Anorexia nervosa is a serious and potentially life-threatening disorder characterized by an intense fear of gaining weight, weight loss, distorted body image, and amenorrhea. Ninety percent of those with anorexia nervosa are women, with the onset occurring between the ages of 15 and 19. However, the disease is appearing increasingly in children as young as age 8, in women older than 25, and in men.
Eating disorders are not typically considered life-threatening illnesses. Yet the death rate from anorexia nervosa is more than 12 times higher than the annual death rate from all other causes combined for young women ages 15 to 24. According to the National Association of Anorexia Nervosa and Associated Disorders, 5% to 10% of those with anorexia die within 10 years of diagnosis, a figure that increases to 18% to 20% by the 20-year mark. Suicide accounts for approximately 20% to 30% of these deaths – a frightening statistic that is often ignored by professionals, families, and patients themselves.
In the US, about 1 in 100 girls and women, and 0.3 to 1.20% of the overall population, suffers from anorexia. Although this may seem like a small number, this deadly disease actually affects millions, with estimates ranging from 8 to 11 million people struggling with eating disorders in the US. Conservative estimates suggest that more than 25% of high school girls are affected by dietary practices of disordered eating. And the sad fact is that only 30% to 40% of those with anorexia will successfully recover.
A Brief History of Anorexia Nervosa
Cases of anorexia nervosa have been chronicled through the centuries, well before strikingly thin models became the ideal of female beauty. The earliest documented case of self-starvation comes from the Middle Ages. In the 14th century, a female saint, Catherine of Siena, became emaciated from an extreme form of fasting and eventually starved herself to death. Other Italian female saints of the same century followed a similar path. They seem to have been motivated not by an intense fear of being fat, but by a desire to deny the claims of the flesh in order to perfect their spirit. Whatever their professed motivation, and despite the intervening centuries, we can recognize from the lives of these female saints familiar symptoms: depression, anxiety, obsessive thoughts, and compulsive behaviors.
In 1689, Richard Morton, MD, described an illness marked by its relentless pursuit of thinness; a pursuit for which he could not determine any medical cause. He concluded that the illness was the result of "violent passions of the mind." Morton described a seductiveness to the illness, where it "flatters and deceives the patient" in its early stages. Certainly, therapists today hear echoes of their own experience in his words. Writing nearly two centuries later, in 1868, the English physician Sir William W. Gull found himself confronted by:
A peculiar form of disease occurring mostly in young women, and characterized by extreme emaciation ... At present our diagnosis of this affliction is negative, so far as determining any positive cause from which it springs … The subjects [are] ...chiefly between the ages of 16 and 23 … My experience supplies at least one instance of fatal termination … Death apparently followed from the starvation alone… The want of appetite is, I believe, due to a morbid mental state … We might call the state hysterical.
Convinced that this strange and disturbing disease was the result of a mental "hysteria," Gull named it anorexia nervosa – nervous loss of appetite. He was certain, with all the certainty that a physician of the Great Empire could possess in the late 19th century, that anorexia nervosa was the result of a psychological dysfunction. So certain, in fact, that he embedded the cause for the disease firmly in the name that he gave it. Yet, he was clearly wrong.
I can understand Gull's perspective. It must have been disturbingly frustrating to see an otherwise healthy patient essentially starve herself to death. This is a feeling similar to what many therapists experience today. What I have more difficulty understanding is how, in the ensuing 140 years, so little has changed in our treatment. Our frustration has not changed. Through the Industrial Revolution, Darwin's publication of The Origin of Species, the advent of motorized travel, airplanes, the Roaring Twenties, the Great Depression, two world wars, nuclear weapons, walking on the moon, the growth of psychopharmacology, the decade of the brain, and on and on, we still cling firmly to Gull's fundamental premise even though it fails to adequately encompass anorexia nervosa or point to effective treatments.
Curiously, the demands of the culture seem to have played much less of a part in the diagnosis of anorexia in the 19th century. That time period certainly did not hold thinness as the ideal of beauty; quite the opposite. Even a cursory look at the art of the time shows voluptuous women as the image of feminine beauty. Anorexics of the 19th century were not responding to a cultural image of thinness. They were opposing a cultural image of beauty. They did not try to lose weight due to a morbid fear of being fat, as modern anorexics do, but instead placed moral value on their weight loss.
