HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)
_REVIEW_
Contribution of social and family factors in anorexia nervosa Greta Wozniak1, Maria Rekleiti2, Zoe Roupa3 1. MD, PhD, Nursing Department, Applied University of Larissa, Greece 2. RN, MSc, General Hospital of Korinthos, Greece 3. RN, MD, PhD, Professor Coordinator for the Nursing Program School of Sciences, European University, Cyprus
ABSTRACT Background: Anorexia nervosa is probably the most substantial eating disorder, with basically unknown causes, centered on psychological factors and affected by many social, biological and cultural ones. The aim of this study was to emerge the complex issues regarding the treatment, the early intervention and the prevention of the anorexia nervosa. The method οf this study included a search of the literature in several databases (Medline, EMBASE and CINAHL) to identify articles related to anorexia nervosa. Results: Patients with anorexia nervosa develop a refusal in ingestion of food, maintaining a distorted self-perception of their body, considering themselves as overweighed. The diagnosis even though is made according international established criteria, varies among the patients taking into consideration additional factors like family and social environment. As the patients refuse to admit the seriousness of their condition, they seek for medical assistance when disorders appear in vital organs, due to de-nutrition. In most cases hospitalization is necessary and includes a suitable diet program and medication treatment. Conclusions: Psychological therapy is a basic part of the treatment, in long-term basis and is employed by behavior therapy and the patient's support. Advising the public and especially parents with children in adolescence, where usually anorexia nervosa occurs, is necessary as the prevention and the early diagnosis is the best treatment. Keywords: Anorexia nervosa, treatment, prevention. CORRESPONDING AUTHOR
Greta Wozniak, MD, PhD Applied University of Larissa Larissa, GREECE, Phone: +30-2410 – 684252 Fax: +30-24210 - 72462 E-mail:
[email protected]
INTRODUCTION
D
isorders in food injection have
last years due to the constantly increased
raised the interest of scientists the
number, mainly of women, that report Page | 257
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severe behavioral problems regarding the
melancholy
and
usually
appears
to
7
food. Two clinical syndromes appear in
sexual immature females.
adolescent
Anorexia nervosa is more commonly
and
adult
age:
Anorexia
Nervosa and Bulimia nervosa.1
appeared during
the recent decades
Anorexia nervosa appears at a rate of 80-
comparing
former
85%, in young women at the age of 12-
reported in females in preadolescence
25 years old, in the middle and upper
age and males. Epidemiological data
socio-economic
report that eating disorders climb up to
profession
a
status,
whose
appearance
ones,
and
and
4% in adolescent females and anorexia
thinness are considered as a professional
nervosa is estimated that appears at 0.5-
and especially desirable requirement,
1% in the same group. It occurs 10-20
while the small male percentage that
times more in females than in males and
suffer
mainly at developed countries, (western
from
good
in
with
anorexia
nervosa
exercising.2,3
compulsive
with
Although
countries).8
anorexia nervosa is described as primary,
Study
many patients may suffer from medical
children come from families that have
disorders,
neurosis,
lost a member, they have been abussed.9
and
depressive
Respective studies reach the conclusion
of
emotional
that the 1/3 of the anorectic patients
psychosis,
personality
disorders
inclination
with
lack
results
show
that
anorectic
expression.4
have
Anorexia nervosa is characterized by
childhood
severe and serious disorders of self-
common
perception
the
abused victims, like low self-esteem,
determined pursuit of thinness.5 It was
feelings of shame and a negative attitude
described for the first time by Morton in
towards their body and the opposite
1689, and was a subject of study in the
sex.4
middle of last century, as a form of
Although the mental, social and physical
hysteria.
was
consequences are particular serious, the
described as a hereditary abnormality of
scientific studies are few and there is a
the central neurological system that
considerable delay in elaboration of
appears only to young females6. In 1883
proof based approaches, especially for
Huchard established the term "anorexia
children and adolescents, in spite the
nervosa" and Freud (1895) suggested
fact that eating disorders occur to this
that
age groups.10-12
of
At
their
first
anorexia
is
body
the
and
disorder
associated
with
been
sexual
and
they
abused seem
characteristics
Contribution of social and family factors in anorexia nervosa
during to
with
have sexual
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HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)
The social conventions and the emphasis
mother associated with the occurrence
to external appearance, that influences
of the disorder to children and especially
mainly
to adolescent females.13
young
associated
people,
with
eating
are
factors
disorders
in
Psychical theory
addition with advertisement and the
According to Bruch (1982) the psychical
contribution of mass media projecting
factors associated with the appearance of
anorectic models as the only way to
the disorder are:
success, the non-acceptance of other
1. Adolescent crisis and new experiences,
values like educational, cultural, social
as inclinatory factors
enlarge the problem. The modern society
2. Raising a child that is only ostensibly
enervates family bonds and reduces the
"normal". They usually hide behaviors
time spent between parents and children,
with lack of recognition, enhancement
setting new priorities, altered from those
and confirmation of child's abilities.
