|
Nursing Continuing Education
Institute Anorexia
Nervosa:
Symptoms and Treatment
| Course Number |
LWN521 |
| Objectives |
At the end of this course, you will 1.
Know the physical consequences of self-starvation. 2. Understand
why "tricks" used by anorexics do not promote weight loss and can
backfire. Know what some of these tricks are. 3. Be aware of the signs
and symptoms of anorexia, and the criteria for diagnosis. 4. Know
issues that are important in treating anorexia and some treatment methods. |
| Credit Hours and Fee |
3.0 CE Credit Hours with a fee of $24.00 |
| Instructor/developer |
Rudolf Klimes, PhD (Indiana U), MPH
(Johns Hopkins U); Adjunct Professor, Folsom Lake College, Folsom, CA; Peggy Arndt, M.A. peggy.arndt@wamcoc.com
and Lisa Arndt, M.A. |
Welcome
to this
3-contact-hour Continuing Education course
(RP 4263) with instant online processing
and certification 24/7. Study the course below, take the 12-question
multiple-choice
TEST, register and pay online. If
you score 75% or above, you may print your CE certificate on your printer as
soon as you finish.
If you have difficulty printing your certificate,
click here.
You may retake the test once.
THE MOST LETHAL
MENTAL ILLNESS: ANOREXIA
Starving to death is not beautiful or poetic; it is
an ugly death and a painful one. Starved bodies ache all the time. The skin
bruises, the muscles cramp and deteriorate, the brain slows and slurs, the
bowels stop working on own (there is nothing glamorous about that), The breath
smells foul, the bones splinter and hurt and break, the body is constantly weak
but ceases to be able to sleep restfully (why? because your body thinks it needs
to stay awake to hunt for food, the body assumes it is in a famine)... the mouth
dries, the eyes fog, the heart flutters and beats hard and painfully, and there
can be many scary moments prior to actual death where the body feels so sick and
like its dying (because it is).
Starving oneself will compromise the body in many
ways. Metabolism is changed in such a way that it becomes more likely that fat
is retained. People who eat more food than anorexics can maintain a naturally
slim body. Once the metabolism is damaged beyond repair, weight can be gained
on only a few hundred calories a day. Anorexia will stop growth in height, and
can result in shrinking height due to osteoporosis. The brain can shrink (the
brains of anorexics have less grey matter). Cessation of menstruation or erratic
menstrual cycles can also result (which may continue after recover and hurt the
ability to have children, as will osteoporosis). Hormone imbalance, which can
cause growth of facial hair and heart strain, can also result from anorexia.
Purging can cause blood vessels in the eye to rupture, resulting in blindness.
Other physical complications include fatigue, skin problems, fine hair growth on
the body, kidney and liver damage, and cardiac arrest (usually due to low
potassium).
Anorexia has the highest death rate of any
psychiatric disorder. Between 5 and 15% of patients die during treatment, and
the number that die altogether is probably 20%. Anorexia affects 5 to 10% of
all American women, and at least 20% of college women binge and purge on a
regular basis. The disease usually starts between ages 14 and 17. (Source:
Bulimia/Anorexia, The Binge/Purge Cycle and Self-Starvation, by Marlene
Boskind-White, Ph.D. and William C. White, Jr., Ph.D., 2000)
Bulimia is also life threatening. The sudden
change in electrolyte balance when purging can stop the heart from beating.
Most bulimics who die do so in the act of purging.
If you have an eating
disorder right now, please be conscious of the damage you are doing and planning
for. Try to find out why you are doing this by getting into treatment. You may
miss out on years of living if you do not reconsider the direction your life is
taking. For treatment, try one of the following links:
http://www.edreferral.com/
http://www.something-fishy.org/treatmentfinder.php (lists contacts all
over world and all over USA).
For a more complete list of physical and medical
complications from anorexia see
http://www.mirror-mirror.org/eatdis.htm
For statistics see National Institute of Mental
Health website at
http://www.nimh.nih.gov/publicat/numbers.cfm
SIGNS AND SYMPTOMS
OF ANOREXIA/BULIMIA
Adapted From Something Fishy at
http://www.something-fishy.org/isf/signssymptoms.php (see site for a
more extensive list)
-
Dressing to hide body shape (e.g. baggy clothes, layers)
-
Obsession with weight, calories and/or fat.
-
Frequent and long trips to the bathroom, often with running water, after
meals.
-
Food rituals such as shifting food around, cutting food into tiny pieces, or
keeping utensils from touching lips; hiding food.