For the next century, eating disorders seemed to exist just below the radar of most psychiatrists and psychologists. In 1947, John M. Berkman at the Mayo Clinic in Rochester, Minnesota, called attention to anorexia nervosa in girls or young women between ages 16 and 30. He attributed the condition to starvation that results from psychic disturbance brought on by relationships with parents. Berkman writes, "Among adolescents the cause for the psychic upset can often be traced to a parent." Since adolescence is the typical age of onset for anorexia nervosa, problems with adolescent development were considered core features for the onset of anorexia nervosa. Psychological theories have described anorexia nervosa as a defense against the emergence of sexual development, difficulty negotiating separation from parents and enmeshed family dynamics.
It wasn't until 1973, when Hilde Bruch published Eating Disorders: Obesity, Anorexia and the Person Within, that the pursuit of thinness, already a strong, cultural dynamic, was raised in the common consciousness. Although Bruch's understanding of the disease had nothing to do with the religious motivations of earlier times, it was more nuanced than simply, "the pursuit of thinness." She understood the centrality of the drive for thinness in modern society, but she also placed that drive within a larger psychocultural context and the rapidly evolving role, status, and image of women. In Bruch's worldview, the drive for thinness is a concrete manifestation of the anorexic's "failed quest for autonomy."
The medical and psychological communities have long blamed anorexia on our culture's emphasis on slimness and the exaggerated response that this emphasis elicits from certain vulnerable women. Thus, anorexia has traditionally been viewed and treated as a psychological disease.
What we now know about malnutrition and starvation, however, makes it clear that our culture's unhealthy preoccupation with slimness – while it is a factor in body dissatisfaction and dieting – is not the root cause of anorexia nervosa. Confusing cause and effect is dangerous; it's like looking through the wrong end of a telescope. Rather than bringing distant objects closer, nearby objects appear to be far, far away.
The True Cause of Anorexia Nervosa
These and other "psychological" theories are difficult to prove and do not account for new biological research. Recent research now suggests a substantial influence of genetic and biological factors in the development of eating disorders. In a large study with over 31,000 twins, genetics accounted for the majority of the risk of developing anorexia nervosa. Scientists have uncovered numerous biochemical and structural brain abnormalities in patients with anorexia. Family studies have confirmed that those with a family member who has anorexia have 10 times the risk of developing anorexia themselves, compared with those from families with normal eating behaviors. Many personality traits, such as shyness and – in the case of anorexia – a drive for thinness, obsessionality, and dietary restraint, have been shown to be heritable as well. However, despite a wealth of genetic findings, it is very clear that genes are merely a biological liability: They do not predetermine that an individual will become anorexic. A host of other factors, including hormonal changes, nutrition patterns, and stress can trigger the expression or, more likely, the "misexpression" of these genes.
While societal pressure to be thin, genetic makeup, certain personality traits, family dynamics, and dieting are all important factors in the development of anorexia, the true cause of the disease is a malnourished brain. The process of self-starvation brought on by systematic food restriction is the root cause of anorexia nervosa. Unfortunately, the psychological effects have received more attention than the starvation process, although not for lack of evidence.
More than 60 years ago, Ancel Keys, a physiology professor at the University of Minnesota, launched a landmark study of the effects of starvation on the body. Thirty-six men, all conscientious objectors to World War II, participated in what became known as the Minnesota Starvation Experiment. For 24 weeks, their caloric intake was severely restricted, and they were forced to walk 22 miles a week. The result was extreme weight loss, of course, but more interesting were the psychological effects of starvation. Like those with anorexia, the men became obsessed with food and eating; they constantly thought about food and even dreamed about it. They even took pleasure in watching others eat and continually chewed gum – sometimes as many as 40 packs a day.
As the starvation phase continued, the men displayed even more of the typical psychological characteristics of anorexia nervosa: depression, obsessive-compulsive behavior (in this case, rituals involving food), anxiety, irritability, and delusional thinking. Like anorexics, they lost interest in sex, their family and social connections began to fray, their ability to concentrate was diminished, and their comprehension and judgment faltered. Thirty-two of the men made it through the starvation stage to the recovery stage, at which time their caloric intake was slowly increased. However, they continued to suffer psychological effects, with many experiencing severe emotional distress and depression. Three weeks into recovery, one individual suffered a horrendous reaction – chopping off three of his fingers with an axe. Although 50 years later he was unsure whether or not the action was intentional, he did vividly recall that he was not psychologically stable at the time. The researchers attributed his actions to a severe degree of "semi-starvation neurosis."
