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Anorexia Nervosa: What's the story?
Eating disorders are severe and often life-threatening mental and physical illnesses that involve complex relationships with food, exercise, and body image. These disorders affect approximately 9% of the population worldwide and directly result in around 10,200 deaths each year. Eating disorders are found in all people regardless of age, gender, ethnicity, or socio-economic status.
There are different types of eating disorders, such as restrictive food intake disorder, binge eating disorder, and rumination disorder. While these disorders share some similarities, each diagnosis has specific criteria distinguishing it from the other. One eating disorder I will focus on in this research paper is anorexia nervosa because of its complex nature.
Anorexia onset typically occurs in adolescence and young adulthood, but it is not confined to these life stages. Moreover, there is no one distinct cause of this eating disorder; research suggests a number of genetic, behavioral, psychological, biological, and social factors that increase the risk of developing anorexia. To elaborate, anorexia stems from a distorted body image, often resulting from emotional trauma, depression, or anxiety. Besides, some people with anorexia may view extreme dieting or weight loss as a way of regaining control in their lives. While there is no cure or definitive treatment for such eating disorders, there are various evidence-based practices proven to promote eating disorder recovery.
In this research paper, I will use a science-based approach to collect data with regard to anorexia nervosa. Therefore, as I set my objective for this study, I will investigate the telltale signs of anorexia nervosa and its symptoms. Moreover, I will examine this disorder's biological assumptions and origins, such as genetic and biochemical explanations. Likewise, I will tackle social and cognitive factors that play a role in developing this disorder. I will also explore treatments that can be done to help individuals recover from anorexia.
To better understand the nature of this disorder, I will support the theories mentioned by outlining some key studies that provide evidence for this paper.
Anorexia nervosa - often called anorexia - is a serious, complex, and clinically challenging disorder that results in significant disability and impaired quality of life. Anorexia is characterized by abnormally low body weight, distorted body image, and extreme fear of gaining weight.
People with anorexia place tremendous importance on controlling their weight or shape, using strenuous efforts that significantly interfere with their lives and deteriorate their health
For example, to prevent weight gain, people with anorexia typically restrict the amount of food they eat. They may also control calorie intake by vomiting after eating or ingesting drugs. They may also try to lose weight by exercising excessively. However, no matter how much weight is lost, the individual believes they are 'not thin enough' and continues to fear weight gain - there are various biochemical, genetic, environmental, and cognitive hypotheses and explanations for this.
It is well established that anorexia has the highest mortality rate among all psychiatric disorders; anorexia is not just about food. It is a remarkably unhealthy way to cope with some severe emotional and psychological problems.
Results and Discussion
I. Signs and symptoms:
There are a wide variety of emotional, behavioral, and physical symptoms that can indicate anorexia.
Physical symptoms vary from person to person; what is considered a low body weight is different for each person, and some individuals may not appear emaciated. Moreover, people with anorexia typically disguise their thinness, eating habits, or physical problems. Still, some physical symptoms are considerably severe and life-threatening and cannot be hidden.
These physical symptoms include severe weight loss, a thin appearance, insomnia and sleeplessness, dehydration, fatigue, light-headedness and fainting, constipation, dry, yellowish skin, bluish discoloration of the fingers, arrhythmia (i.e., irregular heart rhythms), low blood pressure, amenorrhea (i.e., absence of menstruation), thinning and breaking hair, and eroded teeth and calluses on the knuckles (from induced vomiting).
Individuals with anorexia may exhibit specific behavioral changes before physical symptoms are noticeable.
These behavioral symptoms may include severely restricting food intake through dieting, fasting, or skipping meals, lying about how much food they've eaten, excessive exercising (which may take the form of exercising for too long, too often, or too intensively), binging and self-induced vomiting to get rid of ingested food, eating only particular low-calorie foods that they deem "safe," preoccupation with food, and social withdrawal.
Emotional symptoms may increase and become more severe as the disorder progresses. They include depression, anxiety, low self-esteem, poor body image, irritability, agitation or other mood changes, and a flat mood (i.e., lack of emotion).
