Diagnosis and Management
By Dr. Maurice Blackman, MA, MB, BCh, FRCPC
From the July/August 1996 issues of Medical Scope Monthly
This article is the first of a series of articles that will deal with the diagnosis and management of anorexia and bulimia nervosa. These two conditions constitute a considerable cause of morbidity and some mortality in the young female population.
Anorexia nervosa is characterized by a drive for thinness, a distorted body image, and an obsession with weight and food. The term anorexia is derived from the Greek word "orexia" which means a "loss of appetite" and nervosa which is derived from the Latin root "nervus". Put together the term Anorexia Nervosa, first originated by Sir William Gull of England in 1874, means a "nervous loss of appetite." This however is misleading for there is no true loss of appetite in anorexic patients, but a deliberate suppression of appetite promoting self-starvation in their endless compulsion with thinness. The person credited with the earliest medical account of anorexia was an English physician by the name of Richard Morton in 1689. In his book, "The Treatise of Consumptions," Morton described, "a condition he referred to as a nervous consumption caused by sadness and anxious cares" (Halmi, 1992 pp. 379). He described the case of an 18 year old girl, ....... in the month of July she fell into a total suppression other monthly courses from a multitude of cares and passions of her mind but without any symptom of the Green sickness following upon it. From which time her appetite began to abate and her digestion to be bad; her flesh also began to be flaccid and loose, and her looks pale.... She was wont by her studying at night, and continual paring upon books ... I do not remember that I did ever in all my practice see one, that was conversant with the living so much wasted with the greatest degree of a consumption (like a skeleton only clad with skin), yet there was no fever, but on the contrary a coldness of the whole body; no cough, or difficulty of breathing, nor an appearance of any other distemper of the lungs or of any other entrail: No looseness, or any other sign of a colliquation, or preternatural expense of the nutritious juices. Only her appetite was diminished, and her digestion uneasy, with fainting fits, which did frequently return upon her...... she was after three months taken with a fainting fit and died."
Another landmark publication came seventy-five years later by Robert Whytt, a professor of medicine at Edinburgh. In his book, "Observations on the Nature, Causes, and Cure of those Disorders Which Have Been Commonly Called Nervous, Hypochondriac or Hysteric to Which are Prefixed Some Remarks on the Sympathy of the Nerves," Whytt documented a case study a self-starvation he referred to as a "nervous atrophy." (Halmi, 1992 pp. 169-193).
In the late 18th century, Dr. Louis-Victor Marce published a report on "a hypochonchondriacal delirium." Which clearly described the emotional nature of the problem.
"I would venture to say that the first physicians who attended these patients misunderstood the true signification of this obstinate refusal of food: far from seeing in it a delirious idea of a hypochondriacal nature, they occupied themselves solely with the state of the stomach, and prescribed, as a matter of course, bittos, tonics, iron, exercise, hydro-therapeutics with a view to stimulate the activity of the digestive functions. However, apparently excellent these therapeutic measures may be, they always proved insufficient when the malady was in the advanced stage. It is then no longer the stomach that demands attention........ it is the delirious idea which constitutes henceforth, the point of departure, and in which lies the essence of the malady; the patients are no longer dyspeptics they are insane. (Halmi 1992 pp. 263-284)
In 1873 Dr. Charles Lasegue. also stressed the emotional aspects of this illness referring to it as "hysterical anorexia." Similarly Sir William Gull also "suggested that the disease arose from a morbid mental state and a disturbed nerve force" (Epling & Pierce 1991).
This view of anorexia was challenged in 1914 by a pathologist Dr. Simmonds who found one woman's refusal to cat the direct result of an anterior pituitary lesion. This case study led to many physicians disregarding the emotional aspects of anorexia nervosa and instead defining it and treating it in physical and endocronological terms. It wasn't until 1938 that the focus shifted back and anorexia nervosa was again considered a largely emotional illness (Epling & Pierce 1991).
Diagnosis of Anorexia Nervosa
The current issue of the Diagnostic Manual of the American Medical Association, DSM IV, lays down the criteria for the diagnosis of anorexia nervosa follows,
A) 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 a period of growth, leading to body weight less than 85% of that expected.)
B) Intense fear of gaining weight or becoming fat, even though underweight.
C) Disturbance in the way which one's body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.
D) In postmenarcheal females, amenorrhea i.e., the absence of at least three consecutive menstrual cycles, (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen administration).
Anorexia may be primary or secondary. In primary anorexia the anorexia is the central condition and any associated psychiatric condition such as depression is secondary. However in the differential diagnosis of anorexia nervosa one must consider major depressive disorder associated with loss of appetite and anhedonia, and Schizophrenia where the food refusal is part of a delusional system around body image or eating. Anorexia may also be secondary or co-morbid with Obsessive Compulsive Disorder or may be component of Personality Disorder.
