CHAPTER 20. ANOREXIA
Anorexia nervosa is an illness in which sufferers to not take in food. It is different from another food disorder, known as bulimia. Bulimia is the "unpredictable, episodic, and rapid ingestion of large amounts of food during short periods of time, followed by self-induced vomiting (Stunkard, 1983:22)." Bulimia, or binge-eating, afflicts nonobese as well as obese people. The diagnosis of anorexia includes such symptoms as loss of 20 percent of body weight; loss of the menstrual period; thinning hair; dry, flaking skin; constipation; hyperactivity; sleep disorders; difficulty in regulating body temperature; and an abhorrence of sexual behavior (specifically of becoming pregnant) (Levenkron, 1982:12).
Typically, anorexia occurs in females from twelve to twenty- one years of age. Very few women, however, actually become o1 3 anorexic. Only 0.5 percent of all young women become subject to the disorder, and, of these, only 10 percent actually starve to death. Cases of anorexia are very rare in men and those diagnosed may be misdiagnosed. They may be suffering instead from brain damage, schizophrenia, or other medical problems.
Of those anorexics who seek help, approximately 40 percent of individuals with severe anorexia nervosa will recover within six years, and only 5 percent will die (Crisp, 1983:93). But many anorexics never enter clinics.
With the rise of feminism anorexia has received a great deal of notoriety. It is the "politically correct" disease in the sense that feminists love to use it to accuse the male-dominated society of overstressing thinness in women. Certainly the male- dominated society needs to be criticized, but the more accurate target for criticism is the fashion industry, plus the overconcern of Americans with looking healthy. Be that as it may, anorexia nervosa is really best seen as a psychiatric problem of phobia. Certainly the culture can aggravate the situation, but it cannot change the basic physiological cause.
Anorexia is now seen as a psychiatric disorder. Phobias concerning changes in bodily appearance are the illness's most outstanding feature. And as a psychiatric disorder, heredity plays a big role. In a study of 34 twins and 1 set of triplets, the concordance for anorexia nervosa was 55 percent for identical pairs, and 7 percent for the dizygotic pairs. This strongly suggests, as is the case for obesity, that genetic factors play an important role (Crisp, et al. 1985).
Anorexics suffer from a variety of hormonal abnormalities: there are low levels of luteinizing hormone; lowered estrogen; and decreased synthesis of growth hormone. In many patients the onset of the hormonal difficulties precedes the development of the anorexia (Grove and Schlesinger, 1982:368-369). There are also reports of depression in anorexia and bulimia sufferers before the onset of symptoms of the eating disorders; persistence of depressive symptoms in anorexia nervosa beyond weight recovery; a positive family history of a major affective disorder; and positive indicators of biological depression (see Pope & Hudson 1984, cited in Woods & Brief 1988:307).
Crisp (1983:92) notes that anorexics avoid many of the social consequences of adolescence by reducing their weight, obliterating secondary sexual characteristics, and returning to a prepubertal o1o- role. In anorexia the development of the illness centers around puberty and the phobic avoidance of food. For instance, some anorexics speak of the fear of choking on their food, or of vomiting after eating. Anorexics retreat into increasingly low body weight and become ever more terrified of any slight weight gain. Anorexics are afraid that weight gain will reveal to others her loss of control over her own body.
Weight loss triggers emotional disturbances, just as with obese people. As food obsessions become prevalent the anorexic engages in obsessive-compulsive rituals. Feelings of inferiority about intelligence, personality, and appearance are common. Disinterest in sexuality and indeed a fear of intimacy, physical or emotional. Delusional thinking, especially with regard to body size. Paranoid fears of criticism from others. Depression and anxiety and denial. (Levenkron, 1982:2-3)
Anorexia nervosa resembles the behavior in animals with lesions of the lateral hypothalamus. Investigators placed rather large bilateral lesions in the lateral hypothalamus and observed a severe disruptions in eating and drinking. Rats and cats with such lesions were reported to be aphagic, that is, they refused food even when it was placed directly into their mouths. Scientists, however, do not think that the disorder is the result of actual lesions of the lateral hypothalamus.
Fortunately, there is hope for anorexics. There have been positive treatment outcomes for patients on antidepressant medications (see Pope & Hudson, 1984).
A Note on Bulimia
Some studies have suggested that there is an excess of major depression in the first-degree relatives of anorexic and bulimic persons (Hudson, Laffer, and Pope, 1982), and has led to the use of anti-depressant medication in the treatment of both anorexia nervosa and bulimia. (Agras, 1987:11)
The bulimic is more likely to eat when depressed or anxious. (They know they can always purge themselves of the food later.) This differs from the anorexic who is less likely to eat when depressed (probably because depression and anxiety set off the phobic reaction) (Agras 1987:12). Many bulimics resemble people exhibiting starvation behavior. For instance, they complain about a "carbohydrate" craving and have increased desire for sweets. Animal studies reveal that when animals are deprived of food in short-term experiments, they prefer sweet-tasting foods, which they normally avoid.
There is a new treatment for bulimia. With the use of the anticonvulsant phenytoin, the frequency of binging has been reduced (Stunkard, 1983:22).
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