Introduction

Anorexia nervosa is a severe mental disorder with life threatening possibilities. It is an eating disorder in which a person affected with this illness tries to keep his or her weight as low as possible as compared to the ideal weight for that age of person through various means.

Some people try to restrict their diet thinking that they are obese but actually they're not. They develop false illusion in their mind that they are overweight and their body shape needs to be trimmed.

Some people develop intense fear of being plumped but actually they are underweight. They continue to think about their weight and means to reduce the weight.

Some people start doing excessive exercise or take laxatives to remove food from the body so they completely reduce the weight.

Other common behavior includes; hiding behavior about less eating and lying about the quantity and timing of food. People affected with this eating disorder hide themselves and pretend as if they are eating normal diet on timely manner. They also have a habit of strong rejection about accepting their seriousness of this eating disorder and they causally take this issue as a modern lifestyle.

The sunset of illness starts usually in adolescent age mainly at the age of 13 – 17 years. Recent studies have found that the average age of sunset of anorexia nervosa has gone down to a level of 09- 12 years. It is also a fact that females ratio is very high than the male ratio if we compare the gender ratio for this illness but irrespective to that it can be found in any age group irrespective of geographical boundaries.

Young girls and professionals such as models, film stars and athletes are more prone to get affected with this disorder as slim and trim shaped body is the ultimate demand in these professions.

Causes

The cause of anorexia nervosa is idiopathic in nature. Scientists has studied the different aspects and came to the conclusion that this eating disorder is the total combination of genetic factors such as hormones and genes as well as involvements of psychological and environmental factors too. There is no role of family conflicts which was earlier assumed a factor for this disturbing eating disorder but is widely accepted that some people are more vulnerable to anorexia nervosa due to their distinct personality traits.

The main contributing factors are:

• Genetical Factor – Research studies have shown some results that due to lack of normal diet neurotransmitters such as noradrenaline and serotonin do not function perfectly which induces the patient in reinforcing its obsessive behavior of starvation and malnutrition. The more the patient stars the greater will be the tendency to lose weight. Some experts link the genetic connection with the obsessive behavior. eg the white women has more tendency towards precision about their body than the black women.

• Psychological Factor- The stress in life and work also ignites the risk of anorexia nervosa. Female falls to peer pressure very easily by virtue of their nature. Young working women compete with each other and stick to minimum diet up to the level of starvation so that they can reach to their desired level of perfect body. They got obsessed with their weight up to such an amount that; they never accept that they thin and malnourished. It has been studied that the stress reducing hormone 'cotisol' is found less in people affected with anorexia nervosa.

• Environmental Factor- Modern beauty definition has directed the thinness mantra for success in both the career and in the life. Media has also discriminated against the image of perfect body by projecting thin and ultra thin models in most of the advertisements and beauty shows. The beauty pageants have changed the perception of perfect body shape and this leads to creating pressure on teenage and adolescent girls to adopt non health behavior for reducing weight. Girls in their puberty concerned more about their weight than boys. Most of the teenage girls are making habit of consuming low-caloric, low nutrition led foods which led them to greater risk of developing anorexia nervosa. It has also found that eating disorder is more prevalent in some communities who were found overweight from the generations.

Symptoms

A person affected with eating disorder shows number of signs and symptoms. But the early effort of the person is to lose weight even up to the level of starvation.

Patient usually shows different physical, emotional as well as behavioral symptoms which are:

• Clear and rapid weight loss
• Osteoporosis or swollen joints (mainly in arms and legs)
• Hair loss with dry scalp and skin
• Skinny or bonny appearance
• Low RBC and WBC counts
• Fatigue and Insomnia
• Constipation and bad breath
• Drying out
• Giddiness and nausea sensation
• Discoloration of nails into bluish color
• Three continuous absence of menstruation cycle (also known as amenorrhea)
• In some cases the saliva glands and tonsils will be swollen with regular episodes of vomiting which results into swollen face
• Low blood pressure and disturbed heart beats
• Hypothermic and very low tolerance of cold

Emotional and behavioral symptoms may include:

• Rejection to maintain a normal weight
• Providing false information about intake of food
• Extreme workout and exercise to reduce weight
• Fear of gaining weight
• Less social involvement and looking for more privacy by avoiding friends and family
• Hide or discard food or eat too slowly
• Cut the vegetables and fruits in very small pieces
• Short temper and depressed mood with episodes of rapid mood swing
• Preoccupation with food and recipes
• Less sexual interest
• Regularly in search of new drugs, diet and other accessories for weight loss.

