Anorexia nervosa: what are the symptoms, how to intervene

Anorexia nervosa is an eating disorder that involves an excessive assessment of one’s weight and body shape, as a result of which food intake is reduced and, consequently, weight tends to be considerably lower than normal, thus putting the person’s health at risk

The condition of being underweight is accompanied by various psychological and behavioural symptoms that tend to reinforce and maintain the disorder, increasing its severity and leading the person to experience intense discomfort to the point of hindering their functioning in everyday life.

What is anorexia nervosa?

Anorexia nervosa (AN) is an eating disorder that predominantly affects the female sex, particularly the 14-18 age group, although the first signs can usually be seen as early as pre-adolescence or early adolescence.

It is characterised by an overestimation of weight and body shape that leads to an underweight condition due to a decrease, even drastic, in food intake.

Sufferers report an intense fear of gaining weight and an altered relationship with their body, which is experienced with feelings of inadequacy and discomfort: patients tend to see themselves as normal weight or overweight despite being severely underweight.

Worries about weight can become more and more intense and disabling, leading the person to feel the need to exercise strict and constant control over eating.

Failure to treat the condition leads to a chronicisation of the disorder, with worsening of symptoms and increased impairment in the person’s daily functioning.

Anorexia nervosa: the symptoms

The symptoms of anorexia are varied and include both physical and psychological consequences.

The problems associated with anorexia nervosa are particularly severe and can, over time, have fatal consequences.

In fact, anorexia is among the psychiatric disorders with the highest mortality rate to date.

This is because treatment is often put in place later, when the disease has become chronic.

People suffering from anorexia nervosa, in fact, generally tend to hide as much as possible both their thinness and their problems with food intake and deny the presence of an actual disorder.

Refusal of treatment is also very common, as this would lead to weight gain.

Anorexia nervosa, the physical symptoms

The severe weight loss typical of anorexia nervosa can affect the functioning of the organs with very serious consequences.

The disorders that people suffering from anorexia can develop are neurological, cardiac, hormonal, gastrointestinal, pulmonary, liver and kidney disorders.

Specifically, the main physical manifestations of anorexia are:

  • Amenorrhoea (absence of the menstrual cycle), infertility or complications during pregnancy and childbirth.
  • Fragility and weakening of the body’s bones (osteopenia and osteoporosis) and brittle nails.
  • Dermatological disorders, from the development of dermatitis and xerosis, to brittle hair.
  • Haematological and immune problems such as anaemia and lowered immune defences.
  • Muscle weakness with reduction in lean mass.
  • Reduced blood pressure and slow heart rate (bradycardia).
  • Severe cardiovascular diseases (arrhythmias, mitral prolapse, reduced cardiac volume).
  • Electrolyte imbalances and kidney disorders.
  • Gastrointestinal problems and disorders.
  • Constant feeling of cold and lowered body temperature.
  • Hormonal dysfunctions such as hypothyroidism.

Anorexia nervosa: psychological and behavioural symptoms

In addition to the physical symptoms and underweight, there are a series of other psychological and behavioural manifestations that tend to aggravate and complicate the clinical picture, favouring the maintenance cycle of the disorder.

These symptoms are:

  • Intense fear of gaining weight.
  • Decreased food intake, hence calorie intake, resulting in rapid weight loss.
  • Presence of “phobic foods”, i.e. foods that create strong anxiety in the person and are therefore avoided.
  • Strict control and calculation of ingested calories, which often takes the form of using applications on the mobile phone and weighing any food.
  • Need to always be on the go and exaggeratedly increase daily physical activity to burn off any excess calories.
  • Presence of rituals during meals, such as repeatedly cutting food into very small pieces.
  • Altered perception of one’s own body image, otherwise known as body dissipation.
  • Low self-esteem, feelings of deep inadequacy and self-loathing.
  • Obsessive-compulsive manifestations and rigidity of thought.
  • Difficulty recognising and regulating emotions.
  • Difficulty maintaining attention.
  • Problem solving deficits.
  • Memory problems.