of previous generations.
3.
Purpose of this study is to highlight the
mechanism,
complex
the
control of the body, as an effort to
treatment, the early intervention and the
maintain a level the dominance over
prevention of the anorexia nervosa.
their selves.14
Etiology
issues
of
concerning
anorexia
nervosa
and
The
preponderant which
is
psychological the
complete
Social-Psychological factors
associated factors
Many scientists ascribe the disorder to
The causes of anorexia nervosa are multi
psychological and social mechanisms.
factored and there are many relative
They
theories from the scientific community.
seems to be a reaction to the demands of
It is supported that the disorder is
adolescence for more independence and
caused by a coalescence of biological,
increased social and sexual activity. In a
social-cultural
way,
and
psychological
-
believe
patients
that
anorexia
through
the
nervosa
disorder
psychical factors. There also the view
replace the normal adolescent quests
that the causes of anorexia nervosa are
with the constant concern of food and
only psychical or that there is no clear
control of their body weight. They report
evidence
that there are troubled relationships
regarding
the
exact
pathogenesis that induces the disorder.
between
parents
and
the
anorectic
But all scientists agree at the significant
children try to draw their attention. In
role of the family and particularly the
patients' family history are mentioned Page | 259
E-ISSN: 1791-809X
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Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens
cases of depression, alcoholism, and eating disorders.
15
the causes of anorexia nervosa. They believe
that
the
importance
of
Biological factors
psychological,
1. Heredity: Anorexia nervosa is reported
factors
in significally higher frequency among
Biological factors may be associated with
individuals that are biological related to
hormonal changes that occur during
anorectic patients and in genetic level
adolescence. Psychological mechanisms
there are evidence that it is occurred at a
may be involved in the changes in
rate of 50% between identical twins and,
personality and behavior during the
at rate of 10% in fraternal twins or twin
human life and social factors may be
sisters.
related with the idealization of thinness,
2.
Neurochemical
factors.
Biological
theories are focused in the function of hypothalamus,
where,
based
that
social
varies
plays
a
to
and each
powerful
biological individual.
role
in
our
culture.18,19
on
observations and clinical results, there is
Beginning and probability of prognosis
a protogenic dysfunction. Over-secretion
of anorexia nervosa
of cortisol is detected to malnutrition
Few data are available by researchers
and depression. There are increased
regarding the onset of the disorder. 85%
corticotropin
is
of the incidence is detected between 13-
released to cerebrospinal fluid of these
20 years of age, with adolescence being
patients. Also amenorrhea is reported
the most critical period of lifetime, and
before the occurrence of weight loss. An
the
increased level of ceretonin in brain
disorder after the age of 40 almost non-
reduces the appetite, and leptin seems to
existent,
have an important roll in regulation of
disorder is often
fat sites in the body, and as a result to
stressful event. The prognosis of the
the regulation of appetite. Anorexics
disorder is extremely difficult to be
have lower leptin levels in blood that are
defined, as it is influenced by the
increased with the temperature rise.16,17
structure of personality. Persons that are
Theory of unknown etiology
hysteric, with intense obsessions, and a
Group of scientists support the view that
bad
anorexia nervosa is an open question in
relationship, are very likely to develop
medicine and there is no psychiatric
the disorder in future. Also individuals
theory to support sufficiently by its own
with family history of anorexia nervosa,
CRG
levels
and
it
probability also
of
the
developing beginning
of
the the
associated with
background
Contribution of social and family factors in anorexia nervosa
of
a
maternal
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HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)
or
with
medical
history
of
diseases are at the same risk.
