4. Anorexia: Symptoms, Causes, Therapy

Brief overview

• Description: mental illness, eating disorder with addiction-like character, strong, partly life-threatening weight loss by radical dieting and/or sport, distorted body image
• Symptoms: massive weight loss, underweight, urge to starve, need for control, fear of gaining weight, thoughts revolve around weight and nutrition, physical deficiency symptoms, lack of insight into the illness
• Causes: disturbed stress processing, genetic factors, disturbed neurotransmitter metabolism, strong need for control, high demand for performance, western ideal of beauty
• Diagnosis: severe underweight, self-induced weight loss, body schema disorder, disturbed hormone balance
• Treatment: mostly inpatient therapy, normalization of weight and eating behavior, behavioral therapy individual and group sessions, family therapy
• Prognosis: About 50 percent of those affected largely overcome the eating disorder with therapeutic help. The shorter the duration of the anorexia or the milder the disorder, the better the prognosis. Fatal course in about 10 percent of those affected.

Anorexia nervosa: Description

Anorexia is one of the eating disorders, along with bulimia nervosa and binge eating disorder. Severe weight loss is the most noticeable symptom of anorexia nervosa. Ultimately, however, it is only the outwardly visible sign of a profound psychological disorder. To cure the disease, it is not enough to simply eat again.

Addiction-like urge

The disease has an addiction-like character: the urge to starve is almost irresistible for patients. The special thrill is to have the greatest possible control over one’s needs and body. For outsiders, this is hardly comprehensible.

Moreover, anorexics do not have any insight into their illness for a long time. It is difficult for them to admit to themselves that they have problematic eating behavior. They therefore often resist therapy.

Anorexia nervosa is a serious mental illness. Some of those affected die due to malnutrition or by suicide.

Who is affected by anorexia nervosa?

Anorexia nervosa: symptoms

The main symptoms of anorexia are significant, self-induced weight loss, a pronounced fear of gaining weight despite already being underweight, and a distorted perception of one’s own body.

Because malnutrition affects many important bodily functions, numerous physical (body) complaints also occur.

Weight loss

Severe weight loss is the most noticeable sign of anorexia. Sufferers avoid high-calorie foods and obsess extensively over food content information. In some cases, anorexic people reduce their meals so much that at times they consume only water.

Some sufferers try to further reduce their weight through excessive exercise. Some also take laxatives or dehydrating agents to lose weight.

Underweight

On average, anorexics lose 40 to 50 percent of their original weight. According to clinical diagnostic guidelines, a body mass index (BMI) of 17.5 or more is considered anorexic in adults. This is 15 percent less than normal weight. Different thresholds apply to children and adolescents, as the body mass index cannot be calculated for them using the usual formula.

If you openly talk to those affected about their thinness, they often react irritably.

Cachexia: life-threatening underweight

If the emaciation is massive, one speaks also of a Kachexie. In such a pronounced underweight, the body’s fat reserves are largely depleted and large amounts of muscle mass have already been lost. The body is then extremely weakened – a life-threatening condition.

Cachexia at this stage is visible from the outside. The bone contours stand out strongly, the eyes are deep-set, and the cheeks appear hollow. Usually, patients try to hide these typical anorexia signs. They wear clothes in several layers that cover the body as much as possible.

Distorted body image

Neither protestations from others nor objective weight measures such as the BMI can convince anorexics of their factual underweight. The body schema disorder is a serious problem that can only be overcome by professional help over a longer period of time.

Constant preoccupation with one’s own weight

A very characteristic sign of anorexia is the constant preoccupation with one’s own weight and diet. Anorexic people have a panic fear of gaining weight and being too fat. This does not necessarily mean that they lose their appetite. Rather, their entire thinking revolves around the topics of food and dieting. They are intensely concerned with recipes and love to cook for others.

Constant control

Sufferers know the calorie content of most foods and keep a strict watch on how many calories they take in through food each day. Anorexia is ultimately an attempt to maintain control over oneself and one’s body.

