Anorexia nervosa is an eating disorder characterized by voluntary starvation and exercise stress. Anorexia nervosa is a complex disease, involving psychological, sociological and physiological components. A person who is suffering from anorexia is referred to as 'anorexic' or (less commonly) 'anorectic'. "Anorectic" is the noun form, where "anorexic" is the adjectival form. These two are often used incorrectly when applied. The term is frequently but incorrectly shortened to anorexia, which simply refers to the medical symptom of lost appetite.
Anorectic can also refer to appetite-suppressing drugs.
Characteristics of anorexia
The causes of anorexia are a matter of debate in medical circles and society in general. General perspectives fit between the poles of it being physiological or psychological (with the potential for sociological and cultural influences being a cause to various degrees) in origin. Many now take the opinion that it is a mix of both, in that it is a psychological condition which is often (though not inherently) borne of certain conducive neurophysiologic conditions.
The primary physiological characteristics of anorexia nervosa are voluntary starvation and exercise stress. In addition to intentional starvation, subjects will also take part in a high level of physical activity. Anorexia nervosa also has a negative impact on the immune system and the central nervous system (CNS).
It is also thought to be linked to serotonin and dopamine abnormalities.
Many individuals who have obsessive-compulsive disorders also have an eating-disordered parent, presumably connected with shared genetic characteristics.
Anorexic subjects will often go through a cycle of recovery and relapse.
There is increasing speculation that the onset of anorexia has a genetic component, with a certain gene linked to abnormalities with the neurotransmitter chemical serotonin being shown to be more common amongst sufferers than the general population. Such genetic characteristics might potentially equate to an easier path towards overly high serotonin levels, thus instilling heightened levels of anxiety and the like. Biologically, when a person is in a state of starvation, their levels of serotonin decrease, and thence increase again upon the consumption of food because of the tryptophan amino acids contained therein (tryptophan is used by the body to synthesise serotonin). This raises the spectre that the anorexic is conditioned into avoiding food to reduce his or her anxiety, and that there may be yet another layer of complexity with respects to the cause/effect relationship between physiological factors and the mental beliefs of the anorexic.
Dietary minerals and heavy metals
Victims of mercury, lead, beryllium and arsenic poisoning have been known to develop anorexia as a symptom thereof. Some psychological traits associated with anorexia are consistent with deficiencies in important vitamins and minerals, such as magnesium and the B vitamins. Zinc deficiency is common among anorexics, thereby resulting in heightened levels of copper which is associated with depression and nervousness. That these deficiencies (or untoward exposure to heavy metals) can produce powerful psychological effects, such as depression, anxiety, and loss of appetite, is not widely known. Conversely, overexposure is also harmful.
There exists an animal model of anorexia nervosa that closely mimics the physiological effects of the disease. In the animal model, subjects are intentionally subject to starvation and given unlimited access to exercise. Under these conditions, without intervention, subjects will eventually run and starve themselves to death. Compared to cases of food restriction without exercise access, the subject will not starve themselves to death.
In the animal model of anorexia nervosa, it has been shown that repeated cycling of recover and relapse will lead to physiological adjustments from the subject. Subjects under these conditions will eventually become "resistant" to the animal model, and will not starve themselves to death. Subjects under these conditions show a metabolic adjustment.
Primary physiological effects
* Voluntary starvation
In the animal model:
* Negative impact on the immune system
Psychological effects of anorexia
Anorexia nervosa alters an individual's body image to the point where it is perceived as being fat and bilious irrespective of their actual size. This distorted body image is a source of considerable anxiety, and losing weight is considered to be the solution. However, when a weight-loss goal is attained, the anorexic still feels overweight and in need of further weight loss.
The attainment of a lower weight is typically viewed as a victory, and the gaining of weight as a defeat. "Control" is a factor strongly associated with anorexia nervosa, and an anorexic typically feels highly out of control in his or her life. However, the nature of the condition with respect to such psychological factors is highly complicated.
