(Article revised January 2008)
Medical Director Cygnet Hospital Ealing, 22 Corfton Rd, Ealing
London W5 2HT
The Priory Hospital, Priory Lane, Roehampton, London SW15 5JJ
And: 51 Sloane St, London, SW1X 9SW
And: 19 Cliveden Place, Sloane Square, London, SW1W 8HD
Anorexia Nervosa is an illness that mainly affects adolescent girls although it can less commonly affect boys or girls younger or older than this. The most common features are loss of weight coupled with an apparent change of personality and a number of changes in behaviour. The weight loss, which is progressive, often starts with an apparently normal weight reducing diet. It may only be after this has continued for several months that it seems a cause for worry, usually because by then the weight loss is extreme. Once anorexia nervosa is established a sufferer will usually become completely obsessed by her need to lose weight, and blind to any efforts to persuade her to give it up. Attempts to frustrate this destructive path are generally met with anger or deceit or a combination of both. Confrontation, rational discussion, bullying or bribery usually fail to cause more than a very brief change of eating behaviour. Reducing weight has inevitable consequences so that a typical anorexic will lose her menstrual cycle and increasingly think of nothing but food and weight. A girl of average height will probably be unable to continue at school or lead a normal life once her weight falls below around six stones. At some stage most anorexics will stop trying to lose weight and will try to eat in a way that allows them to stabilise their weight well below normal levels. It is at this stage that many of them first realise that they are unable to control their eating habits and are driven to seek help.
As weight falls a typical anorexic will often withdraw from contact with friends and become more isolated. She may seem to inhabit a world that is separate from others and that is dominated by her need to control her eating and weight. To her friends she will seem to be less outgoing, lose her sense of humour and be more serious. Academic work is sometimes the only other thing that can dominate her interests. An anorexic will often show increased obsessional behaviour especially in the kitchen where it appears as an increased concern with cleanliness, orderliness and precise timing of meals. She may well wish to cook for the family and sometimes she may encourage them to overeat. She will regress, behaving younger than her chronological age, and appear to lose confidence, becoming less assertive, less argumentative and more dependant. At the same time as she becomes more dependant on her family her behaviour will increasingly control the lives of all around her.
There are many different theories that have been put forwards to explain why Anorexia Nervosa develops. If you want to read a brief resume of these then click here. In my view there is some truth in all of them and yet none quite manage to explain the illness. I should like to suggest that Anorexia is an illness that develops gradually over a period of months or longer. Several different causes contribute to the illness and at different stages of its development different causes are the most important. One way of trying to understand this is by considering that it develops as a journey into illness.
The journey appears to start with weight loss. The most common reason for it is deliberate weight loss to look better or to feel better. In this case the drive to lose weight is clearly influenced by the attitudes of our social environment. It can also start less commonly when the reason for weight loss is different, for example when weight loss occurs as a result of some other illness, mental or physical.
Those who go on to develop the illness are most commonly adolescent girls suggesting that there are things about being a girl teenager that increase vulnerablity to the illness. Other associations that seem to increase risk of developing anorexia include the nature of the personality of the girl herself, aspects of her family its members and relationships, and stresses and problems occurring outside home, often at school. Most of these things could be said to be responsible for a loss of self esteem and self worth.
The personalities of the girls tend to be conformist, compliant, and hard working. They are often popular with teachers and may have seemed to be little cause for worry over the years. As their contemporaries go through the difficulties of adolescence they seem models of sensible behaviour by comparison. They tend to be mildly obsessional. They are organised and tend towards tidiness. These traits may be quite marked before the onset of anorexia but they are usually accentuated by the disorder.
Family relationships are liable to be strained by the illness even if they have seemed previously good. The families of anorexics are often high achieving with high expectations of their children. The anorexic seems excessively willing to accept this value structure, setting standards for herself that can seem extreme. During adolescence, when the continuing growth of the child needs encouraging towards independence, the family may be still demanding conformity of behaviour. A sense of fun, an enjoyment of being unconventional, and a tolerance of alternative values may seem to be missing from her world. She may seem to over identify with her mother especially and this distorts her relationship in ways too complicated to describe this short text.
In the year or so that precedes the start of anorexia there is often an increase in the problems or pressures that create anxiety or unhappiness. These frequently seem to be from the school environment because of the common age group of the girls. Typical stresses are the build up towards taking G.C.S.E. and ‘A’ level exams and feelings of rejection arising from difficulties with relationships with close friends, girls or boys.
The final step in the development of illness is a process of entrapment. Having lost a lot of weight, thoughts about food and weight so dominate the thinking that a anorexic becomes detached from all other issues. They become isolated from family and friends and effectively live in a world of their own. At this stage the low weight causes them to have a high appetite drive. This makes it terrifying to eat and especially to change the way they control their eating because they feel all the time that they will lose control forever and so gain weight to become obese. Needing to eat something they develop a complex set of rules to eat by and then stick rigidly to them. This makes eating feel safer. But these rules lead them to continuing slow weight loss even though they try to maintain weight at the low level. At this stage of illness the issues that may have helped lead them into it, such as wanting to be slim, seem to lose their importance and the illness becomes locked by the fear weight gain and fear of loss of control.