-
Hair loss.
-
Pale or “gray” skin.
-
Frequent complaints of feeling cold.
-
Loss of menstrual cycle.
-
Bruised knuckles, bleeding in eyes, bruising under eyes or on cheeks.
-
Insomnia.
-
Being perfectionist.
-
Reading books or visiting websites on anorexia and or weight loss.
There are websites devoted to promoting anorexia as a :lifestyle" that is
safe. Such sites are called "pro-ana" and can aid the illness and trigger
negative reactions.
-
Visible food restriction, use of diet pills, laxatives, enemas or Ipecac, or
dramatic weight loss.
-
Dizziness, headaches, or frequent sore throats.
-
Statements putting self down about being fat, eating, or about being
worthless or stupid.
CRITERIA FOR ANOREXIA
Anorexia Nervosa is diagnosed when the patient
shows a refusal to maintain body weight at or above a minimally normal weight
for age and height, an intense fear of gaining weight or becoming fat, even if
underweight, and a disturbance in their experience of their body weight or
shape, denial of the serious nature of their low body weight, or self evaluation
based too strongly on body weight or shape. In postmenarcheal females (women who
begun menstruating but have not yet gone through menopause), amenorrhea (the
absence of at least three consecutive menstrual cycles) is another criterion.
A minimally normal weight would be less than 85%
of that expected; or in a growing child or adolescent failure to make expected
weight gain during period of growth, leading to body weight less than 85% of
that expected.
There are two types of anorexia: the restricting type in which
the person has not regularly engaged in binge-eating
or purging behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas), and the binge-eating or purging type in which the person
has regularly engaged in binge-eating OR purging behavior (i.e., self-induced
vomiting or the misuse of laxatives, diuretics, or enemas).
FACTORS IN
DEVELOPING ANOREXIA AND BULIMIA
No specific life experiences are associated with
developing either anorexia or bulimia. Psychological stressors that lower
self-esteem can result in increased concern about weight. Social factors that
encourage unrealistic thinness do have an impact. Cultures where thinness is
encouraged have an increased incidence of eating disorders. Gender differences
reflect the differences in the valuing of beauty and thinness in males and
females. The fact that the attitudes of those without eating disorders
are similar to those with eating disorders goes to show that the culture has an
influence and people with eating disorders are not aberrant in their thinking.
There is some evidence from studies of twins that bulimia is more associated
with environmental factors and anorexia is more associated with a genetic
predisposition (possibly for compulsive personality traits). (Source: Nature
and Nurture in Psychiatry, Joel Paris, M.D. 1999)
Eating disorders cause biological changes which
then perpetuate the disorder. Since almost all teenage girls diet, simply being
an adolescent female is a risk factor for eating disorders. When weight is
regained, other symptoms go away. Most teens with eating disorders are not
different from other adolescents in character disorders, dysfunctional families
or serious underlying problems. (Source: Bulimia/Anorexia, The Binge/Purge
Cycle and Self-Starvation, by Marlene Boskind-White, Ph.D. and William C.
White, Jr., Ph.D., 2000)
There is a study at Harvard Medical School of the impact of television on
eating disorders before and after exposure to television. This study was done in
the late 1990's in Fiji. Prior to access to television, no girls used vomiting
to induce weight loss. Three years after the introduction of television 11% of
girls were using self-induced vomiting for weight control, dieting had become
commonplace. with 69% of girls having gone on diets and 74% stating that they
were too fat. The girls said that they were trying to copy the television
characters. Girls in homes with television sets were three times more likely to
show symptoms of eating disorders. (Source: BBC News, UK, Friday 31 May, 2002).
BODY
IMAGE
Eating disorders are unique for many reasons, but
one reason is that they have a rather distinct visual image connected to them.
This is part of a metaphor of unexpressed pain. If a person feels s/he can't
speak about their fears, thoughts, hurts, and ideas (etc.) then that person
feels silenced. But what if they subconsciously or consciously figure out a way
to express those things, not with words, but with their own bodies?
In the eating disorders, image is a big component.
It is no accident either that if we feel unable to share our pain verbally that
we might try to share it physically. For example, if a daughter feels silenced
by the family and overbearing sibling, perhaps the daughter will starve herself
to look as small as she feels. Smart, in a way, but it doesn't end up working.
Instead of being seen for who she is by the family, she will now be seen as the
"crazy one" and that won't help at all.