II. Biological origins:
Many scientists agree that anorexia is a biological rather than a social disorder. The biological approach has two key arguments for the origins of anorexia nervosa. First, there is a genetic argument that holds that the disorder is inherited and runs in families. The second argument is that there are neurochemical reasons for anorexia - specifically, altered levels of serotonin and dopamine, neurotransmitters that regulate similar bodily functions.
Psychologists believe that anorexia nervosa originates from biological factors through genetic and neurochemical arguments.
i. Genetic explanations
Many psychologists are trying to better understand how our genes can cause such dysfunctional behavior. The answer to this question remains unclear, but psychologists believe that there are different factors that can play a role in developing this disorder, such as low serotonin levels, which could have a genetic basis. However, psychologists concluded that no single gene could trigger anorexia, but many genes interact together, making the person more susceptible to it.
Before modern technology, psychologists used twin studies to understand anorexia nervosa. Their research depended on monozygotic (identical) and dizygotic (fraternal) twins. Results were measured by knowing the concordance rate for identical twins – this is connected to the percent for which these twins manifest aspects towards a specific behavior (in this case, anorexia).
One study that provides an insight into twin studies and anorexia is the study of Holland et al. (1988). The researchers allocated monozygotic and dizygotic female twins. They interviewed all twins and surveyed them to diagnose their eating behavior. Results were measured using concordance rate, which showed that the rate was significantly higher in identical twins (56%) than fraternal twins (5%). This may suggest that anorexia nervosa could have genetic origins.
Nowadays, with modern technology, psychologists and researchers are using the GWAS method (Genome-wide association studies) to compare the DNA of two groups of participants; the first group would be for people who have anorexia and the second group for people who don’t have the disorder. After which, they will take a sample of the participant’s DNA to check for genetic variants to be read. If the same genetic variant is manifested frequently in people with the disorder (in this case, anorexia nervosa), then we can say that this gene variant is associated with the disorder.
A study carried out by Scott-Van Zeeland et al., 2014 used modern technology GWAS to understand anorexia nervosa showed that anorexia is linked to a gene variant responsible for encoding an enzyme that regulates cholesterol metabolism. This insinuates that interference of cholesterol processing could cause low moods and eating disorders associated with anorexia nervosa. This explains why people with anorexia nervosa have high cholesterol levels despite being underweight.
In conclusion, the genetic argument can explain why some people are more vulnerable to anorexia than others.
ii. Biochemical explanations
Another biological factor for anorexia nervosa is the neurochemical explanation, especially those associated with certain types of neurotransmitters such as serotonin and dopamine. When these neurotransmitters go out of their optimal ranges, they cause mental disorders. Although anorexia nervosa is the result of an interaction between biological and environmental factors, the biochemical factors are central to understanding why some people develop this disorder, recover from it or perhaps have a relapse and stay ill.
Psychologists have recognized that anorexic people typically have high levels of serotonin. Serotonin is a neurotransmitter responsible for stabilizing the mood of a person. It also helps with good sleep patterns and is connected with feeling good. Serotonin affects our behavior and mood.
With that said, people with anorexia nervosa have high production of serotonin levels, which suppresses the individual’s appetite and makes the anorexic person suffer from a continual state of anxiety and obsessive behavior.
When an anorexic individual produces excessive serotonin levels, their brain reacts to this stimulus by restricting food, reducing their calorie intake, and going into starvation mode. This means that food deprivation is a neurochemical reaction and a mechanism of ‘self-help’ for the anorexic person to reduce the excessive serotonin levels as it helps the person with anorexia cope with their state of anxiety and decrease it.
Furthermore, psychologists have noticed that dopamine also plays a role in anorexia nervosa. Dopamine is a chemical messenger in the nervous system responsible for feelings connected with pleasure, satisfaction, and motivation. It is also involved in weight and eating behaviors.