Many authors from Freud onwards have considered that the illness represents in some way a flight from normal development into an adult. Sexual, social, emotional and physical change are resisted and the loss of weight leads to a reversal of the normal growth pathways in all these areas. There are a range of things that might lead an adolescent girl to be reluctant to grow normally and these are reflected to some extent in the lives of sufferers.
The illness appears to lead to profound loss of self worth, self esteem and self confidence in a group who are already at the least mildly diminished in this way. The illness seems to sheild sufferers from their unpleasant feelings as a direct consequence of the weight loss. As weight drops they feel emotional things in a less powerful way and of course they spend increasing amounts of time thinking only about food and food related issues. Any problems that they may experience seem to diminish in importance as the effects of illness lead them to withdraw from most aspects of life.
It may be therefore that as the illness progresses psychological factors begin to play an increasingly important role and are part of the reason why the sufferers become entrapped by the whole process of illness.
The human body copes with periods of semistarvation and weight loss fairly well. Subsequent return to normal weight and eating pattern is usually accompanied by the restoration of physical normality including the ability to have children. During the period of weight loss the body tries to conserve energy as best it can and so inessential functions become gradually lost. The menstrual cycle stops as the weight falls below about forty-six kg. and may stop earlier if the eating pattern is very abnormal. The circulation diminishes with coldness of the hands and feet that often become reddened. The heart rate slows and the blood pressure falls. Danger from a failing heart becomes a risk at very low weights, below around five stones, if the weight loss is extremely rapid, or if the chemistry is distorted by an extreme of vomiting, purging, or diuretic (water tablet) abuse. It is hard to assess a dangerously low weight but sudden death will more frequently occur once the weight has fallen by forty per cent of normal. In practice this often means somewhere near five stones. Prolonged weight loss during adolescence may eventually lead to permanent failure of normal growth but this is only common when the illness begins early in adolescence and lasts for several years. A similar severity of anorexic symptoms may lead to the problem of osteoporosis, or thinning of the bones, later in life.
This is a condition in which there are considerable variations in severity making simple generalisations about outcome difficult. Some girls have mild illnesses and may regain a normal weight successfully at home either spontanously or with fairly superficial help. The underlying issues may be fairly straightforward and easily resolved. Over a period of a few months everything may have returned to normal. Girls with more severe illnesses will need more help and it is not uncommon to find that they need the intensity of help that only an inpatient anorexic unit can provide. The most severly ill patients may need several admissions and can be gripped by illness for a number of years.
Regaining of a normal weight successfully is an essential component in the process of recovery but is not the only element of it. The course of this illness is closely linked with development and maturation. Recovery is often associated with the continuation of maturation after a period of emotional regression and it therefore involves several stages. Regaining normal weight with a normal eating pattern is the first priority and may require admission to hospital for its achievement. The return to normal eating unmasks the underlying psychological issues so that these may be explored. These issues will need to be managed according to what problems arise in practice, a task that varies from one patient to another. Finally the girl will need to begin to lead a normal life again, a task that may be slow and tentative as a result of the profound loss of confidence that is so characteristic of the illness.
Therapy programmes on eating disorder units are usually aimed at exploring and dealing with the underlying issues. The intentio is that these will have identified and sufficiently resolved by the end of her inpatient treatment that the girl will be able to chose to control her eating. Notwithstanding it is likely to require a period of twelve to eighteen months before there are no residual symptoms and signs present.
Some girls will have complex difficulties that are hard to identify or that are resistant to treatment. They may turn out to have a more prolonged course and may need several courses of treatment. There is no reliable way of predicting the severity at the start of the illness. Those with more prolonged illnesses, those who have been at the lowest weights, and those who vomit may tend to greater severity. There remain a small number of girls who die from this condition despite energetic and expert treatment. It is important to remember that anorexia nervosa is potentially dangerous and must be taken seriously from the start.
Accessing treatment can be difficult as the help available varies from one place to another. Treatment is time consuming and partly as a result of that is expensive, creating a problem for many health authorities and for insurance companies. Most sufferers should first go to their general practitioner or school doctor. He/she may well have a good knowledge of the local availability of appropriate treatment. If specialist help is needed he should be consulted as to choice of person and place. Another source of unbiased advice is the Eating Disorders Association.
The N.H.S. has a number of anorexic units often based within teaching hospitals. Many of these are excellent. The difficulty is that they often have long waiting lists. It may take several months to wait for an assessment interview and will probably take further time before admission if this is deemed necessary. Your general practitioner should be able to find out what the situation is locally quite easily.
The private sector also runs eating disorder units and many of these are also of good quality. However inpatient stays frequently run to several months so cost may be high. For most people medical insurance is necessary and it is wise to check the amount of cover available. The area where you live may not have an eating disorder unit run by the N.H.S. If this is so the N.H.S. may buy treatment from the private sector. Assistance will be needed from your general practitioner and from the admitting hospital but in practice this means that the area health authority may pay for private care on a private unit of your and the GP’s choice.
Dr Rowan's Secretary is stationed in the Priory Hospital, Roehampton.
Direct line Telephone Number: (0044) or (0) 208 392 4211
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Email peter.rowan@psychiatrist4u.co.uk