It is often the case that other psychological difficulties and mental illnesses exist alongside anorexia nervosa in the sufferer. Mild to severe manifestations of depression are common, partly because an inadequate food energy-intake is a well-known trigger for depression in susceptible individuals. Other afflictions may include self-harm and obsessive-compulsive disordered thinking (aside from such disordered thinking connected to their eating disorder). However, not all anorexics have any such problems besides their eating disorder.
Many anorexics reach a low level of body weight at which hospitalisation and forced-feeding are required on a long-term or recurring basis in an attempt to keep them from literally starving themselves to death. Prolonged starvation will result in death as the body's systems shut down, this in itself being the major danger factor of anorexia aside from intense mental suffering and the risk of suicide.
Some anorexics may incorporate bulimic behaviours into their illness: binge-eating and purging themselves of food on a regular or infrequent basis at certain times during the course of their illness. Alternatively, some individuals might switch from having anorexia nervosa to having bulimia. While bulimia poses less of a mortal danger to life and limb, many who have suffered both say that bulimia involves more mental suffering.
Anorexia alters ones body image so that one does not see the truth about oneself even when one looks in the mirror — to the anorexic mindset, there is no such thing as being too thin. Anorexics acknowledge their condition to different degrees — at one extreme, they do not see their "disease" as dangerous and resent being labelled as psychologically ill; at the other, they understand and accept that they have a problem, yet the anorexia still takes control over their thinking to fluctuating degrees. In ways not too dissimilar from people who have had cult programming or post-traumatic stress disorder, an anorexic may be "triggered" into manic disordered thinking by being exposed to certain words or conditions.
Some people eat unusually small amounts of food for reasons other than their own perceived obesity. Examples include those who fast for religious reasons, execute a hunger strike as a political statement, or are attempting to lengthen their lifespan through caloric restriction. Such individuals are not ordinarily considered anorexic, although some modern critics of religious asceticism have likened habitual fasting to anorexia nervosa.
Sociological effects of anorexia
Anorexia can be traced back to or connected with 19th century American society. Joan Joacobs Brumberg, in her article "The Appetite as Voice" stresses the importance of the history of Anorexia nervosa. "A history of anorexia nervosa must consider the ways in which different societies create their own symptom repertoires and how the changing cultural context gives meaning to a symptom such as non-eating" (Brumberg, p.159). During the Victorian era, medical examiners were more interested in physical characterics, or what the patient's body had to say, rather than his/her description of their illness. Young women were also viewed as a non-reliable source for information. Related to the section below on contemporary culture, doctors of the 19th century viewed the connection between culture and the disease very differently. "In effect, ninteenth-century medicine did not relate anorexia nervosa to the cultural milieu that surrounded the Victorian girl. The ideas of Victorian women and girls about appetite, food, and eating, as well as the cultural categories of fat and thin, were not mentioned as contributing to the disease. Only in the twentieth century has medicine come to understand that society plays a role in shaping the form of psychological disorders and that behavior and physical symptoms are ralted to cultural systems" (Brumberg, p.160).
The mass media and advertorial marketing, such as beauty advertising, are also frequently viewed as being implicated in triggering eating disorders in teenage girls, although it has recently come to light that there appear to be girls exhibiting anorexic behaviours in remote parts of Africa that have not been exposed to modern forms of advertising. These girls link their self-starvation to religious causes.
Although anorexia is usually associated with western cultures, the exposure to western media has caused the disease to appear in some third-world nations.
In recent years, the Internet has enabled anorexics and bulimics to contact and communicate with each other outside of a treatment environment, with much lower risks of rejection by mainstream society. If an anorexic is already socially withdrawn, such a network of friends can be very helpful in bringing him or her back. On the other hand, the Internet is also a powerful tool with which people can isolate themselves. A variety of websites exist, some run by sufferers, some former sufferers, and some by professionals; attitudes on these sites range through a no-holds-barred, tough-love "put it in your mouth" approach through simple acceptance and even to promotion of anorexia as an "alternate lifestyle" (pro-ana, see below).
The following is considered the "textbook" definition of anorexia nervosa to assist doctors in making a clinical diagnosis. It is in no way representative of what a sufferer feels or experiences in living with the illness. It is important to note that an individual can still suffer from anorexia even if one of the below signs is not present. In other words, it is dangerous to read the diagnostic criteria and think either oneself or others must not be anorectic because one or more of the symptoms listed are not present.