Starvation as a normal state

Anorexics feel that no weight is too low. Starving becomes an addiction and reducing food becomes a kind of race against oneself. The feeling of hunger becomes the normal state, and they find the feeling of fullness unpleasant. At some point, the weight loss is so threatening that patients have to be admitted to a clinic.

Excessive performance orientation

Anorexics are remarkably often intelligent and very performance-oriented people who try to complete all tasks as perfectly as possible. They are particularly ambitious when it comes to sports or school. However, they withdraw more and more from social life. This self-desired social isolation is a warning sign that should be taken seriously.

Mood swings and depression

Very often, anorexics also suffer from severe mood swings and depressive moodiness. These anorexia symptoms may be a result of malnutrition and constant internal pressure to lose weight. Psychological disorders that often occur simultaneously with anorexia include depression, anxiety, obsessive-compulsive and addictive disorders, and personality disorders.

Anorexia damages the entire body. Due to malnutrition, it reduces its energy consumption to the bare necessities of life. All organ systems are affected. This explains the multitude of possible physical consequences of anorexia:

• slowed heartbeat (bradycardia) and cardiac arrhythmias
• @ low blood pressure (hypotension)
• constipation (constipation)
• freezing and hypothermia (hypothermia)
• deficiency of red blood cells, white blood cells and platelets (pancytopenia)
• dry skin
• hair loss
• downy hair (lanugo hair) instead of normal body hair
• in girls/women: cessation of menstruation (amenorrhea), infertility
• in boys/men: problems with potency
• sexual listlessness (loss of libido)
• disturbance of electrolyte and vitamin balance
• decrease in bone mass (osteoporosis)
• Kidney dysfunction
• liver dysfunction
• Concentration difficulties
• Developmental delay in children and adolescents
• Brain atrophy (atrophy of the brain)

Hormonal disorders

Evolutionarily, this may make sense: a woman with anorexia would not be able to carry a child at all, which is why the body prevents pregnancy due to the lack of sex hormones.

Also due to hormonal imbalances, boys and men with anorexia also suffer from a loss of libido and often potency.

Anorexia: Causes and risk factors

The exact causes of anorexia have so far only been conjectured. What is certain, however, is that the disease anorexia nervosa cannot be traced back to a single trigger, but that the reasons for anorexia nervosa are manifold.

Thus, biological and psychological as well as sociocultural factors contribute to the development of anorexia nervosa and reinforce each other.

Biological factors

Disturbed stress processing

Genetic factors

Genes seem to play a crucial role in anorexia. For example, the disease occurs more frequently in some families. Twin studies also show a clear link between a person’s genetic makeup and the occurrence of anorexia.

In fraternal twins, one in ten develops anorexia when the other twin already has the disease. In monozygotic twins, it is even one in two. However, it is not clear how exactly the genes influence the risk of the disease.

Disturbed neurotransmitter metabolism

As with many mental illnesses, the neurotransmitter metabolism in the brain is also disturbed in anorexics. Among other things, the level of the neurotransmitter serotonin is elevated in them. This neurotransmitter influences eating behavior and the feeling of fullness.

Animal studies have shown that serotonin increases the feeling of satiety and thus has an appetite-suppressing effect. An elevated level could therefore make it easier for anorexic people to give up eating.

Serotonin could therefore contribute to maintaining the anorexic behavior. However, this does not explain the typical symptoms of the eating disorder, such as fear of gaining weight and the body schema disorder.

Psychological causes

Desire for control

Anorexics often state in conversations with therapists that the desire for control over their own bodies is one of the biggest motivations for starving themselves. This need for control is acted out through strict dieting.

Psychologists interpret anorexia as the expression of an inner conflict that cannot be managed in any other way. In science, there are several theories that describe possible causes of anorexia in early childhood. Traumatizing experiences – for example, the divorce of parents or the death of a family member – are frequently mentioned psychological causes.

Puberty

At the onset of puberty, girls have the highest risk of developing anorexia. Some experts suspect that general excessive demands during this phase of life full of upheavals can trigger anorexia.

High demand for performance

Anorexia occurs more frequently in middle- and upper-class families. Those affected are usually remarkably intelligent, ambitious and perfectionistic people. Extreme discipline and a high demand on one’s own body are typical.

