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Anorexia nervosa is a disorder
in which a person starves herself past slimness to the point
at which she is so emaciated that her life is put in danger.
Stringent dieting and fasting are present in bulimia nervosa
also but the characteristic symptom of this condition is that
episodes of intense cravings for food with secretive, gross
overeating (binges) occur. These binges are followed by a
"purge" to avoid any weight gain from the food eaten.
The sufferers are so terrified by the idea of gaining weight
that they are driven to make themselves sick, fast for several
days, exercise excessively or abuse large quantities of laxatives,
diuretics or diet pills. Women with bulimia nervosa can be
underweight, overweight, or normal weight, depending on the
balance of bingeing and weight control methods
SYMPTOMS
It is unusual for the sufferer
with anorexia nervosa to be concerned about her health; on
the contrary, she will be overactive and study or exercise
excessively. This makes it difficult for even family members
to realise something is wrong until the disorder is severe.
The family may not realise that nutritional intake is inadequate
as her meals may consist of large quantities of vegetables
or salads. Appetite is not usually lost, rather the opposite,
she thinks about food constantly. The sufferer will disguise
the extent of her weight loss by wearing voluminous clothing.
Often there is a distorted body image; she remains convinced
that she is fat even when it is apparent to every one else
that she is not. One clear sign is that her periods will stop.
In contrast the sufferer from
bulimia nervosa is mortified and worried by her behaviour
but is too ashamed to reveal it. She is frightened of the
physical damage she is causing herself. Friends and relatives
will notice that although the sufferer does not eat with them
at mealtimes, or will only eat small amounts of low calorie
foods, large quantities of food may be missing from the refrigerator
or cupboards. The preoccupation with weight and shape may
mean that it takes a long time to choose clothing each day,
and dismay caused by her appearance or behaviour will lead
to the cancellation of appointments. Evidence of vomiting
or purging may be present in the bathroom.
WHY IS IT IMPORTANT TO
GET TREATMENT?
It requires an enormous amount
of skill and persuasion to help someone with anorexia nervosa
to acknowledge that they have a problem. Early recognition
may prevent the development of a severe form of the illness
and the need for specialised treatment may thus be averted.
If left untreated anorexia or bulimia nervosa begin to dominate
the sufferer's life: she becomes unable to concentrate on
anything else. Her character also changes, she may be difficult
to get along with and may become deceitful.
It is important to remember
that young women can die from this illness, and that a quarter
of cases have a chronic illness which disrupts their life
profoundly and in some cases leads to suicide.
Accounts of bulimic behaviour
in popular magazines may suggest that it is a magic solution
to the difficulties of slimming whereby you can eat your cake
and not have to suffer the consequences. This is far from
true. Women with bulimia pay a huge toll.
WHAT ARE THE COSTS?
Starvation has physical, psychological
and social costs. The whole body pays: sleep is disturbed;
cold is intolerable, the heart and circulation is weakened;
bones fracture; cholesterol increases; production of red and
white blood cells decreases; muscles weaken; hair redistributes;
the bowels stagnate; the brain shrinks; concentration and
complex thought ceases; misery replaces joy and enthusiasm;
social interaction becomes arduous.
Methods of weight control
also have life-endangering risks and inevitable costs. Vomiting
dissolves away teeth, damages the gullet and leaches from
the body the salts, which are vital for heart, muscle and
kidney function. Laxatives destroy bowel muscles and drain
away salt and water. Other medications taken to aid weight
loss increase irritability and nervousness.
The body will fight back.
It will crave for missing nutrients, it will only feel satisfied
when the stomach is almost bursting, the salivary glands will
swell (fattening the face) and it will suck up salt and water
(leading to a puffy face, stomach and ankles).
FREQUENCY
Three out of every hundred
women have a severe form of bulimia nervosa in their lifetime.
Milder forms of the illness are common and merge into the
cultural variation in diets or food fads. Anorexia nervosa
is less common, affecting 7 in a thousand 15-year-old schoolgirls
(an age of greatest risk) and 3 in a thousand of all women.
Milder forms of the illness are more frequent.
CAUSES
Anorexia nervosa is an illness
that has probably afflicted women over the centuries. One
explanation of this is that some people have a constitution,
which puts them at risk of developing anorexia nervosa. This
is manifested by the inability to terminate a diet or to regain
appetite after an illness or major loss. Those people who
are at most risk are perfectionists who conscientiously plan
and order their life. Food and eating may be the one area,
which can be successfully controlled and not subject to the
whims of fate. Eating disorders may be a way of coping with
problems in life: a way of avoiding issues or emotions, which
seems too painful. Common, but mistaken, beliefs are that
families cause anorexia nervosa, or that the problem is merely
that of a "naughty" girl behaving wilfully or stubbornly.
Once the disorder becomes
established a vicious circle develops. In the initial stages
she may be complimented on her slim appearance and commended
for her self-control, which may well encourage her. Eventually,
the stomach shrinks and empties slowly so that bloating and
discomfort makes eating difficult. Depression and lack of
social contact isolates the sufferer from any influence, which
could shift the preoccupation with food and eating.