Body image is such a major part of eating
disorders... and attempts to "speak" through one’s body usually backfires and
the person ends up with the kind of attention they don't want and remains
without the attention they do want. It is a tricky, tricky disease. Borrowing
from wisdom of the Big Book of Alcoholics Anonymous, I would say eating
disorders are "cunning, baffling and powerful".
For education on body image and the media see
http://www.about-face.org/
ANOREXIC “TRICKS”
AND THEIR CONSEQUENCES
Various “tricks” of being anorexic are used,
however they often do not have the desired effect. Here is a list, and what
happens when these tricks are used.
1. Hiding. Masking feelings and hiding from
oneself, for example: wearing baggy clothes, using weights to fool the scale,
lying, moving food about, stealing. Often people who are anorexic are smart, but
use this intelligence to avoid their life.
2. Laxative abuse. Often used, this does
not result in weight loss for the following reasons: use of laxatives will
decrease metabolism and slow the digestive tract. Long-term users actually gain
weight without increasing calories because of metabolism changes and chronic
constipation. Laxative use increases the chances of death. Users start to
smell, and this cannot be covered up with perfume. They spend a lot of time
finding private bathrooms because of smell and noise. Since laxatives cause the
body to lose water, there is apparent weight loss at first, but all calories are
still digested and as soon as water is ingested the weight (water) reappears.
Laxatives are physically addicting and the body will begin to depend on them for
normal bowel function. The colon muscles become weak and the need for laxatives
increases. (To get off laxative you must taper off or seek medical help.)
3. Diuretic abuse. Like laxative abuse, this
does not work for achieving weight loss. Diuretics may reduce bloating, however
any weight loss is simply water loss since diuretics target excess water. Use
can be dangerous since you can die from dehydration. Diuretic use is also
addictive. (Taper off or seek medical help.)
4. Diet pills. Over the counter diet pills
do not work. If they did work, no one in America would be overweight. The diet
industry is the only business that has a 98% failure rate and is still going.
The results of diet pills are at best temporary and minor. The side effects can
be psychological addiction and wasted money.
5. Other drugs. It is common for people
with eating disorders to also have chemical addictions. Some drugs cause
initial weight loss (uppers, speed) but this is a side effect that is unreliable
and does not last. Some can lead to weight gain and damaged metabolism. The
drugs that cause initial weight loss are associated with depression. The only
drugs recommended for people with eating disorders are antidepressants.
6. Syrup of Ipecac abuse. This is a poison
that is for use in emergencies to induce vomiting. Use for weight loss is
deadly. Syrup of Ipecac can eat away at your throat and stomach and make you
sick for hours. One patient used this and had such severe, permanent damage that
it killed her 5 years after she recovered from her eating disorder. If you use
this, stop now. See a physician as soon as possible.
7. Other purging methods. Use of fingers or
objects to induce vomiting does not cause permanent weight loss. Purging is not
about weight loss but about feelings. Purging is often associated with anger.
COMPETITION AND
COOPERATION
Among some anorexics there is competition. This is
seen in hospitals, schools and colleges. They will pick each other out of the
crowd and rate themselves against other anorexics. Am I as thin? Do they have
body hair growing all over? Visible ribs and collarbones? Veins? Eating support
groups can be places where this competition takes place and leaders of such
groups need to be aware of this and to bring it out into the open. Part of
letting go of disordered thinking is to talk about the competitive thoughts and
feelings. This competition is unique to anorexia. Most people with mental
illnesses do not compete to be the sickest!
In addition to competition, there can also be
cooperation among those with eating disorders. This happens frequently but is
not often talked about. Friends help each other develop eating disorders.
There are “binge buddies” who can share their dark side and still be accepted by
each other. Such buddies teach each other how to be sick and can keep each
other sick through this bond (like drinking buddies who are alcoholic). They
are bonded by their secrets and disease, but this is not a real friendship.
Like pushers who offer drugs to “friends” they need to be seen as “bad” friends.
MALE ANOREXIA
There seems to be an increase in male teenagers
with anorexia. What is alarming is that these are not like the adults. The
anorexia is disturbingly strong in these young guys. It also isn't related to
the expected athletics as much as it is related to a fashion image. This image
is known as "gothic" whose followers are often young artists expressing
themselves while exploring the shadow side of self.
Their "look" is not the typical beauty ideal of a
muscular, strong man but instead of a pale slim young man who is able to upset
the establishment by wearing forbidden clothes, make-up & hairstyles, all the
while pushing the gender boundaries.
