Anorexia Nervosa Essay, Research Paper

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 (Neum?rken, 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 (Neum?rken, 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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