Eating disorders are a cause for serious concern from both a psychological and anutritional point of view. They are often a complex expression of underlyingproblems with identity and self concept. These disorders often stem fromtraumatic experiences and are influenced by society`s attitudes toward beautyand worth (Eating Disorder Resource Center, 1997). Biological factors, familyissues, and psychological make-up may be what people who develop eatingdisorders 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 weightloss.
It is the result of self imposed and severe restrictions of food and fluidintake, a distorted body image, an intense fear of becoming fat, and a poor selfesteem. Besides dieting to extremes, anorexics often over exercise to loseweight. Anorexics themselves are often the last to realize how undernourishedand 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 denialthat makes it so hard to convince anorexics to seek help (Eating DisorderResource Center, 1997). This paper`s focus is to look in more detail at thepsychological and societal factors contributing to anorexia nervosa, as well asthe nutritional and physiological complications that arise for people on suchseverely restrictive diets. Psychological and Societal Contributions AnorexiaNervosa was first described by an English physician by the name of RichardMorton in 1689. Until 1914, it was considered a disease that arose from a morbidmental state and a disturbed nerve force. That year, Dr.
Simmonds, apathologist, found one woman=s refusal to eat to be the direct result of ananterior pituitary lesion. This shifted the focus away from the emotionalaspects of the disorder to more physiological and endocrinological terms. It wasnot until 1938 that anorexia nervosa was once again considered a largelyemotional disorder (Blackman, 1996). In fact, one of the criteria for thediagnosis of anorexia nervosa according to the manual of The American MedicalAssociation (DSM IV) is an intense fear of gaining weight or becoming fat, eventhough underweight. Another clearly psychological requirement for diagnosis, isa 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 theseriousness of the current low body weight (Blackman, 1996).
Anorexia nervosamay be a primary disorder in which other psychiatric conditions are secondary,such as depression. It may also be secondary itself to a disorder such asschizophrenia or co-morbid with obsessive compulsive disorder. As well, it canalso be a component of a personality disorder (Blackman, 1996; Carlat, 1997). The anorexic sufferer is typically female. Ninety-percent of all cases occuramong adolescent girls or young women but the number of males with the disorderis on the rise (Blackman, 1996; Carlat, 1997; Kinzl, 1997). It is estimated that1% of girls ages 12-18 meet the criteria for full blown anorexia and as many as5-10% have milder forms of such eating disorders if the criteria is applied lessstringently (Blackman, 1996).
Anorexics are usually high achieving youngsterswho may be heavily involved in sports (e. g. gymnastics, swimming, cheer leading,ballet, etc. ). These people are often competitive, perfectionistic, withobsessive compulsive personality features.
Fears of growing up or discomforttoward sexuality may also be precipitating factors (Blackman, 1996). Studieshave shown that 75% of American Women are dissatisfied with their appearance andas many as 50% are on a diet at any one time. Even more alarming is that 90% ofhigh school junior and senior women regularly diet, even though only between10%-15% are over the weight recommended by the standard height-weight charts(Council on Size and Weight Discrimination, 1996). The majority of these womendo not develop eating disorders; however, 1% of teenage girls and 5% ofcollege-age women do become anorexic or bulimic (Council on Size and WeightDiscrimination, 1996). Perhaps these figures represent the women who are lessable to cope with their bodily dissatisfaction and thus are the ones who takedieting to the extreme.
The disordered eating behavior usually starts out with apattern of dieting or particular food choices, such as avoiding certain foodswhich are seen as fattening. As the disorder progresses, anorexics becomeresourceful in hiding their troublesome behavior and may start to avoid eatingwith their families. They may also attempt further weight loss by compulsiveexercising. The condition can become well advanced before parents even notice,as anorexics may wear many layers of clothes to conceal their thinness.
Oftenthe diagnosis is not made until the person is brought to a clinic for problemssuch as physical weakness, lack of energy, excessive sleepiness, and recent poorperformance in school (Blackman, 1996). Actually, certain familial relationshipsseem to be more prevalent among anorexic sufferers. Studies have shown manyanorexic families are enmeshed, overprotective, conflict avoidant, and asco-opting the anorexic in destructive alliances with one parent or another. Theparents themselves tend to be more affectionate and neglectful than parents ofnon anorexic children.
