What is Anorexia Nervosa ?
Clinic description
Anorexia nervosa is a severe psychiatric disorder, which is more generally part of eating disorders and which often appears in adolescence (mean age 17, with two peaks of frequency at 14 and 18). Although it still predominantly affects girls, anorexia nervosa tends to be increasingly common in the male population.
The symptomatology of this disorder is usually described by the triad of 3 symptoms: anorexia, massive weight-loss, and amenorrhea.
- Within this framework, anorexia, a major symptom of the clinical picture, corresponds to a voluntary dietary restriction, linked to an intense fear of gaining weight. Thus, certain foods are progressively excluded from the diet (either because of their caloric values or simply because of the beliefs associated with them). Food intake thus becomes highly ritualised and controlled : this shows the excessive interest in food.
- Massive weight loss, from this point of view, is a direct consequence of dietary restriction, often spectacular, but never considered sufficient for the patient. Generally, for a diagnosis of anorexia nervosa to be made, a minimum loss of 15% of the theoretical weight expected for the person (according to his or her sex, height, age…) is required.
- Finally, amenorrhoea corresponds to the non-appearance or disappearance of menstruation in women.
This stereotypical clinical picture is formed in three to six months after a period when the patient begins a diet to lose a few kilograms considered superfluous. Sometimes, a triggering event can precipitate the symptomatology (e.g. family conflict or separation, mourning, birth, moving house, emotional break-up).
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Other clinical characteristics are frequently present: physical hyperactivity, reduced sleep time (voluntarily or due to insomnia), poorly invested sexuality, depressive reactions, emotional dependence, etc.
Medical Care
Anorexia nervosa is one of the most difficult psychiatric pathologies to treat, among other things because of the denial of the disorder and the absence of verbally expressed complaints. These manifestations thus delay the implementation of treatment. Early identification and management of the disorder can prevent complications or chronicization of the disorder and thus improve the prognosis. In all cases, the management of anorexia is often long, so it is essential to inform the patient and his or her entourage before the start of the treatment plan.
The management of anorexia nervosa is always multidisciplinary (somatic, psychiatric, nutritional…) and is justified by the multifactorial origin of this pathology.
- Nutrition and dietetics : This nutritional and dietetic re-education allows in particular to restore clear and simple dietary rules in order to restore an adapted diet. It helps the patient to regain autonomy in terms of food.
- Somatic: This treatment is necessary in order to monitor and treat body complications related to undernutrition and renutrition.
- Psychotherapy : Psychological care aims to help the patient better understand the disease and its symptoms, promote adherence to care and motivation for change, strengthen self-esteem, improve social and family relationships, and treat possible psychological conflicts or suffering. It is important to involve parents in the care process. There are currently a multitude of psychotherapeutic approaches in the management of ACT (supportive psychotherapies, analytically inspired psychotherapies, cognitive-behavioral therapies, family therapies, motivational therapy, etc.).
Outpatient care is recommended as a first line of treatment and helps to preserve family and school habits and thus facilitate adherence to care. However, when the criterion of the seriousness of the disorders is too important and the patient does not adhere to the therapeutic project and is in danger, day or full-time hospitalization becomes inevitable.
Evolution
The great heterogeneity in eating disorders explain the massive disparities in their evolution. The evolution duration varied between a few months (rarely below 18 month) and forever. In anorexia nervosa, there is no absolute pronostic criteria. However, hospitalization selectionate subjects who resist ambulatory care and who have the most severe symptoms. On the other hand, bad family relations and personality disorder might also be bad evolutionary pronostics.
Relapses are frequent and concern loans for half of cases. The weight and eating habits normalize in 75 to 80% of cases at 5 years. Periods come back spontaneously but irregularly in 50 to 60% of cases, it is a good prognostic factor. 15% to 25% of people with anorexia evolve toward a chronicity established beyond 4 years of the disease evolution, which means that people with anorexia would have trouble with food among their lives.
