ANOREXIA NERVOSA
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Self-inflicted, severe calorie restriction leading to starvation in an 
otherwise healthy young person may seem paradoxical in a society where 
almost one third of the population is obese or overweight.  But 
anorexia nervosa--an eating disorder characterized by extreme weight 
loss (greater than 25%), distortion of body image and an intense fear 
of being overweight--is rapidly becoming a public health issue: About 
one percent of white, middle-upper class adolescent girls and young 
women are affected.  When one considers that nearly twenty percent of 
college women have symptoms of bulimia, a related syndrome of binge 
eating and purging, the problem is of even greater concern. 

Males, blacks and orientals occasionally become anorexic; however, 
white females comprise the vast majority (95%) of the patients.  The 
onset is often at puberty, almost always before age twenty-five.  Life 
stress--e.g., onset of menstruation, family discord, difficulty at 
school--may be the precipitating factor. 

The full-fledged disorder is manifested by obsession with food, 
dieting and body weight.  Voluntary starvation is frequently 
accompanied by calorie-burning spurts of physical activity such as 
long distance cycling or running.  Binge eating followed by self-
induced vomiting or heavy laxative or diuretic use (signs of bulimia) 
may be associated.  In severe cases extreme weight loss and emaciation 
ensue.  Among the other manifestations are intolerance to cold, 
constipation, missed menstrual periods, low body temperature, 
decreased blood pressure and heart rate, dry skin, swelling, increased 
body hair, enlargement of the salivary glands, kidney stones, thin 
bones, low blood counts and disturbances in body chemistry and 
hormonal balance. 

Characteristically the patients have poor insight into their disorder. 
Fatigue and emotional upset, especially depression, go unreported or 
are overtly denied.  Furthermore, anorexics neither feel hungry nor 
realize their thinness. When asked to judge their body size relative 
to normal or thin persons, they overestimate their proportions; in 
other words--they always "feel fat." 

Although many of the signs of anorexia nervosa suggest a physical 
cause, all can be explained on the basis of a primary psychological 
disturbance.  In fact, many anorexics share a similar family 
background and underlying personality type.  Their parents are often 
professional persons or other achievers who are overdirective and 
place a high premium on performance.  The girls aspire to perfection 
and exhibit many obsessive-compulsive traits.  They are eager to 
please, yet unable to reach their own or their parents' standards; 
they have a low self esteem.  A history of overweight in childhood is 
not unusual. Importantly, there is an emphasis on food preparation, 
eating behavior, body weight and thinness which can become the focal 
point for family discord.  Poor communication within the family and 
troubled interpersonal dynamics strain the parent-child relationship 
even further. 

The treatment of anorexia nervosa demands a multidisciplinary approach 
involving the primary care physician, nutritionist, psychiatrist or 
other mental health professional, and often a specialist in eating 
disorders. Individual, group and/or family counseling as well as 
behavior modification techniques may be employed.  Psychotherapeutic 
methods help the patient to gain insight into her disease, increase 
self-esteem and develop socially. Antidepressant and appetite 
stimulant drugs have also been tried, but the results have been 
variable.  Further studies are needed.  Regardless of the approach 
regular, structured meals and nutritional support are emphasized. 

Many anorexics can be managed as outpatients with frequent visits to 
the office.  Sometimes, however, hospitalization is required to 
institute therapy, interrupt an otherwise refractory eating pattern or 
treat medical complications. Intravenous fluids and forced tube 
feedings are reserved for severe cases. 

Despite a concerted effort, the treatment is difficult and time-
consuming: a three to four year clinical course is not uncommon.  The 
prognosis is variable, and many patients suffer recurrences.  The 
overall mortality--from starvation and suicide--can be as high as six 
percent.  Poor prognostic signs include older age at onset, longer 
duration before diagnosis, presence of bulimia and concomitant 
depression. 

For further information about eating disorders, contact the American 
Anorexia/Bulimia Association, 133 Cedar Lane, Teaneck, New Jersey 
07666, Ph: (201) 836-1800.