The Minnesota Starvation Experiment clearly showed that eating too little food for a prolonged period of time causes psychological symptoms, and many of these symptoms are similar to those described by patients with anorexia nervosa. The psychological symptoms didn't cause anorexia; they emerged as a consequence of starvation. The men who participated in Keys's experiment were determined to be psychologically healthy at the beginning of the study.
Toward a New Understanding of Anorexia Nervosa
The treatment of anorexia nervosa has remained essentially static for more than five decades. After years of treating patients with eating disorders, it's become painfully apparent to me that psychiatry misunderstands anorexia. Psychiatrists have confused the obvious effects of anorexia nervosa (depression, anxiety, obsessive-compulsive behavior) with its causes. Thus, they're treating depression, panic attacks, compulsions, obsessive behavior, and other psychological conditions in an effort to quell anorexia, when it's actually the starvation that is causing these conditions in the first place.
This new understanding of anorexia is beginning to draw support among researchers around the world. Cecilia Bergh, PhD, and Per Sodersten, PhD, at the Karolinska Institute in Stockholm have written about this and direct a treatment program founded on the hypothesis that the symptoms of anorexia are a consequence of starvation rather than a mental disorder. A 2003 article by Shan Guisinger, PhD, in Psychological Review concludes that psychological treatment for anorexia "has had too little to offer" and concurs that the symptoms of anorexia are biological responses to low body weight.
Guisinger proposes that anorexia actually reflects an ancestral adaptation to times of starvation. As our ancestors were most likely foragers, humans were at one time exposed to periods of starvation and famine. In response to these adverse situations, our bodies respond by declining our metabolic rate by as much as 40% and developing behavioral and neuroendocrine mechanisms that increase our desire for food. For short periods of time, these are advantageous to survival, because they make individuals more efficient at conserving energy and seeking food. Prolonged periods, however, are detrimental, as individuals become lethargic and obsessed with eating. This scenario mirrors anorexia. Guisinger argues that part of the failed treatment of anorexia stems from professionals who fail to take into account its evolutionary roots. Understanding anorexia requires more than just looking at its symptoms.
Approaching anorexia nervosa as a psychological disorder does not take into account the brain's physiological response to a shortage of essential nutrients. Regardless of culture, psychological traits, or family pressures, the results of starving remain the same: a malnourished mind. This is where so many experts and researchers go wrong. Incorrectly assessing the root cause makes it impossible to find an effective treatment. It's like smacking your head on an open cabinet and taking lots of aspirin to relieve the pain. When a CT scan reveals that you actually have a small brain bleed, you realize that you've not only treated the wrong root cause, but you've actually made things worse because aspirin can cause further bleeding.
The medical field has pursued treatment after treatment for anorexia nervosa while misunderstanding the cause of the disorder, which is a nutritional deficiency syndrome. If professionals were less focused on blaming the culture, the patients' psychological problems, or the functioning of their families, perhaps we could have recognized 50 years ago that a malnourished brain is a critical and, I believe, the primary cause of anorexia nervosa.
While professionals who treat anorexia agree that disordered thinking about food, eating, and body image are core clinical symptoms, not all professionals understand that malnourishment of the body and brain lies at the root of the problem. To convey the importance of self-starvation and malnutrition as the underlying mechanism in anorexia, I suggest a new term: malorexia – perhaps a new diagnosis?
The term malorexia incorporates the Latin root mal, which clearly evokes the sense of feeling bad. It is a reminder that "bad" nutrition and "bad" intestinal absorption are inherent in an illness of starvation. I would describe malorexia this way: it is a complicated illness of restrictive eating and self-starvation initiated by multiple factors that contribute to severe malnutrition and consequent biochemical disturbances in the brain. When the brain does not receive essential nutrients such as amino acids, zinc, fatty acids, and B vitamins, it cannot function normally. Malorexia – a distant relative of vitamin deficiency diseases such as scurvy and pellagra – is the clinical result of any pathway that leads to the restriction of essential nutrients.
To begin to understand the mind of an anorexic, imagine a moment of panic that you have experienced, and recall the feelings of overwhelming dread. While those feelings eventually dissipated for you, they do not disappear as easily in individuals with anorexia. Only compensatory behaviors, such as increased food restriction, excessive exercise, and substance abuse – all of which can further harm the body – can make the anxiety temporarily wane. Individuals with anorexia cannot simply be talked out of their panic.
Once an individual stops eating and becomes malnourished, one of the subsequent effects in the brain is a marked pervasive anxiety. In other words, people with malorexia have a disorder of pathological fear. These feelings of overwhelming panic and anxiety are so powerful that they not only take on a life of their own, but they can also determine an individual's behavior.