Somatics complications, which refers to everything related to the body, are sometimes severe. Indeed, a stunted growth and an absence of puberty is frequently observed as a bone issue called osteopenia and osteoporosis. Chronic undernutrition weakens the body so much that people with anorexia have a shorter life expectancy rather than the general population.
There are also psychic complications with an impoverishment of personality with less envy of intellectualizing the world. Moreover infertility is a serious risk for young women with anorexia of childbearing age.
In a psychiatric point of view, there is an evolution for patients with anorexia to a depressive symptomatology, and anxiety disorder like social phobia and obsessive-compulsive disorder.
Death occurs in 4 to 10% of cases because of complications related to undernutrition or suicides.
Healing is a slow process and is evocating only after a durable stabilisation of 4 years minimum. It occurs in 50 to 60% of cases if we only take to account somatic symptoms (i.e. the 3A triad) but only in 30 to 40% of cases if we consider the other psychiatric symptoms which contribute to the patient’s isolation. Some healing criterias can be identified like the full disparition of 3A triad, autonomization in daily life, a better perception of the body image, a capacity to have life’s goals etc. In any case, anorexia nervosa evolution is variable from a patient to another and it is really difficult to predict the becoming of patients.
Useful links
For health professionals :
Link to the page of the inter-university diploma (Lille, Montpellier, Nantes) on eating disorders : https://medecine.univ-nantes.fr/formation-continue/diu-troubles-du-comportement-alimentaire-2019319.kjsp
For patients :
Authors : Pauline Guilbaud, Lucie Jerez & Ophelie Toublanc
Words we have learned :
- Amenorrhoea (aménorrhée)
- Dietary restriction (restriction alimentaire)
- Food intake (l’apport alimentaire / l’alimentation)
- Denial (le déni)
- Chronicization of the disorder (chronicisation du trouble)
- Undernutrition (dénutrition)
- Loans for half of (prêt de la moitié de)
- Impoverishment (appauvrissement)
Bibliography
Flament, M. F. (1995). Épidémiologie des troubles des conduites alimentaires. Epidémiologie Psychiatrique. Ellipses. Paris: Rouillon F, Lépine JP, Terra JL.
Herpertz‐Dahlmann, B., Müller, B., Herpertz, S., Heussen, N., Hebebrand, J., & Remschmidt, H. (2001). Prospective 10‐year follow‐up in adolescent anorexia nervosa—course, outcome, psychiatric comorbidity, and psychosocial adaptation. Journal of Child Psychology and Psychiatry, 42(5), 603-612.
Hjern, A., Lindberg, L., & Lindblad, F. (2006). Outcome and prognostic factors for adolescent female in-patients with anorexia nervosa: 9- to 4-year follow-up. British Journal of Psychiatry, 189(5), 428-432. doi:10.1192/bjp.bp.105.018820
Jeammet, P. (2011). Anorexie, Boulimie-Les paradoxes de l’adolescence. Fayard/Pluriel.
Jeammet, P., Brechon, G., & Payan, C. (1991). Le devenir de l’anorexie mentale; une étude prospective de 129 patients évalués au moins quatre ans après leur première admission. La Psychiatrie de l’enfant, 34(2), 381.
Maria, A. S. (2014). Caractérisation et remédiation des difficultés cognitives et émotionnelles dans l’anorexie mentale: une objectivation est-elle possible? (Doctoral dissertation, Paris 5)
Morgan, H., Purgold, J., & Welbourne, J. (1983). Management and Outcome in Anorexia Nervosa: A Standardized Prognostic Study. British Journal of Psychiatry, 143(3), 282-287. doi:10.1192/bjp.143.3.282
North, C., Gowers, S., & Byram, V. (1997). Family functioning and life events in the outcome of adolescent anorexia nervosa. British Journal of Psychiatry, 171(6), 545-549. doi:10.1192/bjp.171.6.545
Sullivan, P. F. (1995). Mortality in anorexia nervosa. American Journal