Anorexia Nervosa: Literature Review

Anorexia nervosa, or better known as anorexia, is an eating disorder with which countless women and men battle every day, with worldwide prevalence. Anorexia is considered to be a psychiatric illness, which has long term effects on those who suffer from it, both psychologically and physically. The etiology of anorexia is multifactorial with genetic, biological, environmental, psychological and sociocultural influences. There are many different models of intervention to treat anorexia, which are each met with different measures of success. Social workers today can play an important role in prevention, psychoeducation, and treatment of this eating disorder.

(Campbell, 2014)

According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition), to be diagnosed with anorexia, one must have significantly low weight, due to restriction of food intake. One will suffer from a true fear of gaining weight and will exhibit persistent behaviors which prevent weight gain, even though the person is significantly underweight. The person suffering from anorexia may put a great emphasis on their body weight and shape, and it will affect their self-regard. They will refuse to recognize the severity of their low body weight. (American Psychiatric Association, 2013)

The DSM divides anorexia into two distinct types: restricting type and binge-eating/purging type. The person who has the restricting type, will not have engaged in recurrent binge eating or purging behaviors within three months. One who is diagnosed with the restricting type will accomplish their weight loss through fasting, excessive dieting, and extreme exercise. Those with the binge-eating/purging type of anorexia will have engaged in persistent binge eating and purging episodes. Purging behavior includes self-induced vomiting, enemas, diuretics, or misuse of laxatives. Someone with moderate anorexia will have a BMI of 16-16.99, severe anorexia will be 15-15.99, and extreme cases of anorexia will have a BMI that is less than 15. (American Psychiatric Association, 2013)

Prevalence

Anorexia is most commonly seen in adolescent girls. The average age of onset ranges between 14 and 18, however there are cases of anorexia developing in later stages of life. In general, it is more common among females than males; because women, and particularly adolescent girls, are generally more concerned with their physical appearance and body image. (Umarani, 2016) The prevalence rate for men is approximately one-tenth of the prevalence rate of anorexic women. (Zide, 2016) However, there has been increasing evidence reflecting the rise of anorexia among male athletes, especially sports where a being thin can be an advantage for players such as boxers or wrestlers etc. (Glazer, 2008) Children, adolescents, and adults from all social and economic classes are at risk for developing anorexia, it is not specific to a certain culture or ethnicity. While anorexia is a disorder that is a worldwide problem, it is definitely more prevalent in Western cultures, where there is an abundance of food. (Zide, 2016)

Etiology

Despite advanced knowledge of medicine and psychology today, the exact causes of anorexia are unknown. As with many mental illnesses, what causes someone to develop an eating disorder is difficult to determine. However, there are risk factors that have been identified which can play a role in how an individual will perceive their body, thereby making them more susceptible to develop anorexia. These factors include psychological, sociocultural, and biological variables such as peer pressure, personality type, media influences, and body image.

One of the major social factors that has been identified is the cultural emphasis today on being thin. This is another reason why anorexia is more prevalent among Western cultures, where body image is a large focus of society. (Campbell, 2014) Technology and media influences play a large role in relaying this cultural message to us today. Television programs emphasize many different types of cosmetic surgeries, and programs that focus of the lives of models emphasize the importance of having a designer body. The advertisement commercials are all about diet products, weight loss programs, and exercise equipment. Fashion and fitness magazines feature models who are wasted and have incredibly well-toned bodies. This is the societal influence that puts Western civilizations at a greater risk for their youth to develop anorexia.

Research has pointed to personality traits which are at a greater risk of developing anorexia. Studies show that those who are diagnosed with anorexia tend to have a heightened need for perfectionism. Individuals who are perfectionists will be very self-critical and set very high standards for themselves. They can impose completely unrealistic demands on themselves. Perfectionism is an attempt to control their anxiety. (Farstad, 2016) Additional personality traits which have been found to be risk factors include negative emotionality and neuroticism. These individuals are more likely to experience negative feelings more often, such as anger, guilt, anxiety, depression, and fear. Additionally, personality traits of impulsivity and negative urgency have been specifically linked to binge eating and purging. These individuals tend to engage in rash actions when they are distressed, thereby resulting in spontaneous episodes of binge eating and purging when are overwhelmed or anxious. (Culbert, 2015)

Whether or not anorexia it genetic, is widely researched, but remains unclear. While anorexia does have genetic correlations, such as metabolic traits, research has not yet clearly established how significant the role of genetics plays when it comes to the etiology of anorexia. (Duncan, 2017) Because there are high rates of familial aggregation, a lot of attention has been given to the study of the genetic component of anorexia. Studies done on identical twins have provided researchers with evidence that genetics do play a role in anorexia. Researchers conclude that enough evidence points the fact that there is a genetic component to anorexia, however, environmental factors influence gene expression. Additionally, genetics are not a single factor that causes an eating disorder, rather they can be one of a few contributing factors. (Duncan, 2017)

