Dr. M.J. Bazos, MD Patient Handout


About Your Diagnosis
Anorexia nervosa is a form of eating disorder. It is a condition that can have life-threatening consequences if not properly treated. In this condition, here is a refusal on the part of patients to maintain body weight at or above what is normal for their age and height. In addition, individuals with anorexia nervosa also have an intense fear of gaining weight or becoming fat, even though they are generally underweight. When asked about their ideal weight, patients with anorexia nervosa will never be able to give a number because they will always believe they should be thinner than they actually are. Individuals who have anorexia nervosa also seem to have an abnormal perception of how their body looks, despite normal weight for their height. There also is a strong denial about the serious physical consequences of low body weight and rapid weight loss. In women who have already had their first menstrual period, there is generally an absence of menstrual cycles secondary to malnutrition and starvation. To make a diagnosis, there needs to be at least three consecutive menstrual cycles missing. This loss of menstruation in someone who has already begun to have periods is called secondary amenorrhea. The individual with anorexia nervosa may have periods of binge eating behavior, but this is usually followed fairly rapidly by some sort of activity to eliminate the food (purging). Although anorexia nervosa is often depicted in the media, it is actually a fairly rare illness. The groups at highest risk for this condition are adolescent girls and young women, but even there, it affects only about 0.5% of that population. It is true, however, that the occurrence of anorexia nervosa has increased significantly during the last 50 years, mainly related to societal attitudes about weight loss and acceptable physical appearance. Anorexia nervosa is basically a condition that affects women, much more commonly than men in a ratio of 10:1 or even 20:1. It is more common in higher socioeconomic classes. Some occupations such as modeling, ballet dancing, figure skating, and being a jockey appear to confer a much higher risk for the development of anorexia nervosa, probably because of the emphasis in these occupations on thinness.

Living With Your Diagnosis
Anorexia nervosa seems to develop more rapidly in environments in which food is readily available, but in which being thin is to perceived to be desirable. We really do not know what causes anorexia nervosa, but some other risk factors are associated with the disease. There may be a genetic component; that is, it may be passed on from parents to children. The mothers of patients with anorexia nervosa are often described as overprotective, intrusive, orderly, and very much concerned with perfection. They are also described as being fearful of separation. On the other hand, fathers of patients with anorexia nervosa are often described as withdrawn,
passive, very emotionally distant, moody, workaholics and in general fairly ineffective and absent. Undoubtedly the American fascination with thinness increases the risk for anorexia nervosa in this population. It is much more common among Caucasian women than among African-American or Hispanic women. In looking at the childhood of women who later become anorexic, they were often very compliant children. They did not go through the usual acting out and difficult stages that occur around 2 years of age, the so-called terrible twos. When they approached adolescence, they began to develop the eating disorder, which served as a very powerful tool to disrupt the family and became their first rebellious act against their parent’s wishes. In addition, there may also be some concern among pubertal women revolving around their budding sexuality. They may have concerns about heterosexual contact, and some fear of menstruation and the possibility of pregnancy. The development of anorexia nervosa with its secondary amenorrhea delays the onset of sexual maturity, leading to decreased anxiety about sexual issues among these patients. As might be expected, there are many medical problems associated with anorexia nervosa. These include abnormalities of the skin, cardiovascular problems such as low blood pressure, slow heart rate, and abnormal heart rhythms, anemia, inability to fight infection, abnormal blood chemistry (such as low potassium, sodium, albumin, and total protein), dehydration, constipation, low thyroid hormone levels, and osteoporosis or bone disease. In assessing a patient with suspected anorexia nervosa, it is very important to obtain a weight history, including the individual’s highest and lowest weights and the weight that she would like to be now. It is also important to take a dietary history and have the patient describe a typical day in terms of food intake and any food restrictions. Many times anorexic patients will engage in elaborate behavior to purge themselves of food they have eaten. This includes self-induced vomiting, which may cause dental caries and cavities, excessive exercise, abuse and misuse of laxatives and enemas, and use of diet pills and water pills. Abuse of syrup of Ipecac to induce vomiting is also fairly common. In the initial assessment, there may be a strong sense of denial on the part of the patient about the anorexia nervosa. A complete physical examination and laboratory testing should be done to rule out some of the physical problems mentioned earlier, and a decision should be made as to whether to treat the patient as an outpatient or to admit the patient to the hospital.

The first goal of treatment for the patient with anorexia nervosa is to engage the patient and her family. Frequently there are strong feelings of guilt, and these must be addressed. The patient will often minimize problems and suggest that the concerns of the family are simply an overreaction. A second goal of treatment is to assess and address the patient’s active medical problems. Depending on the severity of the illness, this may require hospitalization. Treatment usually involves psychotherapy, and occasionally medication if there is a depressive or anxious component. It should be remembered, however, that medications that cause a rapid weight gain, such as antidepressants like Elavil and Sinequan, should be avoided because the patient will rebel against any rapid weight gain. The patient is usually weighed once a week, and a gain in body weight of about 2–3 pounds a week is
expected. Many programs use negative and positive feedback, allowing patients to do things that they enjoy if they gain the weight or preventing them from doing so if they do not. It is important during this phase to provide patients with significant emotional support and reassurance, to address their fears about gaining weight, to educate these patients about the dangers of semistarvation, and to reassure them that they will not be allowed to gain “too much weight.” In most treatment units that are experienced in treating anorexia nervosa, invasive techniques such as nasogastric feeding or intravenous feeding are rarely needed and are only used for life-threatening circumstances. Unfortunately, a large percentage of patients with anorexia nervosa remain chronically ill. About 30% to 50% of patients successfully treated in the hospital require hospitalization again within 1 year of discharge, so outpatient programs after hospitalization are essential. There are, of course, side effects from medications used to treat anorexia nervosa. For example, some of the tricyclic antidepressants used to treat depression in anorexia can cause weight gain, drowsiness, blurred vision, constipation, and a fast heartbeat. There remains a significant mortality rate (death rate) associated with this condition.

The DOs
If you have anorexia nervosa, it is very important to follow your doctor’s recommendations to avoid binging behavior, and to talk to a nutritionist about a safe diet. When shopping, you should buy clothes that fit, not clothes that you have to lose weight to get into.

The DON’Ts
If you have anorexia nervosa, you should not weigh yourself daily; you should avoid use of drugs, diet pills, and caffeine designed to promote weight loss; you should not use laxatives unless instructed to do so by your physician; and you should not engage in activities/occupations (modeling, ballet dancer, being a jockey) where emphasis is placed on weight loss. You should shop for food judiciously and avoid eating alone, if possible.

When to Call Your Doctor
You should report any unusual problems to your physician such as unusual thoughts, paranoia or hallucinations, significant depression, and any suicidal thoughts. Also, if you have done well for some time, notify your doctor if your urge to binge and purge begins to increase. Also, it is very important to minimize stress in your family, so some sort of family therapy is often helpful.

Anorexia and Bulimia
Eating Disorder Resources on the Internet: