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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

Understanding Anorexia Nervosa

Allan N. Schwartz, LCSW, Ph.D. Updated: Jan 7th 2007

Finally, the fashion and media industries appear to be paying attention to the dangers of anorexia nervosa. For decades, both industries have placed very thin models on center stage. The message conveyed to young women was unmistakable: "if you wish to be beautiful, you must be skinny." The recent deaths of some top models in Brazil and the greater awareness of the public about the health dangers of being too skinny have convinced some of the top executives in both industries that it is time to be more aware of health rather than just being skinny.

Nevertheless, Anorexia Nervosa continues to plague the lives of young women and their families. While a small percentage of men do develop anorexia nervosa, the overwhelming majority of people with this disorder are female. NEDA, the National Eating Disorder Association, estimates that one in every 100 girls develops anorexia. As early as age ten and twelve girls become aware of weight and begin the process of dieting and exercising. If they develop anorexia it can last until age 35 and in some cases becomes a life time problem.

In Middle School many girls will not eat their lunches. The reason is that they feel embarrassment about eating in front of boys. In addition, they are reluctant to eat in front of other girls for fear of appearing to be greedy. Losing weight becomes a competitive issue for many of these females who judge themselves by how much thinner they are as compared to other girls in school.

What Is Anorexia Nervosa?

Anorexia is a disorder characterized by the fact that a female weighs less than 15% of normal body weight for their age and height. These females do not think of themselves as thin. As a matter of fact, no matter how much weight they have lost, they think of themselves as being fat. As a result, they severely restrict their food intake and obsessively exercise for the purpose of losing more weight.

Generally speaking, these young women are extremely intelligent and achieve excellent grades in school. They are perfectionist, demanding and expecting the best possible performance from themselves in all areas such as academics, athletics and social interaction.

Along with the symptoms of anorexia, most of these young people experience extreme anxiety, depression and self loathing, distorted body images and obsessive-compulsive symptoms.

Symptoms of Anorexia:

Anorexia is a dangerous disorder resulting in the deaths of almost 6% of victims of this illness each decade. Even as these tragic women are dying of starvation, they insist on the belief that they are fat.

Symptoms:

1. Severe restriction of food intake.

2. Complete denial of the fact that they are skinny.

3. A deadly fear of gaining weight.

4. Loss of menstrual cycle.

5. Loss of secondary female characteristics, so that hips become narrow, breasts shrink and hair loss occurs.

6. Nails become brittle.

7. Osteoporosis or thinning of bones occurs increasing the danger of fractures.

8. Compulsive exercising of all types.

9. Blood pressure drops to dangerous levels with the danger of fainting.

10. Body temperature drops so that these people often feel cold.

During meals, these young women may fill their plates with food but push the food around and actually take in very few calories. They will then complain of feeling "full" particularly if anyone at the dinner table points out the plate remains full of uneaten food.

These girls also wear long over sized clothing that hides their real appearance. If asked why they are wearing "baggy" clothes they will state that they want to hide their fat. Of course, they are really hiding their skinniness but seem unaware of this.

The Why of Anorexia:

Anorexia Nervosa has existed as long as civilization. There are historical reports of this disorder among the Ancient Egyptians and Romans, through the Middle Ages and up until the present time. The question is what causes this disorder?

Many theories have been advanced and research continues to be done on the causes and cure for this eating disorder. Here are a few of the theories on the causes of anorexia:

1. One explanation for anorexia is that limiting caloric intake becomes the one way that many girls believe they can exercise control over their lives. Raised to be nurturing and believing they have no real power, these young people discover that the one area in which they can exert full control is by controlling their food intake and their weight. It is important to understand that these girls feel extremely hungry and think about food all of the time. For them, the achievement is to resist hunger pangs and obsessive thoughts about food by exercising and refusing to eat what they consider to be "unhealthy food."

2. In addition, this becomes the one certain way that these perfectionist girls can reach goals they set for themselves. The problem is that there is no limit for the goal of weight which is why too many die of malnutrition.

3. Another explanation is related to the value of sexual beauty. Today, in an age where the media and fashion industry puts such a high value on women being skinny, these young people emulate the females they see on television, in the movies and in teenage magazines. Also, they take seriously the constant messages (meant for obese people) that it is healthier to be thin than to be heavy. Attempting to achieve physical beauty as defined by society and to be as healthy as possible, these young women diet and exercise to the point where they become obsessed.

4. There is increasing evidence that there is a genetic basis to anorexia. Obsessional thinking combined with one or another type of eating disorder in the family seems to set the stage for anorexia. If it is true that some forms of anorexia are inherited then a cure could be available in the future.

