ANOREXIA NERVOSA: THE SHATTERED ROSE - Written by Dr. med. Christina de Almeida dos Santos, Psychiatrist

Background

Anorexia Nervosa is one of the most lethal psychiatric illnesses, and to comprehend it, I often create an analogy with an admirable rose, that in the height of its splendour, with its admirable crimson, the rose consumes itself and slowly loses each of its once enviable petals of a perfect life. As the fading flower, so do the anorexic girls let life drain away on a steep decline on the pointers of a scale. This dismal process, but also the exciting process of recognition, treatment, and recovery are described in the book “When Beauty Becomes an Obsession” [“Quando a beleza de torna obsessão”] (São José dos Pinhais Public Health School - 2021).

Anorexia nervosa affects 0.5 to 1% of the population, primarily adolescents (aged 12-15), predominantly females (90%), and is prevalent in professions that excessively prioritise aesthetics and the body, such as models, actresses, dancers, jockeys, gymnasts, and digital influencers.

The term "anorexia" is inappropriate because patients with anorexia nervosa, at least in the early stages of the disease, feel hungry but deny such feelings and reject all forms of food intake. Furthermore, Anorexia Nervosa (AN) is characterised by a drastic reduction in food intake leading to extreme weight loss, intense fear of gaining weight or maintaining weight within the normal range, and a distortion of body image (even when severely underweight, anorexic individuals perceive themselves as fat, plump). In some cases, patients may experience isolated episodes of binge eating followed by purging behaviours to avoid weight gain, such as self-induced vomiting, use of laxatives, diuretics, and weight-loss medications.

Recognising Anorexia Nervosa: Behaviours, Causes, and Complications

In practice, patients with anorexia nervosa can be recognised by the following behaviours:

• Different diet: Progressive avoidance of certain foods and, later on, entire food groups (fats, carbohydrates, meats, and dairy products), reducing the diet to sugar-free beverages, dietetic chewing gum, and some types of fruits and vegetables. Daily calorie intake can be as low as 100 to 200 calories,
• Eating rituals: Dividing food into small pieces, separating them by colour, size, and texture,
• Excessive slowness in ending a meal (can take up to 2 hours),
• Culinary exploration (preparing high-calorie and elaborate dishes for family members),
• Checking rituals: frequent measuring and weighing after the food intake,
• Disguise behaviour: hiding under loose clothes.

The development of anorexia nervosa cannot be attributed to a single known cause. A combination of biological, psychological, and environmental factors is likely to be the cause of the disease. For instance, studies suggest that genetics may play a significant role, as individuals with first-degree relatives with anorexia nervosa are 10 times more likely to develop it.

Personality traits such as inflexibility, perfectionism, and rigidity are often presented as factors of psychological vulnerability. Anorexic patients often exhibit stereotypes of perfection: top students in their classes, exceptional ballet dancers, and perfect and well-behaved daughters who are organised and punctual.

The genesis of AN is attributed to the related Environmental factors:

• Family factors: excessive focus on weight and body shape, also dysfunctional eating behaviour (restrictive or compulsive).

• Media and social media play a negative role by idealising an unattainable thin body as the standard of beauty, promoting comparison with digitally altered images of unreal bodies using filters and edits. Thinness is frequently associated with self-fulfilment, power, and the key to success.

Clinical Complications

Anorexia nervosa is associated with a variety of clinical complications stemming from malnutrition or inappropriate compensatory methods (such as induced vomiting, use of laxatives, diuretics, enemas, and weight-loss medications; improper use of insulin and thyroid hormones, breastfeeding to lose weight, self-inflicted bloodletting, among others).

Often, these alterations can be reversed with weight restoration and maintaining a better nutritional status. To ensure survival, the body enters a sort of self-cannibalism, consuming its muscles, bones, brain mass, and even organs. As a result, patients with anorexia nervosa present, among other symptoms:

• Reduction in the grey matter of the brain, leading to cognitive impairments;

• Reduction in bone mineral density, potentially leading to osteoporosis;

• Mitral valve prolapse of the heart, with palpitations;

• Pain, muscle weakness, and paralysis;

• Constipation and delayed gastric emptying;

• Thin and brittle hair;

• Dry, yellowish skin covered in lanugo (fine hair layer all over the body);

• Fertility changes;

• Alterations in sodium and potassium levels, potentially leading to life-threatening cardiac arrhythmias

It is worth mentioning that AN is the psychiatric disorder with the highest mortality rate, with staggering rates reaching 18%. One of the principal causes of death is suicide (which is 18 times higher compared to the general population), followed by renal and cardiovascular complications. Approximately 50% of adult patients with AN report suicidal ideation, and up to 26% attempt suicide.

According to the AED (Academy for Eating Disorders), the risk of premature death in a woman with AN is 6 to 12 times higher than in the general population. The vast majority of anorexic patients (70-90%) have comorbidity with other psychiatric disorders, such as depression, anxiety disorders, ADHD, alcohol and substance use disorder, and personality disorders.

The treatment should be multidisciplinary, with a specialised team in eating disorders, which includes a nutritionist, psychologists, psychiatrists, physicians, and physical educators. The main objectives are the restoration of appropriate weight and the normalisation of eating behaviour.

Eating disorder treatments at The Kusnacht Practice

At The Kusnacht Practice, we are highly skilled in the treatment of a multitude of eating disorders. We have helped transform the lives of many clients in the past and have a striking track record in this area.

With health and care excellence, our team of professionals use a variety of strategies with a fully personalised programme as unique as an individual's fingerprint, including Psychotherapy, Neuromodulation Therapies, Relapse Prevention, Clinical Hypnotherapy, Mindfulness, Limbic Chair and Biomolecular Restoration and Rejuvenation (BIO-R®) Therapies, and diverse Medical and Psychiatric approaches.

Whether we are dealing with Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or other presentations of Disordered Eating (i.e. Orthorexia, Drunkorexia, Emotional Eating, Grazing or Mindless Eating), our team of professionals will find a solution and help reinstate a healthy relationship with food, improve body image satisfaction, and improve emotional regulation skills.

In order to learn more about eating disorder treatments at The Kusnacht Practice, contact our specialists.

Written by Dr. med. Christina de Almeida dos Santos
Psychiatrist, Member of the Academy for Eating Disorders
Partner Psychiatrist for Eating Disorders at The Kusnacht Practice - Switzerland