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Initial Stage: Common physical symptoms
In the initial stage of anorexia nervosa, physical symptoms are linked to body weight loss, food restriction, excessive exercise, interrupted menses, and inadequate nutritional status.
Initial Stage: Weight preoccupation
Females are typically hypersensitive to developing breasts and hips. Appearance of these adult female sexual characteristics causes panic among vulnerable adolescents. In some cases adolescents with anorexia nervosa are overweight when the disorder begins. They may recall a chance statement about their weight by a relative or close friend, or a suggestion about a weight reduction plan by a health professional, as the trigger for their initial food restricting behavior.
Initial Stage: Dietary behaviors
The adolescent with anorexia nervosa usually develops a personal philosophy about her diet, limiting herself by eating food only from certain categories and in certain ways. She especially limits total food energy and fat consumption, and may manipulate the fiber, fluid or sodium content of her diet. In addition, she may force herself to vomit or misuse laxatives and/or diuretics to rid herself of ingested food energy and body fluids. Vomiting may follow episodes of binge eating, and be followed in turn by fasting.
Initial Stage: Exercise habits
The type and amount of activity they engage in also varies but teenagers with anorexia nervosa ritually perform excessive calisthenics and other strenuous activities. They are drawn to high risk and solitary activities rather than team sports (They often deny fatigue and may limit rest and use stimulants). They are so frequently involved in junior and senior high school athletics and dancing that coaches and teachers should be educated about the disorder. Knowledgeable adults, teachers and coaches recognize an eating disorder is developing when a student exercises to her/his detriment, training compulsively beyond reasonable endurance while rapidly losing or maintaining an unhealthy weight.
Initial Stage: Menses
It is well known that adolescents (as well as older women) in a state of starvation are amenorrheic. Psychological changes and physical stress interfere with endocrine regulation of the menstrual cycle. Cessation of menses occurs in about one third of adolescents with anorexia nervosa before they have lost sufficient weight and body fat to cause the interruption, however. Further, amenorrhea often lasts beyond the point when they have regained close to normal weight and body fat. This indicates both physical and psychological aspects of the disorder contribute to the complicated mechanisms underlying amenorrhea. It is also clear that malnourished young women will not experience menarche. When energy is inadequate to fuel all body processes both males and females shunt the scarce resource to life-supporting, as opposed to reproductive, functions.
Initial Stage: Nutritional status
In the initial phase of anorexia nervosa, semi-starvation does not appear to effect the body measurably other than through weight loss. Stored fat and muscle components as well as the total body register the loss. The short-term nature of the starvation apparently does not lead to the same synergism between malnutrition and infection seen in populations chronically in semi-starving conditions. Deficiencies in specific nutrients have not been reported, possibly because the catabolic state decreases requirements. The increased demand for nutrients (especially minerals) in adolescence is reason to be concerned about sub-clinical and long-term deficiencies, however. Symptoms of severe starvation may become apparent if weight loss continues unchecked. Nutritional problems listed in the Crisis section undermine basic health, indicating a life-threatening crisis.
Initial Stage: Intervention strategies
When anorexia nervosa first appears, a team of experts will need to assess the situation and determine the most appropriate treatment. Initial actions will be planned to avert a serious threat to health. All members of the family will need to work with the therapeutic team to accomplish this goal.
Initial Stage: Timely recognition of symptoms
Recognizing the symptoms of anorexia is the most important early intervention strategy. Friends, school personnel, family and health professionals who are alerted by developing problems can take steps to initiate treatment. Younger people do not always fulfill all the diagnostic criteria of an eating disorder. The possibility of a disorder should not be dismissed if all symptoms do not perfectly fit. Symptoms, attitudes and behaviors that are detrimental to health should be treated whenever they are identified. See Eating Disorders not Otherwise Specified described in Prevalence, Chapter 1.
Initial Stage: Psychotherapy
Individual and family psychotherapy by experienced mental health care providers will enable both the affected adolescent and her family to adopt more appropriate attitudes and behaviors. In therapy, families learn to support the physical and psychological development of their children. With support the adolescent can give up harmful habits as she matures.
Initial Stage: Medical nutritional therapy
Initially, the nutritionist on the health care team will assess and monitor the adolescent’s nutritional status, helping to determine her overall state of health in order to establish a diagnosis and therapeutic goals. The nutritionist will also begin to correct the adolescent’s misunderstandings about nutrition and help her modify her eating habits to meet her physical needs. Nutritional counseling should take advantage of the adolescent’s ability to change rather than impose a rigid system of dietary planning by a professional. A strong and more directive stance will need to be taken if no readiness for change can be identified.