Both also correspond to the prevailing values. In anorexics, these ideals, which are conveyed from kindergarten age, can fuel the disease.

Weak self-confidence

Anorexics are also often not very self-confident. The apparent control over one’s own body initially boosts self-confidence – patients feel more confident and stronger.

Starvation is rewarded in this way, and this in turn reinforces the eating disordered behavior. If stressful factors also come into play in this difficult life situation (e.g., a problematic relationship with parents, divorce of parents, tensions among friends, a move), this can trigger anorexia.

Sociological causes

Anorexia as a means of pressure

The child thus achieves a position of power from which it can put pressure on the parents. Refusal to eat as a means of exerting pressure can be observed above all when there are many unresolved conflicts in the family. However, it is only one of many possible causes of anorexia.

Western ideal of beauty

The Western beauty ideal currently propagates unnaturally slim bodies. The pressure to be slim is reinforced by very thin role models from the media. The weight of models is below normal weight. As a result of this distorted body ideal, children and young people gain an unrealistic image of how thin or fat a person normally is.

Constant teasing and negative comments about the figure can trigger anorexia against the backdrop of this general “slimness craze.” Conversely, today everyone reaps praise and admiration when they have lost weight. A diet is then often the “gateway drug” to anorexia.

Anorexia: Examinations and diagnosis

If anorexia is suspected, the pediatrician or family doctor is a good first point of contact. He or she can first assess the extent of the risk by examining the patient and determining blood values.

A typical characteristic of anorexia is the lack of insight into the illness. In many cases, therefore, it is not the person affected who seeks medical or psychological help, but rather relatives who are concerned.

Anamnesis interview

Anamnesis is the first step in any medical or psychological consultation. During the interview, the patient reports on his or her personal history of anorexia, any physical complaints and previous illnesses. If anorexia is suspected, the doctor might ask the following questions, for example:

• Do you feel too fat?
• How much do you weigh?
• How much weight have you lost in the last four weeks?
• Are you trying to lose weight on purpose, for example, by exercising excessively or by not eating enough?
• What is your desired weight?
• (For girls/women:) Has your period stopped?
• Do you have any other physical complaints such as weakness, dizziness, or heart palpitations?

The interview is followed by a physical examination. During this examination, the doctor obtains a general overview of the patient’s general physical condition. Among other things, he will listen to the heart and the abdomen with a stethoscope.

He will also measure the body weight and height of the person concerned in order to determine the body mass index – as an objective measure of underweight. Underweight starts at a BMI of less than 17.5, and the BMI of anorectic people is often much lower.

Blood tests

The doctor also obtains important information about the general physical condition by determining various blood values. For example, blood tests can be used to check the function of the liver and kidneys and blood formation, and to detect dangerous disturbances in the salt balance (electrolyte balance).

Further medical examinations

Malnutrition can damage any organ system of the body. Therefore, it depends on the specific complaints, what other examinations the doctor will perform.

Psychological examinations

“Eating Disorder Inventory” (EDI).

A professional questionnaire on eating disorders such as anorexia and bulimia is Garner’s “Eating Disorder Inventory” (EDI). The current EDI includes 91 questions that capture typical psychological characteristics of anorexia and bulimia patients. They fall into eleven categories:

• Striving to be thin – e.g.: “I am terrified of gaining weight.”
• Bulimia – e.g.: “I stuff myself with food.”
• Body dissatisfaction – e.g.: “I think my hips are too wide.”
• Self-doubt – “I don’t think much of myself.”
• Perfectionism – e.g.: “Only top performances are good enough in my family.”
• Distrust – e.g.: “I have a hard time expressing my feelings to others.”
• Interoceptive Perception – e.g.: “I have feelings that I can barely name.”
• Fear of growing up – e.g.: “I wish I could return to the security of childhood.”
• Asceticism – e.g.: “I am embarrassed by my physical needs.”

Diagnostic Interviews

Psychotherapists often use the Diagnostic Interview for Mental Disorders (DIPS) or the Structured Clinical Interview for DSM-IV (SKID) to make a diagnosis. They can be used to identify eating disorders as well as other psychiatric disorders.

