Anorexia Nervosa is an illness that mainly affects adolescent girls although it can occur both in boys or girls younger or older than this. The most common features are loss of weight coupled with a change in behavior. The weight loss is slowly progressive and often starts with a perfectly normal weight reducing diet. It may only be after this has continued for several months that it seems a cause for worry, usually because by then the weight loss is extreme. To start with the girls are single minded in their determination to lose weight. Attempts to frustrate their efforts are generally met with anger or deceit or a combination of both. Confrontation, rational discussion, bullying or bribery will probably fail to cause more than a very brief change of eating behavior. Continuing weight loss will lead to increasing concern by the family. A girl of average height will probably be unable to continue at school once her weight falls below around six stones.
The personality changes that she may experience will be those of increasing seriousness and introversion. She will become less outgoing and less fun. She will usually begin to lose contact with her friends and may appear to lose interest in everything apart from food and academic work. She may show increased obsessive behavior especially in the kitchen where she may become concerned with cleanliness, orderliness and precise timing of meals. She may well seem to wish to cook for the family and appear to encourage them to overeat. She will regress and appear to lose confidence. She may become less assertive, less argumentative and more dependant. At the same time her behavior will increasingly control the lives of all around her.
There are some aspects of cause that are unknown. From what we do know it seems that this is a disorder of many causes that come together to produce the illness. These recognized ingredients include the nature of the personality of the girl herself, aspects of her family its members and relationships, and stresses and problems occurring outside home, often at school. There is an increased risk in families in which there are other anorexics and this probably indicates a genetic predisposition also. The trigger is weight loss from any cause, the most usual being a normal weight reducing diet to lose ‘baby’ fat.
The personalities of the girls tend to be conformist, compliant, and hard working. They are often popular with teachers and may have seemed to be little cause for worry over the years. As their contemporaries go through the difficulties of adolescence they seem models of sensible behavior by comparison. They tend to be mildly obsessive. They are organized and tend towards tidiness. These traits may be quite marked before the onset of anorexia but they are usually accentuated by the disorder.
Family relationships are liable to be strained by the illness even if they have seemed previously good. The families of anorexics are often high achieving with high expectations of their children. The anorexic seems excessively willing to accept this value structure, setting standards for herself that seem extreme. During adolescence, when the continuing growth of the child needs encouraging towards independence, the family may be still demanding conformity of behavior. A sense of fun, an enjoyment of being unconventional, and a tolerance of alternative values may seem to be missing from her world. She may seem to over identify with her mother especially and this distorts her relationship in ways too complicated to describe this limited text.
In the year or so that precedes the start of anorexia there is often an increase in the problems or pressures that create anxiety or unhappiness. These frequently seem to be from the school environment because of the common age group of the girls. Typical stresses are the build up towards taking G.C.S.E. and ‘A’ level exams and feelings of rejection arising from difficulties with relationships with girls or boys.
Bulimia Nervosa is an illness that is most commonly found in girls of later adolescence and early adulthood. It is very rarely found in men. It is characterized by episodes of binge eating; eating large quantities of food in a short time. This behavior may be very severe with enormous quantities of food, most typically carbohydrates being consumed. To prevent the otherwise inevitable consequence of weight gain there are periods of food restriction and often vomiting, laxative abuse or excessive exercising. When vomiting is used then the binges may become multiple with repeating cycles over several hours in which the sufferer eats until full, then vomits and eats again. With increasing severity the girls’ lives become more chaotic with the focus increasingly on the bulimic behavior. Such is the drive to eat that they may scavenge leftovers from a dustbin or steal in order to feed the compulsion. They generally find their own behavior disgusting and are deeply ashamed of it so that it almost always occurs in secret.
Signs that may indicate that there is a problem include a tendency to leave the table immediately after a meal. Vomiting is most frequently induced by forcing two fingers of the right hand down the throat. This often causes a chronic blister just below the knuckle where it rubs on the upper teeth. Repeated vomiting quite often leads to swelling of the salivary glands that show as soft swellings at the base of the ears or just under the chin. If it goes on for many years the swellings become hard and permanent.
Repeated vomiting causes a loss of stomach contents and because this includes the acid secretions that are needed for digestion it leads to changes of body chemistry. Laxative abuse causes similar distortion of chemistry and the two behaviors together are most likely to be dangerous. Major disturbance of the blood chemistry, particularly loss of potassium, and rupture of the stomach are occasional causes of sudden death but fortunately this is rare unless the behavior is extreme. Acid from the stomach constantly washing over the teeth dissolves the enamel which will cause lasting damage particularly to the four central upper teeth. Irregularity of the menstrual cycle is common and sometimes it stops altogether. There is an association of ovarian cysts with the illness that is likely to reduce fertility but most are able to conceive normally once they are recovered. As with all eating disorders the greatest risks are from suicide or self harm as a result of feelings of depression and hopelessness.