* Refusal to maintain body weight at or above a minimally normal weight
for age and height (e.g., weight loss leading to maintenance of body
weight less than 85% of that expected; or failure to make expected weight
gain during period of growth, leading to body weight less than 85% of
Restricting Type: during the current episode of anorexia nervosa, the
person has not regularly engaged in binge-eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics,
Anorexia has the highest death rate of any psychiatric illness. Starvation can cause major organs to shut down. A heart attack is one of the most common causes of death in those suffering with an eating disorder. People can die from eating disorders at any body weight.
Osteoporosis is another danger of anorexia. Low calcium intake is only part of the problem. Even in those who take in adequate calcium through food or supplements, amenorrhea prevents the body from absorbing it fully.
While anorexia may occur in individuals across the demographic divides, it definitely appears to be far more prone to developing among those in certain groups, such as:
* females (95% of anorexia nervosa sufferers are females)
Anorexia nervosa is typically stereotyped as being a disease of teenage females. However, in real-life, almost any individual can be a sufferer, as even children as young as three have been known to develop the disease. The most common times of onset are at puberty, and during times of transition such as moving from school to university. Males are at a greater risk of not recovering from the disease due to a reluctance to report symptoms.
The disease is believed to be far more common in some societies than others, especially those of Europe, the Americas and Australasia.
Though many do not realize it, younger children can also exhibit symptoms of anorexia nervosa. Children as young as five years may begin to diet, perhaps mimicking behaviour they see in their parents. (For example, if a mother is obsessed with her weight, her daughter may begin to weigh herself.) These young anorexics have a fear of becoming "fat" and refuse to eat, as in classic anorexia nervosa.
Indicators of anorexia
Anorexic people may:
* be too thin and/or appear to have lost weight;
Currently, the DSM-IV lists amenorrhea as a required characteristic of diagnosis, as it nearly always accompanies anorexia nervosa in females. However, while very emaciated women will never menstruate (unless they use a form of hormonal-replacement therapy), some women cease to have their menses before appreciable weight has been lost. Conversely, a small percentage of women reach weights that are quite low and still manage menstruate somewhat regularly. Further, the eating disorders work group of the DSM is attempting to have the amenorrhea requirement removed as it makes diagnosis in males problematic. Researchers have often pointed to lack of sexual potency in males as the equivalent of female amenorrhea, but there continues to be a lack of consensus regarding this criterium.
Anorexics are likely to be perfectionists. A 2003 study by Sutandar-Pinnock and others analyzed the correlation between high perfectionism scores as measured by the Multidimensional Perfectionism Scale (MPS), and anorexia nervosa as measured by the Eating Disorder Inventory (EDI). The control group participated in a family study, and was indirectly involved. The experimental groups were categorized as good outcome patients, who had regained weight after treatment; and poor outcomes, who did not regain weight after treatment. The mean scores for perfectionism in both good and poor outcome patients were higher than the control group, statistically significant. The perfectionism scores for the poor outcome were statistically significantly higher than the good outcome group in 4/5 categories.
Although anorexics are less likely to choose fattening foods to eat, this is not always so. They may set their food-restriction objectives by food energy (calories) rather than by food type—for example, one may set a goal of 100 calories in a day and the food chosen to attain that number may very well be a cereal bar one day and an apple the next.
Treatment of anorexia
Successful treatment of, and recovery from, anorexia is possible, but it can take many years. The earlier intervention arrests the course of the disease, the more successful the treatment is likely to be. Anorexia nervosa has the highest death rate of all mental illnesses, with as many as 20% of anorexics eventually dying of complications of the disease, usually from heart/organ failure or low levels of potassium. Once an anorexic reaches a certain weight, death becomes a very real possibility. The BMI (or body mass index) where this starts becoming a danger is generally around 12 to 12.5.(As a point of reference, a normal BMI is between 19 and 23, most "centrefold" models have a BMI of 18, and most fashion models come in at 17. An anorectic BMI is usually defined as being below 17.5.)