5. Dysfunctional family life is also seen as a possible cause of anorexia. Fathers who criticize their daughters for being over weight add to the danger that they will become anorectic. In addition, authoritarian homes in which parents are very strict and in which there is a lot of arguing and hostility adds to the likelihood of girls developing this disorder.

Families have boundaries and members have role definitions. However, it has been observed that in many of the family systems from which anorectic girls come, boundaries between generations and between individuals are often violated. Therefore, girls who become anorectic suffer from developing a real sense of autonomy and independence because of intrusions on the part of the parents. Without a strong sense of separateness, exerting control over food intake by not eating becomes the only way many of these females can develop any sense of power and control.

6. Psychodyamically, it is thought that anorectic girls hate being female and wish to be males. According to this theory, girls want to lose their menstrual cycle and appear more masculine in an effort to deny their femaleness.

Treatment:

Treatment of anorexia is extremely difficult partly because of the strong denial on the part of the patient. It is hard to convince someone that they need treatment when the patient cannot see that they have a problem. For this reason, the younger the patient when the therapeutic intervention occurs the better the result.

In providing treatment for anorexia one of the questions that must be asked and carefully weighed is whether or not hospitalization is necessary. Usually, if the loss of weight is to such a degree that health and survival are in danger then hospitalization is required. The particular type of hospitalizations is specifically for eating disorders where, on an inpatient level, the issues of food intake and weight loss are discussed in psychotherapy and in groups. Medication is administered to reduce the serious depression that accompanies anorexia.

If the young woman can be maintained at home then outpatient treatment is what is called for. In the case of anorexia, there is a team of treatment specialists that are needed to help the young person with this illness. The team consists of the following:

A. Psychiatrists for anti depressant and anti anxiety medications.

B. Psychotherapist for individual and group sessions. The therapist can come from psychology, social work or psychiatry as along as they are trained in eating disorders. Family sessions with the patient are an important and integral part of the treatment.

C. Nutritionist who is trained in the treatment of anorexia and bulimia. The nutritionist monitors food intake on a daily basis by requiring the patient to complete a comprehensive log of everything that is eaten each day in addition to moods and feelings in connection with the food intake. Also, education is provided about food categories, calories, value and instructions about what and how much to eat at each meal.

D. Medical Doctor to do weekly weigh-ins and health checks.

E. It is important for the patient to understand that failure to maintain at least a minimal weight can result in hospitalization.

There is a constant consultation among all members of the treatment team so that everyone is fully aware of the status of the patient and what changes in strategy are called for. These regular consultations also help prevent the patient from causing friction among team members by "playing one off against the other."

Note: One of the interesting but disturbing things about the family of anorectic girls is how unaware they are of how little the patient is eating and how much weight is lost. It is often necessary for someone from outside of the family to make the parents aware of what is happening. Whether or not there is a genetic factor in this eating disorder it is clear that much of it is tied to family dynamics so that family therapy is a necessary adjunct to treatment on both an inpatient and outpatient basis.

Have an Anorectic Daughter?...Do Not Scold:

Once denial on the part of the parents is broken through and they realize they have an anorectic child...

For many parents faced with a child who is showing symptoms of anorexia the temptation is to scold, punish and argue. These are the worst possible strategies because they will be met with resistance, either direct or passive. Directly, these very bright young women can argue anyone under the table, using reason and their own form of illogic to defeat anyone who is attempting to convince them that they are thin or do not eat. The result is that parents end up feeling even more frustrated and helpless. Punishment and force do not work because they result not only in more resistance but in a greater resolve to lose weight.

What Can Parents Do Once They Are Aware?

Rather than using confrontation and conflict in an attempt to force eating, parents need to go with their daughter to the family physician, have her weighed and take referrals from the MD to the nearest eating disorder facility available. Avoiding argument and allowing the professionals to deal with the issue is the best policy.

However, this does not mean that parents should say nothing and pretend all is well. Like one psychologist recommends to his parents of anorectic kids, use "hit and run" tactics. This means that a short and brief reference be made either to not having eaten or to looking to thin and, then, retreat and say nothing more. These short sorties are the best policy. Engaging in all out warfare does not succeed.

Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at dransphd@aol.com for details.

    Reader Comments
    Discuss this issue below or in our forums.

