|Classification according to ICD-10|
|F50.1||atypical anorexia nervosa|
|ICD-10 online (WHO version 2019)|
Anorexia nervosa ( Greek / Latin : roughly translated as "nervous loss of appetite") or anorexia is a form of eating disorder . Affected people have a disturbed perception of their own body and refuse to eat for fear of gaining weight.
Other names are also anorexia mentalis ( mental anorexia ), apepsia hysterica or outdated anorexia hysterica (in the 19th century). Anorexia nervosa is not synonymous with the term anorexia , which only describes a general loss of appetite, regardless of the cause.
The historian Olwen Hufton writes that probably some of the "holy" Women of the early modern period, who indicated that they do not need food or only hosts to live, suffering from anorexia.
This eating disorder was first diagnosed and described in 1689 by the English doctor Richard Morton. The second published work on anorexia nervosa, at that time still under the name Anorexia hysterica, comes from the Englishman William Gull . He published three case reports in 1868 . He concentrated on the description of somatic (physical) changes.
In 1873 the French internist Ernest-Charles Lasègue described anorexia hysterica as a uniform clinical picture on the basis of eight cases . Lasègue distinguished the symptoms from extreme fasting by emphasizing the overactivity of the sick people.
The anorexia hysterica making it the first and entity described eating disorder , both authors emphasized the psychogenic context of the disease.
Anorexia nervosa has an estimated incidence ( prevalence ) of 0.7% among female teenagers . Although it is less common than bulimia (eating and vomiting), it is not uncommon for severe physical complications to have a significantly less favorable course. The disease most commonly begins in teenagers, although a diet that subsequently gets out of control can be a starting point.
However, the disease can also occur in adults or even before puberty . Only one in twelve sufferers is male; In recent years, however, anorexia nervosa has also been diagnosed more and more often in male patients. Perhaps this is not due to an actual increase in the number of men affected, but rather to the fact that parents are increasingly looking for help for sons.
Most people with anorexia nervosa suffer from a body schema disorder : They perceive themselves to be "too fat" despite being underweight or being thin. Your self-esteem depends not only on general performance at work, hobby or private life, but also to a particularly large extent on your ability to control your body weight. The thoughts of the sick are restricted and always revolve around the topics of nutrition , weight and body diagram.
“The anorexic woman refuses to eat and is more concerned with it than most gourmets. [...] She rejects her body, but concentrates on it in all of her thoughts and actions. [...] She wants to be independent and independent, but behaves in such a way that her interaction partners almost inevitably control her. "
The hallmark of anorexia nervosa is the self-induced weight loss, which is achieved by reducing food intake; especially foods that are considered to be "fat making" are omitted. Those affected who only show this passive behavior are referred to as the restrictive subtype .
But there is also a “ purging type” of anorexia nervosa similar to Bulimia nervosa (English: to purge = to carry away). Those suffering from this subtype also actively accelerate their weight loss: For example, through self-induced vomiting, improper use of appetite suppressants , laxatives (laxatives) or diuretics , use of enema (enemas) or excessive sporting activity.
The diagnosis is made based on the result of various examinations:
- physical ( clinical ) examination revealing many of the symptoms mentioned
- Paraclinical examinations, such as electrocardiograms and laboratory blood tests
- Creation of a so-called psychopathological finding as part of the anamnesis
If it is suspected that other causes have caused the underweight, further investigations will be initiated. The main distinguishing feature ( differential diagnosis ) from bulimia nervosa is body weight. Anorexia nervosa is diagnosed if the patient is self-induced underweight and the body mass index is below 17.5.
The following criteria must be met for a diagnosis. In Germany, the coding for billing the service providers (health and pension funds) is carried out according to the ICD-10 .
To assess the low body weight, the body mass index is used and the extent of anorexia nervosa is divided into:
In the DSM-5, a distinction is made between a full form, in which all criteria are met, and a partial form, in which not all criteria occur.