serious
20,21
anorexia nervosa are discriminated to medical complications of the disorder, including
Progress
and
prognosis
of
anorexia
hypokalemia,
bronchopneumonia, cardiac arrhythmia,
nervosa
coronary disease, pancreatitis, necrotic
Anorexic patients ask for medical advice
colitis and suicides.25
long after the appearance of very serious symptoms, many of them unwillingly,
Symptoms and behavior characteristics
after their family encouragement. The
The self-enforcement starvation of the
progress of the disease varies, from
patients, who are not having disorders in
immediate recovery after the treatment,
appetite, and are visibly obvious, causes
to unsteady progress of weight recovery
the
with recurrences, and to constant fatal
behavioral and physical changes.
aggravation. Studies report that the 1/3
Behavior of anorexic
of the patients is cured, at the 1/3 there
Anorexic persons have a disorder image
health condition is improved and at 1/3
of the normal weight and shape of the
the disorder becomes chronic.22
body and they consciously chose ways
Generally the prognosis is not good. The
for weight loss that gradually lead to
extended
disease,
dying. They seem to have obsessive
depression, frequent vomits and the
characteristics, high sense of duty and
excess
morality
duration weight
of
loss
the are
negative
symptoms
of
and
the
an
disorder
inclination
by
to
prognostic points, including hospitalized
independence. At the beginning they are
treatment, sensitivity to various diseases,
intensively busy preparing their meals,
and
family
with
intense
and they avoid high calorie foods, weight
As
positive
at least four times daily, and follow strict
prognostic points are considered the
exhausting diets.26 After a while they are
reduction of stress, a strongly supportive
entering the second phase, where their
family and friendly environment, and
behavior constantly changes, the family
also strongly structured personality.3
begin to realize the problem, although
The mortality of the hospitalized patients
patients still deny it and refuse any
is more 10% due to either excess weight
conversation about it, as a result there
loss or inanition or to suicide attempts.24
are
The causes of death in patients with
members, and gradually they become
psychopathology.
23
daily
conflicts
within
family
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Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens
isolated. Their interest for any kind of activity is lost and reduced, their ability
Diagnosis of anorexia nervosa
to concentrate is reduced as well as their
The patents with anorexia nervosa seem
sexual activity. The patients adopt a
to have a certain behavior regarding the
contrary behavior, obstinacy, laziness,
shape
emotional instability and detachedness.27
Diagnosis of anorexia nervosa is based
Physical symptoms
on diagnostic criteria established by
Abrupt weight loss at a rate of 25% of
American Psychiatric Association (DSM-
the normal body weight, initially in
IV) that are in valid worldwide and are
males
referred
causes
delay
in
stature
and
and
weight
of
to
their
body.
psychopathological
pubescence and in female’s amenorrhea,
symptoms and signs and to evidence of
and in
endocrinologic disorders (Table 2). 33
both
metabolism.
sexes
In
continue
deterioration depression,
reduced
of
thyroid
occurs
body’s
intense
the
shape,
xerodermia,
Treatment
approaches
of
anorexia
nervosa
intolerance of high and low temperature.
There
Gradually
getting
treatment of anorexia nervosa. The first
thinner and the presence of lanugo (hair
is to rehabilitate the state of nutrition.
that looks like neonatal lint) becomes
For anorexic patients this means to
obvious on face, shoulder blade and
regain the body weight to normal levels.
hands
The
head’s
as
inflammation
well of
hairs
as
are
inflation
salivary
two
second
main
aim
is
aims
to
in
alter
the
the
As
pathological behavior of eating, so that
organism tries to adapt with low intake
the body weight is preserved to normal
of energy, appears a variety of organic
limits and to control the use of laxatives
disorders,
and other pathological behaviours.34
such
as
glands.
and
are
bradycardia,
arrhythmias and decrease of arterial
Usually
blood pressure having as result periods
outpatient
of
hospitalization is a severe weight loss
hypotension.
dental
problems,
formicary,
It
exceeds hands’
inflexibility,
anemia,
and
legs’
stress
and
anorexia
and
is
setting.
treated
in
Evidence
emaciation,
an for
hypotension,
hypothermia,
electrolyte
upheaval, insomnia and early awakening.
presence
suicidal
During laboratory testing the endocrine
psychosis, and the failure outpatient
disorders become obvious by disorders at
treatment.
hormonal prices (Table 1).30-32
The
of
treatment
disorders, ideation
approach
Contribution of social and family factors in anorexia nervosa
is
or
a
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HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)
combination of behavior therapy and supportive psychotherapy.