Dopamine is what makes a person get going and achieve things and plays a vital role in the reward system.
However, altered dopamine levels can also play a role in developing anorexia nervosa. This has been primarily observed in women with anorexia who had imbalances in the levels of dopamine released in their brains. This chemical abnormality has been associated with an overproduction of dopamine, which leads to anxiety, hyperactivity, and restricting activities that give you pleasure, like eating food.
Yet, what remains unclear to cognitive psychologists is if activation of dopamine results from the disorder itself or if it results from a nutritional shortage.
In conclusion, chemical abnormalities associated with serotonin and dopamine can play a role in developing anorexia nervosa.
III. Environmental origins (social factors):
Anorexia nervosa is the result of an interplay between biological, cognitive, and sociocultural factors. Often when psychologists zoom in on the causes of anorexia, they focus on the social factors and neglect cultural factors.
Psychologists concerned with the sociocultural approach acknowledge different theories for the etiology of anorexia. One of which is associated with the ‘Social Cognitive Theory’ developed by Albert Bandura, who believed that behavior is learned from the environment through observation. The learner watches their role model and sees that this person received positive feedback. The learner is then encouraged to model the same behavior in order to get direct reinforcement. With that said, people don’t need to experience everything in person; a lot of the time, we learn simply by watching someone do the act.
The Social Cognitive Theory is believed to be closely tied with anorexia as it encourages the individual, especially women, to be of a certain size, weight, and looks. Correspondingly, women who develop anorexia set up expectations of what is beautiful and what the ideal body shape should look like. These ideas are instilled into anorexic people’s minds because of the images derived from media and social networks that idealize tall and thin women. Hence, we can conclude that exposure to images of thin women and western media aids in the development of this disorder.
One study that supports the idea of the connection between the social cognitive theory and anorexia is the study of Groesz, Levine, and Murnen (2002). The researchers allocated women in this study who were presented with different images: thin models, average-sized women, big-sized women, or non-living objects. This was done through 25 studies in a meta-analysis. The findings of this study showed a correlation between anorexia and the theory of social cognitive theory. Women who were not happy with their body shapes were affected the most when they saw images of thin women. These women felt an increased level of dissatisfaction compared to other women who were not dissatisfied before the experiment.
i. Why women have a higher risk for anorexia nervosa
Eating disorders, among which is anorexia, are much more common among women than men. A study by the National Institute of Mental Health shows that the lifetime prevalence of anorexia nervosa was three times higher among females (0.9%) than males (0.3%). However, it is clear that, although virtually all women are exposed to the same sociocultural influences, only a tiny proportion develop clinical eating disorders (Hudson et al., 2007).
Popular conception has long held that women are more concerned with body image than men, and recent studies have shown that women are more likely to have body dissatisfaction than men. Hence, this vulnerability to body dissatisfaction may be a factor underlying the higher rates of anorexia in women (Preston and Ehrsson, 2016). To clarify, social pressures are believed to play a key role in negative perceptions of body appearance. Since women tend to be more susceptible to such societal pressures, this may partly explain why eating disorders are more common in women than men.
Previous studies have shown that patients with eating disorders, particularly anorexia, tend to overestimate their body size - that is, they perceive themselves to be bigger in size than they actually are. However, little is known about the neural mechanism underlying negative feelings towards the body and how they relate to body perception and eating disorder pathology. Therefore, Dr. Preston and her team aimed to pinpoint the brain activity that might underlie body perceptions for their study.
Regarding the procedure, the team enrolled 32 healthy individuals - 16 men and 16 women. None of the participants had a history of eating disorders, and their height and weight were measured upon enrollment. Each participant was required to wear a headset that offered them a first-person video of either a "slim" or "obese" body; in other words, it looked like the body belonged to them. To enhance this illusion, the researchers poked the participants' torso with a stick in synchronization with the video. During the experiment, each participant had their brain activity monitored through an MRI.