Anorexia is a serious and potentially fatal disease. The extreme underweight leads to physical problems:
- Heart : slow heartbeat , low blood pressure , changes in the excitation of the heart muscle (especially: prolonged QT interval ) and cardiac arrhythmias , which can lead to sudden cardiac death .
- Blood : disorders of electrolytes (especially dangerous: hypokalemia with arrhythmia), blood sugar , blood poverty , leucopenia and thrombocytopenia .
- Hormones : low levels of sex hormones ( LH , FSH , estrogen ), resulting in: amenorrhea , infertility , sometimes a lack of breast growth in women. Loss of libido and potency in men. Low levels of thyroid hormones . Slightly increased concentration of glucocorticoids .
- Bones : Osteoporosis with an increased risk of fracture
- (if vomiting frequently) Teeth : erosions from stomach acid , tooth decay .
- other organs : indolence and chronic constipation , stomach cramps , nausea , kidney failure , bladder weakness ( incontinence ).
According to Manfred Fichtner, up to 15% of those affected in adulthood should die from the effects of the disease either through complications such as cardiac arrest or infections, or through suicide . Some of the surviving patients suffer from long-term effects such as osteoporosis or kidney failure for their entire life .
The sick are very sensitive to cold and their body temperature can be lowered because the body slows down the metabolism and the heat-insulating subcutaneous body fat is missing. Other symptoms include dizziness, fainting spells, and hormonal disorders. In addition, dry skin and lanugo hairs can grow on the back, arms and face.
Women do not have periods ( amenorrhea ). Taking the contraceptive pill covers up this symptom, so the occurrence of menstrual bleeding is not a sure exclusion criterion for anorexia nervosa. However, the artificially supplied hormones do not regulate the entire disturbed hormone balance.
If the disease begins before puberty, the growth in height ends prematurely and sexual maturity does not occur or occurs only after a delay ( pubertas tarda ): In girls, the female breast does not develop , in boys, the development of the testes and penis does not occur .
The causes for the development of anorexia nervosa have not yet been fully clarified. Most likely, an interaction of psychological and social factors with hereditary factors. It is still unclear whether the changes in brain function found in anorectics are the cause or the consequence of the disease.
It is now assumed that the following factors work together in the development of anorexia:
- an inherited disposition to develop the disease
- social factors, which include not only the ideal of slimness but also a changed role expectation ,
- individual factors like lack of self-esteem as well
- certain family factors.
The twin research was able to show that the genetic share is considerable and can be up to 80%. First-degree relatives of anorexic patients have a 10-fold higher risk of the disease than people without a family history.
So far, however, no specific genes have been identified which clearly and directly promote the development of anorexia. Research is currently (2010) particularly focused on genes that are related to an easily disruptive neurotransmitter system of serotonin . Recent studies indicate that epigenetic mechanisms may play an important role .
Systemic therapists assume that the main cause of anorexia lies in the family.
In most cases, according to this approach, we are dealing with an inconspicuous middle-class family who like to present themselves as absolutely "intact"; the opinion of outsiders - particularly with regard to the patient - has the highest priority. If adolescents are ill, parents can often determine that they have high performance requirements. If this endeavor is disappointed, this is often not punished with obvious penalties, but with the accusation against the young people of having disappointed trust. The image of the "iron fist in a silk glove" describes this impressively. Low emotional support, low contact, emotional coldness, low or limited affection and high expectations ( meshing ) of the parents also seem to play a role. From a systemic-family-therapeutic point of view, families with anorexia sufferers have a great striving for harmony among family members, and there is no confrontation with conflicts and negative feelings (anger, anger, insecurity, fears).
The meshing is also taken into account . What is meant by this is the possession of the patient's life by the parents and the lack of any privacy. Of course, there is not the anorexic family . In the biographies of people with eating disorders - predominantly with bulimia nervosa - sexual abuse was found to be above average . It is not clear whether this is actually an etiological characteristic.
