Anorexia: Description

Patients with anorexia nervosa (anorexia nervosa) have a pathological desire to reduce their body weight more and more. The beginning of the disease is often a diet. Over time, thoughts about one’s own body weight increasingly determine the entire everyday life of those affected. Although they only consist of skin and bones, they feel too fat and want to lose more weight.

Anorexia nervosa is one of the eating disorders along with bulimia and binge eating disorder. The severe weight loss is the most noticeable symptom of anorexia. Ultimately, however, it is only the outwardly visible sign of a profound mental disorder. To cure the disease, it is not enough to simply eat again.

Addiction-like urge

The disease has an addiction-like character: the urge to starve is almost irresistible for the patients. The special kick is to have the greatest possible control over your needs and your body. For outsiders, this is hardly comprehensible.

Anorexics (anorectic people) also have no insight into the disease for a long time. They find it difficult to admit to themselves that they have problematic eating habits. They therefore often resist therapy.

Anorexia nervosa is a serious mental illness. Some of those affected die due to malnutrition or suicide.

Who is affected by anorexia?

Anorexia usually occurs for the first time in early adolescence. However, the age limit is increasingly moving downwards. In the meantime, children are already suffering from it. Most anorexics are female and between 15 and 25 years old. But boys and men are also developing anorexia nervosa more and more often.

Anorexia: symptoms

The main symptoms of anorexia nervosa are significant, self-induced weight loss, a pronounced fear of gaining weight despite already being underweight and a distorted perception of one’s own body.

Since malnutrition impairs many important bodily functions, numerous physical (physical) complaints also occur.

Weight loss

The severe weight loss is the most noticeable sign of anorexia. Those affected avoid high-calorie foods and deal in detail with the ingredients of foods. In some cases, anorexic people reduce their meals so much that they temporarily consume only water.

Some sufferers try to reduce their weight by exercising excessively. Some also take laxatives or diuretics to lose weight.

The desire for further weight loss and constant weight control eventually determine the entire thinking and everyday life of those affected. They consider weight stagnation or even weight gain to be serious setbacks, whereupon they intensify their efforts.

Underweight

Anorexics lose an average of 40 to 50 percent of their original weight. According to the clinical diagnostic guidelines, a body mass index (BMI) of 17.5 or more is considered a sign of anorexia in adults. That is 15 percent less than the normal weight. Different thresholds apply to children and adolescents, as the body mass index cannot be calculated with the usual formula.

Cachexia: Life-threatening underweight

If the weight loss is massive, it is also called cachexia. With such a pronounced underweight, the body’s fat reserves are largely used up, and larger amounts of muscle mass have already been lost. The body is then extremely weakened – a life-threatening condition.

Cachexia is visible from the outside at this stage. The bone contours are strongly protruding, the eyes are deep, the cheeks appear hollow. Patients usually try to hide these typical signs of anorexia. They wear garments in several layers that cover the body as much as possible.

Distorted body image

Anorexics perceive their own bodies in a distorted way. Despite being underweight, many consider themselves fat. Experts refer to this phenomenon as body schema disorder. Outsiders find it difficult to understand that those affected actually feel overweight when looking in the mirror.

Neither assurances from others nor objective weight measures such as BMI can convince anorexics of their actual underweight. Body schema disorder is a serious problem that can be overcome over a longer period with professional help alone.

Constant preoccupation with one’s own weight

A very characteristic sign of anorexia nervosa is the constant preoccupation with one’s own weight and diet. Anorexic people are terrified of gaining weight and being too fat. This does not necessarily mean that they lose their appetite. Rather, her whole thinking revolves around the topics of food and diets. They deal intensively with recipes and enjoy cooking for others.

Constant control

Those affected know the calorie content of most foods and pay close attention to how many calories they consume daily through food. Anorexia is ultimately an attempt to keep control of oneself and one’s body.

Anorexics chalk up enduring and overcoming the feeling of hunger as a success. Eating food eventually becomes torture, as eating means a loss of control for them and creates a guilty conscience.