35,36
The
modern
social
models
idealize
It is very
women with low body weight, with
important the approaching way of the
result the increasing number of incidents
person, in order to develop positive
of anorexia nervosa, especially among
behavior. This includes the learning of
adolescents. Long-term aim should be
behavior, and then follows de learning
the reducing effects of eating disorders
and relearning,
and the associated risk factors.
causes
of
the
without seeking the previous
pathologic
Scientists
emphasize
the
need
of
behavior. The aim of this behavior
encouraging the patients to seek therapy
treatment is to restore the normal way of
and to treat them with understanding,
eating. In
37
while the goals and limits of treatment
hospitalized
treatment
a
strict
are attainable. Also, they suggest specific
protocol is followed to anorectic patients
instructions regarding the level of the
in order to gain a certain weigh daily,
needed treatment to psychological and
regarding the intakes and outtakes of
behavioral
calories, and there is a close monitoring
anorexia
till 2 hour after the meal, to avoid
professionals should realize that the
induced vomiting to patients with excess
recovery of the disorder is a slow
weight loss.
procedure.
issues nervosa.
that All
characterize the
medical
The financial cost for this kind of Conclusions
disorders is high and onerous for the
Although there is a significant progress
families of the patients. Beside the long
in treatment of anorexia nervosa, the
period of time, there are many variations
conclusions, of the few studies during
in the force of the disease, and many
the
times hospitalization is necessary and
last
decade,
have
showed
a
wackiness in research, as it seems that
treatment
the ways of developing prevention and
multidisciplinary team of professionals
treatment programs of anorexia nervosa
for the patients and their families.
are not connected with the risk factors
Anorexia nervosa is a psychiatric disease
and the necessity of finding a treatment
with high mortality rates in young
approach that combines the traditional
patients. It is need the state to organize
methods of therapy with new ones, and
units for patients with eating disorders
this due to limited knowledge.
and
to
is
fully
common
cover
to
engage
treatment
a
and
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Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens
hospitalization. The public information is
6. Silverman JA. Richard Morton's
essential and especially to parents with
second case of anorexia nervosa:
adolescent children, as we believe that
Reverend Minister Steele and his
prevention and early recognition of the
son - An historical vignette. Inter J
problem are better than treatment.
Eat Disord, 2006; 7(3): 439 – 441. 7. Habermas
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adolescents with eating disorders. Curr Opin Pediatr, 2009; 21(4): 457-64. 47.Pratt
BM,
Woolfenden
SR.
Interventions for preventing eating Page | 267 E-ISSN: 1791-809X
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Quarterly scientific, online publication by Department of Nursing A’, Technological Educational Institute of Athens
ANNEX Table 1: Abnormalities in Anorexia Nervosa
FUNCTIONAL SYSTEM
FINDINGS
Endocrine metabolic
Normal thyroid gland Normal TSH* Decreased T3 and BMR Increased serum cholesterol Normal pelvic examination results Decreased FSH, LH, response to LHRH Decreased estrogen production Increased cortisol and urine free cortisol ACTH normal or increased Decreased suppressibility by dexamethasone Decreased serum insulin and RBC insulin bitting GTT flat or diabetic Salt and water balance maybe abnormal Deficient ADH Normal or increased serum GH Decreased GH response to glucagon, propranolol, TRH and levodopa Decreased, increased or normal serum Ca ++ and PTH
Hematologic
Anemias Leucopenia Thrombocytopenia
Miscellaneous
Increased ESR (mild) Decreased serum albumin Changes in serum globulins
Contribution of social and family factors in anorexia nervosa
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HEALTH SCIENCE JOURNAL® Volume 6, Issue 2 (April – June 2012)
Table 2. Diagnostic criteria DSM-IV for anorexia nervosa (APA, 1996) DIAGNOSTIC CRITERIA
The refusal to maintain body weight at or above a though the person is underweight
DETERMINATION
A) Restrictive type Β) Hyper-appetite/ Purgative type
Excessive fear of weight’s increase or fear of fat although the individual is thin
Grossly distorted self-perception regarding the weight or the shape of the body.
Amenorrhea, for at least three consecutive periods.
Page | 269 E-ISSN: 1791-809X
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