Introduction

Being fit and having a toned up body is what all of us aspire. Being lean and slim and being able to eat everything without putting on weight is what most of the girls dream. But when you become too much obsessed by increasing body weight, it is one thing that is worrisome. Do you feel that you are overweight when actually everyone else thinks you to be too lean? Do you don’t eat or force vomiting after eating in fear of putting on weight? Is your body weight too less for your height and age? If answer to any of the above questions is yes, it is really serious as you might be having Anorexia nervosa.

What is anorexia nervosa?

Anorexia nervosa is an eating disorder. It is a condition which is usually seen in females but can also occur in males. Person affected has a poor self-image about his/her weight, has too low body weight as compared to height and age and has weight loss behaviours.

What causes anorexia nervosa?

Anorexia is one such disorder which can be attributed to many causes. It can be either due to genetic, psychological or biological reasons. These causes are explained one by one as follows.

• Genetic: Anorexia nervosa has shown to have genetic predisposition. The female siblings of the affected individuals are more prone to be affected by anorexia nervosa.

• Psychological: Since anorexia nervosa occurs usually in adolescence or early twenties, there are many psychological causes that can have a deep impact on the developing psyche. Family factors such as overprotectiveness, lot of conflicts and rigidity can also be a predisposing factor for anorexia. Secondly, poor self-image either due to lack of self-identity or due to parent’s obsession with food or dietary problems in early life. According to some scientists it has also been attributed to the fixation to oral stage (regression to childhood) or as an escape from emotional problems of adolescence.

• Biological: Dysfunction of some parts of the brain can cause anorexia nervosa. The part of the brain that is linked with anorexia is hypothalamus.

What are the signs and symptoms of anorexia nervosa?

Usually a person affected doesn’t feel that he/she is sick or has some disorder. There are some secondary complains which are associated with it. Some are related to psyche and mental well-being and some to the general physical condition of the individual. They have been explained separately as under:

Psychological symptoms: There are a wide range of symptoms that are observed. Symptoms vary from social withdrawal to low self-esteem, depression and irritability. There is low energy, loss of libido and insomnia. It also affects the concentration, memory and decision making. Most important there is loss of appetite and obsessiveness regarding food.

Physical symptoms: Just like a wide array of physical symptoms there is a wide range of physical symptoms as well. Physical symptoms vary from general physical health concerns, headache, fainting, dizziness and lethargy to weight loss. Cold hands and feet, dry skin, hair loss is also observed. Due to poor eating habits constipation is also seen. Low BMI and low weight also result in hormonal changes and amenorrhoea.

How is it diagnosed?

A careful history taking and physical examination is required to make the diagnosis. Your doctor might ask you and your caretaker/ parents about the complete history. To make the diagnosis following things are assessed

1. Body weight should not be less than 15% for normal height to weight.
2. If BMI is 17.5 or less, anorexia can be suspected.
3. Self-induced weight loss due to avoiding high calorie food, induced vomiting, crash dieting, too much exercise.
4. Low self-esteem and poor self-image.
5. Hormonal imbalance causes certain disorders such as amenorrhoea, loss of libido, impotence, abnormal insulin secretion, raised GH levels.
6. Delayed or arrested puberty.

It is often confused with

• Cancers
• Irritable bowel disease.
• Chronic debilitating illness
• Gastric disorders such as crohn’s disease
• Other psychiatric disorders such as depression
• OCD (obsessive compulsive disorder) and social phobia.

How is it treated?

• Pharmacological: The pharmacological management is same as for Obsessive compulsive disorder if there are obsessive thoughts regarding food. Fluoxetine is the drug of choice; or if previously TCAs or chlorpromazine has been used for weight gain.
• Psychological: Since anorexia nervosa has a deep psychological root, Psychotherapy is very useful. If onset is early or if medical help is sought timely family therapy is quite useful; in chronic or long term cases behaviour therapy or CBT(Cognitive behaviour therapy) is very useful for the individual in long term.
• Awareness and education about healthy nutritional requirements for an individual is also important.
• Hospitalisation: It should only be sought if there are associated medical conditions.

Criteria for admission to hospital

Hospitalisation may be necessary for patients with significant medical or psychiatric problems. The major criteria for admission to hospital are as follows:

• Extremely rapid or excessive weight loss that has not responded to outpatient treatment.
• Cardiac complications or other acute medical disorders.
• Marked change in mental status due to severe malnutrition.
• Psychosis or significant risk of suicide.
• Failure of outpatient treatment (e.g. inability to break the cycle of disordered eating or engage in effective outpatient psychotherapy).

Admission should not be viewed as punishment by the patient and the goals of inpatient therapy should be fully discussed with the patient (and their family):

• Addressing physical and/or psychiatric complications.
• Development of a healthy meal plan.
• Addressing underlying conflicts (e.g. low self-esteem, planning new coping strategies).
• Enhancing communication skills.

What is the prognosis?

• If untreated, this condition carries one of the highest mortality figures for any psychiatric disorder (10-15%).
• If treated, rule of thirds (1/3 full recovery, 1/3 partial recovery, 1/3 chronic problems).

Poor prognostic factors include:

1. Chronic illness
2. Late age of onset
3. Bulimic features (vomiting/purging)
4. Anxiety when eating with others
5. Excessive weight loss
6. Poor childhood social adjustment
7. Poor parental relationships
8. Male sex

References

• Oxford handbook of psychiatry, 1st edition.
  Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision. Washington, D.C., 2000.