Approaches include hospitalization, psychotherapy, specialised anorexia treatment-centres, and family counseling. The prescription of psychotropic drugs such as antidepressants is also practiced. Support groups such as Overeaters Anonymous, which deals with eating disorders in general, can also be helpful.
Appropriate treatment of any present vitamin and dietary-mineral deficiencies, particularly in the common case of zinc deficiency, may be highly beneficial to the sufferer's mental and physical well being.
Anorexia is notoriously hard to treat, with sufferers often either emphatically denying that they are ill or paradoxically, accepting that they have anorexia, but seeing nothing wrong with their "lifestyle choice". This latter view is evidenced by the growing number of "pro-ana" websites and discussion groups where self-identified "anorectics" come together to reinforce their beliefs and behaviours, creating a positive feedback loop.
Another difficulty in treating anorexia nervosa is the prevalence of relapse. For some people, anorexia may be a chronic disease. In a study, within two years of hospital discharge, 35% of former anorexics had relapsed into anorexia. The greatest risk for a relapse was anywhere from six to seventeen months after discharge.
Anorexia is one of the most expensive illnesses to treat, with adequate care for the disease costing well over $100,000. Because of the high mortality rate of the disease, this is seen as a cost effective solution. Unfortunately, lengthy hospitalization is required to treat the disease adequately and many health care providers will not pay for adequate care. Hospitalization stays of 45 days are recommended for effective treatment, yet the usual stay that healthcare providers will pay for is 7 days, along with half the adequate amount of psychotherapy which is recommended.
Interacting with sufferers
The best help an anorexic can receive is unconditional love and empathy. Anorexia is fundamentally less about food than an individual's psychological need to feel safe — in that he or she does not.
As is common among sufferers of some eating disorders, an anorexic may be very secretive about his or her disorder. Being confronted by another about it for the first time may result in feelings of panic and distress, so an informed and considerate caution is recommended. However it is important to remember that anorexia is a dangerous disorder that signifies chronic suffering in an individual — it is important not to delay in seeking help for the person whom you believe has anorexia or bulimia. Researching the condition and consulting your local eating-disorder support-network are good beginnings.
In handling an anorexic dependent, it is dangerous to "just force" him or her to eat without support. Eating for most anorexics is not as easy as "just eat" as with non eating-disordered people. While being firm is important, keep in mind that eating things which are not considered "safe" will most likely trigger fear and panic in the sufferer.
* Jessica Alba
Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Karolinska Institutet (Sweden) treatment model focussing on teaching people how to eat again. Supposes that psychiatric conditions could be more symptomatic than causal. Showing remarkably positive results and seeking further replication.
Wasted (ISBN 0-06-018739-5), by Marya Hornbacher, an autobiographical look at her lifetime of Bulimia nervosa and Anorexia nervosa.
Reference: Brumberg, Joan Jacob. "The Appetite as Voice." Food and Culture: A Reader. Ed. Carole Counihan and Penny van Esterik. New York: Routledge, 1997.159-179.
Pro-ana is a largely Internet-based movement which views the eating
disorder anorexia nervosa as a lifestyle choice rather than a medical
condition. There are a growing number of pro-ana websites and discussion
groups where self-identified anorexics come together to discuss their
condition, which some claim creates a reinforcing feedback loop. The
movement is controversial because it contradicts current prevailing
psychological and medical views.
Pro-ana websites were first developed to counter the many support websites which encourage recovery from anorexia. Many anorexics believed that the desire to achieve an unnaturally slim figure was not a mental illness, but an alternative lifestyle. Doctors who treat anorexia see pro-ana as a life-threatening danger to current and potential anorexics.
A common assumption is that these sites are actively trying to recruit new anorexics, but this is almost never the case. Some pro-ana websites are fairly exclusive; others always welcome new members into the fold, whether they wish for support in recovery or illness; yet others do not accept anorexics who are recovering or wish to recover. These sites often include tips on how to stay anorexic or be a "better" anorexic, but rare is the site that directly encourages healthy people to become anorexic.
Recently pro-ana has acquired a political dimension, especially in the United States, where participants present themselves as a walking protest against consumer culture.