According to the object psychological psychodynamic view, the main cause of eating disorders is a disturbed parent-child relationship . A central conflict is the striving for autonomy, which is supposed to lead to a detachment of a dependence on the mother and her control, which is experienced as strong ("dependency-autonomy conflict"). However, anorectic people also try to stabilize their self-worth by controlling their weight ("self-worth conflicts") and to achieve an independent identity through their slimness ("identity conflict"). These conflicts cannot be symbolized (i.e. not thought ) psychologically . The expression of the conflicts and their communication to the outside world happens through the physical. In doing so, self-control of one's own body should be achieved. At the same time, the person in question rejects an adult identity and thus also the physical appearance. This is often understood as a defense against instinctual wishes. Mastering one's own body becomes a means of 'living out' the desire for autonomy. These desires are in contrast to the fear of separation from the mother that resurfaces in adolescence . The aggressive striving for autonomy, which often shows up in adolescence, is thus lived out through the body.
In addition, the inability to psychologically symbolize the conflicts is viewed as a structural disorder of varying strength.
Other authors criticize the focus on the family: It has not been empirically proven that the postulated behavioral patterns are specifically for families of adolescents with eating disorders. Even if that were true, it would be unclear whether abnormalities in the family were the trigger or consequence of the mental illness. A focus on the family as the sole trigger could (apart from neglecting other factors) lead to scientifically untenable and emotionally stressful accusations of guilt. Family communication and relationships should be included in the therapy, but as a potential stressor affecting the chances of recovery, not as a trigger of the disease.
For the disturbed perception of one's own body (disturbance of the “body schema”) the criticism of peers, the criticism of mother and / or father and the social ideal of slimness can play a major role. Targeted weight loss reduces anxiety and makes weight loss an effective amplifier .
In western industrialized nations there is a cultural pressure on women to be slim. This ideal of beauty is conveyed through the mass media. Thinness and good looks is mainly used in the advertising often with professional and social success linked . Among other things, diets are touted as a means of achieving this ideal. The disease often begins as part of a diet and is aggravated by the recognition and attention that the person affected (perhaps only) receives from their slim body or their weight loss .
The numerous casting shows on television are accused of promoting anorexia. Such casting shows are, for example, Germany's Next Top Model and The Perfect Model . A study by the IZI ( International Central Institute for Youth and Educational Television of Bavarian Broadcasting ) points to this. In 2009 Maya Götz and Johanna Gather surveyed almost 1200 children and young people between nine and 21 years of age for the scientific investigation of casting shows and their significance for children and young people . The IZI study found that many of the young people were extremely critical of their bodies. This coincides with the results of the Dr. Sommer study by the magazine Bravo from 2009. Götz wrote in it that the girls were significantly more dissatisfied with their bodies than those surveyed in the previous study. In 2003 the Federal Ministry of Family Affairs started the initiative Schau hin! and offers information about casting shows.
Other environmental factors
Serious psychological trauma such as sexual abuse or mistreatment can also be found in the history of anorexia patients. A lack of self-esteem, low self -esteem, and perfectionism are personality traits that exist before the onset of the disease. The assumption that all these factors work together is known as the “psychobiological-social model”.
Extreme weight loss can accompany depression or self-harm ; he can also be accompanied by depression or self-harm. Many people with anorexia nervosa are prone to compulsive behavior or perfectionism in all areas of life.
For the patient, anorexia is primarily a defense against external control . The control of one's own body (for example by counting calories) is a form of self-control and coping with fainting in the process of adolescence . Getting slim is often the central motive only at the beginning of the illness. Sick people with years of disease often experience losing weight as an addiction .
The disease can rarely be cured with brief treatment. The course of the disease is often protracted, and the therapies available often fail to achieve a cure, as the lack of insight on the part of those affected is part of the clinical picture and it is not uncommon for their relatives to send them for therapy. Removal from the pathogenic environment through long-term inpatient psychotherapy is often seen as necessary. In-patient psychotherapy in Germany has the option of having a modern setting made up of body medicine, behavioral therapy, systemic-family therapy, depth psychology and self-help components ready for this complex, multi-causal clinical picture. There are clinics that specialize in the treatment of eating disorders, among other things. Many therapies for eating disorders involve a combination of outpatient therapy at the place of residence and phases of inpatient therapy. Anorexia is one of the mental illnesses with the highest death rate. About 15 percent of the sick die as a result of malnutrition or as a result of suicide.