Starvation as a normal state

Anorexics do not perceive any weight as too low. Starvation becomes an addiction and the reduction of food becomes a kind of race with oneself. The feeling of hunger becomes the normal state, they find the feeling of satiety unpleasant. At some point, weight loss is so threatening that patients have to be admitted to a clinic.

Excessive achievement orientation

Anorexics are strikingly often intelligent and very performance-oriented people who try to do as many tasks as possible perfectly. They are particularly ambitious when it comes to sports or school. However, they are withdrawing more and more from social life. This self-desired social isolation is a serious warning sign.

Mood swings and depression

Very often, anorexics also suffer from severe mood swings and depressive mood. These anorexia symptoms can be the result of malnutrition and the constant internal pressure to lose weight. Mental disorders that often occur at the same time as anorexia nervosa are depression, anxiety, obsessive-compulsive and addictive disorders as well as personality disorders.

Physical (somatic) anorexia nervosa symptoms

Anorexia nervosa damages the entire body. Due to malnutrition, he reduces his energy consumption to the necessities of life. This affects all organ systems. This explains the multitude of possible physical consequences of anorexia:

• Slowed heartbeat (bradycardia) and cardiac arrhythmias
• Low blood pressure (hypotension)
• Constipation
• Freezing and hypothermia (hypothermia)
• Lack of red and white blood cells as well as platelets (pancytopenia)
• Dry skin
• Hair loss
• Downy-like hair (lanugo hair) instead of normal body hair
• In girls/women: cessation of menstruation (amenorrhea), infertility
• In boys/men: problems with potency
• Sexual listlessness (loss of libido)
• Electrolyte and vitamin imbalance
• Decrease in bone mass (osteoporosis)
• Renal dysfunction
• Liver dysfunction
• Difficulty concentrating
• Developmental delay in children and adolescents
• Brain atrophy

Hormonal disorders

The fact that severe underweight in girls and women leads to the cessation of menstruation (amenorrhea) and the loss of sexual desire (loss of libido) is due to the fact that anorexia nervosa disturbs the hormonal balance: As a result of malnutrition, the body can no longer produce certain hormones sufficiently, which affects the menstrual cycle, among other things.

From an evolutionary biological point of view, this can make sense: A woman with anorexia nervosa would not be able to carry a child to term, which is why the body prevents pregnancy due to the lack of sex hormones.

Also due to hormonal disorders, boys and men with anorexia also suffer from a loss of libido and often also of potency.

Anorexia: causes and risk factors

So far, there are only assumptions about the exact causes of anorexia. What is certain, however, is that the disease anorexia nervosa cannot be traced back to a single trigger, but that the reasons for anorexia nervosa are manifold.

Thus, both biological and psychological as well as socio-cultural factors contribute to the development of anorexia, which reinforce each other.

Biological factors

Disturbed stress processing

More recent scientific hypotheses assume that impaired stress processing is the central cause of anorexia. Such disorders can have genetic causes, are already created by influences in the womb or are shaped or intensified by early experiences. Anorexia does not begin when the first symptoms appear, but much earlier.

Genetic factors

The genes seem to play a decisive role in anorexia. Thus, the disease occurs more frequently in some families. Twin studies also show a clear connection between a person’s genetic makeup and the occurrence of anorexia.

In the case of fraternal twins, one in ten develops anorexia nervosa if the other twin is already ill. In the case of identical twins, it is even one in two. However, it is unclear exactly how genes influence disease risk.

Disturbed messenger metabolism

As with many mental illnesses, the messenger metabolism in the brain is also disturbed in anorexics. Among other things, the level of the neurotransmitter serotonin is increased in them. The messenger substance influences eating behavior and satiety.

Animal experiments have shown that serotonin increases satiety and thus has an appetite-suppressing effect. An increased level could therefore make it easier for anorexic people to abstain from eating.

But serotonin has other effects: It lifts the mood and triggers feelings of happiness. This could also make it easier for people with anorexia nervosa to give up food – or even encourage them to do so. Both effects are also confirmed by people who fast for a longer period of time, for example for religious reasons.