Pro-anorexia websites can offer genuine advice, such as admonishing readers to avoid the use of syrup of ipecac to induce vomiting. They can also be a place for the anorexic to talk to people like him or herself, and possibly improve self-esteem over the choice to remain anorexic. Less-friendly pro-ana sites vigorously castigate and mock those who decide to seek treatment for anorexia; however, most are not anti-recovery, and an anorexic who wishes to recover can find support for his or her choice through this network.
Criticism and controversy
Pro-ana sites often encourage potentially dangerous behaviour. Anorexics can post pictures of themselves or others they find worthy of idolization. This is called "thinspiration". Critics claim that this may trigger unhealthy behaviour in visitors. Photos of extremely thin people are seen as something to aspire to, and extremely obese people as what they never want to be (of course many anorexics were never obese). Though less common, pro-anas sometimes misrepresent their lifestyle, touting it as healthy or superior.
To counter this, many anti-ana (pro-recovery) sites have banned the use of "numbers" (weights, BMIs, calories, etc) and pictures. Others post excessive pictures of extremely thin and unhealthy people, claiming that the pictures are intended to point to anorexia as a bad choice. Although these sites are well-meaning, their helpfulness is debated. Visitors might not read the text, looking only at the photographs out of context.
Pro-ana has spawned a media response, if not a moral panic. Some parents who read articles about pro-ana in magazines or see segments about it on television (notably the Oprah Winfrey Show) become convinced that pro-ana is the new way to "extreme diet" for young girls. Pro-ana has also become a highly vulnerable online community, since pro-ana websites are frequently taken down by ISPs, (such as Yahoo! in 2001) raising issues of freedom of speech. However, perhaps because the pro-ana community consists largely of minors, the freedom of speech issue has not been debated to the extent that it has been in the cases of filesharing and pornography.
The anorexic underground
In some circles of the pro-ana movement, anorexia nervosa and bulimia nervosa are personified as women named Ana (for anorexia; hence the pro-ana movement) and Bella or Mia (for bulimia). Members use this to illustrate the anorexic's loneliness: "Ana" is the anorexic's only reliable friend whom they can rely on when everything else feels out of control. Pro-ana sites involve anorexics coming together to talk about their experiences with their shared "best friend".
Many anorexics consider the pro-ana or anorexic "community" to be a type of secret society called the "anorexic underground", whose members are able to identify each other at first glance. This has led to people who identify as pro-ana wearing colour-coded bracelets to signify their disease. The colours for each disorder vary, but they are generally considered to be:
* red: anorexia
The most popular maker of these bracelets is BlueDragonfly. Some anorexics make their own bracelets or buy normal bracelets that happen to be in those colours.
Pro-ana and LiveJournal
The movement has expanded to include many communities on LiveJournal and other sites. The communities are becoming increasingly common and can include thinspiration, support, dieting tips, and occasionally, trolling. The community names often contain words like "beauty", "perfection", or "thinnest". These communities sometimes include support for self-harm and other such behaviours.
Although decreasing in popularity, some of these communities are rating communities. These communities allow new applicants to post pictures and information about themselves, enabling the current members to determine whether they are "good anorexics". They may quantify or "rate" anorexia from one to ten or qualify it as being "anorexic enough" or not.
Pro-ana has also naturally spawned several opposition communities, such as the Anti-Ana community, and many satirical communities, such as Pro-Smallpox and Pro-Scurvy.
The communities have also gained a response among "anti-pro-ana" anorexics who have started communities such as Ed_ucate, a play on the common shorthand for eating disorder, ED. The purpose of these communities is to inform pro-anas about their choice and encourage anorexics to make informed decisions and not spread misinformation. The main focus is on accurate self-diagnosis using the DSM-IV criteria. Many pro-anas are told that they do not have anorexia, but ED-NOS, because their BMI is not low enough to meet the criteria for anorexia. Others are encouraged to go into recovery.
At the height of its popularity (2000-2002), the pro-ana community hosted hundreds of websites. As of now, the movement is less visible. This may be because there are fewer sites, or as some people theorize, that many of these sites have gone underground and moved out of the mainstream due to censorship and the mass deletions of various sites.