When participants looked at their "obese" bodies, the team identified a direct link between activity in the area of the brain related to body perception, the parietal lobe, and activity in the anterior cingulate cortex, the brain region linked to the processing of subjective emotions, such as fear and anger. The researchers also found that such brain activity was more prominent in women than men, suggesting that having an "obese" body is likely to lead to higher body dissatisfaction in women. The researchers state their findings may help explain why women are more affected by eating disorders than men.
IV. Psychological origins (cognitive approach):
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anorexia nervosa is characterized by a distorted body image and excessive dieting leading to weight loss, with a pathological fear of being overweight.
Many psychologists argue that eating disorders are not a result of biological factors, but instead are the result of perception - in particular, a false perception of how one's body actually looks.
The cognitive approach revolves around two main theories. First, there is a theory that faulty thinking based on schema is the reason for the disorder. Secondly, there is the theory of attentional bias.
i. The role of schema
One way we process information is through our schema. A schema is a mental framework based on past experience that helps organize and interpret information and understand the world around us. Individuals with anorexia nervosa tend to have faulty patterns of thinking due to their schema. In other words, their schema distorts their perception of body image. This leads to the Body-image distortion hypothesis.
Bruch (1962) claimed that many patients with eating disorders suffer from the cognitive delusion that they are overweight. Bruch wrote that anorexics show "an absence of concern about emaciation, even when advanced, and the vigor and stubbornness with which the often gruesome appearance is defended as normal and not too thin (p 189)."
In a study of body-image distortion, McKenzie et al. (1993) interviewed women with anorexia and a control group about their body weight and physical ideals. When asked to compare themselves with controls of similar weight, anorexia women were inclined to overestimate their own weight. Not just that, but the researchers also found that when asked about their ideal body weight, women with anorexia chose a much lighter weight than women in the control group.
In the second part of the experiment, the women were given a chocolate bar and a soda. After consuming them, they were asked to re-evaluate their body weight. The women with anorexia felt that they had gained a significant amount of weight, while women in the control group reported that their weight had remained unchanged.
This study proves the faulty thinking that individuals with anorexia suffer from; they often use dichotomous thinking, linking the food they eat to an increase in weight and genuinely believing they are overweight even when they are completely emaciated.
Some researchers suggest that these schemas may develop due t cultural norming or even personal feedback - that is, when such individuals receive a comment about their weight, they will begin to associate it with their self-worth, and the goal becomes to be as thin as possible.
i. Attentional bias
Paying attention to some stimuli and ignoring others is known as attentional bias. When occupied with an existing train of thought, our attentional bias may limit our consideration of alternative possibilities. Psychologists are trying to find a link between anorexia nervous and attentional bias. They suggest that due to factors like perfectionism, obsession with order, and attentional detail, individuals with anorexia nervosa tend to have an attentional bias towards their weight; they focus excessively on losing weight without thinking about the overall effect of their habits.
Southgate, Tchanturia, and Treasure (2008) compared women with anorexia to controls using a Matching Familiar Figures Test (MFFT). This is a modified Stroop test, a type of test in which participants are asked to identify the color in which words are written on a screen. The attentional bias is determined by the amount of time it takes the individuals to identify the colors and how much the meaning of the words interferes with their responses. In the MFFT, the women were shown one image and then eight images, and they were asked to indicate which image was the most similar to the first. The researchers found that women with anorexia had considerably greater accuracy rates than the control groups, indicating that they pay close attention to detail.
Despite extensive research, there are still many questions that the cognitive approach leaves unanswered. Faulty schemas, for example, may be a result of the disorder rather than its cause. Furthermore, many people are unhappy with their body weight and shape but do not develop eating disorders like anorexia; cognitive explanations do not account for this individual difference. Nonetheless, cognitive behavioral therapy has been shown to be effective in treating anorexia, suggesting that faulty thinking and body image schema may play a vital role in the disorder.
