Mental Disorders - Anorexia Nervosa - Essay Example

Anorexia Nervosa Introduction: Anorexia nervosa is a psychiatric eating disorder that is characterized by a low body weight and a negative perceptionof body image. Individuals suffering from this diagnosis suffer from an excessive fear of gaining weight and try to control it by various means, such as starvation, dieting, vomiting or excessive exercise. According to Laske et al,(2000), the disorder involves sociological, neurobiological and psychological components. In her book “The Broken Mirror”, Dr. Katherine Philips of Rhode Island examines the phenomenon of BDD or Body Dysmorphic disorder, which is a psychosomatic condition in which the person becomes fixated upon a perceived flaw in their body which in turn causes disturbance in their lives. All kinds of eating disorders may be seen to originate with this condition, since patients may “not only dislike some aspect of how they look, they’re preoccupied with it. They worry too much….. focus on defects that others don’t see or consider minimal.” (Philips, 2005:3-4) As pointed out by Dr. Philips in her book, eating disorders such as anorexia nervosa arise directly as a result of such an obsessive fixation with one’s appearance, coupled with an embarrassment about the nature of one’s looks and an overall negative perception of body image. As a result, anorexia nervosa manifests itself in the form of painful obsessions with weight and the need to slim down, coupled with eating disorders. Stuart and Laraia (2001) have related the use of food to stress and the unmet emotional needs of a person. They state that "the inability to regulate eating habits and the frequent tendency to overuse or under use food interferes with biological, psychological, and sociocultural integrity" (Stuart & Laraia, 2001:526-527). This produces eating disorders in women, such as Anorexia nervosa, bulimia nervosa, and binge eating, all of which can be categorized as illnesses. Autry et al (1986) have estimated that about 1 to 4 percent of the female population in the United States suffers from anorexia nervosa. Moreover, this condition places a severe strain on the body’s resources and has one of the highest mortality rates of any psychiatric disorder, with about 10% of all people diagnosed with the condition ultimately succumbing to death as a result of the related disruption of body functions due to improper eating (Birmingham et al, 2005). Researchers to explain the disorder have put various theories forward to highlight possible causes for it. Some theories have approached the causal factors from the perspective of family, while other attribute psychological, social or other reasons to account for the disorder. This project aims to take up an examination of anorexia nervosa and the various theories that have been proposed to explain the causes of anorexia nervosa. Anorexia Nervosa: Leon (1984:189) offers a clinical description of anorexic patients as “conscientious, over achieving, obsessive-compulsive, perfectionistic and shy” and offers the view that the anorexic condition arises because the patients feel anxious and out of control and they focus upon gaining control over themselves and their environment by controlling their body weight. Neuman and Halverson (1983) found in their study that the obsession with control may even extend to self directed hostility, which features prominently in the case of an individual suffering from anorexia nervosa. According to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV), the symptoms of anorexia nervosa are (a) fear of fat (b) extreme weight loss and (c) the loss in menstruation. This condition is closely related to Bulimia nervosa, which is also a predominantly psychological condition that produces physical symptome associated with improper food consumption and assimilation in the body. A patient suffering from Bulimia nervosa tends to suffer from a very low self esteem, which results in self induced vomiting after every meal, brought about by guilt at having eaten too much, whne in reality the patient may have eaten so little and assimilated even less, so that she is extremely weak. The patient is obsessed with the thought of food at all times, how she will get it and how she will ensure that it does not add to fat. The Bulimia and/or anorexia patient’s self of self esteem is entirely conditioned by her weight and shape. Dr. Philips’ psychosocial approach that requires social and familial factors to be taken into consideration, appears to offer a comprehensive explanation of the phenomenon of perceived ugliness and being fat, which is associated with the anorexic condition.