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What is Anorexia Nervosa?

Alexander R. Lucas, M.D., author of Demystifying Anorexia Nervosa is Emeritus Professor of Psychiatry and former Head of the Section of Child and Adolescent Psychiatry at the Mayo Clinic. For forty years he has been a recognized authority on anorexia, with a practice that drew patients from around the world. Demystifying Anorexia Nervosa defines anorexia, illustrates how it can evolve and how common it really is, and outlines every part of the treatment process, from the early warning signs that parents should watch out for, to the initial evaluation, to specific treatment plans. In the excerpt below Dr. Lucas defines anorexia. Be sure to check out Lucas’s post from this morning.

What is anorexia nervosa? A great many names and definitions have been suggested for it over the centuries. Simply, it is a condition in which an individual, usually a teenaged girl, loses a great deal of weight because she eats less food than it takes to sustain her body’s metabolic requirement. The weight loss is great enough to cause undernutrition with impairment of normal bodily functions and rational thinking. It becomes more than the simple dieting that most teenaged girls try. Typically, it occurs in a previously healthy individual. Kelly Bemis, a psychologist now at the University of Hawaii, defined it as well as anyone when she wrote, “Anorexia nervosa is a complex of physical, emotional, and behavioral changes occurring in individuals who starve themselves because of an aversion to food or weight gain.” Her definition implies an underlying motivation because of the aversion. The fear of gaining weight or of becoming fat is common. Increasingly, though, in recent years, such a fear is not expressed, and no conscious motivation for the behavior is apparent other than the desire to become thinner and healthier.

There are, of course, many other illnesses that cause weight loss. In some of these sufficient intake of nourishment continues, while in others there is loss of appetite and diminished intake. In conditions called malabsorption syndromes and in inflammatory bowel disease the body has lost its ability to absorb food normally. In metabolic disorders such as diabetes mellitus and hyperthyroidism food is metabolized too rapidly and utilized inadequately to maintain normal weight. Consequently, the body breaks down its own fat and muscle tissues to use them for energy. In other conditions, most notably cancer, the body’s need for nourishment escalates dramatically because of the proliferating cancer cells that avidly consume the energy generated by the food ingested. These are hypermetabolic conditions in which the rate of food and oxygen consumption is increased.

Loss of appetite occurs with acute infectious illnesses, such as “stomach flu.” This results in a person eating less and in temporary weight loss. When the illness is accompanied by nausea and vomiting, more severe weight loss and dehydration occur. Acute illnesses are, as the word implies, short-lived. The infection resolves, and appetite soon returns. There are yet other illnesses in which hunger is diminished. The most common of these is depression. The person with depression eats less because she has lost her appetite, shows diminished interest in food, and loses weight as a result. Unrecognized or untreated, depression may last a long time, resulting in considerable weight loss. In none of the foregoing illnesses other than anorexia nervosa is there motivation and desire to lose weight. Weight loss occurs unintentionally.

Innocent dieting is extremely common among teenagers, much more so in girls than in boys. Usually it leads to only a small amount of weight loss, unless the person dieting is very committed and persistent. Consequently, the weight loss from dieting is usually temporary, and most dieters eventually give in to their hunger. In anorexia nervosa, dieting, often associated with excessive exercise, is persistent and continues beyond what is reasonable. It differs from other illnesses involving weight loss because the body remains healthy for a time, is able to absorb food, and is able to metabolize it normally. The anorexic person feels hungry, at least at the beginning, when she is making great efforts to cut back on what she eats.

Simply put, anorexia nervosa involves substantial weight loss in a previously healthy person because of inadequate nourishment over a long period of time. When an adolescent girl who is about average in height and weight loses a considerable amount of weight—say 15 percent or so below her normal weight—her menstrual periods will stop. The girl with anorexia nervosa typically believes she was getting fat, and still sees herself as being fat even after she has lost some weight. By the time she has lost sufficient superficial body fat and weight to be taken to see a physician, she may persist in this belief and be overconcerned with her body. She may then misinterpret the appearance of her loose skin as flabbiness and fat.

Anorexia nervosa has been known for several centuries, but chiefly in the past 30 years have special efforts been made by the medical profession to describe specific criteria for its diagnosis. This was part of the effort in the field of psychiatry to document objective criteria for diagnosing mental disorders. Unlike many physical illnesses, in which a laboratory test may confirm the diagnosis, the diagnosis of most psychiatric disorders has depended on the identification of certain symptoms the patient feels or on behaviors that others can observe. This is particularly true for anorexia nervosa. Despite our rapidly advancing medical technology, diagnosing anorexia nervosa still depends largely on the story that is elicited from the patient and from her physical appearance. There are no laboratory tests or biological markers that confirm its presence.

Anorexia nervosa has come to be included among the mental disorders largely because psychiatrists have diagnosed and treated patients with the disorder. This has had the unfortunate consequence of overemphasizing its emotional components. In reality, anorexia nervosa is as much a physical= disorder as it is a psychiatric one, and certainly the long-term consequences and complications affect the physical health of the individual. Regardless of the wisdom or accuracy of including anorexia nervosa among psychiatric disorders, the disorder and its definition have become established in the psychiatric nomenclature. An unfortunate consequence of this labeling has been the preclusion of insurance benefits for anorexic patients in policies that exclude or limit psychiatric benefits.

…Publicity was accorded to dramatic cases of extreme emaciation, among which there have been some individuals who died. There are many causes and reasons for a person to become anorexic. The cause cannot simply be traced to body chemistry, innate temperament, family constellation, life experiences, or society. For most who are afflicted, multiple factors interact in complex ways to determine how the disease is manifested. And there is much diversity and variability among those who develop the disease. Some individuals are vulnerable in ways that are still not fully understood. Fortunately, most girls and boys in our society do not have it in themselves to become anorexic. Yet they are exposed to the same circumstances as those who do. Without certain vulnerabilities most girls do not become anorexic despite being exposed to circumstances that lead to the disease in others. Different characteristics in the makeup of the individual and her life experiences lead to the onset of the disorder. Patients with anorexia nervosa look and behave remarkably alike during the illness because of its profound starvation effects, but they arrive at their illness in diverse ways. Moreover, they follow different paths as they recover, remain ill, or respond to treatment. Most typically the illness happens at some time during puberty. That causes the pubertal process to be stalled. For recovery to occur, the stages of pubertal and adolescent development must be revived and successfully completed…

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