Though there is presently an increasing prevalence of anorexia among males, 90% of all cases occur among adolescent girls or young women. In fact, it is now estimated that approximately 1 % of girls between the ages of twelve and eighteen years meet the criteria for full blown anorexia and as high as 5-10% have milder forms of such eating disorders if diagnostic criteria are used less stringently (Vandereycken and Van Deth, 1994). Furthermore, whereas anorexia was once considered a disorder predominately of the higher social class, it is presently becoming represented among all socioeconomic classes. Between5-9% of these anorexics will die from either self-starvation, suicide, or electrolyte disturbances (Vadereycken and Van Deth 1994).
Anorexia in Males
The first medical account of anorexia nervosa in males was described by Morton in 1689. However it was considered so rare and so much an illness of females that it was all but forgotten until the 1970's when there was a re-emergence of interest in male anorexics. Since then the literature has recognized that males with anorexia share similar central features as females suffering from anorexia but have unique issues in terms of social pressures and vulnerabilities.
The literature identifies three major factors which differentiate male and female anorexics. First and perhaps the most important factor is premorbid weight. Males diagnosed with anorexia are often obese to begin with, as opposed to females who "feels" overweight. Male patients more often than women dieted for attaining goals in a particular sport such as wrestling, swimming, etc.. Finally more men dieted to prevent themselves from developing medical complications witnessed in other family members such as coronary disease and diabetes (Yager et al 1992).
The adolescent with Anorexia typically is a high achieving youngster often involved heavily in sports such as gymnastics, swimming, cheer leading, or ballet dancing. The disorder tends to begin in early adolescence although it may occur in the prepubertal period. In prepubertal girls anorexia may retard growth and development so that puberty is delayed up to three years.
The anorexic tends to be very competitive, perfectionistic and have marked obsessional personality features. The onset of dieting often begins following a chance remark by someone, perhaps coach, friend or other individual who is important to them suggesting that they are getting fat, big or clumsy and their performance is suffering. Other patients cite as precipitating causes media influences, wanting to look like a favorite film star or model. In other cases these girls articulate a fear of growing up and becoming adult. Discomfort towards sexuality has been found among both male and female anorexics (Herzog et al 1992).
The anorexic behavior usually begins a with pattern of dieting or particular food choices usually avoiding foods that are perceived as fattening. The Anorexic becomes quite resourceful in hiding the eating anomalies and may avoid eating with the family. Further attempts to reduce weight might include compulsive exercising, The anorexic may wear multiple levels of loose clothing to hide thinness, and the condition may be far advanced before parents recognize what is happening. In extreme cases the diagnosis is only made during clinic visits for physical problems including physical weakness, lack of energy, excessive sleepiness and failure at school. Chronic starvation caused by anorexia has also been seen to induce seizure activity or fainting attacks.
At the time of first presentation the adolescent often looks pale, tired and wasted, bradycardia may be present, and the skin is cold to the touch. Characteristically a fine downy hair may be present on the arms and torso. The adolescent is in total denial about her condition and may insist that she is fat. Laboratory investigations may reveal quite bizarre values and in particular there may be dehydration and severe electrolyte disturbances that can be life threatening. In post menarchal girls there is cessation of the menstrual cycle which has probably not been present for some time and occurs when more than 20% of expected body weight has been lost.
The etiology of anorexia is not known although there is a vast array of theories biological, psychological and psychosocial.
Genetic factors may play a part in anorexia nervosa and sisters of anorexics have a higher incidence of anorexia than the general population. Twin studies have shown a higher concordance in identical than non identical twins, so that some genetic bias is probably present. Eating disorders have also been found in mothers of anorexics again suggesting some familial causes. Anorexia as previously noted has been linked to hormonal disturbances particularly in the hypothalamus and anterior pituitary gland. Anorexia has also been shown to be associated with right temporal disturbance on EEG and Spect Scan (Drebitt and Blackman Journal of the American Academy of Child Psychiatry, 1992). It is beyond the scope of this presentation to consider this area in detail except to postulate that physical, including hormonal changes may be secondary rather than primary. Studies done in the 1950s in the USA with volunteers subjected to various periods of starvation showed that starvation itself could induce many of the hormonal changes associated with anorexia. In particular the absence of menarche can be related to the bodies reaction to the extreme fat loss and the non viability of pregnancy under these conditions. Also, it was found that starvation could also induce mental states such as anxiety, depression and even psychosis.