The disorder should not be defined as solely a nutritional problem, although nutritional counseling is an important component of comprehensive therapy. Refocusing, through psychotherapy, on primary emotional and interactional problems rather than the power struggle over food and exercise patterns will often enable the adolescent to gradually abandon her compulsive striving for thinness. She can begin to devote her energy to recovery.
Initial Stage: Progressing from initial to crisis stage
Avoidance of intervention or lack of progress during initial therapy usually leads to physical and mental deterioration. With this crisis stage of anorexia nervosa, intervention must be directed toward both the psychological and physiological symptoms, which are severe.
Crisis Stage Anorexia Nervosa in Adolescence
Crisis Stage: Psychological effects of starvation
A crisis associated with anorexia nervosa can cause great distress among family, friends, and professionals. The family may believe the adolescent’s abnormal eating behaviors are the sole problem, failing to understand the underlying multifaceted disturbance. They may seek treatment that does not require them to be involved in psycho-therapy. As she becomes truly cachectic, specific characteristics of starvation are superimposed on the already disturbed psychological state of an adolescent with anorexia nervosa. Unhealthful behaviors, distorted perceptions, and weight phobia become more pronounced. The symptoms below, termed starvation neurosis, and documented in a classic study by Ancel Keys et al (in The Biology of Human Starvation, U of Minn. Press, 1950, vol. II) of volunteers who underwent starvation designed to mimic conditions in Europe during World War II, are clearly seen in the syndrome of anorexia nervosa.
- Cognitive processes center on food. Thoughts of food intrude constantly; the major part of the waking hours are spent in contemplating it.
- Behavior includes toying with food and hoarding it, especially during re-nourishment.
- Coherent, creative thinking is impaired.
- Mental function is characterized by apathy, dullness, exhaustion, and depression.
- Interest in sex wanes.
Crisis Stage: Behavior pattern
Most adolescents with anorexia nervosa resist what they see as intrusions by professionals or others seeking to intervene. They are secretive and hide their rituals. They may appear apathetic but have sudden flashes of bad temper, as starving people of all ages usually do. Adolescents with anorexia nervosa may obsessively plan menus, read recipes, cook and serve food to others, manipulate food before eating it, and record all that they eat. They frequently recite “calorie” and fat content of food, but have distorted views and knowledge of nutrition. Pretending to eat, they may hide and dispose of food. These behaviors are driven by the disturbed adolescent’s fear of gaining weight which intensifies in a crisis.
Crisis Stage: Overall physical state
In the crisis stage of anorexia nervosa, the adolescent’s physical state deteriorates. Electrolyte and cardiac abnormalities are among the signs that starvation is approaching a life threatening stage.
Crisis Stage: Physical signs of starvation
As the crisis stage develops, the individual is unable to take care of herself. The physical symptoms of human starvation are now superimposed on the other problems inherent in the disorder. Physical signs of starvation commonly seen in adolescents with severe anorexia nervosa include:
- Fat store depletion
- Muscle wasting
- Skeletal appearance (cachexia)
- Amenorrhea/delayed menarche
- Fainting (postural hypotension)
- Irregular pulse/heart beat (cardiac arrhythmia)
- Fissures at corners of mouth (cheilosis)
- Yellowed skin (carotonemia)
- Dry, scaly skin
- Fine downy hair (lanugo) growing over body (hirsutism)
- Thin, dry, brittle hair
- Loss of hair from head (alopecia)
- Degradation of fingernails
- Bluish tips of fingers and ear lobes (acrocyanosis)
- Feeling extremely cold or hot (inability to regulate body temperature)
- Frequent night urination (inability to concentrate urine)
Crisis Stage: Currently studied nutritional problems
In acute and severe human malnutrition, all body tissues are affected. Recent research has focused on bone demineralization, growth failure, and structural changes in the brain of severely malnourished adolescents. Intra-cranial cerebrospinal fluid spaces enlarge in adolescents with anorexia nervosa, meanwhile brain tissues change. Adolescents with anorexia also suffer reduced bone mass, delayed pubertal development and fail to reach their potential height. Studies relate these detrimental symptoms specifically to lower than normal body weight-for-height and document improvement with re-nourishment. The possibility that certain of the brain, bone and growth abnormalities are, however, irreversible is of special concern and dictates ongoing monitoring and aggressive early treatment. The seriousness of damage to the brain and bone documented to the present indicates that the effects of semi-starvation during adolescence on all body tissues should be studied.
Crisis Stage: Endocrine abnormalities
Adaptations to starvation by the hypothalamus result in extensive alterations in the body functions it controls in, a pre-pubertal state in adolescents with anorexia nervosa. The adolescent with anorexia is amenorrheic, is unable to adapt to heat and cold, suffers sleep disturbances, and is unable to conserve body water. The inability to maintain adult levels of sexual hormones could account for the lack of interest in sex described in anorexia nervosa since the earliest recorded cases.