Diagnosis

ICD-10 F50.0-F50.1

ICD-9 307.1

Usually it is the general practitioner who diagnoses the problem based on the symptoms. The general practitioner (GP) typically suggests the person to go for some medical test and exams to verify the diagnosis. These tests will help the GP to determine the cause of weight loss and to know the amount of damage done due to weight loss. It also helps the practitioner to rule out any other complications associated with anorexia nervosa. Sometimes some tests needs to be repeated to monitor the patient health condition.

The examination includes:

• Physical examinations- This include examination of stomach, blood pressure, temperature, weight, examination of eye, mouth and skin to rule out any other medical complications.

• Medical test- These test are needed to know the functioning of the vital organs of the body including liver, kidney, thyroid gland, gall bladder etc.

The important tests which GP usually prescribes are:

• Blood test (Blood count)
• ELISA
• Western Blot Analysis for identifying specific antibodies and proteins
• Bone density test for osteoporosis
• Thyroid hormone Test
• SMA-20 test that include test of aluminum, potassium and chlorine level.
Glucose test for diabetes and hypoglycemia
• Secritin- CCK Test to assess functional level of pancreas and gall bladder
• Liver Function Test
• Total protein Test
• ECG
• Electrolytes
• Kidney function test
• Urinalysis

• Psychological examination- Anorexia nervosa not only brings physical problem but the mental problems too. The Psychological examination aims to evaluate the consequences with behavior disorder and the possible treatment plan thereafter. The expert generally evaluates the mental disorder with history taking, observation, asking several questions about eating habits or with the help of assessment questionnaires.

The American Psychiatric Association (APA) in DSM-IV manual has led down the criteria for anorexia nervosa. These criteria are; fear of gaining weight, denial of maintaining body weight, and denial of admitting seriousness of the problem.

The European Psychiatric Association in ICD-10 manual has also led down the criteria similar to DSM -IV with addition of criteria that patient uses different methods to maintain low body weight eg using laxatives, continuous exercise, avoiding starch foods, stick to diluted food and recipes.

Treatment

Treatment of anorexia is a long process. When a person is diagnosed with anorexia nervosa the expert usually the GP and psychiatrist along with other specialist like dietician, psychologist, and counselor may prescribe combination of two or three types of treatment depending upon the severity of the problem. The specialists also take decision if the person needs to be treated as an outpatient, day patient or as inpatient in a hospital or in a clinic.

Medical Treatment

After diagnosing the problem with presence of various complications in the vital organs of the patient the doctor may prescribe saline and glucose to maintain necessary electrolytes in the body and bring the body at normal hydration level. In such situation assessing the situation as emergency doctor can take decision to admit the person in the hospital for compulsory treatment. The physical health and weight needs to be routinely monitored for the improvement. There are no specific medicines available for the treatment of anorexia; however doctor can prescribe some antidepressants to reduce your anxiety level and to treat associated symptoms like obsessive compulsive disorder (OCD).

Serotonin-specific reuptake inhibitor (SSRI) class drugs are usually prescribed and that only for the adults above the age of 18 years to treat anxiety and obsessive compulsive disorder (OCD) in combination with nutritional supplements to regain the weight. But due to the side effects such as dizziness, nausea, vomiting, tremor, rashes, mouth dryness SSRIs are opted and administrated for short duration.

Psychological Treatment

One of the primary goals of the treatment is to eliminate those behaviors that lead to eating disorder. The psychotherapist can choose from a range of available psychological treatments which are stated below:

Cognitive analytical therapy (CAT) – This therapy attempts to remove the eliminating behavior through three stage process viz. reformulation of the past events, recognition of the problem and revision of unhealthy behavior.

Cognitive behavioral therapy (CBT) – This is a part of individual based therapy which tries to help in thinking more realistically through positive behavior conditioning. The therapist tries to show the effects of anorexia through unhealthy thoughts of food and diet and how to change our thought so that we act positively. The ultimate aim of this therapy is that the patient should gain self-esteem and learn positive ways to cope up with anxiety and stress. This therapy usually conducts in a day treatment program or in a psychiatric clinic.

Family therapy (FT) – Anorexia does not just affect on one individual; it can have a big impact on the whole family. It is known that the person affected by anorexia nervosa does not have the ability to take the healthier decisions. That's why the role of family is very important to provide counseling and regular persuasions to the patient. Family member involves themselves in discussing the effects of anorexia and the methodologies to overcome the situation. Family based therapy is very effective for children and adolescents as family members stays with them.

