The term anorexia de riva from the Greek “anorexia” and literally means “lack of appetite”. However, this is not a completely appropriate definition, as the central knot of anorexia is not the fact of not feeling hunger (which is often very present and generally denied by the person perhaps precisely because it is strongly feared) but a pathological desire to be thin.
Generally, the criteria established by the Association of American Psychiatrists (DSM 5) are used to make a diagnosis of Anorexia Nervosa:
- Need-related calorie intake restriction, leading to significantly low body weight in the context of age, gender, development trajectory and physical health. Significantly low body weight is defined as a weight below the normal minimum or, for children and adolescents, less than the minimum expected.
- Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even if it is significantly low.
- Alteration of the way in which the weight or shape of their body is experienced by the individual, excessive influence of body weight or shape on self-esteem levels, or persistent lack of recognition of the severity of the current underweight condition.
You can then specify a subtype :
Restricted type: During the past 3 months, the individual has not experienced recurrent episodes of bingeing or purging (eg, self-induced vomiting or inappropriate use of laxatives, diuretics, or enemas). In this subtype, weight loss is mainly achieved through diet, fasting and / or excessive physical activity.
Binge eating / purging type : During the past 3 months, the individual has experienced recurrent binge eating or purging (i.e., self-induced vomiting or inappropriate use of laxatives, diuretics, or enemas).
The stage of the disease can then be specified :
In partial remission : Following the previous full satisfaction of the criteria for anorexia nervosa, Criterion A (low body weight) was not met for a substantial period of time, but both Criterion B (intense fear of gaining weight or becoming fat or behaviors that interfere with weight gain) and Criterion C (alterations in self-perception regarding weight and body shape) are still satisfied.
In complete remission : Following the previous full satisfaction of the criteria for anorexia nervosa, none of the criteria have been met for a substantial period of time.
You can then specify the current severity level . The minimum severity level is based, for adults, on the current body mass index (BMI) (see below) or, for children and adolescents, on the percentile of the BMI. The ranges are derived from the World Health Organization categories for thinness in adults; for children and adolescents, the corresponding BMI percentiles should be used. The severity level can be
increased to reflect clinical symptoms, the degree of functional disability and the need for supervision .:
- Mild: Body mass index ≥ 17 kg / m 2
- Moderate: Body mass index 16-16.99 kg / m 2
- Severe: Body mass index 15-15.99 kg / m 2
- Extreme: Body mass index <15 kg / m 2
People suffering from anorexia nervosa are therefore underweight due to a sharp decrease in food intake. To understand if a person is underweight and also to establish the severity of his thinness, the Body Mass Index is used, which indicates the ratio between a person’s weight in kilograms and the square of his height expressed in meters. Anorexia Nervosa is usually diagnosed when the body mass index is equal to or less than 17.5 (reference value for women over 18 years of age).
Anorexia sufferers often do not realize their thinness, indeed they are terrified of the idea of gaining weight and becoming fat. You try to have a very strict “discipline” on the control of food and your weight. People with anorexia also place too much importance on weight and body shape to evaluate themselves, as if their self-esteem depends on being thin and being able to control their diet.
Another feature of anorexia in women is amenorrhea, that is, the lack of menstruation for at least three consecutive months due to weight loss and food restriction. Even when the person regains the weight in some cases it takes some time before the menstrual cycle returns to be regular.
Often the disease can begin gradually and subtly. For example, a girl may begin to eat a little less for different reasons: to lose a few kilos thought to be too much, for general digestive problems, for physical ailments or surgery. It is common for the onset of the disorder to be preceded by stressful events or by major life changes such as school or residence changes, relationship breakup or school difficulties.
There are two different forms of anorexia, one defined as “restrictive” in which weight loss and control are due to fasting, food restriction and, sometimes, excessive physical activity (hyperactivity); and one defined with bulimic crises and / or with compensatory behaviors, which is characterized by the presence of bulimic crises and / or behaviors which, together with fasting, have the purpose of decreasing body weight: self-induced vomiting, improper use of diuretics and / or laxatives.
These two forms also differ from a psychopsychological point of view, the restrictive form is often characterized by rigidity, obstinacy, perfectionism and obsessive-compulsive spectrum disorders and has a more favorable prognosis; the bulimic-purgative form is often accompanied by intense psychological distress, depression and impulsive behaviors.
Psychological characteristics
Many patients count the calories of everything they eat, prepare sophisticated and high-calorie recipes not for themselves but for family members; moreover, in some cases they can implement real “rituals” such as taking a long time to eat even small quantities of food, chopping the food into many small parts, accumulating it or hiding it, or eating only certain foods cooked in a particular way.
Many anorexics despite evident thinness, seem unable to see themselves thin and have an altered body image. Their self-esteem is also closely linked to weight and body shape: weight loss is considered an achievement achieved through self-discipline and strict control.
The psychological characteristics most frequently described in patients with Anorexia Nervosa are:
depression
perfectionism
low self-esteem
interpersonal difficulties
fear of growing up
Depression
Weight loss and fasting can, through biological mechanisms, promote the onset of depression. The person withdraws more and more in himself and in his illness, becomes more and more irritable, loses interest in the things he once liked and contact with others can sometimes become unbearable. In this context, fasting or bulimic crises, if any, can have an anesthetizing function, a way to prevent you from thinking about what is scary. Often people with Anorexia Nervosa appear apathetic and indifferent, as if they don’t care about the condition they are in, masking in most cases the fear of coming into contact with the most intimate parts of themselves and the fear of not being understood.
Perfectionism
Often those suffering from Anorexia Nervosa put a lot of effort into study or work. Ambition and competition often hide a fragile identity that needs constant approval from others and to prove to oneself that one is capable of succeeding in something, only to never be satisfied with the result obtained: a high grade or praise at work they are never enough. This is why we speak of “clinical” perfectionism, and not “normal” perfectionism.