In addition, people with anorexia nervosa may develop parallel psychological disorders such as depression, anxiety, panic, insomnia, and be prone to alcohol or substance abuse.

How is anorexia diagnosed?

The clinical assessment is usually carried out by a team of professionals specialised in the treatment of eating disorders.

The diagnosis, therefore, is made through the combined assessment of the psychotherapist, the psychiatrist or internist and the nutritionist, who will base their assessment on the material collected through the clinical interview and through certain physical and psychodiagnostic tests.

Weight is assessed using the Body Mass Index (BMI), a parameter based on the ratio of weight to the square of height expressed in metres.

Those who are normal weight according to this calculation are in the range of 18.5 to 24.9.

Those who suffer from anorexia, on the other hand, have lower values, relating to the underweight category and the severity of the condition.

More specifically:

  • Mild: body mass index ≥ 17 kg/m2
  • Moderate: body mass index 16-16.99 kg/m2
  • Severe: Body Mass Index 15-15.99 kg/m2
  • Extreme: Body mass index < 15 kg/m2

The psychological diagnostic criteria for anorexia nervosa are those set out in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5, 2014). They are therefore specific diagnostic models that follow three criteria:

  • Restriction of caloric intake relative to need, leading to a significantly low body weight in the context of age, gender, developmental trajectory and physical health. Significantly low body weight is defined as less than the minimum normal weight or, for children and adolescents, less than the minimum expected weight.
  • Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even if significantly low.
  • Alteration in the way the individual experiences weight or body shape, excessive influence of weight or body shape on self-esteem levels, or persistent lack of recognition of the severity of the current underweight condition.

In addition to the diagnostic criteria just listed, there are two subtypes of persons with anorexia nervosa:

  • Restricted type: During the last 3 months, the individual has not presented recurrent episodes of binge eating or elimination behaviour (e.g. self-induced vomiting or inappropriate use of laxatives, diuretics or enemas). In this subtype, weight loss is mainly achieved through dieting, fasting and/or excessive physical activity.
  • Binge/elimination type: During the last 3 months, the individual has presented recurrent episodes of binge eating or elimination behaviour (i.e. self-induced vomiting or inappropriate use of laxatives, diuretics or enemas).

How is anorexia nervosa treated?

As with the diagnosis, the treatment of anorexia nervosa involves a multidisciplinary approach and therefore the combined intervention of psychotherapist, psychiatrist and/or internist and nutritionist, so as to intervene on the different fronts on which the symptomatology acts.

The psychotherapist intervenes in different ways according to the symptomatology presented by the person, going to work on different factors, from motivation to treatment, passing through the mechanisms that generate anxiety and fear of gaining weight, to the prevention of relapses.

Everything is approached with respect for the patient’s emotional experience and life history, based on a collaborative (and not coercive) approach.

The psychiatrist and/or internist physician is generally the coordinator and manager of the treatment process, acting by monitoring the patient’s health conditions, as well as intervening with any pharmacological therapies and providing prescriptions and medical indications.

The nutritionist or dietician, on the other hand, will be in charge of drawing up the dietary regime to be followed, in agreement with the patient, intervening on any allergies, intolerances or food choices, providing the correct information on dietary education, and promoting the recovery of normal weight.

Central to the process of analysis will be the work on the acquisition of awareness of the disease, the motivation to follow the treatments indicated by the specialists, the containment of symptoms, the maintenance mechanisms of the behaviour and the prevention of future relapses.

Various forms of psychotherapy exist and all have been found to be moderately effective in the treatment of anorexia nervosa.

Currently, official guidelines of several associations in the field and recent scientific publications generally recommend a cognitive-behavioural psychotherapeutic approach or an approach based on family therapy.

Usually, the course of treatment for anorexia nervosa ranges from 6 months to 2 years, but can be influenced by various factors, subjective or environmental; therefore, each treatment plan is established according to the person’s specific needs and condition.

Fundamental, in these terms, is both preventive intervention and relapse prevention: the person who experiences the onset of symptoms must therefore promptly inform their doctor and psychotherapist so that they can intervene before the disorder worsens.

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