Unfortunately, there is not a lot of support for psychological approaches to the treatment of anorexia nervosa. However, it is essential to mention that, to psychiatric experts, prevention of the disorder is just as important as treating it. For example, Dr. Patrick Sulivan, the co-founder and chair of the Coordinating Committee of the PGC, conducted a GWAS study that begins the process of preventing anorexia nervosa in the future. With continued work on the study, neuroscientist collaborators could possibly home in on cell types and identify the network or networks that are influenced or dysfunctional in anorexia nervosa. Then, with clear routes to target, they could leverage modern combination high-throughput drug screening to identify or develop therapeutics that directly target the illness's biology. That is especially important for anorexia because there are no medications that are effective in treating the illness.
The treatment of individuals with anorexia nervosa is divided into two parts. Psychologists' initial objective is to guarantee safe weight gain to avoid medical issues. The second objective is to use psychotherapy to uncover detrimental tendencies and provide coping strategies to prevent future relapse.
Psychotherapy is preferred over biological therapies and pharmacological treatment for eating disorders like anorexia because it is more personal, effective, and can be adjusted to each case. Unlike drug therapy, it focuses on treatment through addressing the patient's life problems and understanding their situation.
i. Cognitive behavioral therapy
Cognitive-behavioral therapy (CBT) combines two therapies: cognitive therapy and behavioral therapy. According to Aaron Beck, one of the pioneers in cognitive therapy, "psychological problems are associated with maladaptive thinking patterns and unhealthy behaviors that can be modified through a working relationship between the client and a therapist."
In contrast to more traditional forms of psychotherapy, CBT focuses on the individual's current issues and symptoms rather than their past history. The therapist seeks to identify the cognitive and behavioral factors playing a role in the disorder. These goals are achieved through the three primary phases of CBT treatment; behavioral, cognitive, and maintenance & relapse prevention phase. Each stage has its own objective, which contributes to the overall treatment, such as establishing regular eating patterns and helping the patient recognize and adjust unhealthy habits.
Pike et al. (2003) conducted a study with the help of 33 patients with anorexia nervosa (after they were released from the hospital, where they underwent medical treatment) to test the effectiveness of CBT. The patients were randomly assigned to one of two types of therapy: cognitive-behavioral therapy (CBT) or nutritional counseling. They were treated for one year. Patients that received nutritional counseling relapsed earlier and at a higher rate (53%) than those in the CBT group (22%).
CBT has several drawbacks, despite the fact that treatment appears to minimize the likelihood of relapse, and patients rarely experience any side effects. CBT, for example, has been criticized for failing to address the patient's past experiences; it concentrates on symptoms rather than causes and ignores the disorder's possible biological nature. It also takes time to be effective.
i. Family systems therapy
Family systems therapy is a type of psychotherapy used to treat anorexia nervosa in adolescents. Anorexic teens can use family therapy to recognize and understand their frequently dysfunctional role in the family and how their eating practices contribute to that role.
Families of children with eating disorders, according to Minuchin et al. (1975), share the following characteristics: enmeshment (i.e., over-involvement of the parents in the lives of the children), lack of conflict resolution, overprotectiveness, and rigidity (i.e., the family avoids change).
The "Maudsley Method," a form of family therapy, has been shown to be beneficial in the treatment of teenagerswith anorexia nervosa. Parents are responsible for feeding their anorexic teenagers in order to help them gain weight and alter their eating habits. The key goal is to improve communication between parents and children to reduce anxiety and tension in the household.
With a sample of 32 female teenagers living with anorexia nervosa, Paulson-Karlsson et al. (2009) investigated the effectiveness of family therapy. Patients were evaluated before starting treatment and again 18 to 36 months later in terms of the symptoms they were experiencing, their BMI, and the level of family cohesion. 75% of the patients were in complete remission with a reduction in anorexia symptoms at the 36-month follow-up. Not only that, but they reported a more stable environment in their homes.
Despite this and other studies, there is still a scarcity of data on the efficacy of family therapy. Although many clinicians believe it is effective, the majority of the evidence comes from case studies or research with limited sample sizes. There needs to be a lot more research done to see if there is something about the therapy that makes it successful.
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