Systemic family therapy treatments are often recommended. In this context the anorectic patient appears as a symptom carrier of a family; Accordingly, it is not he alone that needs treatment, but the patient's family . She has to learn that forms of expression and rules have to be changed in such a way that communication and conflicts can be expressed directly in the family and thus no more symptoms are necessary. It is not individuals that are changed, but the rules within the system.
Psychodynamic treatment approaches (analytical psychotherapy and psychotherapy based on depth psychology) are also used. They are intended to make unconscious conflicts that have led to the emergence of the symptom aware and thus enable the personality to mature further. Some representatives of analytical psychotherapy report an improvement in the symptoms without addressing the maladjusted eating behavior in the therapy.
Often, cognitive-behavioral treatments are also used. Your goals are
- affect the distorted body perception of the patient,
- change attitudes towards food and
- To convey ways of better conflict management and social skills .
In addition to psychotherapeutic treatment, the use of SSRI-type antidepressants in particular plays a major role, as they can be used to treat the accompanying disorders that accompany and maintain anorexia, such as social anxiety and depression. Neuroleptics can also be used with a calming or mood-stabilizing effect. Depending on your physical condition, you need to be particularly careful with drug therapy, if necessary only in an inpatient setting.
An experimental therapeutic approach that relates directly to the body schema disorder is the hourly wearing of tailor-made wetsuits to improve the sensory integration performance of the brain, which has been practiced at several locations from the Charité in Berlin for several years.
A disorder-specific therapy includes, in addition to stabilizing eating behavior, psychotherapeutic treatment of the patient. If the patient is critically underweight - there is an acute risk of death with a BMI below 13 - inpatient treatment in a hospital with parenteral nutrition is necessary, whereby the patient is supplied with nutrients / electrolytes via a venous access . This force-feeding serves to support life and is to be understood as a therapy to prevent the physical consequences - including death - of the disease.
As a last resort in an otherwise untreatable anorexia nervosa, with the risk of a lethal course of the implant can be one-sided Gehirnstimulators in the dentate be drawn subcallosus into consideration. At least one phase I study showed success in three of six patients with refractory anorexia nervosa.
Anorexia in Public
In art and music
- Lene Marie Fossen was a Norwegian photographer who also became known for self-portraits of her disfigured body.
- Daniel Johns , the singer of the group Silverchair , deals with his illness in the song Ana's Song .
- Christina Aguilera uses pictures of an anorexic in her video for the song Beautiful from the album Stripped . In the course of the video, she smashes the mirror in which she had previously looked at herself critically.
- The songs Lucy At The Gym and Supermodel. by Jill Sobule deal with anorexia in various forms.
- A hunger artist by Franz Kafka treats anorexia as an allegory . Kafka is considered anorexic.
- The singer Karen Carpenter died of anorexia nervosa in 1983. The disease, which until then had been largely ignored by the public, was thereby / thereafter more perceived by the media. The band Sonic Youth dedicated their song Tunic (Song for Karen) to Carpenter's fate .
- The black metal band Anorexia Nervosa bears the name of this disease.
- A song by the radio / electro-industrial band Suicide Commando bears the name of this disease.
- The song Sophie by Eleanor McEvoy is about the anorexia and the death of the protagonist.
- The song Courage by Superchick deals with the topic Anorexia
- The song Anorexia Nervosa by X-Fusion addresses this issue.
- The French woman Isabelle Caro (she was 1.64 meters tall and weighed only 31 kilograms) became known as the “skinny model” in 2007 when photographer Oliviero Toscani photographed her for a campaign against anorexia. The pictures of the emaciated, naked young woman hung in the streets of the fashion capitals of Milan, Rome and Paris and caused a sensation. Caro developed anorexia at the age of 13. She consciously went public with her illness, gave lectures and wrote an autobiography about her suffering. This was published in 2008 with the title The Little Girl Who Didn't Want to Get Fat . Caro died of pneumonia in November 2010.
