Anorexia Nervosa
Historical Background
Section titled “Historical Background”In contrast to bulimia, anorexia is not a modern phenomenon. Nor is it geographically limited to the Western world. Anorexia is found across all cultures.
The term “anorexia nervosa” was coined as early as 1874 by William Gull, its discoverer. He already said at the time:
“The lack of appetite is, in my opinion, due to a morbid state of the mind (soul).”
How right Gull was, we know today.
As early as 1867, Sarah Jacobs became a tourist attraction through her emaciation. Reports of fasting saints (in India a requirement for a holy man) go back to the 12th century.
Catherine of Siena, for example, fasted repeatedly from the age of 16, until she ultimately refused all food intake at the age of about 30 and died in 1380.
ICD-10 Classification: F50.0
Section titled “ICD-10 Classification: F50.0”Guidelines
Section titled “Guidelines”Anorexia nervosa is characterized by a deliberately self-induced or maintained weight loss. The disorder is most common in adolescent girls and young women; adolescent boys and young men, as well as children before puberty and older women up to menopause, are much less frequently affected.
Anorexia nervosa constitutes an independent syndrome in the following respects:
- The clinical features of the syndrome are easily recognizable, so that the diagnosis can be reliably made with a high degree of agreement among different clinicians.
- Follow-up studies have shown that a considerable number of non-remitted patients continue to display the main features of anorexia nervosa in a chronic form.
Causes
Section titled “Causes”Although the causes of anorexia nervosa are still difficult to grasp, the conviction is growing that above all an interaction of sociocultural and biological factors, as well as non-specific psychological mechanisms and personality vulnerability, play a role.
The disorder is associated with malnutrition of varying severity, which secondarily leads to endocrine and metabolic changes as well as other physical functional disturbances.
Diagnostic Criteria
Section titled “Diagnostic Criteria”1. Body Weight
Section titled “1. Body Weight”Actual body weight at least 15% below expected (either through weight loss or never achieved weight) or Body Mass Index (BMI) of 17.5 or less.
In prepubertal patients, the expected weight gain during the growth period may fail to occur.
2. Self-Induced Weight Loss Through:
Section titled “2. Self-Induced Weight Loss Through:”- a) Avoidance of high-calorie foods
- b) Self-induced vomiting
- c) Self-induced purging
- d) Excessive physical activity
- e) Use of appetite suppressants or diuretics
3. Body Schema Disturbance
Section titled “3. Body Schema Disturbance”A specific psychological disturbance: The fear of becoming fat exists as a deeply rooted overvalued idea. Those affected set a very low weight threshold for themselves.
4. Endocrine Disturbance
Section titled “4. Endocrine Disturbance”An endocrine disturbance on the hypothalamic-pituitary-gonadal axis:
- In women: Amenorrhea (absence of menstruation)
- In men: Loss of libido and potency
Additionally, the following may be present:
- Elevated growth hormone and cortisol levels
- Changes in peripheral metabolism of thyroid hormones
- Disturbances of insulin secretion
5. Pubertal Development
Section titled “5. Pubertal Development”If the disorder begins before puberty, the sequence of pubertal developmental steps is delayed or inhibited:
- Growth arrest
- Lack of breast development and primary amenorrhea in girls
- In boys, genitalia remain childlike
After remission, pubertal development is frequently completed normally, but menarche occurs late.
Subgroups of Anorexia
Section titled “Subgroups of Anorexia”F50.00 - Anorexia Without Active Measures
Section titled “F50.00 - Anorexia Without Active Measures”Anorexia without active measures for weight reduction (vomiting, purging, etc.)
Associated terms:
- Ascetic form of anorexia
- Passive form of anorexia
- Restrictive form of anorexia
F50.01 - Anorexia With Active Measures
Section titled “F50.01 - Anorexia With Active Measures”Anorexia with active measures for weight reduction (vomiting, purging, etc., possibly in combination with binge eating episodes)
Associated terms:
- Active form of anorexia
- Bulimic form of anorexia
Differential Diagnosis
Section titled “Differential Diagnosis”Depressive and obsessive symptoms as well as features of a personality disorder may occur. Then the distinction from this disorder or the use of more than one diagnostic code becomes necessary.