For this purpose, the psychotherapist asks questions that the patient answers freely. The therapist classifies the answers using a point system.

Diagnostic criteria of anorexia nervosa

The diagnosis of anorexia is made when the following four symptoms are present:

• Underweight (at least 15 percent below normal weight).
• self-induced weight loss
• Body schema disturbance
• Hormonal imbalances (endocrine disorders)

Anorexia test for self-assessment

The best known anorexia test for self-assessment is the “Eating Attitude Test” (EAT) by Garner and Garfinkel. The EAT includes 26 statements about eating behavior and attitude regarding figure and weight. They are answered on a scale from “always” to “never.”

Examples of statements in the EAT are:

• “I avoid eating even when I am hungry.”
• “Other people think I’m too thin.”
• “I feel the need to throw up after I eat.”
• “I’m obsessed with getting thinner.”

Anorexia tests on the Internet

Self-tests on the Internet also ask about typical thinking patterns and behaviors associated with eating disorders. Such online tests for anorexia cannot replace a medical or psychological examination, but can provide an initial orientation as to whether eating behavior is disturbed.

Anorexia nervosa: Treatment

Anorexia is more than an out-of-control beauty disorder. It is a very serious and life-threatening illness that almost always requires professional treatment.

The main goals of anorexia treatment are:

• Normalization of weight
• Change of eating behavior
• Restoration of a normal perception of the body
• Therapy of individual and family problems

Inpatient treatment

Anorexic people can be treated as outpatients, inpatients or day patients. In most cases, however, inpatient treatment in a clinic specializing in anorexia is necessary.

This is especially true for patients with a body weight of less than 75 percent of normal, a life-threatening physical condition, or suicide risk due to depression. The goal is long-term behavior change, not just short-term weight gain.

Normalization of weight

At the beginning of treatment, the individual target weight is usually determined. For successful therapy, patients should gain between 500 and 1000 grams per week.

In addition, a therapy plan is created that is tailored to individual needs. An important part of the therapy, is the control of the achieved weight. According to studies, patients who leave the clinic before reaching normal weight are at greater risk of relapsing.

Learning to eat normally

Anorexics first have to relearn a normal way of dealing with food. Therefore, nutritional counseling, cooking classes, grocery shopping and an individual meal plan are part of the program in many clinics.

Operant conditioning is also used to motivate patients to eat. This means that desired behavior – in this case eating – is rewarded or noncompliance is punished. For example, a reward or punishment can be permission or prohibition from visiting.

Psychotherapy

“Focal psychodynamic therapy” seems to be particularly successful for treating anorexia. This evolution of psychoanalysis has been tailored specifically for people with anorexia. It treats the causes of anorexia and helps patients cope with everyday life.

The focus here is on dealing with emotions. Above all, the individual triggers for this illness are explored. Without treating the psychological roots of the disease, the risk of relapse is very high.

Group therapy

Group therapy is a useful help for anorexia nervosa. Patients can share their experiences with other sufferers and see that they are not alone with the problem.

Family therapy

Family therapy can be very effective, especially for young patients, because anorexics need the support of their families to heal.

Family members are often overwhelmed with the disease. Good guidance and a family contact help both the patient to cope at home and the family members to deal with the situation.

Medication

To date, there is no medication that successfully supports weight gain. In many cases, however, other psychological disorders occur in addition to anorexia, such as depression or obsessive-compulsive disorder. These disorders can be treated with medication, among other things.

Lack of insight into the disease

Because people with anorexia often lack insight into their illness, many sufferers do not seek treatment.

Anorexia nervosa: Course and prognosis

The course of anorexia nervosa can vary greatly from person to person. As a general rule, the younger the patient, the better the chances of recovery. In addition, the prognosis also depends significantly on how low the weight is, how long the patient has been anorexic and what physical and mental resources he or she has. In addition, the support of the social environment and especially the family is extremely important for the recovery of the anorexic.