So, serotonin could help maintain anorexic behavior. However, the typical symptoms of the eating disorder, such as fear of gaining weight and body schema disorder, cannot be explained by this.

Psychological causes

Desire for control

In conversations with therapists, anorexics often state that the desire for control over their own body is one of the biggest motivations for starvation. This need for control is lived out through the strict diet.

Psychologists interpret anorexia as the expression of an inner conflict that cannot be overcome otherwise. There are several theories in science that describe possible causes of anorexia in early childhood. Traumatic experiences – for example, the divorce of parents or the death of a family member – are frequently mentioned psychological causes.

Puberty

At the beginning of puberty, girls have the highest risk of developing anorexia. Some experts suspect that a general overload in this phase of life full of upheavals can trigger anorexia.

Growing up, becoming a woman – that seems threatening to some girls. They therefore also reject the change of their child’s body to that of an adult woman. The strong weight loss often has the desired effect here: Due to the extreme starvation, the period often fails to materialize, and the slim figure corresponds more to that of a child than that of a woman.

High performance standards

Anorexia nervosa is more common in middle- and upper-class families. Those affected are usually remarkably intelligent, ambitious and perfectionist people. Extreme discipline and high demands on one’s own body are typical.

Both also correspond to the prevailing values. In anorexics, these ideals, which are already taught from kindergarten age, can fuel the disease.

Weak self-confidence

Anorexics are also often not very self-confident. The apparent control over one’s own body initially strengthens self-confidence – patients feel more confident and stronger.

Starvation is rewarded in this way, which in turn reinforces eating disordered behavior. If stressful factors are added to this difficult life situation (e.g. a problematic relationship with the parents, divorce of the parents, tensions in the circle of friends, a move), this can trigger anorexia.

Sociological causes

Anorexia nervosa as a means of pressure

The refusal to eat can also be used as an instrument of power vis-à-vis parents in conflict situations. The child quickly notices that parents are worried about their starving child. At the same time, however, the food intake can hardly be forced by the parents.

The child thus reaches a position of power from which it can put pressure on the parents. Food refusal as a means of pressure can be observed above all when there are many unresolved conflicts in the family. However, it is only one of many possible causes of anorexia.

Western ideal of beauty

The Western ideal of beauty currently propagates unnaturally slim bodies. The pressure to be slim is reinforced by very thin role models from the media. The weight of models is below normal weight. Through this distorted body ideal, children and adolescents gain an unrealistic picture of how thin or fat a person usually is.

Constant teasing and negative comments about the figure can trigger anorexia against the background of this general “slimness mania”. Conversely, today everyone earns praise and admiration when they have lost weight. A diet is then often the “gateway drug” to anorexia.

Since women are judged more strongly by their appearance than men, they are even more exposed to the ideal of beauty. This could be an explanation for why women are so much more likely to suffer from anorexia than men. But even for men, the external appearance is increasingly coming to the fore. They are now also increasingly affected by anorexia.

Anorexia: examinations and diagnosis

If anorexia nervosa is suspected, the pediatrician or family doctor is a good first point of contact. He can first assess the extent of the risk by examining the patient and determining blood values.

Anamnesis interview

At the beginning of every medical or psychological consultation there is the anamnesis: In the conversation, the patient reports on his personal anorexia history, any physical complaints and previous illnesses. If anorexia nervosa is suspected, the doctor could ask the following questions, for example:

• Do you feel too fat?
• How much do you weigh?
• How much weight have you lost in the last four weeks?
• Are you trying to intentionally lower your weight, for example through excessive exercise or inadequate nutrition?
• What is your desired weight?
• (for girls/women:) Has the menstrual period failed to materialize?
• Do you have other physical complaints such as weakness, dizziness or heart palpitations?

Physical examination

The interview is followed by a physical examination. In doing so, the doctor gets a general overview of the general physical condition. Among other things, he will listen to the heart and abdomen with a stethoscope.