The father in particular is often controlling (Blackman,1996). Physical and/or sexual abuse are also not uncommon features in familieswith anorexics (Carlet, 1996; Kinzyl, 1997). Even though these trends are trendsoften seen, there are many anorexic families that do not fit this profile. Oneof 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 orbody size (Blackman, 1996). Self worth is equated with a desirable slimappearance.
This creates a vulnerability to eating disorders for people who areespecially concerned with meeting this ideal. Western culture in particular hasan obsession with looks. Slim, attractive people are linked to beauty, success,and happiness. Our society teaches us to value such superficial standards andbombards us with images of the idealized female body through mediums such asmagazines, films, and television (Blackman, 1996).
One only has to watchtelevision or read the latest magazines and take note of just how few overweightor average looking people there are appearing in advertisements to verify thisfact. Anorexia nervosa in fact predominates in industrialized developedcountries; yet is extremely rare in less industrialized and non westerncountries (Blackman, 1996). As well, immigrants who have migrated to awesternized country have been found to become more prone to develop eatingdisorders (Blackman, 1996). For the sufferer of anorexia, the onset of thedisease often begins with a chance remark by someone important to them, possiblya coach or a friend. They may suggest that they are getting fat, big, clumsy, orthat their performance (if they are athletes) is suffering (Blackman, 1996).
These remarks, as unintentional or innocent as they may seem to the personmaking them, only serve to reinforce society=s attitude that gaining weight isunacceptable. For others, it may will be the media itself that precipitates thedevelopment of the disorder. Some patients cite wanting to look like a favoritefilm star or model as their initial motivation to lose weight (Blackman, 1996). Males With Eating Disorders Typically, dieting and eating disorders such asanorexia nervosa are associated with females at or near adolescence. A groupthat often gets overlooked in the studies are males. Eating disorders are notrare among males; 10-15% of all bulimic patients are male, while 0.
2% of alladolescent and young males meet the stringent criteria for bulimia. Thesefigures are similar for anorexia nervosa (Carlat, 1997). Males are now beingstudied more frequently to determine whether or not they differ significantlyfrom females with respect to eating disorders. If males are found to not differsignificantly from females in this respect, then those who support a morebiologically based view of the disease, gain support. Things such asschizophrenia or depression for instance could then be seen as major determiningfactors.
If however, it is found that certain cultural and psychological riskfactors are the same for both males and females, then the sociocultural view ofeating disorder etiology gains support (Carlet, 1997). Males in fact do sharesome similar central features as females who suffer from anorexia; but they alsohave their own unique issues with regard to social pressures and vulnerabilities(Carlet, 1997). Unlike females who typically Afeel emailprotected, males are often obeseto begin with. Males are more likely to diet to attain goals in a particularsport like wrestling or swimming.
Males also diet to prevent themselves fromdeveloping medical complications witnessed in other family members such ascardiovascular disease and diabetes (Blackman, 1996). In several cases involvingmales, their profession was found to be clearly related to the onset of theeating disorder (Carlat, 1997). One patient studied by Carlat et al. reportedtaking appetite suppressing pills in an effort to keep slim for acting roles andwithin several months he began a pattern of binge eating and self-inducedvomiting. 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 ofonset was 19.
3 years. The average education level was 1. 6 years of college atthe time of their first treatment (Carlat, 1997). This does not necessarily meanthat this group is more susceptible to developing eating disorders as theseresults could have been influenced by how the sample was taken. With regard tothe core concerns about body image and weight, it appears that males withanorexia may be more similar to their female counterparts than to male bulimicpatients (Carlat, 1997). Like females, Carlat et al.
found that male anorexicsclearly feared weight gain and desired a body weight of only 75% of their idealbody weight (Carlat, 1997). Perhaps the biggest finding with males is the highprevalence of homosexuality/bisexuality in those with eating disorders ascompared to the general population. Recent data estimates 1%-6% of healthy malesare homosexual and that only 2% of females with eating disorders are homosexual(Carlat, 1997). Homosexuality was found to have a 27% prevalence among malepatients with eating disorders however. Anorexic males in particular were alsofound more likely to be asexual (defined as having a lack of interest in sex fora 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 thetestosterone lowering effect of protein-calorie malnutrition, combined withactive repression of sexual desire (Carlat, 1997). The high rate ofhomosexuality and bisexuality among males with eating disorders can serve asevidence for both psychosocial and biological views of the etiology of eatingdisorders. Psychosocially, homosexuality can be seen as a risk factor that putsmales in a subculture system that places the same importance on looks andappearance in men as the larger culture places on women (Carlat, 1997).
