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Anorexia nervosa

The exact causes of anorexia nervosa are unclear, although most experts believe it is likely to be the result of a combination of factors.

The exact causes of anorexia nervosa are unclear, although most specialists believe it is likely to be the result of a combination of factors

Psychological factors

Many people who develop anorexia share certain personality and behavioural traits that may make them more likely to develop the condition. These include:

  • a tendency towards depression and anxiety
  • finding it hard to handle stress
  • excessive worrying and feeling scared or doubtful about the future
  • perfectionism – setting strict, demanding goals or standards
  • being very emotionally restrained
  • having feelings of obsession and compulsion (but not necessarily obsessive compulsive disorder) – unwanted thoughts, images or urges that compel them to perform certain acts

It has also been suggested that some people with anorexia have an overwhelming fear (phobia) of being fat.

Environmental factors

Puberty seems to be an important environmental factor contributing to anorexia. It may be the combination of hormonal changes and feelings of stress, anxiety and low self-esteem during puberty that triggers anorexia.

Western culture and society may also play a part. Girls – and, to a lesser extent, boys – are exposed to a wide range of media messages that constantly reinforce the idea that being thin is beautiful.

Magazines and newspapers also focus on celebrities' minor physical imperfections, such as gaining a few pounds or having cellulite.

Other environmental factors that may contribute towards anorexia include:

  • pressures and stress at school, such as exams or bullying, particularly teasing about body weight or shape
  • occupations or hobbies where being thin is seen as the ideal, such as dancing or athletics
  • a stressful life event, such as losing a job, the breakdown of a relationship or bereavement 
  • difficult family relationships
  • physical or sexual abuse 

Anorexia often starts off as a form of dieting that gradually gets out of control.

Biological and genetic factors

It has been suggested that changes in brain function or hormone levels may also have a role in anorexia, although it is not clear if these lead to anorexia or if they develop later as a result of malnutrition.

These changes may affect the part of the brain that controls appetite, or they may lead to feelings of anxiety and guilt when eating that improve when meals are missed or after excessive exercise.

The risk of someone developing anorexia is also thought to be greater in people with a family history of eating disorders, depression or substance misuse, which suggests genes could play a role.

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Anorexia nervosa

The treatment for anorexia nervosa usually involves a combination of psychological therapy and supervised weight gain.

The treatment for anorexia nervosa usually involves a combination of psychological therapy and supervised weight gain.

It is important to start treatment as early as possible, particularly if someone has already lost a lot of weight, to reduce the risk of serious complications of anorexia.

The treatment plan

GPs will normally be closely involved in ongoing treatment, although other healthcare professionals are usually involved, including:

  • specialist counsellors
  • psychiatrists
  • psychologists
  • specialist nurses
  • dietitians 
  • paediatricians – in cases affecting children and teenagers 

Before treatment starts, members of this multidisciplinary care team will carry out a detailed physical, psychological and social needs assessment and develop a care plan.

Most people are treated as an outpatient, which means they visit hospitals, specialist centres or individual members of their care team for appointments, but return home in between.

In more severe cases, people may need to stay in hospital or a specialist centre for longer periods during the day (day patient) or may need to be admitted as an inpatient.

Psychological treatment

A number of different psychological treatments can be used to treat anorexia. Depending on the severity of the condition, treatment will be for at least 6 to 12 months or more.

Cognitive analytic therapy (CAT)

CAT is based on the theory that mental health conditions such as anorexia are caused by unhealthy patterns of behaviour and thinking developed in the past, usually during childhood.

CAT involves a three-stage process:

  • reformulation  looking for past events that may explain why the unhealthy patterns developed
  • recognition  helping people see how these patterns are contributing towards the anorexia
  • revision  identifying changes that can break these unhealthy patterns

Cognitive behavioural therapy (CBT)

CBT is based on the theory that how we think about a situation affects how we act and that, in turn, our actions can affect how we think and feel.

In anorexia, the therapist will attempt to show how anorexia is often associated with unhealthy and unrealistic thoughts and beliefs regarding food and diet. For example, thinking that:

  • "putting on weight is the single worst thing that can happen in my life"
  • "everyone I know secretly thinks I am fat"
  • "if I finish the whole meal then people I am eating with will think I am greedy and worthless"

The therapist will encourage the adoption of healthier, more realistic ways of thinking that should lead to more positive behaviour.

Read more about cognitive behavioural therapy.

Interpersonal therapy (IPT)

IPT is based on the theory that relationships with other people and the outside world in general have a powerful effect on mental health.

Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt caused by problems with interacting with people.

During IPT, the therapist will explore negative issues associated with your interpersonal relationships and how these issues can be resolved.

Focal psychodynamic therapy (FPT)

FPT is based on the theory that mental health conditions may be associated with unresolved conflicts that occurred in the past, usually in childhood.

The therapy encourages people with anorexia to think about how early childhood experiences may have affected them. The aim is to find more successful ways of coping with stressful situations and negative thoughts and emotions.

Family interventions

Anorexia does not just impact on one individual. It can have a big impact on the whole family. Family interventions are an important part of treatment for young people with anorexia.

Family interventions should focus on the eating disorder. They involve the family discussing how anorexia has affected them. They also help the family understand the condition and how they can help.

Gaining weight safely

The care plan will include advice about how to increase the amount eaten so weight is gained safely.

