Anorexia

Anorexia Nervosa

By Alice Baland, MA, LPC, RD/LD

The earliest sited case was in 1686 by Richard Morton about a 20-year old girl:

“ . . . like a Skeleton only clad with skin, yet there was no fever, but on the contrary a Coldness of the whole Body . . . Only her Appetite was diminished, and Digestion uneasy, with Fainting Fitts, (sic) which did frequently return upon her.” (Costin, 1996, Pg. 4)

First Case Study

The first case study with descriptive detail from the patient’s perspective is about Ellen West (1900-1933) who at age 33 committed suicide to end her desperate struggle that had manifested itself through an obsession with thinness and with food. Ellen kept a diary which contains perhaps the earliest record of the inner world of the eating disordered person:

“Everything agitates me and I experience every agitation as a sensation of hunger, even if I have just eaten. I am afraid of myself. I am afraid of the feelings to which I am defenselessly delivered over every minute. I am in prison and cannot get out. It does no good for the analyst to tell me that I myself place the armed men there, that they are theatrical figments and not real. To me they are very real.”

The woman of today suffering from an eating disorder, like Ellen West, appears to exhibit rigid control of her “out of control-ness,” making an effort to purge herself of yearnings, ambitions, and sensual pleasures. Emotions are feared and translated into somatic experiences and eating disorder behaviors, which serve to eliminate the feeling aspect of self. Through their struggle with their bodies, anorexics are striving for mind over matter, perfection, and mastery of self, all of the things for which, unfortunately, their peers and our society in general, willingly praise and applaud them. This, of course, entrenches the patterns into the very fabric of each individual’s identity. Persons with anorexia nervosa seem not to have this disorder, but to become it. Quotes like Ellen’s are repeated by patients today with amazing similarity:

Anorexic: “I am in my own prison. No matter what anyone says, I have sentenced myself to thinness for life. I will die here.” Judy, 1994.

Anorexic: “It does not matter if everyone else tells me that I am not fat, that it is all in my head. Even if it is in my head, I placed the thoughts there. They are mine. I know my therapist thinks I am making a bad choice, but it’s my choice and I do not want to eat.” Andrea, 1995.

Anorexia: “When I eat I feel. It is better if I don’t feel. I am too afraid.”

A cardinal feature of anorexia nervosa is, not only the loss of appetite, rather a strong desire to control it; as well as refusal to eat, extreme weight loss, amenorrhea, low pulse rate, constipation, and hyper-activity. Even as anorexics deprive themselves of food, they obsess about it all day. They want to eat so badly that they cook for and feed others, study menus, read and concoct recipes, go to bed thinking about food, dream about food, and wake up thinking about food. They simply don’t allow themselves to have it and, if they do, they relentlessly pursue any means to get rid of it.” (Costin, 1996, Pg. 6).

Medical & Nutritional Concerns of Anorexia Nervosa

Leukopenia and mild anemia are common
Dehydration may be reflected by an elevated BUN (blood urea nitrogen)
Hypercholesterolemia is common
Liver function tests may be elevated
Hypomagnesemia, hypozincemia, hypophosphatemia, hyperamylasemia occasionally
Induced vomiting may lead to metabolic alkalosis (elevated serum bicarbonate)
In females, low serum estrogen levels are present; in males, low serum testosterone
EEC – sinus bradycardia Resting metabolic expenditure is often significantly reduced
Osteoporosis (resulting from low calcium intake and absorption)

Physical Observations

Amenorrhea, constipation, abdominal pain, cold intolerance, lethargy, excess energy
Emaciation – most obvious finding
Hypotension, hypothermia, dry skin
Peripheral edema, especially during weight restoration or on cessation of laxative and diuretic abuse
Dental enamel erosion from induced vomiting
Scars or calluses on the dorsum of the hand from contact with the teeth when using the hand to induce vomiting

Course

Average age of onset is 17, with some data suggesting bimodal peaks at ages 14 and 18 years. Rare in females over 40. The onset is often associated with a stressful life event, such as leaving home for college. Course and outcome are highly variable. Hospitalization may be required for some to restore weight and to address fluid and electrolyte imbalances. Of individuals admitted to university hospitals, the long-term mortality rate is over 10%. Death most commonly results from starvation, suicide, or electrolyte imbalance.

The APA guidelines for the treatment of eating disorders report that hospitalized or third-stage referral populations of anorexics show that at least 4 years after the onset of the illness, about 44% have “good” outcomes (weight restored within 15% of recommended guidelines and menstruation was regular). “Poor” outcomes were reported for 24%, whose weight never approached 15% of that recommended and whose menstruation remained absent or sporadic. Intermediate outcomes were reported for 28% of the anorexics, whose results were somewhere between the “good” and the “poor” groups.

The ANAD study reported that 5-10% of anorexics die within 10 years after contracting the disease. 18-20% of anorexics will be dead after 20 years, and only 30-40% ever fully recover, while 20% bounce in and out of hospitals. Only 50% report being cured. However, without increasing knowledge, experience, and expertise in working with these patients, we cannot expect these statistics to improve.