Feeding the starving brain the nutrients that it requires will help break the starvation cycle and quiet the overwhelming thoughts of fear and anxiety. Implementing the right psychiatric medications and the proper nutritional support can bring freedom from anxiety and relief from intrusive thoughts.
In my book Answers to Anorexia, I have developed an integrative medical approach for treating anorexia. The five steps below comprise focused, effective interventions that should be initiated after a comprehensive evaluation by a professional who is experienced in treating eating disorders. Following my plan will optimize both physical and psychological health.
The first three aspects of my approach to anorexia involve evaluating and addressing specific conditions that may sustain the destructive symptoms of anorexia and prolong the course of the illness. A medication component as well as an individual's nutritional status are also addressed in the last two aspects of my approach. The plan includes:
• testing for and correcting zinc levels in the body
• testing for elevated levels of urinary peptides
• testing for celiac disease
• using referenced-EEG to identify the most beneficial psychiatric medications addresses the medication component
• testing for and correcting underlying nutritional deficiencies involves an overall assessment of an individual's nutritional status
Step 1: Testing For and Correcting Zinc Levels
Testing for a zinc deficiency involves a simple taste test, but the benefits of correcting low levels of zinc in the body are enormous. Studies worldwide have shown that the mineral zinc likely has a significant role in the development of anorexia, as it alone can cause altered taste perception and a decrease in appetite, both of which can lead to decreased food intake, weight loss, and depression.
Being a mineral, zinc is not made by the body, but rather is acquired through eating food that contains zinc. Unfortunately, foods that adolescents are likely to eat – such as pasta – are low in zinc and can actually prevent the body from absorbing zinc from the foods it is most present in, such as meat and fish.
Without adequate zinc, general health – as well as appetite regulation and psychological functioning – will suffer. Fortunately, if a person is found to need it, zinc supplementation is widely available and well tolerated.
Step 2: Testing For and Correcting Elevated Levels of Urinary Peptides
Underlying digestive problems can compound the illness of anorexia, and can even prevent full recovery. It's important to identify and address these as part of treating anorexia. Testing for substances called urinary peptides via a simple urine test is necessary, because the presence of abnormally high levels of peptides indicates that the individual has a deficiency or dysfunction of a digestive enzyme called dipeptidyl peptidase IV.
Without adequate functioning of this digestive enzyme, a person's body cannot completely digest foods that contain dairy and/or wheat proteins (called casein and gluten, respectively). Incompletely digested casein and gluten proteins are harmful because they can directly affect the brain; they can trigger a number of psychiatric symptoms, including obsessive thoughts. Not only is this obsessive thinking about food, meals, and one's body inherent in anorexia, but it is one of the factors that often contributes to relapse and prevents a sustained recovery.
If a person has elevated levels of these peptides in the urine, treatment – which includes supplemental digestive enzymes as well as eliminating casein and/or gluten from the diet – can be tremendously successful.
Step 3: Testing for Celiac Disease
Testing for celiac disease involves blood tests and biopsy of the small intestine. I include it here because identifying and successfully managing celiac disease in patients with anorexia can dramatically improve the long-term clinical outcome of the eating disorder.
Celiac disease is an autoimmune disorder. Autoimmune disorders are conditions in which the body actually causes damage to itself. Whenever an individual with celiac disease eats foods containing a protein called gluten, the body attacks itself, potentially causing widespread and irreversible damage. Some gastrointestinal symptoms that people can experience if they have celiac disease include abdominal pain, diarrhea, constipation, bloating, and weight loss.
Unfortunately, people may have undiagnosed celiac disease for years!
Once diagnosed, management of celiac disease involves completely eliminating gluten (found in wheat and other grains) from the diet and restoring nutritional deficiencies.
Step 4: Using Referenced-EEG to Identify the Most Beneficial Psychiatric Medications
Although my approach to anorexia focuses on nutritional factors, the correct psychiatric medication can markedly decrease a patient's clinical symptoms, which can then allow the individual to participate more actively in the recovery process. Yet, given all of the psychiatric medications available, the combinations a patient can be put on are endless, and there is still no guarantee that a patient will feel better!
The new tool that I recommend, called referenced-EEG (rEEG), eliminates the guesswork involved in choosing medications. Used for more than 10 years to hone medication selection in patients with anorexia, rEEG measures individuals' brain waves noninvasively and compares them with a known database. This information can be used to determine which medication, or combination of medications, will work best given the way that the individual's brain functions.
