One of the most talked about and controversial Eating Disorders, Anorexia gets a lot of time in the spotlight. Yet so many people still don’t understand that it is a serious mental illness, or how it functions.
The DSM-V is the diagnostic manual created by the American Psychological Association (APA), and in it contains the diagnostic criteria for each of the Eating and Feeding Disorders. As per the DSM-V, for an individual to be diagnosed with Anorexia Nervosa, they must display;
A) Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B) Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight, AND
C) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
It can then be specified into one of two types;
- Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
- Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
Once the diagnosis is made, and the sub-type has been specified, it’s severity is then classified through measurement of BMI. This is where things get controversial.
Mild: BMI ≥ 17 kg/m2
Moderate: BMI 16–16.99 kg/m2
Severe: BMI 15–15.99 kg/m2
Extreme: BMI < 15 kg/m2
When we use weight criteria alongside the term ‘severity’, we start to classify the seriousness of a person’s illness. For someone making the diagnosis with limited knowledge of Eating Disorders this may cause exclusion and overlooking of certain clients because their BMI may not classify them as “Severe” or “Extreme” enough. For someone living with the illness, this causes invalidation and sets them up to have the thought “I’m not sick enough, I need to lose weight”.
There is a lot of unspoken competition that comes with an Eating Disorder.
In our delusions, we convince ourselves that we will not be taken seriously or don’t deserve treatment unless we weigh a particular weight, or reach a certain BMI.
The weight criteria for Anorexia Nervosa strengthens this.
While it’s important for a medical professional to monitor a person’s weight in recovery, it should not be used as a severity specification. Let’s look at a real life example;
- Diane is a 25 year old female who has been referred to mental health services for concerns of her eating patterns. In the past month, she has spent $5,000 on food, has been seen bingeing up to 15 times a day, has bags of vomit hidden in her room, and has expressed fear of gaining weight. Despite having a low weight, she believes she needs to lose more weight. Diane has a BMI of 18.
- Amber is a 25 year old female who has been referred to mental health services for concerns of her eating patterns. In the past month, she has spent $5,000 on food, has been seen bingeing up to 15 times a day, has bags of vomit hidden in her room, and has expressed fear of gaining weight. Despite having a low weight, she believes she needs to lose more weight. Amber has a BMI of 14.3.
Two identical cases that differ purely in weight.
However, as per the DSM-V, Diane would be diagnosed with Bulimia Nervosa, and Amber would be diagnosed with a binge-purge subtype of Anorexia Nervosa, with an ‘extreme severity’. Despite both women having equally distressing symptoms, Amber would be more likely to receive treatment at a public inpatient facility. In certain countries, Diane wouldn’t even be eligible for treatment through health insurance as she is deemed at a ‘healthy weight’.
But both women live the exact same hell, and they both deserve the exact same amount of support and treatment.
While the American Psychological Association may not be in any hurry to remove the weight criteria for Anorexia Nervosa, we as carers, family, friends and health professionals CAN. We can see each patient as a person with a serious mental illness who needs love and help. We can see past the weight and the body types, and know that weight is not a indication of severity for an Eating Disorder.
What causes Anorexia Nervosa?
Like all Eating Disorders, Anorexia is caused by a combination of things. There may never be a clear-cut answer as to what has caused a particular person’s illness, but there tends to be the presence of issues in at least one of three areas;
- Biological (genetic susceptibility)
- Environmental (societal pressures/thin ideal, toxic family, lack of supports, history of bullying, neglect or abuse)
- Personality (perfectionism, impulsivity/emotional dysregulation, neuroticism)
How does Anorexia Nervosa affect the body?
The major cause of resultant medical conditions that come with Anorexia Nervosa are results of malnutrition and added stress placed on the body in this state. That may look like;
- Weight loss
- Lanugo (thin white hairs over body)
- Anaemia (low levels of iron in the blood)
- Electrolyte Imbalance
- Intolerance to cold
- Lowered immunity
- Dizziness and low blood pressure
- Hair loss
- Lowered libido
- Infertility due to loss of period in females or low sperm count in males
- Loss of tooth enamel (resulting from frequent purging)
- Osteoporosis (loss of bone density) which puts a person at higher risk of fractures
- Loss of muscle tone
- Low heart rate
- Weakened heart/heart failure
- Cardiac arrest
- Kidney failure
- Low blood sugar (which can drop dangerously low overnight and cause death during sleep)
And that’s just the physical effects of Anorexia. There are multiple cognitive and behavioural implications that are very often overlooked;
- Obsession with calories, food, preparation of food
- Distorted image of self and body
- Low self esteem
- Rigidity around meal times
- Ritualistic behaviours around food and food preparation
- Mood swings
- Persistent low moods
- Overwhelming anxiety
- Feelings of being out of control
- Rigid thinking
- Strong urges to engage in disordered behaviours despite exhaustion (i.e. Excessive exercise)
- Social isolation
- Constant feelings of guilt and shame
- Avoidance of all activities involving food or body (e.g. going to the beach, attending family dinner, showering and seeing body in mirror)
- Obsessive body checking behaviours
- Dissatisfaction with body that causes significant distress
- Excessive spending on food for binge-eating or other means of losing weight (gym memberships, diet pills, laxatives, diuretics, etc).
- Recurrent suicidal thoughts
- Suicide attempts
- Self harm
Symptoms that often go unseen or unheard of as Eating Disorders tend to be very secretive illnesses. Suicide risk is elevated in Anorexia Nervosa, with rates reported as 12 per 100,000 per year (Preti et al. 2011). Anorexia Nervosa has the highest mortality rate of all mental illnesses and is caused by effects of malnutrition, cardiac arrest, heart failure and suicide.
How is Anorexia Nervosa treated?
Treatment for all Eating Disorders require intervention in the following domains;
- Medical/Physiological: monitoring of weights and blood levels, management of medical complications (e.g. Potassium or other electrolyte infusions), weight restoration in or out of hospital, medication.
- Psychological: psychotherapy (cognitive behavioural therapy and dialectical behavioural therapy most common), exposure therapy with ‘fear foods’.
- Nutrition: creating and maintaining a meal plan (as per dietitian).
- Environmental: addressing possible issues within the family/home environment, support from peers, networking with other people with an Eating Disorder to share experiences.
These areas can be addressed both within and outside the hospital system, however it is recommended that a person has a strong, supportive team of professionals around them at all times to address their needs in recovery. A team is usually made up of a psychiatrist, general practitioner, psychologist, counsellor, dietitian, and in some cases a social worker, occupational therapist or physiotherapist. Models of care occur within inpatient settings (public or private hospital, in either dedicated Eating Disorder ward or general psychiatric ward), partial inpatient settings (day programs within the community) and outpatient settings (attending private sessions with health professional).
It is common for people with an Eating Disorder, to also be experiencing one or more other mental illnesses. It is therefore important for these to be managed with medication and/or psychotherapy. A person may also have a lot of underlying maladaptive coping mechanisms, and should be educated and encouraged to seek out healthier alternatives to use when experiencing distress. For example, instead of skipping a meal to cope with overwhelming feelings of rejection from a family member, reach out to a trusted friend, or journal thoughts and feelings that arise. This process is incredibly difficult for the person to do, as turning to their Eating Disorder for comfort is both a habit and a safety net. Taking that away, can cause further distress on top of the stressful situation that initially triggered them.
A supportive and understanding social network is also important in recovery, as our friends and family are the ones who are with us 24/7. Therapists and doctors encourage strong family involvement, especially when a person is under the age of 18. They address concerns within the family dynamic to ensure when a person is discharged from a service, they are going into a safe environment in which they will be supported to continue recovery.