    How can this disease just take over my daughters life - - May 11th 2010

    My daughter who is 23years old 169cm in height weighing at the time of admission 37kg her BMI being 13 indicative of malnutrician and having to have a N.G tube to feed her still remains in deep denial. Dispite the desperation of her wanting to get out of hospital she still refuses to eat and acknowledge that she has this monster of and eating disorder that is controlling her life and that of her loving family. One day at a time I say to myself,  small steps , some days are worse then others as I see her struggling to come to terms as to why she is in hospital sectioned. Its seems so sad like a punishment to her as she cannot see why she is there. Thats what hurts the most. Its not like a broken leg you can see  it and it will heal in a certain time frame. Can any one offer any more support please or support groups for the parents of suffers. Thank you shonnys Mum

    A Mother's Lesson - Allan N. Schwartz, PhD - Mar 20th 2010

    Hello Layala,

    Thank you for your many updates on your daughter and her fight against Anorexia. Unfortunately, she will never have this completely behind her. Most likely, she will continue to quite well but will be plagued by sudden thoughts and doubts about her weight and her body. The main thing to do is just what you said, "take one day at a time," and that is true for both you and her. '

    Dr. Schwartz

    A Mother's Lesson - LAYLA - Mar 19th 2010

    Well..it has been 8 months since my daughter has been a recovered anorexic...I take that back...you are never fully recovered! She will fight this demon forever and he will gain control over her life, if she succumbs to his powers! With therapy, a meal plan that my daughter has mastered and a family and boyfriend that are 100% behind her, Natanya should be able to manage this addiction! One slip..one stressful day...it can be all over with a relapse occurring in a matter of days! The power of the mind! Again, as a Mother of beautiful daughters(and what mom doesn't find her off-spring beautiful?), always find the positive in them and try not to dwell in their physical appearances..their beauty lies inside their soul and their hearts. So our journey takes us one day at a time, and each new day offers it's own challenges and conquests. We take baby steps and try to concentrate in the here and now....that's all we have! All the best to you now and always! Layla

    LifetimeStruggle - Layla Steelman - Nov 17th 2009

    Just a brief update on my daughter's progress with ED. Thanksgiving is just around the corner and we as a family, are grateful to have "our Natanya" back home in recovery. The struggle goes on, but her Dietitian, her family and her new boyfriend, help keep our beautiful daughter on track. She keeps her food journal, follows her meal plan pretty religiously and vents to me when she is stressed out or "mad at the world" and says that it's unfair that ED ruined her life! I do believe that eating disorders are forever and one must never let them conquer..ED will kill you if you lose your self-esteem! You are the master of your own destiny..never lose sight of this! As Natanya's mother, I urge any one of you with an eating disorder, to seek professional therapy...you cannot conquer ED alone! Love and best wishes for a meaningful and blessed Thanksgiving! Layla Steelman

    In recovery and willing to mentor - Layla Steelman - Oct 15th 2009

    My daughter came home from her extended treatment in Arizona this past summer. She moved back home with our family and is in recovery! She looks beautiful, she feels energized and has a new supportive boyfriend. Our old daughter is back and follows a meal plan religiously, goes to her dietitian and attends support group meetings weekly to continue with her progress. Her mood swings have disappeared, her facial hair is gone and her skin is glowing, as is her walk! She has a new shapely body and looks like a real woman should look! I am grateful to have her back home with a loving, support unit and she has a second chance to have a healthy, productive life that she deserves!

    My Daughter Is Saving Her Own Life - Layla Steelman - May 18th 2009

    I am the mother of an Anorexic Daughter who is currently in treatment at a rehab center, The daily treatment program did Not work for my daughter, so we had to intervene and send her out-of-state to this nationally known clinic for more and advanced treatment. Painful? you better believe it! I now talk to my daughter about 3-4 times a week and put my faith and trust in this program and their team of caring therapists. It has been almost 3 weeks since I dropped "my 23 year old baby" off at this clinic. I miss her, obsess over her and only hope for the day that she will come home to her loving family with a substantial weight gain and a healthy mental outlook. I am so frightened that when my beautiful daughter moves back home,she might relapse. I must concentrate on the NOW and realize that with therapy, our support and love..my daughter will once again have a healthy and productive life!

    Anorexia stories - Diane - Jan 13th 2007
    You are providing a great service on this blog. Relating to Anorexia, just this week a mother/daughter have been posting about the daughter's struggle with Anorexia. You can find these posts: Kristen's blog can be found at http://kristenssocalledlife.blogspot.com/ Dawn's blog address is: http://grandmaofthree.blogspot.com/ It has been very helpful to read Kristen's first hand experience with Anorexia while simultaneously reading her mother's perspective about this struggle with a life threatening disorder. Diane

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