Step 5: Correcting Underlying Nutritional Deficiencies
When people do not eat a well-balanced diet that includes proteins, whole grains, fruits, and vegetables, they may not be getting the essential nutrients that their bodies require for healthy growth and normal functioning. Consider the amount and types of foods consumed by an individual with anorexia. Imagine all of the vitamins, minerals, amino acids, and essential fatty acids that are not getting into the person's body! Underlying nutritional deficiencies can cause not only medical complications, but also serious psychological ones. For example, a deficiency of magnesium is commonly associated with anxiety, insomnia, and constipation. Vitamin B and C deficiencies can result in symptoms of depression, fatigue, and decreased appetite. A lack of sufficient fats in the diet, leading to a deficiency in essential fatty acids, can be associated with psychiatric conditions such as depression, attention deficit hyperactivity disorder, and bipolar disorder.
Fortunately, most nutrient deficiencies can be identified through blood and urine laboratory tests. Once a person's specific nutritional needs have been determined, a plan can be devised to restore her to optimal levels through supplementation. Most patients with anorexia do not mind taking nutritional supplements, as they contain few calories. The effects of supplements alone can be significant. When taking them, patients subjectively feel better – more focused and less anxious – and can become better partners in the recovery process. The use of digestive enzymes and probiotics can dramatically improve the bloating and digestive disturbances that frequently interfere with compliance with any refeeding program. Many patients are grateful when clinicians respect this physical discomfort by utilizing supportive nutritional supplements rather than dismiss everything as "eating disorder behaviors."
I have treated more than 1000 patients with anorexia nervosa over many years. They are without exception profoundly malnourished. Yet, their most vividly articulated distress continues to be how fat they are and how they need to lose weight. No issue of sexuality, parental conflict, or separation can cause such a distortion of perception and priority. What is going on in the anorexic is a physiological dynamic. The patient is literally starving her brain. The pieces of the puzzle are diverse. Yes, there is a powerful psychological component to anorexia. But there is also a profound physiological one. The factors that may contribute to the onset of anorexia nervosa may be unrelated to the physiological dynamics that sustain the illness and cause such emotional turmoil for patients and their families. Anorexia is a nutritional disease. Understanding this points us in a therapeutic direction – anorexia has nutritional solutions.
A family with a loved one diagnosed with cancer is often provided with a well-organized system of care, including adequate health insurance coverage. A family who is trying to find help for a child's eating disorder often has a treacherous journey without professional consensus or even a clear understanding of what direction to take.
Optimal nutritional support and correcting nutritional deficiencies are the first steps in recovery. What follows is a clearer path to health and recovery. Patients with nutritional support experience improved mood, better sleep, greater focus on school or work, and fewer obsessions around food. They become more resilient to stress and more responsible for lifestyle choices.
Cultural and societal factors should no longer shoulder a
ll of the blame; anorexia is not simply a desire to be thin taken to the extreme. Dwelling on the reason that a person stops eating is important but not sufficient for successful treatment. It's far more important to understand the effects of starvation on the brain and the resultant biochemical changes that affect behavior. Anorexia is a complex, multifaceted disorder with genetic, psychological, biological, and subsequent malnutrition associated with self-starvation that ultimately contributes to the clinical symptoms observed as well as the difficult and lengthy recovery process. Treating only the psychological components of the illness without addressing the fact that the brain and body are malnourished is not enough. To ensure recovery, the malnourished brain needs to heal with nutritional restoration of essential minerals, vitamins, and fatty acids. For many clinicians around the world, however, these simple common-sense concepts have been referred to as "controversial."
The goal of eating disorder treatment is to appreciate the unique genetic and psychological complexity of each individual. As science and technology evolve, new treatment approaches like rEEG and targeted nutritional therapy bring hope for the future.
References available at www.jamesgreenblattmd.com.
Dr. Greenblatt is the founder and medical director of Comprehensive Psychiatric Resources, a private integrative psychiatric practice (www.comprehensivepsychiatricresources.com). Dr. Greenblatt also serves as an assistant clinical professor at Tufts Medical School. His books, Answers to Anorexiaand The Breakthrough Depression Solution, draw on his many years of experience and expertise in integrative medicine and treating eating as well as mood disorders.
Dr. Greenblatt lectures extensively throughout the US on integrative therapies for mental health. He educates professionals in integrative psychiatry through individual and group supervision programs. Contact him at: Comprehensive Psychiatric Resources, 203 Crescent St., Suite 110, Waltham, MA 02453; 781-647-0006.