The need for approval extends, especially in adolescents, to the body as well. Criticism from other kids or trivial teasing about your physical appearance can sometimes be the “spring” for wanting to be different and start dangerous diets. The ideal to be achieved is a perfect body, like the one seen on TV or in magazines, and for the teenager, their body never seems to be thin enough and never perfect enough.
Low self-esteem
Lack of self-esteem is a key aspect in understanding and treating an eating disorder. Especially during adolescence, self-esteem is continually challenged; requests from parents or teachers, the search for autonomy and the development of sexuality favor this questioning.
Having low self-esteem is not only a risk factor in developing an eating disorder, but it is an important maintenance factor. In many anorexic patients, self-esteem and self-confidence can come from the ability to control hunger, fast and lose weight.
Interpersonal difficulties
Often people who develop an Eating Disorder already have difficulties in relating to others and with the disease relationships become even more tense and problematic.
In other cases, the disease leads the person to isolate himself or to limit contacts to simple formalities. Others can be experienced with intolerance and irritability, not only because they do not “understand” your problem, but because they can observe and judge their own body and physical appearance.
It is not uncommon for DCAs to avoid social situations that have to do with eating in company, such as going to a pizzeria or restaurant, not only because this creates embarrassment and discomfort but because in this way it is possible to continue to put into practice the eating practices have now become an essential part of the life of the person suffering from Anorexia (fasting, binging, vomiting).
Fear of growing up
Fear of growing up accompanies most teenagers.
We pass from a time in which one is totally dependent on parental care to an age in which “one must” detach and separate from the parental figures. Very often grumpiness, anger and aggression constitute a way, albeit a stormy one, to achieve autonomy. The fear of growing up is, in part, the fear of abandoning the certainties and support of parents to meet their choices and test their skills in sometimes difficult situations.
Sometimes it can be the parents themselves who, to protect their children, tend to devalue their abilities or try to solve any problem for them.
In Anorexia the fear of growing up may not manifest itself with aggression towards parents, but with a refusal of food.
Medical Complications
Anorexia Nervosa can have serious physical consequences related to drastic weight loss. This is why it is important to keep the medical condition under control through periodic clinical checks and blood tests, unless the condition is so severe that it requires hospitalization.
Metabolic complications
Electrolyte imbalances, particularly hypokalemia Hypoglycemia and liver enzyme movement Hypothermia and dehydration Hypercholesterolemia and hypercarotenemia
Endocrine complications
Low levels of estrogen, gonadotropins and testosterone Hypercorticadrenalism Increased GH
Neurological complications
Signs of brain atrophy on CT scan (which usually regress with weight recovery) EEG abnormality (metabolic encephalopathy) and seizures Peripheral polyneuritis
Cardiovascular complications
About 80% of anorexic patients have a slowing of the heart rhythm and a decrease in blood pressure.
More rarely cardiac arrhythmias and electrocardiogram changes are due to hydro-electrolytic imbalances (especially potassium); these cases occur in the presence of severe emaciation or recurrence to vomiting or diuretics and laxatives.
Gastrointestinal complications
Complications in the gastrointestinal tract are almost always present, linked to strong food restriction, the abuse of diuretics and laxatives and vomiting. Frequently, patients with Anorexia Nervosa report difficult digestion, abdominal bloating and constipation. These alterations tend to improve with the gradual resumption of a normal diet.
If vomiting is present, dental complications may occur (caries and periodontal disorders due to gastric acid contained in the vomit), enlargement of the parotid glands, esophagitis and gastritis.
Kidney complications
About 70% of people with anorexia may have transient changes in kidney function, including: decreased ability of the kidney to concentrate urine, changes in ion concentrations, an increase in plasma urea.
The most severe damage occurs in people who abuse laxatives and diuretics. A rarer change is peripheral edema, which is usually transient and mild. It tends to worsen in the presence of vomiting, laxatives and diuretics and occurs together with a decrease in the concentration of proteins in the blood. Another kidney complication, albeit very rare, is water intoxication. The latter is due to the intake of large quantities of water and is a very serious condition that can cause epileptic seizures and death.
Hematological complications
Mild anemia (i.e. deficiency of red blood cells), a moderate decrease in platelets (thrombocytopenia) and white blood cells (leukopenia) are very common. These alterations are reversible and tend to normalize with weight gain and the restoration of a normal diet.
Osteoarticular complications
The most common complication in the bone is osteoporosis, which is a rarefaction of the bone tissue. This condition also tends to return to normal after weight gain.
In cases of early onset of the disease, ie before the menarche, there may be a slowdown or arrest of bone growth for which the height of the girls can be significantly lower than the average.
Dermatological complications
The most frequent dermatological complications are: dry and dehydrated skin, increased hair (lanugo), presence of a yellowish color in the extremities (hypercarotenemia). Medication use and vomiting can cause purpura and skin rashes (rarely).
Evolution
Anorexia Nervosa is a disease that can have a very long course, with periods characterized by improvements followed by subsequent exacerbations and relapses. Apart from a few exceptions, in which there is a short duration of illness, anorexia has a chronic course. In the long term (after more than five years) more than half of patients can be considered cured, although in many of them some level of psychological distress remains and a tendency to have worries and disturbed behaviors about food and the body .
About 20% of cases tend to become chronic, while partial syndromes remain in 30% of cases. In many cases, Anorexia Nervosa can evolve from the restrictive form to the bulimic-purgative one or towards normal-weight bulimia.
Mortality data for this disorder range from 0% to 21% with an average of 5%. Mortality is due to complications related to malnutrition, electrolyte imbalances and suicide.
