Saturday, 23 July 2011

Anorexia Nervosa

Published in "Panorama"

A ‘Weighty’ Issue

14 year old Mita is obsessed with her appearance. Grossly underweight for her age, she is nevertheless preoccupied with losing more weight! Jemima at 17, spends at least 20 hours of her waking time, a week, before the idiot box. She relentlessly diets to make her body a copy of the ‘icons of success’ that she watches on TV. Seema stubbornly denies getting into bouts of anger. She claims it’s only stress and fatigue that bring on these episodes!

Mita, Jemima and Seema, may all be victims of Anorexia Nervosa, says Dr.Sanjay Khanna, Psychiatist, Zulekha Hospital, Sharjah.

At least 4% of young adolescents today are suffering from Anorexia, the relentless pursuit of thinness, and 90 – 95% of them are females, says Dr.Khanna. “The disorder generally starts around the age of 13 years and peaks at 17 – 18 years, though it is not uncommon to have even 4 year olds suffering the disorder.”

Anorexia is characterized by the fact that the youngsters refuse to maintain normal body weight appropriate for their age and height. The victims are usually underweight, weighing 85% or less than what they should be. Yet they are obsessed with their image and try to lose more and more weight and are in constant, intense fear of adding on weight and becoming fat!

Dr.Khanna explains that Anorexics are of two kinds: The Restrictive types and the Binge Eating or Purging types. Youngster who refrain from eating any kind of food fall under the Restrictive category. They exhibit typically odd food behaviours like stuffing their pockets with large quantities of candy, et al, but will not eat them. They show great interest in cooking and serving the food to others but they themselves will not eat what they’ve prepared. If they are asked to eat, they prefer eating alone! Most of these people come to0 medical attention when they’ve lost a lot of weight, says Dr.Khanna.

The Binge eating kinds try to restrict eating , but often they take large quantities of certain foods, following which they suffer from guilt. To assuage the guilty feeling, they try to bring out whatever they’ve eaten, by vomiting, doing heavy exercise or by using laxatives and enema.

What causes Anorexia Nervosa? Biological, psychological, family, social and media factors contribute to the disorder in varying degrees, reveals Dr.Khanna. “There are certain biochemical and hormonal factors involved. For instance, if the patient is depressed, she may have depressed thyroid functions and lower hormonal levels and these may contribute to anorexia. Genetic factors predispose some people to anxiety, obsessive compulsive behaviour and perfectionism, which manifest as an eating disorder.”

According to certain studiesw, it is believed that youngsters with a mother or sister who has had anorexia, are 12 times more likely than others with no family history of the disorder, to develop it.

Says Dr.Khanna, “People with anorexia have a low self esteem and often lack a sense of identity and they tend to be perfectionists. They have unrealistic expectations of themselves and others and even though they might accomplish various things, they feel inadequate and worthless.”

Sometimes, it is troubled relations with parents, generation gap and consequent conflicts, that can contribute to anorexia. Youngsters with the disorder often complain of feeling smothered in overprotective families, abandoned, misunderstood and lonely. These patients often lack a sense of maturity and want to take control of their parents, especially the mother and because they have no active method of controlling their parents, they resort to anorexic eating behaviour, feeling a sense of victory over them, reveals Dr.Khanna.

Societal and media factors are other important contributory forces, emphasizes Dr.Khanna. According to certain US researches, an average child in the US watches more than 21 hours of TV every week, sees many movies a year and reads a lot of fashion magazines. Success, beauty and happiness are synonymised with looking thin and attired stylishly in all these media, luring youngsters to emulate these characters.

How does one identify a youngster with anorexia? The early stages of an eating disorder can be difficult to define and identify, agrees Dr.Khanna. What is the point at which normal dieting can become a health and emotional problems? When does weight loss cross over to becoming a cause for pathological concern? While these may be tough questions to answer, it is important to detect anorexia as early as possible to take remedial measures, cautions Dr.Khanna.

Enumerating certain signs and symptoms to look out for, Dr.Khanna emphasizes the role of parents, particularly, mothers, in being alert to certain behavioral patterns in their children:

The youngster skips meals, takes very little food, pecks at it and gives excuses for not eating with others.

Chooses only certain items of food, particularly low fat foods.

Looks dangerously thin and is always checking body image in front of a mirror.

There are rough marks at the knuckled of the fingers, resulting from using them to induce vomiting.
The individual has a waxy smile which is a typical feature of anorexics.

The person has no inclination for social activities or interactions.

Is irrational and denies anything is wrong with her, argues, sulks and withdraws into a shell, refusing help.

Has trouble concentrating, seeks perfection in self and others.

Has trouble expressing feelings, is moody, irritable, touchy and suffers from bouts of depression.

What could be the complications from untreated anorexia? Dr.Khanna cautions that if not stopped, starving, stuffing and purging can lead to irreversible physical damage and even death. Untreated anorexia could lead to a host of problems, according to Dr.Khanna:

Energy gives warmth to the body. In the absence of eating food, energy levels are low and the body feels cold to touch. In an effort to keep the body warm, explains Dr.Khanna, some hair grows all over the body, even on the face and stomach.

Reproductory functions can shut down and the adolescent girl may experience irregular periods or even their stoppage.

If excessive vomiting and laxatives are used, they may sometimes lead to cardiac arrest also, cautions Dr.Khanna. Researches have shown that just due to eating disorders, 1000 girls die in the USA every year. There may be cardiac problems, loss of cardiac muscles, ECG changes, erythmias and slow heart rate, says Dr.Khanna.

There may be delayed gastric emptying, bloating abdomen, abdominal pain and constipation.

Blood loss and anaemia may result.

On account of the weight loss, patient may have loss of fat or muscle mass, thyroid hormone structure may be disturbed and the person may become intolerant of cold because they no longer maintain normal body temperature.

Due to vomiting and purging, there may be electrolyte imbalance, loss of vital minerals like calcium, potassium and magnesium. The consequent metabolic changes may bring about inflammation of different glands and because the patient is constantly vomiting, the hydrochloric acid in the stomach will come into the mouth, causing erosion in the mouth area and of the dental enamel, especially of the front teeth since acid is in contact with these areas, says Dr.Khanna.

In addition to all these problems, there may be damage to the liver and kidneys, stunted growth due to undernourishment, weakened immune system, fainting spells, seizures, sleep disruptions, low blood sugar, tremors, restlessness, severe depression leading to suicidal tendencies and disrupted family life, explains Dr.Khanna.

What does treatment and management of anorexia involve? “The first thing”, explains Dr.Khanna, “is to analyse the patient, get a complete neurological examination done. A complete physical examination is also in order with investigations for the electrolyte balance, blood, urine, ECG, so as to know the level of complication that has set in. In most instances, it is beneficial to hospitalize these people because they never realize they have a problem and even if they do, they are ashamed and afraid to admit it.”

One of the most important aspects of treatment is psychotherapy and counseling sessions, emphasizes Dr.Khanna. “Family education therapy is important and the patient should be involved in support groups. It is important to remember that eating disorders are treatable though the recovery is a difficult process, time consuming, involving months and even years sometimes. Since there are a multitude of factors contributing to the disorder, each person’s situation is different and hence treatment also needs to be individualized.”

Parents for their part, must partake of meals with their child, not compare her/him with peers, siblings or other youngsters; try to praise them for what they do, not for how she/he looks; discourage obsessive behaviour and help her/him look at her/his positive qualities.

Once treatment is given, what are the chances of a relapse? “Yes, definitely there are chances of relapse,” agrees Dr.Khanna, “because of the mental condition involved in the disorder. So good psychiatric follow up is essential.”


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