Group therapy (GT) – This therapy usually administered in psychiatrist hospital where persons with eating disorder are given behavior modification exercise in a group. This type of therapy helps in developing peer review and forming informal group for improvement.

Interpersonal therapy (IPT) – This therapy helps to develop the disconnected relationships with the peers, friends and the outside world which most importantly helps in developing mental health. This therapy helps to socialize the person in its society.

Weight- recovering Treatment

Patient can not recover from anorexia nervosa without restoring his or her healthy weight. The psychiatrist works with the patient to develop behavioral strategies to regain healthy weight. The dietitian gives guidance on healthy and nutritional diet including developing diet chart to regain weight. Psychologist as well dietitian helps the patient through encouragement of having small amounts of food initially and then gradually increasing the diet up to normal eating pattern of three meals a day. Patients are also recommended to take diet supplement rich in vitamins and calories to regain the loss chemicals and nutrient from the body.

Complication and Risks

It is has observed that most of anorexia nervosa patients can not recover easily. Most of the patients develop anorexia nervosa as a chronic disorder. If anorexia nervosa is not treated at early stage it will lead to chronic level with complications of heart problems and kidney failure and finally lead to death.

Most common complications are:

• Reduction in bone density (fragile bone)
• Loss of muscle strength particularly in women and girls
• Low blood cells counting (anemia)
• Hypotension (Low blood pressure)
• Low potassium levels (cause dangerous heart rhythms)
• Malnutrition and dehydration
• Repeated episodes of vomiting or otherwise dirrhea
• Fits attack due to excess loss of electrolyte
Thyroid hormonal imbalance
• Erectile dysfunction and loss of sex drive

Other health problems

Long-term anorexia nervosa can lead to serious complications which can be permanent in nature such as damaged bones, tooth decay. Person with anorexia nervosa also has risk of cardiovascular problems such as irregular heart beat (arrhythmia) and coronary heart disease with decreasing of heart muscles. People may also suffer poor blood circulation resulting into tremor and blurred vision.

Long term anorexia nervosa results in loss of important minerals from the blood such as calcium, potassium and sodium which play an important part in keeping the electrolyte balance in the body. They are important chemicals in maintaining normal renal, cardiac and brain function.

Hypokalaemia or very low level of potassium can lead to fits (seizures), renal failure and restlessness. Low level of sodium which is known as hyponatraemia can cause perplexity within the person and low calcium can cause bone weakness, tooth decay and muscle pain.

The highest risk factors found with the young girls, those people who have family history of anorexia, those people who are in transition phase like leaving school and joining college, and the professionals in sports and fashion industries. They have to take extra precautions.

Prevention

There is no proven technique or drugs to prevent anorexia. Primary care physicians are helpful to identify the early signs of this eating disorder and prevent into development further. If any of the family members or friends is found with low self-esteem, losing certain weight and following the abnormal dieting requests ask him or her to speak to doctor and try to give proper counseling so that he or she can understand the situation seriously.

Unconventional Medicines- Some experts suggest using alternative medicines which can help in bringing down the anxiety level. Although these alternative medicines have not proved scientifically but they are famous in different parts of the world. Some of the well known alternative medicines are:

• Meditation
Massage
• Acupuncture and acupressure
• Yoga

Life style change- Changing the life style can also help in tackling the eating disorder. It will not only increase the low- self esteem but also helps in reinforcing the positive behavior to overcome the problem. Some of the life style changes needed is:

• Do not come under peer pressure and do not follow the media, players, and models blindly.
• Do not skip the food and stick the timings even if you are not hungry
• Give family and friends plenty of time. Socialize yourself.
• Maintain your self esteem. Check your health and weight regularly.

Conclusion

Cases of anorexia varied from each case to case. Mild cases of severity can be easily estimated but the cases with complications of physical and mental problems need more time and effort to treat. In most of cases of eating disorder the patient create a negative self image and refusal to accept his or her deteriorating health as a problem. Here they do not want to go for any type of treatment.

The problem of anorexia is difficult to overcome. Anorexia usually become chronic problem and need long term intervention. Even after completion of treatment the vulnerability to return back to the problem always present if in case the person meets with the same triggers point.

However, in conclusion the best remedy is to go for early intervention and prevention rather opting for various modes of treatment.