Eating Disorders: Anorexia Nervosa

The name anorexia is short for anorexia nervosa – sometimes called the slimmer’s disease. It is an eating disorder in which a person, most often a young woman, deliberately loses weight.
Anorexia often begins with worry about weight as a reaction to the changes in body shape and weight gain which normally occur at puberty. Excessive dieting then leads to a dramatic weight loss. The person loses so much weight that their health begins to be affected, although they may not feel unwell.
Despite the weight loss, they may feel extremely energetic and exercise for hours each day. They continue to diet because they do not think they are thin and feel that gaining weight is the worst thing that could happen. Family whanau and friends may tell them they have become much too thin, but people with anorexia often see themselves as fat when they look in the mirror, even though they are really extremely thin.
Anorexia seldom begins before puberty. About half of all cases start before the age of 19, and almost all before the age of 45. Ninety percent of people with anorexia are women, with about one woman in 100 developing the condition.
Many people with anorexia recover after a few years although a significant number go on to have other problems such as depression, alcohol problems and anxiety disorders. A minority remain very underweight. Approximately one in 100 people with anorexia die each year, usually from the complications of starvation.
Signs of anorexia
Some early signs of anorexia include:
• increasing concern about weight and disgust with body shape
• wearing only baggy or concealing clothing
• exercising too much
• refusing to eat with others
• having rituals around eating, such as counting mouthfuls, eating from a particular plate only, or taking only tiny mouthfuls
• lying about eating (“I’ve already eaten”)
• being moody or angry when asked about dieting.
As weight drops various changes occur in the body.
• Metabolism slows so as not to use up too much energy. Signs of this are slowing of the pulse, reduction in blood pressure and later, lowering of body temperature.
• For women with anorexia, their menstrual periods stop. This is due to reduction in oestrogen (the female sex hormone) production, which also causes the thinning and premature ageing of the bones known as osteoporosis.
• Fat and then muscle is burned up which leads to wasting of the body.
• Blood flow to the arms and legs reduces, making the fingers and toes blue and cold.
• Fine hair may grow on the back, arms and face.
• With further weight loss, vital organs such as the brain and heart may be affected.
• Starvation of the brain causes loss of concentration, difficulty in thinking clearly, depression and irritability.
• Starvation of the heart muscle leads to heart failure or disturbances in heart rhythm which can lead to sudden death.
The person may not be aware of these physical problems except for finding cold weather hard to bear. Often there is little sign of a major problem until the person suddenly collapses.
Risk factors for developing anorexia
People who are at particular risk for developing anorexia include:
• those whose career or sport requires them to be thin – dancers, gymnasts, models or body builders
• those who are overweight
• those with multiple problems including childhood sexual abuse or neglect, drug or alcohol problems and unstable relationships
• those who have diabetes.
Causes of anorexia
There is no known cause of anorexia. It is known that it develops in certain situations.
Social situations. Anorexia has mainly become a problem for the western world in the last few decades. It does not occur in countries in which food is scarce, nor in countries where woman are not encouraged to be thin. In the west, women have been given the message that they need to be thin to be considered beautiful. Since a thin shape is normal and healthy for only a very few women, others must either struggle with feelings of not being good, perfect or self-controlled enough or begin to diet.
Family whanau situations. Those who develop anorexia have a higher than normal chance of having a close family or whanau member who has an eating disorder, depression, obsessive-compulsive disorder or alcohol problems. This may mean that there is a genetic aspect to anorexia, or that these families and whanau have emotional or other problems which make them more vulnerable to social pressures, or both. There may also be an increased chance of broken family or whanau, or there may be abuse within the family or whanau.
The individual person’s situation. A number of writers have described emotional difficulties which they believe are common among those who have anorexia. Some stress the struggle that people with anorexia have to feel in control of their lives. They turn to dieting as something they can feel completely in control of. Others have suggested that anorexia is a response to an overwhelming fear of sex and the stresses of growing up.
Living with Anorexia
A person with anorexia will often say they are fine and just want everyone to leave them alone. They may suggest that it is only the unwelcome concern of others that bothers them. In reality they do not enjoy anorexia and will usually be painfully aware of how miserable and isolated they are, and of how much the anorexia controls their life. They endure a constant struggle with negative thoughts about the self, endless thoughts about food and disgust at their body.
People with anorexia often believe they developed it because things have gone wrong in their lives – it could be abandonment, sexual or physical abuse, being in an unhappy family or not living up to people’s expectations. Other people with anorexia may agree with the view that there is genetic or biological aspect to their condition. A lot of people believe it is a combination of these things. Sometimes people think their anorexia is a punishment for their moral or spiritual failure. It’s important to remember that it is not the fault of the person with anorexia that they have a mental health problem.
The whole family whanau can become consumed with the problem. They worry about how stressful the next meal will be. Brothers and sisters may feel ignored by parents whose attention is entirely taken up by the person with anorexia. They may all worry that the person will die.
Families and whanau, especially parents, can worry that they caused their relative to develop anorexia. Sometimes they feel blamed by mental health professionals which can be very distressing for them. Most families and whanau want the best for their relative. It is important for them to understand what has contributed to their relative’s problem and to be able to discuss their own feelings about this without feeling guilty or blamed.