For more on men and eating disorders see
http://menwithed.healthyplace2.com/
DIABULIMIA
This is a term used to describe the growing number of people with diabetes
that manipulate their intake of insulin to alter their weight. This is extremely
serious for several reasons. The physical toll on the body is higher than with
one disease alone and there is an increased risk of blindness, dehydration and
kidney problems. Without insulin, the cells can't take in sugar so glucose
accumulates in the bloodstream. The person becomes very thirsty, and gallons of
water must be consumed to flush out the glucose. Urination becomes very
frequent. The body becomes dehydrated and very weak. At this point water intake
results in immediate wieght increase as needed body fluids are replenished. This
immediate weight increase (up to 15 pounds overnight? is then difficult to cope
with for someone who is anorexic.
BORDERLINE
ANOREXIA
There are an increasing number of young people on
the edge of anorexia. They maintain a very low weight and are similar to
anorexics in their eating habits, thinking, self-criticism and physical health,
but do not meet the medical criteria for the disease. By chronically
underfeeding themselves, they risk lover immune system function, permanent bone
loss, infertility, dental problems, weakened muscle tissue, and increased risk
of other ailments, especially fractures and sprains. These people tend to have
problems with self-esteem, perfectionism, depression, anxiety, social isolation,
anhedonia (loss of ability to enjoy things) and risk of full-blown anorexia or
bulimia.
ANOREXIA AND
CUTTING
It is estimated that one in 200 young women use self inflicted violence as a
way to deal with intensive feelings. It is common for those with eating
disorders to also cut themselves. The physical pain is a way to distract oneself
from psychological pain and to control the hurt they are feeling. This attempt
to control is a lot like the reasoning of anorexia. Self inflicted violence is a
common response to post-traumatic stress disorder and may not mean the person is
crazy or severely mentally disturbed. It can be treated.
RECOVERY AND
TREATMENT
The first step in recovery is to make efforts to
stop eating disordered behavior. As this change to healthier behaviors
continues, the patient pulls out of the eating disorder. Behaviors that need to
be changed usually include eating rituals and thinking in black and white
terms. A later step is going off a meal plan and freely choosing food, a more
normal behavior. At still later stages, the patient can avoid reacting to a
“bad” body image day, is no longer obsessing about fat, calories or weight.
Overeating, under eating and purging are ways to
avoid feelings, thoughts, discomforts and life. The avoidance is the real
problem. Like drugs, however, food and restricting food affects body chemistry,
so that a person can be addicted to starving. There is a temporary change when
the body starves that produces a slight endorphin rush, so the body has energy
to hunt for food. Some treatment techniques are listed below. For more treatment
information, see Bulimia/Anorexia, The Binge/Purge Cycle and Self-Starvation,
by Marlene Boskind-White, Ph.D. and William C. White, Jr., Ph.D.;
I. Education
Anorexic patients need to be educated about the
effects of starvation on their bodies and on their thinking. Irrational beliefs
about nutrition need to be challenged and accurate beliefs learned. White and
White also tell patients why they can’t pick out a celebrity and copy their
weight, or just pick a weight by explaining the genetics of metabolism, set
point and critical weight (necessary for resumption of menses). (Source:
Bulimia/Anorexia, The Binge/Purge Cycle and Self-Starvation, by Marlene
Boskind-White, Ph.D. and William C. White, Jr., Ph.D., 2000)
II. Metaphors
One approach to treatment of eating disorders is to
find the metaphors in the particular behaviors. There are many metaphors in
eating disorders and investigating these helps people with anorexia know
themselves better. Then they can accept themselves and stop hiding. Here are
some of the possible metaphors:
1. Starvation:
“deny thy self’, usually tied into self-worth issue, deprivation because one
feels deprived of something, the quest for purity-linked to feeling dirty,
possible fear of being an adult and so starving away the adult shape.
2. Binge: wanting to take
a lot in quickly, fear of not having enough, fear of losing out or missing
something, fear of abandonment, desire to “fill up” because life feels empty.
3. Purge: get rid of, get
out violently, often there is a need to release anger, rage, pent up emotions,
this is a dramatic act, a powerful statement is trying to be made, trying to rid
oneself of things they don’t like.
4. Sugar Foods:
a desire for sweetness (ask how else you can find sweetness in life), a
sugar rush (false energy used to offset depression).
5. Crunchy Foods:
to bite down and chew can be an aggressive act; this may be related to
unresolved and unexpressed anger.
III. Awareness of Hungers
Hunger itself is a metaphor. We have hungers for
many things, not just foods. People with eating disorders have often lost touch
with their hungers, on a physical and also on an emotional level. Relearning how
to pay attention to hunger signals is part of recovering from disordered eating.