Crisis Stage: Terminal starvation signs
During a crisis when basic life is threatened, professionals monitor the adolescent’s vital signs and take remedial action . The most outstanding signs that starvation has reached a life threatening stage depend upon the specific type of starvation include now identified:
- Fluid and electrolyte imbalance, with dehydration and edema, indicating the body cannot maintain homeostasis
- Severe cardiac arythmias in the absence of electrolyte imbalances, indicating a wasted myocardium
- Absence of ketone bodies in the urine, indicating a lack of fat used for metabolic fuel, when normal sources are restricted and therefore absence of fuel
- Bloody diarrhea, indicating intestinal tissue damage
Crisis Stage: Intervention strategies
When the adolescent’s condition reaches the crisis stage, health care team must intervene. Hospitalization provides the protection and comprehensive care needed. Intensive interventions are necessary when outpatient treatment has failed or when there is evidence of medical or psychiatric deterioration. The goal will be to treat life threatening symptoms, and nutritionally rehabilitate the adolescent. Psychotherapy supports nutritional and medical stabilization during hospitalization. Following rehabilitation adolescents make even greater psychological gains without the effects of semi-starvation neurosis.
Crisis Stage: Hospitalization
Young people require hospitalization to obtain intensive monitoring and care in order to avoid suffering long-term damage caused when semi-starvation is severe and prolonged. The health care team specializing in treating adolescents with eating disorders will need to work with a trained inpatient staff to achieve the best results from inpatient treatment. The augmented team, experienced in dealing with adolescents, will understand the developmental issues as well as the physiological needs of adolescents. Goals of hospitalization will be to:
- medically and nutritionally stabilize adolescents
- eleminate starvation neurosis so adolescents can progress in outpatient psychotherapy and other treatment following discharge
- help adolescents internaliz the need to regain health by eating sufficient food to meet body needs
An intensive program will guide the adolescent initially, providing incentives within a safe environment for her to assume as much responsibility as she is able. The clear documentation of altered brain and bone stucture, as well as potential retardation of overall growth and develoment constitute an imparative for early specialized intervention.
Crisis Stage: Specialized Day-Treatment facilities
In some situations health care providers may decide a day-treatment intervention is appropriate for an adolescent who can be medically and nutritionally stabilized in a slightly less intensive therapeutic setting. These programs incorporate treatment methods developed in hospital settings and allow adolescents to experience moderating their behaviors in a real world setting. At reduced cost, these programs monitor and guide adolescents while they participate in psychotherapeutic and educational groups as well as attending school. Adolescents are thus supervised during nutritional rehabilitation, yet able to live at home with their families.
Crisis Stage: In-Home Care
Health care providers may determine outpatient care programs are appropriate for affected adolescents and their families in some situations. The treatment team is multidisciplinary as in other settings. Monitoring and treatment sessions at clinics will be frequent. Parents have a major responsibility for carrying out the program at home with the guidance of professionals. The treatment team will support the family in offering food, maintaining prescribed energy expenditure limits, and developing appropriate inter-personal interactions. Parents must also be taught to recognize sudden downturns in the adolescent’s physical status and how to access emergency care. Weight restoration will be prolonged in these circumstances, as the family learns what is necessary to promote recovery.
Crisis Stage: Comprehensive treatment
In a crisis it is essential that care be comprehensive and provided by an experienced multidisciplinary team. All professionals and family who have contact with the adolescent will need to understand and support the treatment plan. Physicians will manage overall care, monitoring symptoms and progress. Nutritional components of therapeutic regimens for anorexia nervosa adolescents in the crisis stage are intertwined with the psychological aspects of the treatment. Nutritional rehabilitation principles apply regardless of the treatment setting. Treatment teams often use a behavioral contract to establish the core relationship between state of wellness and allowable adolescent activities. Professionals, parents and the adolescent will sign the contract, confirming the weight gain required to justify energy expenditure in unnecessary activities. At this stage, speaking with family and friends, using the telephone, and getting out of bed for the bathroom are included as part of the controlled energy expenditure. Even these basic activities may have to be limited to building up the body energy supply. Therefore, adolescents who do not eat will be kept at bed rest at this stage, and monitored, whether in a hospital or other setting.