More support for the relationship between hypothalamic function and anorexia arises from the studies of exercise and dieting conducted by Epling and Pierce 1991. In their research with rats they found that exercise produces a 'runner's high'; opiates are released in the brain which act in suppressing appetite and promoting increased levels of physical activity. They concluded that whatever the original cause of the anorexia behavior, once the pattern is established it is promoted by endorphin secretion, and becomes pleasurable and self reinforcing. Once this activity anorexia cycle begins one is bound to self-starve. This cycle is neither deliberate nor can it easily be stopped.
Epling & Pierce (1991) quote a study conducted by Garner and Garfinkel who compared ballet dancers, models, anorexics, music students and normal University students. It was expected that there would be a higher incidence of anorexia among ballet dancers and models because of the tremendous pressure that is exerted on them to stay thin. Garner and Garfinkel found that six percent of the ballet dancers developed anorexia during training and only 3.5 % of models did (Epling & Pierce 199 1). What was even more significant was the comparison of the ballet schools that the ballet dancers came from. Those dancers who trained at full time ballet schools, which were presumably more competitive and expected more vigorous training from its dancers, were found to be more susceptible to anorexia. These researchers found that whereas 3.8% of the less competitive dancers developed anorexia during training 7.6% of the more competitive dancers became anorexic". Similar results have been shown with athletes suggesting that it is the drive for thinness and extreme exercise that promotes anorexia.
Anorexia predominates in industrialized, developed countries. It is extremely rare those countries that are less industrialized and non-westernized. What is especially significant is that immigrants who have migrated to a westernized country have been found to become more prone to develop eating disorders (Szmuckler 1995). The sociological approach stresses that it is cultural standards and ideals of thinness that initiate eating disorders such as anorexia nervosa. Anorexics are sensitive to society's approval and maintain a perception that it is better to be thin than it is to be fat in a society that is obsessed with weight. Consequently, self-worth is equated with a desirable slim appearance, with a resultant vulnerability to eating disorders. (Szmuckler et al 1995).
Western culture has an obsession with the human body and links a sylph appearance to "beauty, success and happiness" (Canadian Medical Association 1989). We as a society are taught to value certain standards and are bombarded by images of an idealized thin female body through magazines, films, and television etc. (Epling and Pierce 1991).
Though tempting as it may be to conclude that anorexia is a direct result of the pressures put on individuals by society to be thin, the Sociocultural perspective cannot totally explain the loss of appetite and near starvation that some people experience and the difficulty of recovery even in the willing patient. A number of psychological factors have been suggested as being relevant in the causation of Anorexia. Both individual and family psychopathology has been implicated and theories of causation tend to be dependent on particular theoretical biases or perspectives. Thus anorexia has been associated with problems in upbringing, sexual abuse, family dysfunction, low self esteem and poor self concept, over-controlling mothers, distant fathers and sons. The problem has been that studies particularly family studies often deal with the identified patient population in which child parent relationships are already strained and desperate mothers concerned about their child's starvation may indeed attempt to exert considerable control. The anorexic patient places a severe strain on the family and family life tends to revolve around the patients eating habits, conflicts around foods. It is at the end point of this cycle that the patient appears for treatment.
Individuals suffering from anorexia have been described as typically having low self-esteem, and feelings of inadequacy. They fear sexual maturation, are non-assertive behavior, and have difficulty in dealing with stress (Canadian Medical Association 1989).
The anorexic is usually described as having problems separating from the family and developing a distinct self identity. Humphrey notes that these "problems with separation and individualization are thought to result from family wide disturbances in communication, role structure, affect modulation, and boundary diffusion" (Deter and Vandereycken 1992).
Minuchin et al (1978) described anorexic families as "enmeshed, overprotective, and conflict avoidant, and as co-opting the anorectic daughter in destructive alliances with one parent or another. They argued that the family needed the anorexic child to be sick in order to maintain a family homeostasis or balance. Both Garfinkel et al (1983) and Humphrey (1 988) compared the subjective questionnaires of anorexic daughters and their mothers. Both rated the father as "being more disturbed than did the children and mothers in the control families" (Deter and Vandereycken 1992). In fact studies that observed the interaction of family members uncovered that "the parents of anorectic children were both more affectionate and also more neglectful (both parents) and controlling (fathers only). Their anorectic daughters were more submissive .... and were also less trusting and approaching than were teens without an eating disorder" (Deter and Vandereycken 1992).
As noted however these studies were clinical studies with anorexic families and it is not clear whether the findings were primary due to the illness or a secondary effect of it.
It is clear that in the present state of knowledge, the clinician must adopt a pragmatic approach to diagnosis and consider the condition as having roots in biological, psychological and sociological processes with different weightings of these various factors in individual cases.