Not everyone is cured

A portion of anorexics cannot be completely cured. It is believed that half of the anorexics struggle with the disease for life. Even after weight normalization, distorted attitudes about weight and figure persist in many sufferers.

Change to bulimia

About 20 percent of those affected develop – starting from anorexia – another eating disorder: bulimia (binge eating disorder). This is an eating disorder in which a lot of food is eaten in bouts of ravenous hunger and then immediately vomited up again.

Physical and mental long-term consequences

The physical effects of anorexia are often severe, because malnutrition damages all organs. The body does not always fully recover from it.

Danger to life

Anorexia is a very dangerous mental illness. In some patients, the disease ends fatally – either because of the massive deficiency symptoms or because of suicide as a result of the accompanying depression.

Recovery is a lengthy process with progress, but often also with regression. Even after a hospital stay, prolonged therapeutic care is necessary. But the good news is: the effort is worth it.

Anorexia: What is “Pro Ana?”

“Pro Ana” is a movement on the Internet that does not see anorexia nervosa as an illness, but glorifies it as a lifestyle of its own choosing. On the corresponding Internet sites, girls in particular exchange ideas about how they can lose even more weight in order to conform to their “ideal body image.” Despite the imminent danger to their lives, the young people spur each other on to eat as little as possible.

Anorexics who visit “Pro Ana” sites are aware that they fall under the diagnosis of anorexia. However, they do not want to be cured of their anorexia, but rather to become even thinner. They see the anorexic body as a desirable ideal of beauty – a life-threatening attitude.

Access to these Internet sites is often only possible with a password. Particularly strict “Pro Ana” forums make people go through a kind of application process before being admitted to the online community, in order to avoid unwanted guests.

The “Pro Ana” Internet sites are very popular. It is estimated that 40 percent of all adolescents with anorexia visit “Pro Ana” sites.

Corresponding Internet sites also exist for bulimia. These are referred to as “Pro-Mia.” Bulimia, like anorexia, is an eating disorder. Unlike anorexics, bulimics suffer from binge eating and binging.

Religious imprinting

In addition, there is a creed that illustrates the morbid worldview of anorexics (“I believe in a world that is only black and white, in losing weight, forgiving sins, rejecting the flesh, and living a life of hunger.”).

Photos of lean models

The “Pro Ana” pages are also used to show photos of severely emaciated actors and other celebrities. In some cases, the anorexics also upload photos of their own bodies. Those suffering from anorexia share their daily “successes” and report how much they have lost and how little food they have eaten. Gaining weight is considered a failure.

Anonymous exchange and mutual reinforcement

The anonymous contact on the Internet enables anorexics to exchange information without restriction. The problem is that anorectics feel confirmed in their behavior by other anorexics.

We-feeling

There is also strong competitive pressure among the followers. Everyone wants to be even thinner than the others and prove how strong-willed they are.

In addition, anorexics receive information on how they can conceal the disease from their parents and lose weight even faster. Tips are also given on how to falsify weight measurements at the doctor’s office.

Protective measures

This perpetuation of the condition has severe health implications and can be fatal. For several years, various initiatives (e.g. jugendschutz.net) have been checking “pro ana” sites and have already had some of them blocked. However, it is difficult to control what is on offer on the Internet – also because new sites are constantly being created.

In the meantime, there are also app versions of “Pro Ana” for cell phones. The exchange via cell phone cannot be controlled at all. Anorexics can use it to keep in touch around the clock. The pressure not to eat thus exists day and night.

Pro Ana ban?

There have been extensive debates about whether “Pro Ana” Internet sites should be banned. The argument in favor of banning “Pro Ana” sites is the danger that

• the sites create a slimming competition and promote unhealthy methods to reduce weight
• anorexia is presented as a positive lifestyle and the discipline of starvation is glorified like a religion

Visitors to the “Pro Ana” sites, on the other hand, have argued that they have the right to share with others who are experiencing the same as they are.

Undoubtedly, people who follow the “Pro Ana” movement are in dire need of psychological and medical help. However, it is not possible to stop the exchange of members. It is also questionable whether a ban would bring the desired effect or rather give the anorexia movement an even stronger stimulus.