In contrast to anorexia nervosa,
bulimia nervosa is probably a new form of illness, which has
increased markedly over the last two decades in the West.
Changes in our culture and environment may account for this.
Feminists have argued that the changing roles and expectations
of women are the noxious factors in western societies. An
alternative explanation is that the modern fashion for leanness,
with the accompanying increase in dieting, is to blame. Dieting
increases the risk of developing bulimia nervosa 8-fold and
the illness is more common among those whose careers require
a trim figure. An individual is more at risk if, in addition,
she has had a disturbed background or been exposed to untoward
events.
TREATMENT
The first and perhaps most
difficult step in treatment is to acknowledge that there is
a problem with eating. Families and friends need to be knowledgeable,
patient and yet firm. The next step is to visit the family
doctor who will be able to confirm the diagnosis and assess
the severity of the condition. The general practitioner will
be able to give advice on a sensible diet and monitor weight.
Some people find that they
obtain benefit from joining a self-help group. The Eating
Disorders Association has a register of self-help groups throughout
the country. The general practitioner may decide that specialised
help is required and he will refer the sufferer to a specialist,
usually a psychiatrist.
The specialist will need to
gather information (some of which may be sensitive and personal)
so that he or she can understand how the eating disorder developed,
what complications are present and what are the factors which
make change difficult. He or she may be interested in the
information that relatives and friends can provide upon these
issues. Special investigations such as a blood test, ultrasound
or bone density estimation may be required to complete the
assessment.
The major focus of treatment
for anorexia nervosa is weight gain in conjunction with some
form of "talking therapy" to help the sufferer to
come to terms with problems she may be avoiding. In most cases
the education and help required to undertake this could be
given as an outpatient either to the sufferer alone or with
members of the family. Severe forms of anorexia nervosa, which
put the sufferer's life and health at risk, may need to be
treated in hospital. Skilled nursing is the most important
aspect of this treatment, but other professionals - psychologists,
occupational therapists and dieticians - will also contribute
to the understanding of the problem and help to find ways
of solving it. It is unusual for medications to play a major
part in treatment for anorexia nervosa, although antidepressants
and tranquilliser are occasionally needed. Treatment and recovery
is usually a slow process: do not expect immediate results.
It may also be an emotionally painful time for the sufferer.
Treatment of bulimia nervosa
is aimed at restoring a normal pattern of eating, that is
three meals a day, without dieting or using drastic weight
control measures, while also helping the sufferer to learn
to express her emotions and cope with stress in a less destructive
way. Sufferers may find it difficult to believe that treatment
will not lead to weight gain. Education about nutrition and
the controls over food consumption and weight is an important
component of treatment. Treatment may be given individually
or in a group format. Recording the pattern of eating in the
form of a diary is helpful. The therapist will try to help
the sufferer understand why weight control is so important,
and will explore factors in the past or present which may
contribute, using a form of psychotherapy. If the illness
has been severe and prolonged the normal controls over eating
will have been disrupted and it willtake time for these to
return to normal. Medication may be used to supplement treatment
in such cases.
Antidepressant treatment can
also be helpful, but on its own is less effective than with
psychological treatment. Even after recovery, eating remains
an Achilles heel and further relapses may follow stress.
RESEARCH
The primary aim of research
in the Eating Disorders Research Unit at the Institute of
Psychiatry is to build a causal model of eating disorders
which spans both biology and psychology, with the ultimate
aim of providing new treatments for these disorders.
About RIED...
Research Into Eating Disorders
(RIED) is the initiative of Nina Jackson and a vehicle for
raising funds for research into eating disorders at the Eating
Disorders Research Unit, Institute of Psychiatry, via The
Psychiatry Research Trust.
Despite becoming more and
more to the forefront of the public eye, there is still too
often an attitude that these conditions are more to do with
the attention seeking needs of privileged young girls than
serious life threatening illnesses. Anorexia Nervosa is one
of the most common chronic conditions in adolescence and it
has the highest mortality of any psychiatric illness. Currently
there are no drugs to help the sufferer of an eating disorder
as there are for many other psychological illnesses, and the
treatment for re-feeding and recovery is very long term.
As we enter the new millennium
we all hope for new developments that will change the way
that eating disorders are managed and we look forward to a
time when our understanding of these illnesses will be very
different from now. That change will come almost certainly
from painstaking research and perhaps, too, as it so often
has done in medical research over the years, an element of
luck and careful observation.
But research in all forms
takes money and RIED is raising vital funds to realise the
£2,000,000 goal required to have a research Chair endowed.
To achieve results in this field and to save the growing number
of lives that are being lost we must be ambitious and create
new and stimulating blood into the development of this research
and above all have the funds for it to continue.
Meanwhile, the battle of those
who are suffering will continue. Please help us to make a
difference.
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