Mothers, in particular, often feel guilty, responsible and angry with their child for being ‘difficult’. Fathers often feel frustrated, closed out and unimportant. Frequently the parents cannot agree about the seriousness of the problem or what to do. Often one wants to be tougher while the other feels this will only make things worse.
Friends often try and talk about the problem but feel rejected when the person with anorexia gets angry or silent. Friends will eventually begin to avoid them, leaving them feeling more and more isolated.
People with anorexia who are in a sexual relationship often report that the relationship is not satisfactory. It is very important that the partner participates in dealing with the problem. This can be just as stressful for the partner who will need to make sure that they get plenty of support from family whanau and friends.
Despite the difficulties, family whanau and friends need to keep talking about the problem. Even though this may not be welcomed by the person with anorexia, the problem rarely gets better by itself. It is not made worse by talking about it.
Important strategies for recovery
People with anorexia have found the following strategies to be useful and important.
• Learn about anorexia nervosa and the treatment options. Get information to help make sense of what has happened, and so you can learn what to expect.
• Take an active part, as far as possible, in decisions about your treatment and support.
• Get treatment and support from people you trust, who expect the best for you but are able to accept how you are at any time.
• Have the continuing support of family, whanau and friends, who know about the condition and understand what they can do to support your recovery. Involve whanau, friends or other important people (e.g. kaumatua or church minister) in your treatment team if you wish.
• Have the opportunity to receive support from culturally appropriate support groups or organisations who can help you to recover and stay well.
• Avoid or really cut down the use of alcohol and illegal drugs, as these may worsen the condition and increase the chances of relapse.
• Talk to your health professionals if you are considering stopping treatment. Work with them to find some compromise that will ensure continuing wellness but address your concerns about the treatment.
Treatment of Anorexia
Summary of treatment options
At present there is no one best treatment for anorexia. Overall, anyone treating a person with anorexia will be helping them to restore a normal state of nutrition as well as helping them to tackle any psychological or alcohol and drug problems. Treatment may include a number of the following components:
Psychosocial treatments
These are non-medical treatments that address the person’s thinking, behaviour, relationships and environment, including their culture. Psycho-logical therapies (often called therapy or psychotherapy) involve a trained professional who uses clinically researched techniques, usually talking therapies, to assess and help people understand what has happened to them and to make positive changes in their lives. They may involve the use of specific therapies such as family therapy or individual therapies including cognitive-behavioural therapy (CBT), psychodynamic therapy, interpersonal therapy (IPT) or narrative therapy. Some therapists use feminist theories to encourage the person to become more aware of the importance of social pressures on her to be thin. More research is needed before one type of psychological therapy is necessarily preferred over another.
This a process whereby the person is given information about their eating disorder and the complications of anorexia. This can be extremely important to aid family whanau and friends to understand the person better and to help improvement of the disorder. Counselling may include some techniques used in psychological therapies, but is mainly based on supportive listening, practical problem solving and information giving. All types of therapy/counselling should be provided to people with anorexia and their family or whanau in a manner which is respectful of them, with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.
There are no drug treatments which are of established benefit in the treatment of anorexia. There are a few which may help deal with some of its associated problems and are prescribed from time to time. These include antipsychotic and antidepressant medications. If you are prescribed medication you are entitled to know the names of the medicines; what symptoms they are supposed to treat; how long it will be before they take effect; how long you will have to take them for and what their side-effects (short and long-term) are. If you are pregnant or breast feeding no medication is entirely safe. Before making any decisions about taking medication at this time you should talk with your doctor about the potential benefits and problems associated with each particular type of medication in pregnancy.
Hospitalisation may be suggested where there is extreme weight loss and concerns about the person’s physical health.
Complementary therapies
Complementary therapies that enhance the person’s life may be used in addition to psychosocial treatments and prescription medicines.
Eating Disorders Service, Princess Margaret Hospital, Christchurch is a public hospital programme so it is free to Christchurch patients. Patients from other areas are admitted if the patient’s local hospital meets the costs. The unit promotes a largely cognitive-behavioural style of therapy and also works to engage families and whanau and individualise each person’s treatment programme.
Ashburn Hall, Dunedin has considerable experience with the treatment of anorexia, and psychodynamic therapy is an important part of its work. The hospital is privately owned so there is a charge. However, funding may be provided by the person’s hospital in some instances. Ashburn Hall is happy to give information and advice about this.
Child and Family Unit, Auckland Starship Children’s Hospital is available to patients under the age of 18 who are still at school. It is a public hospital programme so it is free to Auckland patients. People from other areas are admitted if the patient’s local hospital meets the costs.

Further Information
The Mental Health Foundation’s website has information about the mental health sector and mental health promotion, news of upcoming conferences both here and overseas, links to other sites of interest and the Foundation’s on-line bookstore. It contains the full text of all the MHINZ booklets which can be downloaded as pdf or Word files.

The Eating Disorders Association (UK)

Eating Disorders Foundation of Victoria

Something Fishy

Anorexia Nervosa and Related Eating Disorders


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