Anorexia Nervosa Notes

Anorexia Nervosa

Refusal to Maintain Weight: Individual refuses to maintain a weight that is at least 85% of the expected weight, considering their age and height.
Intense Fear of Gaining Weight: Overwhelming fear of gaining weight or becoming fat, even though they are underweight.
Disturbance in Body Image: Distorted perception of their own body weight, shape, or size, or denial of the seriousness of their low body weight.
BMI Cutoff: A Body Mass Index (BMI) of less than 17.5 is often used as a cutoff point for diagnosing anorexia.
Amenorrhea: The absence of menstruation, previously a key criterion in DSM-IV, is now considered less useful or relevant in diagnosing anorexia.

Prevalence: Lifetime prevalence is around 0.5% in females.
Gender Ratio: Anorexia is approximately 10 times more common in females than in males.
Course: The onset of anorexia typically occurs in mid- to late adolescence, and the course and outcome of the illness can vary significantly.

Anorexia Nervosa is often complicated by other traits and psychopathology that complicate the picture.
Comorbid Conditions: Depression and anxiety symptoms.
Personality Traits: Obsessional features, perfectionism, low self-esteem.
Social Impact: Social withdrawal.
Physical Complications
Lack of Insight: Limited awareness of the severity of their condition and resistance to accepting the need for treatment.

Crude Mortality Rates: Range from 0% to 20%.
Sophisticated Analyses: Estimate rates of 0.56% per year (Sullivan, 1995).
Comparison:
- Mortality for females age 15-24 = 0.0045% per year.
- Mortality for female psychiatric inpatients = 0.021% per year.
- Suicide rate in general population = 0.00002% per year.
Predictors of Mortality:
- Severity of alcohol use and substance use were correlated with mortality.
- A regression model incorporating Duration of Illness, Affective Disorder During Hospitalization, Suicidality, and Severity of Alcohol Abuse was significant in predicting mortality.

Early Application: Beck’s cognitive therapy principles were applied to anorexia nervosa in the early 1980s (Garner & Bemis, 1982).
Overvalued Ideas: Vitousek (1997) highlighted overvalued ideas about the personal implications of body shape and weight, stemming from personality traits like perfectionism.
Sense of Control:
- Slade (1982) emphasized the need for control as a central aspect of anorexia nervosa.
- Success in dieting reinforces this sense of control.
- The complex nature of control in anorexia is further explored in Surgenor (2002, 2003).

Need for Self-Control: In the context of low self-esteem, perfectionism, and a sense of ineffectiveness.
Control Over Eating: Focused on as an experience of success and control.
Dietary Restriction: Provides immediate evidence of self-control.
Control Over Body Shape/Weight: Especially salient to ascetics.
Effects on Environment: Controlling eating has a strong effect on those in the environment, which may already be clouded with dysfunctional relationships.
Mechanism of Arresting/Reversing Pubertal Changes
Societal Values: Western society values dieting to control shape and weight (Fairburn, Shafran & Cooper, 1999).

Dietary restriction enhances the sense of being in control
- Amount eaten, types of foods, times of eating
Success at dietary restriction is a potent reinforcer
Control over eating as expression of control and worth
Aspects of starvation encourage further dietary restriction
- Hunger perceived as threat to control over eating
- Impaired concentration may heighten sense of chaos/uncontrollability
Extreme concerns about shape and weight encourage dietary restriction
- Especially prominent in Western society (Fairburn, Shafran & Cooper, 1999)

If you aren't thin you aren't attractive.
Being thin is more important than being healthy.
You must buy clothes, cut your hair, take laxatives, starve yourself, do anything to make yourself look thinner.
Thou shall not eat without feeling guilty.
Thou shall not eat fattening food without punishing oneself afterwards.
Thou shall count calories and restrict intake accordingly.
What the scale says is the most important thing.
Losing weight is good/gaining weight is bad.
You can never be too thin.
Being thin and not eating are signs of true will power and success.
(http://www.proanorexia.ca/thincommandments.html)

Meta-analysis of 119 patient cohorts (Steinhausen, 2002)
- Total of 5590 patients
- Variety of different treatment methods. Differences between treatments not assessed
- Mean dropout rate of 12.3% across all studies (Steinhausen, 2002)

Note that there was considerable heterogeneity among the different studies used in the Steinhausen (2002) meta-analysis
Factors unrelated to outcome / with inconsistent findings
- Weight loss at presentation
- Hyperactivity
- Dieting
- Obsessive Compulsive Disorder
- Socioeconomic statu
Predictors of Good Outcome
- Short duration of symptoms
- Good parent-child relationship
- Histrionic Personality features
Predictors of Poor Outcome
- Vomiting
- Bulimia
- Purgatory behaviour
- Premorbid developmental abnormalities
- Eating disorders in childhood
- Chronicity
- Obsessive Compulsive Personality Disorder