He also measures the body weight and height of the person concerned to determine the body mass index – as an objective measure of underweight. Underweight starts with a BMI of less than 17.5. The BMI of anorectic people is often far lower.

Blood

The doctor also receives important information about the general physical condition by determining various blood values. For example, blood tests can be used to check the function of the liver and kidneys as well as blood formation and to detect dangerous disturbances in the salt balance (electrolyte balance).

Other medical examinations

Malnutrition can damage every organ system of the body. Therefore, it depends on the specific symptoms which further examinations the doctor will perform.

Psychological examinations

Anorexia is a mental illness. The psychological symptoms are therefore decisive for the diagnosis. They are collected in the form of various questionnaires and clinical interviews.

Eating Disorder Inventory (EDI)

A professional questionnaire on eating disorders such as anorexia and bulimia is Garner’s “Eating Disorder Inventory” (EDI). The current FDHA comprises 91 questions that record typical psychological characteristics of anorexia nervosa and bulimia patients. They can be divided into eleven categories:

• Striving for thinness – e.g.: “I’m terribly afraid of gaining weight.”
• Bulimia – e.g.: “I stuff myself with food.”
• Dissatisfaction with the body – e.g., “I think my hips are too wide.”
• Self-doubt: “I don’t think much of myself.”
• Perfectionism – e.g., “Only the best is good enough in my family.”
• Distrust – e.g., “It’s hard for me to express my feelings to others.”
• Interoceptive perception – e.g.: “I have feelings that I can hardly name.”
• Fear of growing up – e.g.: “I wish I could return to the security of childhood.”
• Asceticism – e.g.: “I am embarrassed by my physical needs.”
• Impulse regulation and social insecurity – e.g.: “I experience significant mood swings.”

Diagnostic interviews

Psychotherapists often use the Diagnostic Interview for Mental Disorders (DIPS) or the Structured Clinical Interview for DSM-IV (SKID) to make a diagnosis. They can be used to diagnose both eating disorders and other psychiatric illnesses.

To do this, the psychotherapist asks questions, which the patient answers freely. The therapist classifies the answers with a point system.

Diagnostic criteria of anorexia nervosa

Anorexia nervosa is diagnosed when the following four symptoms are present:

• Underweight (at least 15 percent below normal weight)
• self-induced weight loss
• Body Schema Disorder
• Hormonal disorders (endocrine disorders)

Anorexia test for self-assessment

The best-known anorexia test for self-assessment is the “Eating Attitude Test” (EAT) by Garner and Garfinkel. The EAT includes 26 statements on eating behaviour as well as on posture in terms of figure and weight. They are answered on a scale from “always” to “never”.

Examples of statements in the EAT are:

• “I avoid eating, even when I’m hungry.”
• “I especially avoid food with a lot of carbohydrates.”
• “Other people think I’m too thin.”
• “I feel the need to vomit when I’ve eaten.”
• “I’m obsessed with getting thinner.”

Anorexia tests on the Internet

Self-tests on the Internet also ask about typical thought patterns and behaviours in eating disorders. Such online tests for anorexia nervosa cannot replace a medical or psychological examination but can provide an initial orientation as to whether eating behavior is disturbed.

Anorexia: Treatment

Anorexia is more than an out-of-control ideal of beauty. It is a very serious and life-threatening disease that almost always requires professional treatment.

The most important goals of anorexia treatment are:

• Normalization of weight
• Change in eating behavior
• Restoration of normal perception of the body
• Therapy of individual and family problems

Anorexia is accompanied by both physical and mental symptoms. For this reason, treatment is usually carried out in cooperation with a multi-professional team. Such a team includes doctors, psychologists, dieticians and, if necessary, other specialists.

Inpatient treatment

Anorexic people can be cared for on an outpatient, inpatient or semi-inpatient basis. In most cases, however, inpatient treatment in a clinic specializing in anorexia nervosa is necessary.

