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Anerexia and bulimia are the two psychiatric disorders that have the most significant degree of significant physical dysfunction because of the aberrant eating patterns and the problems that occur relative to nutrition. It is a disorder that occurs primarily in white, middle to upper class individuals. We are seeing anorexia gradually extend down into the lower socioeconomic classes. It primarily affects females between the ages of 12 and 20. The instance has increased from about 1:250 twenty years ago, to about 1:100 at the present time. There has indeed been a marked increase in the last 15 -18 years for this disorder. It is commonly seen in individuals who are involved in appearance-related sporting activities or in activities where appearance is a primary determinant of scoring; such as gymnastics, dance, modeling and acting. There’s a significant female predisposition to this with a female to male ratio of eating disorder, anorexia nervosa.
The mortality rate early on was 5% to 10%, and that was primarily because of starvation. The two most likely ways in which an anorexic individual will subsequently lose her life, are from suicide or from organ failure, particularly cardiac dysfunction and cardiac arrhythmias. While one would have
Anerexia nervosa generally begins in adolescence and oftentimes it begins just with the individual feeling a little fat and overweight and wanting to trim down and wanting to lose a little weight. She then begins a diet but that dieting evolves in to a tremendous preoccupation with food. Anerexia is really not a disorder of dieting, it’s a disorder of food. It’s a tremendous preoccupation with limiting their caloric intake and trying to
We don't know all there is to know, obviously, about the pathogenesis of anerexia. We do know that there are a number of factors involved, as depicted here. There are social/culture factors which are very strong and very prominent. You can’t look at television these days without getting a
There are familiar problems which are more characteristic in families from which anorexic individuals will come. They are families often described as being significantly meshed with a lot of rigidity. There are developmental problems within the individual, per se, particularly with ego development; concerns about self-image, poor self-esteem and significant insecurity and there are biological factors that ultimately further perpetrate the process as it goes along. Primarily the effects of starvation.
There is a complex interplay between the factors which are currently being looked at, as far as perpetrating anerexia nervosa is concerned. First of all, there are a lot of adolescent conflicts going on in these individuals. Not the least of course is weight, the concerns about weight, how they look. "Am I attractive?" There are a lot of interpersonal problems and the insecurity. There’s a lot of stress and failure. They then tend to try to separate out one aspect of their life that they can control. So many of the other aspects it seems that they are uncomfortable with, that they have very little
There are four major criteria for anorexia nervosa. The first one is that they have to have lost weight, or never gained weight, to where they are now 85% or less than what they ought to be. So they have a refusal to maintain body weight over a minimal normal weight for age, or they’ve never gained that. So that they are at that 85% expected. So that’s an important number to remember. Secondly, they have an intense fear of gaining weight or becoming fat, even though they are underweight. They don’t look at themselves as being underweight. Everyone else, obviously, has recognized the fact that they are but they don’t and they have an intense fear about gaining weight. If you start talking with them about potentially gaining a little bit of weight, it is just very anxious, anxiety-provoking in them. They have a disturbance in which their body weight or shape is experienced. They get on the scale - not uncommonly - several times a day. If their weight is up just a little bit, their whole day is shot. They are focusing all their mental energy then on trying to lose what they perceive as the little bit of weight that they’ve gained. Or they have an undue influence of body weight and shape on self-evaluation. They are a failure if
The fourth criteria is that they have become amenorrheic. In postmenarchal females amenorrhea or the absence of at least three
The typical restricting subtype, which is the individual who starves herself, tries to get rid of the food. She is not regularly engaged in binging or
They almost appear to have a split in every aspect of their life, in their thinking and their perception of body weight. In what they think they continue to need to do and of course what we know what they need to do. They’re malnourished, cachectic, they are starved, they need to be nutritionally
As far as body image is concerned, and again they will have anywhere from 5% to 20% distortion. They’re thin, continuing to get thinner and thinner and thinner, but their perception of themselves of course is that they are still overweight, they are still fat, they still need to trim quite a bit. Particularly
This is the kind of image that they uniformly get portrayed, or uniformly get presented to them as the goal for their acquisition. Very thin, asthenic sort of individual and you can see again, this individual is obviously proud, successful and quite pleased with all aspects of her life. Let’s look then at what society has portrayed as being body image or healthy body image over the course of a number of centuries. I think this particular statue depicts for
How do you make the diagnosis of anorexia nervosa? Well first of all, obviously, you have to have a clinical suspicion. And again, primarily history and physical examination are going to give you the mainstay for making your diagnosis. You need to ask the right questions. Laboratory tests, as
In any program that looks at eating disorders, it’s also very important to understand what are the other problems occurring with that individual. Not only does she have an eating disorder, but what’s her personality type, how strongly ingrained are the thoughts that she is having relative to food,
On the history, and this is something that you can do easily in ten or 15 minutes in an office visit, is begin to ask them some questions about their diet. About calories, about food. If they’ve lost weight ask them why they started, what their goals are in their weight loss program, and get a lot of feeling right away as to whether this is staying in some reasonable perspective or whether they are having thoughts and processes which are ultimately going to lead them to have a preoccupation with food. They oftentimes have unusual or secretive behaviors about food. Some individuals will eat the very
They are impervious or oversensitive to cold. All individuals who fall below 85% of ideal body weight mentally will start becoming depressed and moody. You can take anybody in this room and starve you down to 85% of body weight you will start to get depressed and moody. It’s one of the
Ask then about whether they are throwing up. I ask them about whether they are using laxatives. They all do have constipation obviously, because of
On physical findings - put them in a gown. They’ll come in with baggy clothes on and two or three sweatshirts because they are cold all the time. Trying to hide how thin they are, oftentimes. Put them in a gown so that you an fully examine them and they can’t hide the degree of muscle wasting
You can play a role in the management of these, although I would caution all physicians not to ever try to assume the care of an anorexic all by themselves. You simply don’t have the time. You don’t have the wherewithal to go through all the mental help and therapy that these individuals
The outpatient goal is to get them to slowly achieve weight. We start them off with a caloric intake about 250 calories above where they were when they came in. Every three or four days we increase their caloric intake by about 250 calories. An interesting thing happens. They lower their
Psychotherapy, nutritional counseling, and again a strong team alliance, because they are going to try to play one of you against the other and try to limit their caloric intake. They’ll hide food. They’ll water load before their weight scales in the morning so that they look like they’ve gained
Again, there are a number of factors which are more commonly present in families of individuals with bulimia nervosa. These are families that are disengaged. They have high conflict difficulties, low expressivity and high achievement goals. There are biogenetic factors which appear to be more commonly present in individuals who are developing bulimia nervosa - and we’ll talk about those in a minute - and of course there are tremendous social-cultural factors; pursuit of thinness and a particular stigma against obesity. As far as their biogenetic underpinning or association with this disorder, there is an association - anywhere from 20% to 70% - of families will have affective disorders; depression, dysthymia, chronic low self esteem, chronic low grade dysphoria, just not feeling well. So there’s a strong association of depression. In fact, in individuals with bulimia about 50% have significant levels of clinical depression and that’s why medications like Zoloft, Luvox or Prozac are very helpful in the treatment of bulimia nervosa, because of the strong association with affective disorders.