Anorexic “logic” can be that one does not deserve anything, can have no needs,
and must not ask for anything. Hungers are seen as bad. People who deny their
hungers are seen to be strong, instead of being seen as cut off from their own
nature and denying reality. Anorexics can be taught that their bodies have
wisdom and have a lot to tell them if they will listen. The body knows what it
needs to look its best, including having a glow of health and having energy.
Reconnecting with hungers takes some practice. Here
is an exercise that can help.
Zen Raison
Take a raison (or other small bite sized piece of
food) and put it in your mouth. Then, slowly and consciously TASTE the flavor
and texture, keeping it in you mouth for a long time, meditating on the entire
simple experience: chewing slowly and consciously, be AWARE of your physical
reactions, from you mouth, throat and stomach. Pay attention to the information
coming from you body, this is the language in which your body speaks to you..it
is a series of sensations.
This exercise can be expanded to include a whole
meal. Eating in this way on a regular basis helps put you in touch with your
body and your hungers.
IV. Hunger Diary
Just like a food diary that nutritionists use, a
hunger journal asks you to pay attention to your hungers and be conscious of
when food hunger may surface and what it feels like and how you react to it
(anger, confusion, surprise, etc.). Write down the time, the body location of
the hunger pains and your thoughts about it. This will help you get to know
your body. The body you have now (not the one you want or wish for). If you do
not feel any hunger at first, do not give up. Someone who has suffered with
disordered eating for a long time has lost touch with his or her hunger and it
may take a while to reconnect. Your body may not be able to feel the sensations
of hunger until some healthy re-feeding type meals have been consumed. Giving
your body a chance is a sign of love and respect for your body that only you can
offer. Trying comes first.
V. Journal Writing
The concept of purging can be useful, that is, to
“let things our” when they bother you. Purging in anorexia and bulimia do not
help because the thoughts and emotions are still held inside. Journal writing,
purging on paper, is a useful tool for gaining awareness of feelings.
VI. An Image Diary
This is an idea that needs to be used carefully.
Photo or video diaries that would chart a few "days in the life of..." may help
you later to see your own pain and suffering in a way you are unable to see it
now. Try, for example, taking a few photos of yourself (dressed minimally)
during a particular bad day in your disease. Put the photos aside (don't dwell
on the images until you are ready!). I'd even suggest to photograph or videotape
yourself during an eating disorder "act" such as a binge, a purge, an excessive
exercise routine, a trip to the bathroom after swallowing laxatives, etc. etc.
Make sure you keep this image diary SAFE and SECURE. It is for you and perhaps a
therapist or VERY trusted friend or other professional. After you have made an
image diary put it aside for a while. Don't immediately watch or look at the
images. It will not be useful or have a profound effect if you contemplate them
right away. Maybe tell your therapist that you did an image diary, or mark in
your calendar a day about 5-6 months into the future upon which you can pull it
out and look at it. Or wait even longer if you can or how it feels right.
Again, it will be powerful to hear your own words, see your own image months
later to get a perspective on how exactly is the eating disorder effecting your
life.
You need to do it for yourself and to yourself,
your future self, and for no other person or reason. If it sounds like it would
not help you, Don't do it. If it sounds like something you might in the future
watch and remember where you don't want to go, or how you want to fight harder
to get better because it was such an awful, ugly time, then give it a try. It's
just an idea, and a warning to your future self, and a diary of how you are
spending your life (your energy, your health) at a particular moment in your own
personal history, nothing more. You can make up your own version of this or work
with a therapist on how something like this could be beneficial.
STATISTICS:
1 in 250 females has anorexia.
1 in 4 young females (12-32) has disordered eating.
1 in 6 people with eating disorder is male.
1 in 10 males has disordered eating.
2 of 10 anorexics die from the disease.
TREATMENT LINKS
http://www.edreferral.com/
http://www.something-fishy.org/treatmentfinder.php this is for treatment,
has lists all over world and all over USA
LINKS TO WEBSITES
ON ANOREXIA AND EATING DISORDERS
http://www.something-fishy.org/, one of
the largest sites on eating disorders
http://www.caringonline.com/, many
links, latest articles
http://www.bodycage.com/
http://anorexicweb.com/ (website of the co-author, Lisa Arndt)
Course developed and written by Peggy Arndt,
M.A. peggy.arndt@wamcoc.com
and Lisa Arndt, M.A.
TEST for CE Students
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