(Penzel 1997). The American Psychiatric Association (APA 1994), is of the view that the diagnostic criteria that must be taken into account when determining whether a person is suffering from anorexia nervosa is that their weight levels are maintained at a level that is less than 85% of the normal body weight for that particular height and age. This is coupled with an intense fear of getting fat and a distorted perception about one’s own body weight or shape. Another distinguishing criterion that indicates the presence of anorexia nervosa is the persistent presence of amenorrhea, that exists for at least three consecutive periods. Most patients of anorexia nervosa resort to compulsive eating, but some who are categorized as restrictor type patients steadfastly refuse to eat much. Cachelin and Maher (1998) have however questioned whether it is appropriate to include amenorrhea as a diagnostic criterion, while Policy et al (2002) question the 85% weight criterion that is used as a distinguishing criterion to pinpoint the existence of the disease. In some cases, anorexia nervosa may also approximate the conditions of bulimia and include symptoms such as overeating and then purging or vomiting to rid the body of the excess food consumed. This is referred to as bulimic anorexia nervosa and according to the American Psychiatric Association (1994) the only difference between bulimia and bulimic anorexia nervosa patients is that the anorexic patients maintain their weight at a cut off of below 85% of the ideal weight for that age and height. Outward physical symptoms that may be noticeable include a body mass index of less than 17.5 percent in adults with all the symptoms of starvation such as reduced metabolism, a reduced heart rate, hypothermia, anemia and reduced immune system function. Additionally, there may also be symptoms such as constipation, headaches, thinning hair, creaking joints and bones, deficiency of zinc, reduced electrolyte and mineral levels in the body, dry skin and brittle nails. An anorexic patient displays certain outward behavioral symptoms as well, such as food restrictions, exercising excessively. Displaying extreme sensitivity to any references to body weight and undue anger when forced to eat those foods that are considered forbidden. The patient may also be secretive about her eating or exercising behavior. Moreover, this condition is also characterized by a marked deterioration in the person’s relationships with her family, poor scholastic and academic performance and the tendency to isolate oneself and withdraw from peers and friends. An anorexic patient also tends towards depression and may suffer from low self esteem, plagued by a constant fear of gaining weight and display moodiness or sudden and erratic changes in mood. Causes of anorexia nervosa: Anorexia nervosa has been explained by employing a biological approach in some cases and a cognitive approach in others. Cognitive theories about anorexia nervosa attribute a great role to emotion and thinking in influencing the onset and prevalence of the disorder. For example, the theory of mind is one that has been advanced to explain anorexia nervosa. This refers to the ability to make infers about the mental states of other people through the ability to engage in complex social interaction. In a study examining the impact of the theory of mind in the case of people suffering from anorexia nervosa, the results showed that persons impaired with the disease were actually impaired in their social interactive ability in the same manner as autistic persons are, and the study also showed that persons diagnosed with Anorexia nervosa performed worse on control tasks.(Tchanturia et al, 2004). The cognitive basis of the causal attributes of the disease lie in the perception of the individual that he or she is fat. The cognitive perceptions of the individuals about their bodies is altered and their perceptions about their own bodies may differ from those of others who may not actually find them to be fat. A recent theory has taken this further by suggesting that normal people may in fact be biased in favor of over confidence, viewing themselves as better than what they actually are, while anorexic people have a realistic perception about themselves. Therefore this view tends to the notion that the important factor that conditions whether or not a person is predisposed to anorexia is the manner in which perceptual information is evaluated .(Jansen et al, 2006). Such states of altered perception may also be responsible for producing the concomitant mental states such as depression and obsessive compulsive disorder. In addition, the altered mental state could also lead to substance abuse and other types of personality disorders, all of which are means devised by the patient to try to cope with the loss of control that they feel over themselves and their own bodies. One of the models that best explains anorexia neurosa is the bipsychosocial model. As Leung et al (1996) point out, this model takes into account all of the factors that may be responsible for the condition – ranging from the familial, social, cognitive as well as personality factors among others. Therefore, it offers a comprehensive explanatory framework within which the complex interaction of the various elements is what ultimately leads to a predisposition to the disease. Some researchers blame the media for the obsession with being slim, which leads to anorexia nervosa. Theories based upon the influence of the media employ a behavioral approach, wherein adolescent behavior is changed or modified through their TV viewing habits. Adolescents spend at least five to six hours a day in television viewing (www.pulsus.com) and in the absence of other influences, notably from their parents or elders advising them that beauty can come in a wide range of shapes and