There are many other risk factors which have been linked to causes of anorexia. Family of origin issues have been proven to be a major risk factor. Growing up in homes of verbal and emotional and sexual abuse makes children prone to develop anorexia. Additionally, growing up in an environment with controlling parents or highly critical parents are risk factors too. Children who were neglected, or grew up in homes where there were always issues around food, (i.e. forcing children to eat, overly strict diet regulations etc.) were also found to be prone to develop anorexia. (Kally, 2008)

Body image issues have been a major contributor to the list of risk factors as well. Having a negative body image has been proven to be an immediate trigger of anorexia, especially for those who develop it at a younger age. Children who grew up in homes where parents were very focused on appearance, were extremely weight conscious, were constantly dieting, and were very critical about their body images were prone to become anorexic. These children constantly have their appearance criticized, and are sometimes put on diets at a very young age. Many of these children are constantly being compared to a thinner sibling, which can reinforce their negative self-perception. (Kally, 2008)

Biological Factors Associated with Anorexia

Amenorrhea, the cessation of the menstrual period, commonly occurs among females with anorexia. This is considered a defining feature of anorexia. The extreme weight loss caused from a decrease in calories causes a suppression of hormones from the pituitary gland that are needed to maintain normal estrogen levels. (Zide, 2016) Besides amenorrhea, there are multiple other medical complications which result from anorexia. These medical complications include minor side effects such as fatigue and lack of energy, as well as major ongoing heath problems, which can eventually lead to death. Gradually, the health risks of anorexia become more severe as the disorder progresses.

Someone is the advances stage of anorexia may have medical complications such as osteoporosis, (caused by the loss of calcium from the bones), constipation, and swollen joints. Cardiovascular and renal problems may be caused from excessive purging. Renal problems include hypotension, and a risk of kidney failure. Cardiovascular problems include bradycardia, a slow heartbeat, and cardiac arrhythmia, an irregular heartbeat. (Zide, 2016) Additionally, anorexics may develop hypokalemic alkalosis, a condition which is caused by an extreme loss or lack of potassium, which may be the result of purging. (Campbell, 2014)

Additional effects of purging include fatigue, weakness, seizures, or mild cognitive disorders. The ""chipmunk appearance that some anorexics may have, is another effect of purging which can cause an infection of the salivary glands, giving the face a puffy appearance. Repeated vomiting causes serious damage to teeth. Vomit is especially toxic because it contains acids from the stomach which aid digestion. However, in the mouth these acids are corrosive enough to wear away at enamel which results in tooth decay. (Campbell, 2014) Other biological symptoms of anorexia include dry skin, intolerance of cold temperatures, thin hair, pale complexion, poor posture, and extreme thinness. (Zide, 2016)

Psychological Factors Associated with Anorexia

Anxiety is a fundamental issue among individuals with anorexia. Suffering from overpowering feelings of agitation, and a constant overwhelming sense that something bad is about to happen creates internal anxiety. The person with anxiety will also become preoccupied with how the outside world view her, with in turn provokes a feeling of external anxiety. Constant reassurance and approval is sought to ease the external anxiety by creating a perfect eating pattern. Controlling what one eats can seem like the answer to the search for relief from anxiety and for perfection. They can engage in ritualistic behavior and see it pay off as they lose weight. And because they can control what they eat, they feel in control of their anxiety. (Farstad, 2016)

A major psychological feature of anorexia is the distortion in the way that individuals see their body size and shape. Body image distortion is when an individual is unable to see herself accurately in the mirror and perceives their features and body size as distorted. Malnourishment is a possible cause for this illusion. The image the individual will perceive may be huge, despite the fact that in reality they are emaciated. This distortion can affect touch as well. An anorexic individual may physically feel that their arms, thighs or stomach is many times the size it actually is. (Campbell, 2014)

When diagnosing an individual with anorexia, clinicians must be aware that schizophrenia might look similar to anorexia in certain ways, especially if the person refuses to eat. However, a clinician should note that although perhaps the person with schizophrenia is exhibiting bizarre eating patterns, they are rarely concerned about the calories involved in the food. Additionally, people with schizophrenia do not have a fear of gaining weight, nor do they perceive body distortions. (Zide, 2016)

Models of Intervention

Recovery from anorexia is a long process, the recovery length depends at what point it is treated. There are a number of designs for the treatment of eating disorders. Four of the most popular are cognitive behavior therapy (CBT), interpersonal psychotherapy (IPT), drug treatment, and group therapy. These are not the only treatment available or necessarily the best for a given patient, but these are the ones that have supporting evidence for their effectiveness. (Culbert, 2015)

