers the disorder seems to be triggered by a dieting regimen, which then spirals dangerously out of control. There is evidence that the brain adapts to prolonged starvation; the longer it persists the more difficult the behavior is to resist.

The first step a professional will take towards a diagnosis of anorexia is an evaluation of the child’s weight relative to the average for her age. If she consistently maintains a body weight 15% below average, whether by weight loss or failure to gain weight, a clinician will dig deeper, and try to find out if she is extremely troubled by weight gain or the prospect of being fat, even though she’s so thin. He will look for evidence of an unrealistic body image or denial of the severity of her condition. Irregular periods can also be a factor in diagnosis. The diagnosis can be of restricting type (no purging) or binge eating/purging type (a kid uses self-induced vomiting or misuse of diuretics, laxatives, or enemas to keep her weight down).

Treatment for anorexia focuses on the devastating behaviors and their effects, and is overwhelmingly psychotherapeutic and medical. No known medication can address the core symptoms of anorexia, though drugs are often prescribed to treat co-occurring symptoms.

Psychotherapeutic: While one-on-one cognitive behavioral therapy is often used for adults with anorexia, the most successful treatments for children and adolescents involve the whole family—intensive family therapy and education that enables parents and siblings to help a child with anorexia return to normal eating patterns. The first goal of any treatment is to restore your child to a healthy weight, and she should be immediately hospitalized for this purpose if she is in any medical danger. Milder cases respond well to family therapy; more severe cases require a hospital stay or a residential program. The disadvantage to residential programs is that patients tend to relapse when they are back at home, unless the family lifestyle has changed to make it incompatible with the dangerous behaviors. Treatment is more effective when the disorder is caught early, and the longer a child stays at a healthy weight, the less likely she is to relapse.

Pharmacological: Some drugs, particularly antidepressants, have been effective in treatment, but they are most often targeted at another condition the child might also have, such as depression or obsessive-compulsive disorder. Treating the co-occurring disorder can make the therapy for anorexia more successful.

Depression, anxiety disorders, obsessive-compulsive disorder, and substance abuse have been associated with the occurrence of anorexia.

The malnutrition associated with anorexia can create serious medical conditions, including anemia, kidney trouble, brittle bones, and hormone and electrolyte imbalances. At worst, it can be fatal: the havoc anorexia plays with the chemical balance in the body can cause the heart to shut down without notice, even in a young woman who does not appear to be dangerously thin. And the disorder can so impair social life, family connections, and personal development that suicide is a serious risk.

Can it be cured?
No. After treatment, some women with anorexia never have symptoms of the disorder again. But relapse is very common. Research shows that the brain adjusts to prolonged starvation, so that the longer a young woman starves herself, the easier, and more tempting, it is for her to slip back into the behavior.

Who should I go to?
Parents should seek out a therapist with experience treating anorexia, who is familiar with the family therapy that appears to produce the best results, and who focuses on the symptoms of the disorder—and getting rid of them. For years, therapists attempted to treat anorexia by trying to tease out the “underlying issues” responsible for the condition through talk therapy. But as one expert comments, “you have the rest of your life to think about your underlying issues.” Right now, the symptoms of the disorder are killing you.

Will treatment make my child fat?
Treatment will restore the health of your child. If you’re invested in health, it will work. If you’re invested in body fat, it won’t.

What is my involvement in treatment?
Vital. A therapist will teach you how to manage your child’s disorder, how to make your home and your family’s lifestyle incompatible with anorexia. It will be critical that you change the way you talk about shape and weight, and help your child change the way she relates to food, to get her eating and healthy again.

How long is treatment?
You can expect to meet with a therapist over the course of 6 months to a year for most cases. But anorexia never really goes away—so watchfulness, and maintaining a lifestyle for your family that is incompatible with anorexia, must be ongoing.

Will drugs help?
Young women with anorexia are often prescribed medications to address co-existing conditions like depression or anxiety. But while these drugs no doubt improve quality of life, the treatment for the core symptoms of anorexia is behavioral.

Can it be fatal?
Yes. Anorexia has the highest mortality rate of any psychiatric disorder. Prolonged starvation wreaks havoc with the chemical balance in the body, which can cause the heart to shut down without notice, even in a young woman who does not appear to be dangerously thin. And the disorder disrupts and undermines lives so severely that many commit suicide.

Why can’t my child see what she’s doing to herself?
People with anorexia have a distorted body image; they can be blind to the ravages they inflict on their bodies because what they perceive is not real, and they are unhealthily fixated on weight and appearance.