sizes (Frank 1999), teenagers tend to accept the traditional notion of beauty as propagated through the American media - tall, slim and blonde. Teenage fashion magazines contribute to this gender bias by setting the standards for what constitutes fashion. Digital technology further contributes to this myth of perfect beauty since it is possible to outwardly present blemish free, perfect photographs of models, whereas the reality may not be as it seems. The image of the ideal body image is a too thin, mannequin like model, who does not present a realistic picture of the average body image that may be considered normal. Thus adolescents are comparing themselves against an ideal, which is false and does not really exist. Hargreaves and Tiggemann (2003:372) conducted research where adolescent girls between the ages of 13 to 15 were shown 20 commercials featuring females in thin, idealized forms and they have concluded that “one brief exposure to 20 images of the thin female ideal (of only about a10-minute duration) can result in increased body dissatisfaction, and maintain a negative effect for at least 15 minutes after the exposure.” This corroborates the views put forth by Botta(1999) who is of the view that adolescent girls are particularly vulnerable to the media promotion of the thin images, since this is the time in their lives when they are seeking outside information to form their new self identity. Therefore the perception that they are fat could lead to an obsession with becoming thin and keeping their weight down, resulting in anorexia nervosa. What happens when a teenager perceives herself as falling short of the ideal body image? She proceeds to modify her eating habits in order to change her size and shape. Most eating disorders arise in the first place because of the perception of the ideal body image is that of being thin, that is being generated through the media and messages from society. Therefore a woman may resort to eating too little to avoid becoming “fat” or become so depressed about her looks that she resorts to binge eating to avoid it altogether. This is the result of a negative body image that a person may have, as a result of a comparison with those considered “ideal” in society wherein the person falls short in some aspect and therefore perceives herself to be ugly or fat. Tiggerman and Pickering (1996:202) have concluded in their research study that a definitive association cannot be made between TV viewing and the dissatisfaction among teenage girls with their body image. They state: “although it is tempting to conclude that watching a large dose of idealized images on television leads to dissatisfaction with one’s body, a correlation cannot determine causality. An alternative scenario, for example, might be that those most dissatisfied with their bodies, or wishing to be thinner, seek out or are more interested in certain types of television.” Therefore, a definitive correlation cannot be made between anorexia nervosa and the influence of media watching, and it is not possible to draw a definitive conclusion that images portrayed in the media are the causal factor leading to dissatisfaction with one’s body and the way it looks. Biological Theories: One of the inescapable facts about this disorder is that there are more young women who suffer from it, as compared to young men. The fact that such a difference exists between the sexes has formed the basis for another theory that has sought to explain the condition, i.e, the socio cultural theory. As Garfinkel and Garner(1982) point out, the fact that one sex is predisposed to the condition indicates that socio cultural factors may play a role in determining who is prone to it. There are several factors that appear to reinforce this view. For example, media images of thin, glamorous people usually figure women rather than men as the objects of admiration and attention. Therefore females are likely to identify with those media images and change their dietary habits. Similarly, Garner and Garfinkel (1982) have also pointed out that the incidence of anorexia nervosa appears to be much higher among dancers and models and this trend is repeated in both men and women. Therefore, this provides an indication that the socio cultural factors may play a role in making certain types of people predisposed to the condition. The differences between males and females and the predisposition of females to suffer from anorexia nervosa is also the basis for the physiological theory about this disease. This condition is most prevalent among adolescent females, therefore this theory highlights the fact that there is no significant difference in males and females in terms of eating habits before puberty. Boys and girls are more or less alike in so far as their physical appearance is concerned, however with the onset of puberty, girls begin to develop more rapidly and this occurs about two years before boys start displaying the signs of puberty.