Cognitive behavioral therapy is based on a model created by Aaron T. Beck to treat depression. Therapy hinges on a premise: when you face a certain situation, how you feel and what you do is mediated by your perceptions and thought patterns. CBT asserts that a person's thinking is what motivates his actions. It is based on the theory that a person's thoughts, emotions, and behaviors are interconnected and can be restructured to support new, healthier thoughts and actions. The ultimate goal of CBT is to get to the core doctrines and help massage them into less rigid, more forgiving truths. (Weiss, 2018)

The CBT model emphasizes the important role that both thoughts and actions play in maintaining an eating disorder. Examples of cognitive factors can be over-evaluation of weight and shape, negative body image, perfectionism, and beliefs about self-worth. Behavioral factors include weight-controlled behaviors such as dietary restraint, binge eating, purging, and body avoidance. Individuals with anorexia often have a negative self-image and a distorted body image. These highly critical thoughts can result in feelings of shame, and anxiety that often trigger weight-controlled behaviors. Guided by a therapist, CBT can help the anorexic individual examine which specific factors are maintaining their disorder and to set personalized goals that are addressed through the various phases of CBT. (Weiss, 2018)

The three phases of CBT are the behavioral phase, the cognitive phase, and the maintenance and relapse prevention phase. In the behavioral phase, the patient and therapist will work together to create a plan to stabilize eating and eliminate symptoms. Because this can lead to intense emotions, coping skills to manage these feelings are taught to the client, and this becomes an important part of treatment. CBT includes in session activities, as well as homework, so behaviors can be practiced in outside environments. In the cognitive phase, the therapist will introduce techniques that are aimed at recognizing and changing thought patterns. Thought patterns that perpetuate the problem are recognized (i.e. ""I will only be respected if I lose weight), and the client will work on developing new thoughts and ideas (i.e. ""my self-worth does not depend on my weight). Other concerns are addressed during this stage as well, such as relationship problems, body image, self esteem problems, and emotional regulation. The maintenance and relapse prevention stage is the final stage which focuses on reducing triggers, preventing relapse, and maintaining progress that was made. (Farstad, 2016)

IPT can also be an efficient tool in the recovery process for an eating disorder sufferer in that it addresses underlying personal issues, targets underlying factors that may be fueling an eating disorder, and encourages the application of strategies for relationship improvement. Throughout the duration of therapy sessions, individuals suffering from eating disorders are guided in learning how to better cope with the tension and anxiety that often outcomes from poor interpersonal interactions, as well as fortify greater self-esteem. For the treatment of eating disorders, IPT is likely to be combined with other forms of psychotherapy, such as Cognitive Behavioral Therapy (CBT), in conjunction with the overall treatment plan for recovery.

When addressing anorexia with medication, treatment is complicated due to the medical issues that come with malnutrition. Psychologically, antidepressants, and anti-anxiety medications can help with underlying mental health issues. Prozac can help with depressive symptoms and potentially with healthy weight maintenance once weight restoration is achieved. Prozac is part of the SSRI family, or the selective serotonin uptake inhibitors. SSRIs assist with increased serotonin levels, that is connected to mood. Zyprexa can also be used to assist with weight gain and obsessive thinking in patients. (Lock, 2005)

Group therapy for eating disorders involves education, interpersonal psychotherapy, cognitive behavioral therapy, or a mixture of all three. There are many benefits of attending group therapy including normalization, support, and acceptance. Groups may be homogeneous, where all the members have the same eating disorder, or heterogenous, where members have different eating disorders. A heterogeneous group typically includes anorexics and bulimics, as they share similar etiology. (Lock, 2005)

The Role of Social Workers

As social workers, we have a vast knowledge of mental illness that the general population does not possess. Mental disorders that may not be apparent to one who is unaware of what to look out for, such as anorexia, may be at a life-threatening stage once they are recognized. By educating the public about the signs and symptoms of anorexia, we can avoid late stage anorexia which requires hospitalization, and possibly even avoid deaths. We can do this by talking to parents with children as young as six or seven, and advocate for awareness programs for educators. If parents and educators are aware of what signs to look out for, and recognize which risk factors make children vulnerable to becoming anorexic, we may reduce the alarmingly high rates of anorexia today.

Besides educating the public on anorexia, practitioners must continue to further their own education on this subject. Anorexia is a complex mental illness, in which there are many areas of research that still must be done to explain unanswered questions. The etiology still remains unclear, and studies continue finding different risk factors which make children vulnerable to develop this disorder. Because this is such a complex disorder, many times the symptoms go unnoticed, or may be misdiagnosed as another disorder (i.e. OCD, schizophrenia) (Zide, 2016) Being the ones to diagnose and treat these individuals is a great responsibility and requires a practitioner to have a vast and detailed knowledge on the subject. Because social workers are the ones diagnosing people, and facilitating group therapy and individual therapy for those with anorexia, they must have a clear understanding of this disorder, and continue to expand their knowledge on the subject. This includes researching other risk factors that may possibly contribute to the etiology of anorexia, exploring different methods of treatment that may be effective, as well as critical thinking.

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