Crisis Stage: Medical nutritional therapy
Nutritional therapy is based on classic principles of nutritional rehabilitation for starving humans. Re-nourishment obviously will begin with a gradual increase in energy intake. In some programs the adolescent will be allowed to choose anything available to other adolescents (or family at home). Other programs impose rules, make additions to what is ordered, or serve a set menu. If a diet is prescribed, following established dietary principles, it should have adequate protein to meet basic needs. Additional energy will be made up of complex carbohydrates and a small amount of fat. Sodium and sugars should be moderated as they may enhance fluid retention. Fibrous foods should be included to achieve bowel regularity, with the added caution that adolescents may experiment in using excessive amounts of fibrous foods as laxatives. The overall diet should be rich in micro-nutrients, especially calcium and iron. Supplemental vitamins and minerals can be given in amounts recommended for daily intake, though these are not routinely prescribed. It should be clear that taking vitamin supplements does not substitute for eating regular food.
Crisis Stage: Nutritionally complete liquid formula
If an adolescent refuses to eat normal food, a nutritionally-complete-liquid formulated for adults, prescribed and dispensed as a medicine, may be used. If the adolescent refuses all oral feedings it may be necessary to use nasogastric or parenteral methods. Invasive methods will be presented as lifesaving procedures, not as punishment for refusing to eat. Nourishment by mouth is the preferred route and is possible in most cases.
Crisis Stage: Body responses to re-nourishment
People being rehabilitated after starvation, as well as those reaching a starving state, generally develop edema. Because anorexia nervosa adolescents fear gaining weight, swelling with fluid increases their anxiety. The edema seems to an adolescent to be proof that she will “expand” as she feared. Anticipatory guidance can help her accept edema and other temporary body changes during refeeding. Assurance that professionals will guide her in gaining strength without adding excess fat can desensitize her to an increase in body size. The intervention team will reinterpret nutrition misconceptions that have supported a adolescent’s life threatening behaviors. Thus, adolescents can be reminded that:
- Storing calcium in bones and replenishing nutrients in the brain will increase weight but not body size.
- Nutrients filling up shrunken cells maintain normal life, they are not “fat”.
- A person must have stored energy to keep him/herself strong enough to live.
Long-Term Recovery Stage Anorexia Nervosa in Adolescence
Long-Term Recovery: Role of the clinical nutritionist
The clinical nutritionist/dietitian on the therapeutic team provides nutritional care while working within the framework of mutually established psychotherapeutic goals. The focus of the adolescent’s energy is directed away from food phobias toward recovery. Techniques developed by the social sciences and experience in modifying the disordered eating behaviors and attitudes help accomplish this. The nutritionist’s knowledge of energy balance applied to an individual adolescent’s needs is required to establish dietary intake and nutritional rehabilitation goals throughout therapy.
Long-Term Recovery: Psychosocial issues
The adolescent with anorexia who has recovered from a starvation crisis will still have to overcome the developmental arrest that brought her to the crisis. Several years are usually required for recovery. The adolescent will need to solve problems concerning choice and preparation for a vocation, financial support, and relationships with peers (including the opposite sex), along with maintaining adequate nourishment and accepting her inherited physique.
Long-Term Recovery: Physical issues
Before fully recovering from anorexia, adolescents will often experience wide swings in weight from extreme thinness to obesity, and some may develop bulimia. An adolescent may see herself as somewhat detached from her body and experiment with extreme food habits before adopting a more reasonable perspective. By restricting food and experiencing stress she may not regain her menses as soon as expected. She may feel bloated and have bouts of edema as physical responses to starvation and refeeding. Until she is fully nourished her skin may be yellow from time to time as result of carotenemia.
Long-Term Recovery: Intervention strategies
During recovery the psychotherapeutic goal will be to facilitate normal physical and psychological development, preparing the adolescent for a full healthy adult role in society. True psychological maturation will enable her to function without depending on unhealthy eating and exercise habits. Nutritional counseling will provide her with needed information and retraining about food and the physical aspects of life; education regarding healthy weight management techniques will also be useful. Issues such as the level of nourishment necessary to maintain the menstrual cycle will resurface from time to time, as cognitive and emotional development proceeds. Returning to such issues will enable her to deal more capably with them as she matures. Guided experiences in eating out, grocery shopping, cooking, and entertaining, prepare adolescents to manage food in the environment without overfocusing on it. A team of psychological, nutritional and medical specialists will provide necessary care, and monitor her progress toward recovery.
Long-Term Recovery: Final outcome
Strong resistance to treatment and a high incidence of relapse and partial recovery are common outcomes of anorexia nervosa in adolescents. Many will retain symptoms into adulthood. Results of outcome studies reported to date indicate that although weight-for-height-for-age proportion improved in a majority of the adolescents, menstrual cycles were often unsatisfactorily maintained, ideas about food and weight remained disturbed, and psychosocial maladjustment was common. The relationship of depressed body weight to depressive symptoms, as well as to sex role and body image distortions, and the observation that fewer than the expected number of children are born to adolescents formerly diagnosed with anorexia nervosa, are equally disturbing.