(Crisp et al, 1982). Therefore, the girls may perceive themselves as bigger and bulkier than the boys and may therefore try desperately to reduce her size by dieting. This occurs despite the fact that during this growing stage, the girl is in need of greater nutrition. In this connection, some experts have suggested that hormonal changes may be the causal factor for anorexia nervosa. For example, a recent suggestion that has been made by Kaye et al (2005) is that anorexia nervosa is linked to a disturbance in the serotonin system in the body, especially if the content of the hormone is high in those areas of the brain that are equipped with a 5HT1Areceptor system, because this is the area of the brain that is linked to moods, anxiety and impulses and therefore high levels of serotonin can lead to high levels of anxiety. However, when there is starvation, the levels of serotonin are reduced, as a result of which the concomitant anxiety is also reduced. However, this theory has generated criticism because it is not possible to specifically separate the cause and effect of the hormone vis a vis starvation. For example, starvation itself could produce disorders in the levels of serotonin and thereby generate disturbances in the brain’s neurochemistry. But it cannot be definitely stated that this is a pre existing factor that may predispose a person to suffer from anorexia nervosa. Furthermore, as Kaye et al (2005b) point out in a related article, disturbances in the serotonin system may still be evident even after the body has recovered from anorexia nervosa, thereby further negating the possibility of a connection between the disorder and serotonin levels. A similar debate exists on the views of Strober (1986) who has suggested that hormonal changes occurring during puberty may play a role in eating habits. Since these hormonal changes have a side effect, i.e, they produce biochemical changes within the body, they may result in eating disorders. But Garfinkel and Garner (1982) have criticized this theory on the basis that such a connection between hormonal changes and anorexia nervosa has not been conclusively established. Moreover, they also point out that Strober’s theory advocating that the change in hypothalamic function may be responsible for hunger and the craving for food with anorexics experience, is flawed because of the lack of separation of cause and effect. For example, Hsu (1983) points out that once normal weight gain has occurred and normal eating habits are taken up, the hypothalamic function is also restored to normal levels, thereby providing an indication that this may not be a major factor that is causal in anorexia nervosa. Furthermore, Malson (1992) also points out that this theory fails to explain the gender differences in occurrence of the disorder and fails to explain why it is more prevalent among females rather than males. Such an explanation cannot be made solely on the basis of a glandular disorder. Feminist theories have made an attempt to explain the differences among males and females as far as this disease is concerned. Orbach (1979) points out that the most common approach adopted under the feminist theory is the conflict that arises between the traditional, submissive female role that has been defined for generations and the more modern role of the liberated woman. There is a greater deal of pressure on the modern woman because she is expected to cope with her responsibilities and take care of others while at the same time, she is also expected to take control of her own life and become more competitive with others. As a result, a modern woman is expected to be slim and glamorous and in full control of her own life. However, for the growing adolescent, the biological changes taking place within her body lead to a feeling of loss of control and may cause feelings of helplessness or anxiety. Seeking to gain control over her own life makes a young girl seek control over her food habits. The power to overcome her hunger and to control her eating may be a way to cope with the feelings of loss of control, however as Thompson (1993) points out this often results in a situation where the women is left feeling more helpless and dependent on others through the weakness that invades her body from the condition known as anorexia nervosa. There are several other theories that exist in literature on the causes of this condition. One of the earliest is the family pathology theory, in which the development of anorexia nervosa is explained by Strober (1986) within a broader context, as “a link in a chain of non linear, circular and self regulatory interactions among all family members.” This theory emphasizes the importance of the family structure and interaction in establishing a predisposition to the disorder. There has been support and resistance to this theory from experts. For instance, one of the objections that has been voiced is that such studies are retrospective and therefore suspect. Another objection that has been voiced is that few of the studies on anorexia nervosa are properly controlled and the condition is a heterogeneous one. (Garfinkel and Garner 1982). However, despite these drawbacks, Garfinkel and Garner (1982:175) have emphasized the importance of the family unit, seeing the members of the family as “culture bearers” who may be characterized as a “significant force” in facilitating or hindering a child’s adaptation to its culture and shaping the process by which this occurs. For instance, these authors suggest that the family culture and ethic may result in a modification of the manner in which a child adapts to the environment, which could even be a predisposing factor in the illness. Corroborating this view, other researchers have also emphasized the role of the family and the internal family dynamics which could result in the condition of anorexia nervosa being maintained.