This is especially true for patients with a body weight of less than 75 percent of normal weight, a life-threatening physical condition or suicide risk due to depression. The goal is a long-term change in behavior and not just a short-term weight increase.

Normalization of weight

At the beginning of the treatment, the individual target weight is usually determined. For a successful course of therapy, patients should gain between 500 and 1000 grams per week.

In addition, a therapy plan is drawn up that is tailored to individual needs. An important part of the therapy is the control of the weight achieved. According to studies, patients who leave the clinic before reaching normal weight are more at risk of relapsing.

Learning to eat normally

Anorexics first must relearn how to deal with food normally. Therefore, nutritional counselling, cooking classes, grocery shopping, and an individual meal plan are part of the program in many clinics.

To motivate patients to eat, operant conditioning is also used. This means that desired behavior – in this case, food – is rewarded or non-compliance is punished. A reward or punishment can be, for example, the permission or prohibition of visits.

Psychotherapy

“Focal psychodynamic therapy” seems to be particularly successful for the treatment of anorexia. This further development of psychoanalysis was specially tailored to people with anorexia. She treats the causes of anorexia nervosa and helps patients cope with everyday life.

The focus here is on dealing with emotions. In particular, the individual triggers for this disease are explored. Without treating the psychological roots of the disease, the risk of relapse is very high.

Therefore, the treatment of anorexia nervosa includes regular psychotherapeutic sessions in individual and/or group sessions. In these sessions, work is also done on consolidating a realistic body image.

Group therapy

Group therapy is a useful help for anorexia. Patients can share their experiences with other sufferers and see that they are not alone with the problem.

Family Therapy

Family therapy can be very effective, especially for young patients, because the anorexics need the support of the family for healing.

Family members are often overwhelmed by the disease. Good guidance and a contact person for the family help both the patient to find their way around at home and the family members to deal with the situation.

Medication

So far, there is no drug that successfully supports weight gain. In many cases, however, other mental disorders occur in addition to anorexia, such as depression or obsessive-compulsive disorder. These disorders can be treated with medication, among other things.

Lack of insight into illness

Since people with anorexia often have no insight into the disease, many sufferers are not being treated.

However, in the event of acute danger to life and unwillingness to treat, patients can be admitted to a hospital against their will by judicial order.

Anorexia: course and prognosis

Anorexia nervosa can progress very differently from person to person. Basically, the younger the patients, the better the chances of recovery. In addition, the prognosis also depends largely on how low the weight is, how long the patient has been anorexic and what physical and mental resources he has. In addition, the support of the social environment and especially the family is extremely important for the recovery of anorexics.

Not everyone is healed

Some anorexics cannot be completely cured. It is assumed that half of anorexics struggle with the disease for life. Even after weight normalization, the distorted attitude towards weight and figure persists in many sufferers.

Switching to bulimia

About 20 percent of those affected develop another eating disorder – starting with anorexia nervosa: bulimia (binge eating addiction). This is an eating disorder in which a lot of food is ingested during cravings and vomited again immediately afterwards.

Physical and mental long-term consequences

It is not surprising that anorexia nervosa that begins in childhood or early adolescence has particularly serious consequences: Significant developmental delays, both physical and mental, are a typical consequence of malnutrition. The onset of puberty is delayed, and growth is disturbed.

The physical effects of anorexia nervosa are often severe, because malnutrition damages all organs. The body does not always fully recover from this.

Danger to life

Anorexia nervosa is a very dangerous mental illness. In some patients, the disease is fatal – either because of the massive deficiency symptoms or because of suicide as a result of the accompanying depression.

Recovery is a lengthy process with progress, but often also with setbacks. Even after a hospital stay, longer therapeutic care is necessary. But the good news is that the effort is worth it.

Anorexia: What is “Pro Ana”?

“Pro Ana” is a movement on the Internet that does not understand anorexia nervosa as a disease, but glorifies it as a self-chosen lifestyle. On the corresponding websites, girls in particular exchange ideas about how they can lose even more weight in order to correspond to their “ideal body image”. Despite the imminent danger to their lives, the young people spur each other on to eat as little as possible.