Somatic causes of weight loss in young patients must be considered:
- Chronic consumptive diseases
- Brain tumors
- Intestinal diseases such as Crohn’s disease
- Malabsorption syndrome
Exclusion:
- Loss of appetite
- Psychogenic loss of appetite
The Development of Anorexia
Section titled “The Development of Anorexia”Explanatory Model
Section titled “Explanatory Model”Very often, bulimia is confused with anorexia. This means that very often anorexia patients switch from the passive to the active form. The common error here is that treatment targets bulimia. The success then is that the vomiting episodes are stopped, but the anorexia as such remains.
Too often, both disorders (bulimia and anorexia) are underpinned by Borderline Personality Disorder.
Primary Disturbance
Section titled “Primary Disturbance”A person with bulimia or anorexia does not necessarily have an underlying borderline disorder, even when strong indicators exist.
This is rather about the primary disturbance, which was/is not yet a disorder - since not yet manifested. Let us better say about the disturbed state in childhood from which anorexia or bulimia then develops.
It must be noted that if this primary state is not worked through analytically and through behavioral therapy, treatment fails completely.
Typical Family Constellation
Section titled “Typical Family Constellation”Anorexia very frequently occurs in families with two sisters. In these cases, anorexia affects the second-born.
Characteristic Features of Family Members:
Section titled “Characteristic Features of Family Members:”| Mother | Father | Child 1 (f) | Child 2 (f) - Anorexia |
|---|---|---|---|
| Very clean | Responsible | Feminine in expression | Masculine in expression |
| Conservative | Subordinate to mother | Conservative | Rebellious |
| Strict | Overstimulated | Acting by the rules | Ignoring rules |
| Domineering, ambivalent | Sometimes too much alcohol | Playing with dolls | Playing like/with boys |
| Decisive, rule-following | Subordinating | Weak sexuality | Strong sexuality |
| Leading | Inferiority complexes | Low self-esteem | |
| Sarcastic | Family-oriented | ||
| Devaluing | Caring | ||
| Self-doubting | Good-natured | ||
| Self-pitying | |||
| Hysterical | Career | Life |
The Development Mechanism
Section titled “The Development Mechanism”Both parents wished for a second child. Fundamentally, one finds that much has gone wrong in the parents’ marriage and continues to do so. These people are no longer bound by love, but by rules.
The connection between the parents is generally led by the mother; the father subordinates himself.
The core problem:
- The second child is desired, but as a boy
- The birth of the second daughter causes a world to collapse for both
- They project their anger and helplessness onto the second child
Rejected by the mother and not seen for what she is by the father, here begins the child’s path of suffering.
The Inner Conflict
Section titled “The Inner Conflict”The child slides into a psychological conflict that encompasses the following:
- a) Wanting to be a woman but not being allowed to, because she would lose the father’s love
- b) Wanting to be loved by the mother but not knowing how to accomplish it
- because she does everything wrong
- because she would betray the father
- c) The rage at the mother that is increasingly directed inward
- d) The hatred of the sister who is loved
- e) Not wanting to do anything bad
“The child wants to be loved”
This conflict is unmanageable for the child, yet these individuals develop an “EGO” - at the price of physical damage.
The Manifestation
Section titled “The Manifestation”Beginning with the first menstruation and breast development, the inner psychological conflict is externalized.
“Not eating” is:
- A defense or oppositional stance
- An attempt to avoid the emerging female forms
The child’s highest priority is not to lose the father’s love as well. Since this child is now developing into a woman, she will try everything to avoid the emerging female forms: through not eating or vomiting - often in combination with excessive sports.
The sport fulfills a dual function:
- Performance like a boy
- Body like a boy
- The incredible internal tension release / aggression release
From a certain point, the disease becomes self-sustaining and thoughts and feelings become encapsulated.