(Malson 1992) Yet another theory about anorexia nervosa is based upon the ability of the individual to adapt to change and the emotional status of the person. This theory is referred to as the “maladaptive psychosocial adjustment to the challenges of adulthood.” (Furnham and HumeWright, 1992). This theory looks at the problem from a biological perspective, just like the sociocultural and physiological theories. This theory is based upon the premise that food and emotion are linked and that meals play a very important part in a family’s life.(Bruch 1973). According to Crisp (1980) meals form an important link between the emerging sexuality of an adolescent and biological maturity and it is the emotional connection with food that is responsible for producing the disorder of anorexia nervosa. Therefore the biological perspective tends to the view that the development of the condition is an attempt to eliminate the impending signs of maturity, adulthood and emancipation. By employing the means of refusing food or engaging in abnormal practices regarding food, the adolescent attempts to stay safely within the scope of childhood and not venture out into adult territory, because when they are suffering, then they are kept under the care of their parents or guardians and can stay safely within the purview of childhood. Treatment of anorexia nervosa: In accordance with the above theories, the nutritional basis of the disease is also acknowledged in the contention that the disorder is caused through a deficiency of zinc present in the body. Experts have recommended the use of zinc in treating anorexia nervosa since 1979. In a randomized, double blind trial that was conducted using placebos with one half of the participant sample, 14 mg of zinc per day was administered to anorexic patients. The results showed that in so far as treatment of the condition was concerned, the rate of body mass increase was doubled.(Shay and Mangian 2000). It has also been recommended that the other deficiencies induced in the body through malnutrition may also be addressed in this manner, by administering nutrients such as tryptophan, tyrosine, thiamine and norepinephrine, to address the malnutrition symptoms and enable body weight gain in anorexic patients. In order to address the behavioral causes of anorexia nervosa, Blinder et al (1970) had treated patients by using operant conditioning methods. They have applied the results of research studies conducted by other experts such as Bachrach et al (1965:153-163), Hallsten (1965) and Lang (1965: 217-221) that have suggested cognitive learning methods as a useful way to treat anorexia nervosa and bring about weight gain in patients. In this study, operant learning reinforcement was applied in the case of three consecutive patients, for whom any access to physical activity was made contingent upon the gain of weight. The basis of this study was that anorexia nervosa is to be viewed as a specific behavioral pattern that has been learned, added to which influence sin the environment have strengthened the negative effects of such learning. Therefore, the underlying premise is that such undesirable behavior that has been learned is to be unlearned in a hospital environment where food intake levels are brought under control. In this study, patients were treated from four to six weeks, through desensitization of their phobic response to eating and obesity and this resulted in a rapid restoration of weight of the anorexic patients. Conclusions: On the basis of the above, it may be concluded that the various theories that have been suggested that try to explain the causes of anorexia nervosa. Some of them have placed an emphasis on the biological aspects, attributing the hormonal changes occurring with adolescence as being responsible for the disorder. The biological basis of the theories also attributes nutritional deficiencies as a causal factor in anorexia nervosa. It is possible that these theories may have some merit because they are able to explain the prevalence of the condition among females, as well as the fact that the condition is most common in adolescent girls. Moreover, the fact that anorexia nervosa has been cured through the administration of zinc and other nutritional elements indicates that there are strong grounds to support the contention that the causes of the condition are biological. However, the limitation with the biological theories is that they do not pay enough attention to the psychological and emotional factors that may also play a role in the predisposition to and development of the disease. The anorexic person constantly feels that she is fat and overweight, despite the fact that others may not perceive her to be so. There is undoubtedly a psychological element involved in this; as a result, there appears to be some merit in cognitive theories that attempt to evaluate these feelings of low self esteem and self worth that