It isthese similar cultural pressures toward thinness that cause eating disorders (Carlat,1997). From a biological point of view, it can be argued that brain structurebetween homosexual men and heterosexual women are similar (Carlat, 1997),particularly a tiny precise cell cluster known as the third interstitial nucleusof the anterior hypothalamus or INAH3. This cluster of cells in gay men wasfound to be about half the size of the cluster in straight men which puts themin the same size range as heterosexual women. This particular part of thehypothalamus has been strongly implicated in regulating male-typical sexualbehavior (Nimmons, 1994). It may be argued then that homosexual men react toenvironmental stressors in a biologically feminine way, increasing their risk ofeating disorders (Carlat, 1997).
Males, like the females studied by Carlat etal. , were shown to have high rates of co-morbid major depression, substanceabuse, anxiety disorders, and personality disorders. One year after initiallybeing treated, 59% still suffered from their eating disorder. (Carlat, 1997).
This is a cause for concern as there are so many concurrent complications thatcan arise from eating disorders, especially anorexia nervosa. Adverse Effects ofAnorexia Nervosa Anorexic patients are often found to suffer from osteoporosis,anemia, and hypotension (Carlat, 1997). Chronic starvation due to anorexia hasalso been linked to seizure activity and fainting attacks (Blackman, 1996). Theanorexic often looks pale, tired, wasted, bradycardia (slow heart rate) may bepresent, and the skin is cold to the touch.
Another common feature is thepresence of fine downy hair on arms and torso. Laboratory results often revealquite abnormal values. These values are often caused by dehydration and severeelectrolyte imbalances which can be life threatening. Amenorrhea, or absence ofmenstruation occurs in post menarchal girls who lose more than 20% of theirexpected body weight (Blackman, 1996; Rock, 1996). Amenorrhea, in fact isanother one of the diagnostic criteria for anorexia nervosa (for females)according to the DSM IV (Blackman, 1996).
The absence of menarche is related tothe bodies reaction to extreme fat loss and the non viability of pregnancy underthese conditions (Blackman, 1996). Starvation itself as been shown to inducemany hormonal changes in the body as well as inducing mental states such asanxiety, depression, and even psychosis (Kershenbaum, 1997). These are just afew of the consequences associated with anorexia nervosa. There are many othersranging from things as obscure as bilateral foot drop, which was observed in one15 year old girl (Kershenbaum, 1997), to something as serious as sudden deathand even suicide (Neumrken, 1997). Sudden death is defined as the sudden,unexpected, and unexplainable occurrence of death. Some of those who diedsuddenly, 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 (Neumrken, 1997). One would question with all of theadverse consequences, why anorexics still diet. Anorexia produces a *runnershigh= as does exercise. This is a result of opiate release in the brain which inturn suppresses appetite and promotes increased levels of activity. Onceanorexic behavior begins and becomes established, it promotes this endorphinsecretion and becomes pleasurable and self reinforcing. The sufferer then isbound to self starve and the established cycle is no longer deliberate or easilystopped (Blackman,1996).
Treatment Treatment comes in the form of psychotherapy,nutritional education, and refeeding. Nutritional education takes time howeveras the farther a person is below their healthy weight, the more their cognitiveability is impaired (Merriman, 1996). The first of the higher mental functionsto 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 makethem as meaningful to the person as is possible. Refeeding is also not astraightforward process as anorexics often find it quite difficult to gainweight. This is due to an increased diet induced thermogenesis and a lowermetabolic efficiency. Anorexic patients can waste about 50% of the energy oftheir food due to this inefficient metabolism at the start of refeeding, makingthe maintenance of any gain in weight difficult (Moukadden, 1997). Another studyconcluded that even with weight gain after 3 months to a year, it was not enoughto maintain a desirable nutritional status. This was because patients did notreach an adequate body mass index and their immunological indexes were lowerthan in control subjects during an entire one year follow-up (Marcos, 1997).
Conclusions From the information presented, one can only imagine just howcomplex the issues really are that the anorexic attempts to deal with viadieting. The anorexic may be dealing with substance abuse, depression, sexualabuse, confusion about their sexual orientation, or bodily dissatisfaction toname a few. The individual anorexic may be suffering from a combination of suchissues in varying degrees. To what extent, psychological, societal, andbiological factors affect the onset of the disorder is, as of yet, too complexto determine.