- The song Bulemiarexia by the French nü-metal band Eths is about this disease.
- The song Please Eat by Nicole Dollanganger (* 1991)
- The Netflix film To the Bone (roughly to the bone ) portrays an anorexic's struggle for survival.
In August 2006, the 22-year-old model Luisel Ramos died shortly after a fashion show. The cause of death was a heart attack after she had not eaten for several days. Two months later, the Brazilian Ana Carolina Reston Macan died of anorexia. About six months after Luisel Ramos' death, her sister Eliana Ramos also died at the age of 18, presumably also from the effects of anorexia. Isabelle Caro died in November 2010.
In 2009, Alexandra Shulman, the head of British Vogue , criticized the designer of leading couture houses: because their designs were becoming increasingly narrow, models were much too lean. In an interview with the Neue Osnabrücker Zeitung in 2009, designer Anja Gockel argued that the homosexuality of leading fashion designers is the "most important" reason for many models to be anorexic. A boyish figure is the ideal image for gays, while lesbians mostly prefer an androgynous figure. “That's why the models shouldn't have too many bosoms and only a few hips. Anything voluminous is un-erotic for them, not acceptable. "
Statutory protective measures
In Israel, a body mass index of at least 18.5 has been required for models since the beginning of 2013 . The UK's Advertising Standards Authority (ASA) banned a Yves Saint Laurent (YSL) promotional photo in June 2015 and one from Gucci in April 2016 .
In France, too, underweight models are now prohibited by law on catwalks (as of December 2015). Models in France are no longer allowed to work without a medical certificate stating that they are in good health. In the event of a violation against this, the organizer faces a fine of up to 75,000 euros. On January 26, 2016, the law came into force .
In France, a law has been in force since October 1, 2017, according to which every commercial image in which the figure of a model has been subsequently changed by image processing must be marked as "photographie retouchée". Failure to do so could result in a fine of up to 37,500 euros.
In addition to prominent cases in which the illness led to death ( Christy Henrich , Bahne Rabe ), several athletes gave up their careers because of a corresponding illness, including ski jumpers Christian Moser and Stephan Zünd and figure skater Eva-Maria Fitze .
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- ↑ Skinny model Caro dies of pneumonia . Zeit Online , December 29, 2010.
- ↑ Youtube .
- ↑ The war against one's own body , see also Wikipedia
- ^ Lean times for hunger pangs. on: stuttgarter-nachrichten.de May 15, 2012. (All international editions of the fashion magazine Vogue have joined a “health initiative” and want to do without skinny models in the future)
- ↑ Big attack on the designers . Zeit Online , September 23, 2009.
- ↑ Anja Gockel: That's why there are skinny models In: Neue Osnabrücker Zeitung Online. November 6, 2009.
- ↑ Bad gay designers. In: The Standard . November 9, 2009.
- ↑ Israel banishes skinny models. In: Hamburger Abendblatt . January 21, 2013, p. 28.
- ↑ Advertising supervision prohibits skinny model photo of Yves Saint Laurent
- ↑ asa.org.uk
- ↑ ASA Ruling on Guccio Gucci SpA . asa.org.uk - spiegel.de
- ↑ lemonde.fr December 17, 2015
- ^ New law for models in France , last accessed on December 21, 2015.
- ↑ LOI n ° 2016-41, Article 20
- ↑ www.gouvernement.fr: LOI n ° 2016-41 du 26 janvier 2016 de modernization de notre système de santé
- ↑ Décret n ° 2017-738 du 4 may 2017 relatif aux photographies à usage commercial de mannequins dont l'apparence corporelle a été modifiée . legifrance.gouv.fr
- ↑ Article L2133-2
- ^ Marion Lebenstedt, Gaby Bußmann, Petra Platen: Eating disorders in competitive sports. , Federal Institute for Sport Science, Bonn 2004, p. 10f.