The “Pro Ana” movement originated in the USA and spread from there to Europe. “Ana” stands for anorexia, “pro” clarifies the confession of anorexia.

Anorexics who visit “Pro Ana” sites are aware that they are diagnosed with anorexia. However, they do not want to be cured of their anorexia, but rather become even thinner. They see the anorexic body as a desirable ideal of beauty – a life-threatening attitude.

Access to these websites is often only possible with a password. Particularly strict “Pro Ana” forums allow people to go through a kind of application process before being accepted into the online community in order to avoid unwanted guests.

The “Pro Ana” websites are very popular. According to estimates, 40 percent of all young people with anorexia visit “Pro Ana” pages.

Religious-like imprint

Anorexia is practiced on “Pro Ana” pages similar to a religion. On such sites, for example, you can find ten commandments of anorexia: “1. If I’m not thin, I’m not attractive. 2. Being thin is more important than being healthy. 3. I have to do everything I can to look thinner,” etc.

In addition, there is a creed that illustrates the pathological worldview of anorexics (“I believe in a world that consists only of black and white, in the loss of weight, the forgiveness of sins, the rejection of the flesh and in a life full of hunger.”).

Photos of skinny role models

The “Pro Ana” pages are also used to show photos of severely emaciated actors and other celebrities. In some cases, the anorexics also upload photos of their own bodies. Anorexia sufferers share their daily “successes” and report how much they have lost weight and how little food they have eaten. Gaining weight is considered a failure.

Anonymous exchange and mutual reinforcement

Anonymous contact on the Internet enables anorexics to exchange ideas without restrictions. The problem is that anorexics feel confirmed in their behavior by other anorexics.

Sense of togetherness

The exchange among like-minded people creates a sense of togetherness. The followers of the movement feel that they are extraordinary people who are strong enough to resist the feeling of hunger and control their bodies.

There is also strong competitive pressure among supporters. Everyone wants to be even thinner than the others and prove how strong-willed they are.

In addition, anorexics receive information on how to hide the disease from their parents and lose weight even faster. Tips are also given on how to falsify weight measurements at the doctor’s office.

Protective measures

This maintenance of the disease has serious health effects and can be fatal. For several years now, various initiatives (e.g. jugendschutz.net) have been examining “Pro Ana” pages and have already had some of them blocked. However, it is difficult to control what is on offer on the Internet – also because new pages are constantly being created.

In the meantime, there are also app versions of “Pro Ana” for mobile phones. The exchange by mobile phone cannot be controlled at all. Anorexics can use it to keep in touch around the clock. The pressure not to eat thus exists day and night.

Ban Pro Ana?

There were extensive debates about whether “Pro Ana” websites should be banned. The ban on the “Pro Ana” pages is supported by the danger that:

• People suffering from anorexia nervosa are motivated by the content to maintain or worsen the eating disorder
• the sites create a slimming contest and promote unhealthy methods to reduce weight
• anorexia is portrayed as a positive lifestyle and the discipline to starve is glorified as a religion

Visitors to the “Pro Ana” pages, on the other hand, have argued that they have the right to exchange ideas with others who are in the same situation as they are.

Undoubtedly, people who follow the “Pro Ana” movement are in urgent need of psychological and medical help. However, it is not possible to prevent the exchange of members. It is also questionable whether a ban would bring the desired effect or rather give the anorexia movement an even stronger appeal.

In the UAE

The relevance of this issue in the UAE is multifaceted. Culturally, there is a high value placed on physical appearance, influenced by media and societal standards. Additionally, the country’s high obesity rates might paradoxically co-exist with a growing concern for thinness and ideal body types, creating a complex environment where eating disorders can thrive.

Addressing this issue requires a multi-faceted approach, including increased awareness, education, and accessible mental health services to support those affected by eating disorders. By understanding the prevalence and contributing factors, stakeholders can better design interventions to mitigate the impact of these disorders in the UAE.