characterize an anorexic person’s feeling of being unattractive and fat. Moreover, a further limitation with the biological theories is the fact that merely attributing the causal factors of the disease to hormonal factors may not be easily application because of the inability to definitively separate cause and effect. Furthermore it has also been shown that hormonal imbalances may persist even when anorexia nervosa has been cured, therefore suggesting that there may be other factors that may be responsible for the condition. The cognitive theories also take into account some of the external environmental factors that may be responsible for the disease and therefore take into account the environmental and humanistic perspectives as well. Therefore, the major thrust of these theories is that anorexia nervosa is a psychiatric disorder characterized by learned behavior, that can be successfully unlearned. The successful use of operant conditioning techniques indicate that it is possible that anorexia nervosa may be the result of learned behavior and may not be something inherent within a person, therefore a patient can be conditioned to unlearn destructive modes of behavior. The impact of the media and peer influences have also been included within the scope of cognitive theories, since they provide an indication that factors in the environment may be responsible for the condition or a predisposing to that condition. However, these cannot be conclusively be established as the cause of anorexia nervosa because it is difficult to successfully establish the link between one and the other or to achieve a successfully positive correlation between the two. Family based theories have attributed the family as the most important factor predisposing to anorexia nervosa. These theories may have some merit in that the importance of the family and its influence in an individual’s life cannot be under estimated, however they cannot be used as the sole criterion to explain the prevalence of the disease. It ha sbene suggested that the diseased condition develops as a resistance of the child to growing up, and she exhibits the symptoms of excessive body weight liss, etc in order to regress back to a state of childhood where she is cared for and to resist the growing independence of adolescence. However, as pointed out in criticism by researchers, such studies on the family impact in anorexia nervosa are retrospective and therefore, their scientific validity is questionable. Furthermore, family based theories present a problem in so far as treatment is concerned, because it may not be possible to regress back and correct the situation that has caused the anorexic condition in the first place. The best theories that may explain anorexia nervosa are those that incorporate a multi dimensional perspective and take into account all factors that may predispose an individual towards becoming anorexic. The best explanation may be offered by the feminist theory, which has placed the cause of the dilemma squarely as the result of the conflict between traditional values a woman is expected top adhere to – such as being a care taker – and the pressures of the modern age, where she is expected to be competitive and glamorous. As a result, the media images become very important because they symbolize what a women is expected to become. In the pressure to keep up with the glamorous images of the media and in coping with the changes occurring during puberty, an adolescent may feel pressured and out of control. Therefore, she resorts to controlling her food intake and body weight as a means to cope with the pressure and chaos she feels, through desperation and an inability to cope with a competitive, challenging environment. Treatment of anorexia nervosa will be facilitated and improve dif its causes can be correctly identified. While there is merit to all the theories however, it must be emphasized that no single theory can itself account for the causes of the disease. In order to achieve a correct understanding of the causal factors in the disorder, a multi dimensional perspective must be taken into account, with all relevant factors considered. Then while considering the factors in the individual case, it may be possible to arrive at which causal factor is most responsible for the disorder in that particular case. However, on an overall basis, the feminist theory appears to offer the best explanation for the causal factors of the disease. It is able to offer an excellent explanation for why the condition is so prevalent in modern times as opposed to the earlier part of the decade and why it is more prevalent among females as opposed to males, who do not have to cope with revised expectations about their role. Moreover, understanding these causes will also enable a better treatment of the disease by using a multi dimensional perspective – for instance, supplements may be given and learning theory techniques utilized at the same time in order to ensure that both physical and psychological/emotional/behavioral symptoms of the disease are effectively attacked. References: * American Psychiatric Association (APA), 1994. Diagnostic and Statistical Manual of Mental Disorders, (4th ed). 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