It appears to vary from individual to individual, although thereare some features seen more commonly than others. The variability seen with thedisorder on an individual basis is why the anorexic sufferer can not becategorized into a particular stereotypical group. It is not just the whiteadolescent girl who is affected. The disorder affects various other groups aswell and is being seen more frequently in groups it did not typically affect. Ithas been mentioned how the disorder is becoming more prevalent among immigrantswho move to westernized cultures; yet, the disorder is rarely ever seen in lessdeveloped countries. Males also are being seen more frequently to be sufferersof this traditionally female disorder.
This data seems not to point to aparticular group as being more prone to developing anorexia, but instead pointsto 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 awhile they feel good about their weight loss and in control of something intheir life. They inevitably desire to feel like this again so they set out tolose more weight. This cycle continues until someone steps in and helps thesufferer by convincing them to seek help. This can be hard as the anorexic isusually so far in denial that they are the last to realize just what shape theyare in.
The road to recovery is difficult and the body seems to resist anyweight gain during the initial refeeding period. Even after an entire year oftreatment, evidence suggests that recovery has not been achieved and manyanorexics still continue to suffer from their disorder. There are so manycomplications that anorexia can be attributed to that it would appear that thequicker a person complies with treatment and can be recovered, the better. It isquite obvious that anorexia is a complex disorder that partly involves how oneperceives his or her self and what physical standard society dictates theyshould live up to.
The topic has many areas that require further research associety has been shown not to be the entire causative factor for the developmentof the disorder. It has been shown to be one of them however; so until societybecomes more realistic in the ideals it endorses, it is responsible, at least inpart, for the prevalence of this disorder. BibliographyBlackman, M. A Anorexia Nervosa: Diagnosis and Management, @ Medical ScopeMonthly, July/August, 1996 (or see www. tminus10.
com/children/health/anex. htm). Carlat, D. J.
; Camargo Jr. , C. A. ; and Herzog, D. B.
AEating Disorders inMales: A Report on 135 Patients, A American Journal of Psychiatry, 154, August1997, 1127-1132. Council on Size and Weight Discrimination. Facts and Figures. New York: Council on Size and Weight Discrimination, Inc. , 1996.
EatingDisorder Resource Centre of British Columbia. Do I Have an Eating Disorder? . Vancouver: Working Design, 1997. Kershenbaum, A.
; Jaffa, T. ; Zeman, A. ; andBoniface, S. A Bilateral Foot Drop in a Patient With Anorexia Nervosa, AInternational Journal of Eating Disorders, 22, November 1997, 335-337.
Kinzl, J. F. ; Mangwelth, B. ; Traweger, C.
M. ; and Biebl, W. A Eating-DisorderedBehavior in Males: The Impact of Adverse Childhood Experiences, A InternationalJournal of Eating Disorders, 22, September 1997, 131-138. Marcos, A. ; Varela,P.
; Toro, O. ; Lpez-Vidriero, I. ; Nova, E. ; Madruga, J. C. ; and Morand,G.
AInteractions between nutrition and immunity in anorexia nervosa: a 1-yfollow up study, A American Journal of Clinical Nutrition, 66, August 1997,485-490. Merriman, S. H. A Nutrition education in the treatment of eatingdisorders: a suggested 10 session course, @ Journal of Nutrition and Dietetics,6, October 1996, 377-380.
Moukadden, M. ; Bouler, A. ; Apfelbaum, M. ; andRigaud, D. A Increase in diet-induced thermogenesis at the start of refeeding inseverely malnourished anorexia nervosa patients, A American Journal of ClinicalNutrition, 66, July 1997, 133-140. Murnen, S.
K. ; and Smolak, L. A Feminity,Masculinity, and Disordered Eating: A Meta-Analytic Review, A InternationalJournal of Eating Disorders, 22, November 1997, 231-242. Neumrker, K. AMortality and Sudden Death in Anorexia Nervosa, A International Journal ofEating Disorders, 21, April 1997, 205-212. Nimmons, D.
A Sex and the Brain, ADiscover, March 1994, 64-68, 70-71. Rock, C. L. ; Gorenflo, D. W. ; Drewnowski,A.
; and Demitrack, M. A. ANutritional characteristics, eating pathology, andhormonal status in young women, A American Journal of Clinical Nutrition, 64,October 1996, 566-571Health Care