Physical health – as well as weight – is monitored closely. The height of children and young people will also be regularly checked to make sure they are developing as expected.

Only small amounts of food will be expected to be eaten at first, gradually increasing as the body becomes used to dealing with normal amounts.

The eventual aim is to have a regular eating pattern, with three meals a day, possibly with vitamin and mineral supplements.

An outpatient target is an average gain of 0.5kg a week. In a specialist unit, the aim will usually be to gain an average of around 0.5-1.0kg a week.

See treating malnutrition for more information about what gaining weight at home or in hospital may involve.

Compulsory treatment

Occasionally, someone with anorexia may refuse treatment even though they are severely ill and their life is at risk.

As a last resort in these cases, doctors may decide to admit the person to hospital for compulsory treatment under the Mental Health Act. This is sometimes known as "sectioning" or being "sectioned".

Treating additional problems

In addition to the main treatments mentioned above, other health problems caused by your anorexia will also need to be treated.

If you make yourself vomit regularly, you will be given dental hygiene advice to help prevent stomach acid damaging the enamel on your teeth.

For example, you may be advised to not brush your teeth soon after vomiting to avoid further abrasion to tooth enamel and to rinse out your mouth with water instead.

You may also be told to avoid acidic foods and mouth washes. You will also be advised to visit a dentist regularly so they can check for any problems.

If you have been taking laxatives or diuretics in an attempt to lose weight, you will be advised to reduce them gradually so your body can adjust. This is because stopping them suddenly can cause problems such as nausea and constipation.

Medication

Medication alone is not usually effective in treating anorexia. It is usually only used in combination with the measures mentioned above to treat associated psychological problems, such as obsessive compulsive disorder (OCD) or depression.

Two of the main types of medication used in people with anorexia are:

  • selective serotonin reuptake inhibitors (SSRIs)  a type of antidepressant medication that can help people with co-existing psychological problems such as depression and anxiety
  • olanzapine – a medication that can help reduce feelings of anxiety related to issues such as weight and diet in people who have not responded to other treatments

SSRIs tend to be avoided until you have started to gain weight as the risk of more serious side effects is increased in people who are severely underweight. They are only used cautiously in young people under 18.

Read more about the side effects of SSRIs.

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Anorexia nervosa

Katie Metcalfe, 21, is starting a creative writing degree at Cumbria University, but seven years ago her life was very different.

Katie Metcalfe, 21, is starting a creative writing degree at Cumbria University, but seven years ago her life was very different.

"My battle with anorexia started when I was 14. My situation at the time was unusual: I was at a Rudolf Steiner school in Botton Village, near Whitby, in a class with three other boys. The pressure of being the only girl with hormone-raging teenagers was enormous. I had no self-confidence, and my body became a focus of paranoia.

"Stress in my life multiplied when my parents told me there was trouble in their marriage. In addition, we were about to move house.

"Nothing in my life seemed to be right. I started to think that perhaps if I lost some weight and improved my fitness, things would change for the better. I assumed that thin people had fantastic lives and I could too.

"I made a New Year's resolution to go on a diet, so I began to restrict my eating. I cut out fats, carbs and dairy, and lived on rice cakes, apples and lettuce.

"As I began to lose weight I started to feel that life was worth living. At last I seemed to be achieving something. A voice began to whisper in my ear and as I lost more weight, it became louder. Eventually, it was all I could hear. Nothing mattered more than satisfying the voice's need for weight loss and, ultimately, perfection.

"My weight dropped from 8.5st to under 5st. My hair fell out, my skin cracked and bled, my bones ached and my periods stopped. I was also cycling between 13km (8 miles) and 24km (15 miles) a day to satisfy anorexia's need for exercise. But I still didn't believe I was thin enough. When I looked in the mirror, a mound of blubber stared back.

"My mum took me to the GP when my periods stopped, but they sent me home with a diet sheet, which said I must try to eat more.

"Eventually, I collapsed and ended up in hospital after having a minor heart attack while riding my bike. I was kept on a heart monitor for two days. I was sent home with another diet plan and the simple instruction: 'eat'.

"Eventually, my GP realised I needed help. I was admitted to a psychiatric ward in a hospital in Middlesbrough, where I stayed for the next nine months.

"I was put on bed rest for five months. My treatment involved cognitive therapy sessions once a week, and I gradually started to eat small amounts of food again. My recovery was slow. What really helped to pull me through was writing and the consistent support from my family.

"I started to write about my experiences and realised that I wanted to recover so I could help others who were battling with the same problem. I gradually got better and went back home the day before my 16th birthday.

"I have had a couple of relapses, but five years on I am fully recovered, with few long-lasting effects. Although I have been diagnosed with the early stages of osteoporosis, my periods have come back, so I can have children.

"I still feel depressed at times, but writing about it helps me get over it. I eat healthily and exercise for pleasure, not punishment. My book, A Stranger in the Family (Accent Press), has been published and I'm about to start a university degree. A few years ago I would never have imagined that.

"If you're going through what I went through, you must talk about how you are feeling to your parents, friends or doctor, no matter how insignificant you believe your issue might be. It's vital to express depressive feelings because things only get worse if you bottle them up, and this can lead to major health problems.

"Aim to live every day as though it is your last and not submit to anorexia. Try to defeat anorexia before it defeats you. Always remember that help is out there."

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