CC BY
49ORIGINAL PAPERS
Recieved: 9 March 2015/ Accepted: 31 May 2015/ Published online: 15 June 2015
Anorexia as a Psychoemotional Pathology of Young
Women of the 21 Century
Alena A. Shulga 1 ; http://orcid.org/0000-0001-9203-0925 E-mail: alyonka.asa@gmail.com
Ekaterina A. Drobotova 1 ; http://orcid.org/0000-0003-1129-9952
1 Department of Psychiatrics, Narcology and Medical Psychology, Kharkov National Medical University, Kharkov, Ukraine
ABSTRACT
BACKGROUND
Anorexia nervosa characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected. The investigation of anorexia is caused by increase of the number of people with this pathology within the last decade, difficulties of its diagnostics and treatment as well as long-lasting and complicated rehabilitation and possible relapsing course.
METHODS
The intervention group consisted of 80 patients with age group between 6 to 16 y with diagnosis of anorexia nervosa. The following methods of research have been used: clinical-psychopathological, clinical follow-up, pathopsychological, instrumental (EEG has been used, as CT and MRI don’t reflect functional derangements). The treatment of the patients was conducted in two stages.
RESULTS
The study of psychopathological structure and varieties of clinical implications of anorexia nervosa has revealed their variety and made it possible to single out clinical peculiarities of each case in terms of the severity and structure of dysmorphic ideas together with obsessive phobic and affectional disorders. It was significant that there was a specific premorbid habit characterized by combination of schizoid, hysterical, epileptic and anxious character types with features of perfectionism.
CONCLUSION
The treatment of patients with the syndrome of anorexia nervosa needs complex approach. An approximate duration of treatment is 3-6 months. The two-staged therapy has shown a good result over time, however the problem of recurrences hasn't been solved yet. In this question, the psychotherapy has the biggest significance; high hopes are put on family psychotherapy. The innovation offered on the basis of results of the research is the medical examination of the patients with such nosology.
KEYWORDS
Anorexia Nervosa, Eating Disorders, Mental Disorders
INTRODUCTION
Anorexia nervosa is a conscious aversion to food, in most cases aimed to “improving” the appearance due to the assurance of a person in his exorbitant plumpness [1, 2]. According to ICD-10, feeding disorders are ranked to behavioral syndromes, and the complex of disorders characteristic of the disease under examination is denoted in the classification as F 50.0. The relevance of examination of this problem is caused by augmentation of the number of people with given pathology within the latest decades, difficulties of its diagnostics and treatment due to tendency of people with this disease to dissimulation, untimely compellation for the qualified treatment [3-6] as well as enduring and complicated rehabilitation and possible relapsing course. Moreover, the number of patients has increased during the last decades, it is so called “anorexic outburst of population”, the cases of this pathology among men has relatively become more frequent. Actually general prevalence of anorexia nervosa is 1.2% among women and 0. 29% among men [7, 8].
Most of the people (90%) with anorexia nervosa are girls, in their teens, and young women. The most frequently the disease manifests at the age of 1325. In spite of the fact that the prevalence rate of the described pathology may seem not so significant - averagely 1-3 cases on 1000 people, we should take into consideration that it is a serious, dangerous and potentially lethal disease, one of the few in psychiatrical practice that has a significant case lethality itself. According to the statistics of different countries, the mortality rate of anorexia nervosa is 1020% [10].
Moreover, anorexia is often accompanied by depression. Many of those who need treatment of
ISJM | VOLUME 1 | No 2 | 2015
26
ORIGINAL PAPERS
this pathology commit a suicidal attempt. Even after recovery former anorexics suffer from the aftereffects of the disease. 1/3-1/2 of patients are not able not only to recover their health completely, but to reach normal findings characterizing the state of the organism from the physical point of view [11].
On the whole, we can say that currently anorexia is still a topical issue that hardly answers the medical treatment and has a big frequency of recurrences which explains the aspiration to examine and describe as many as possible of these case follow-ups [12, 13].
The purpose and the objectives. Study of clinical peculiarities of anorexia nervosa connected with consistent individual characteristics of the course of disease, and consequently the individual efficiency level of the comprehensive therapy.
METHODS
The research was conducted on the base of mental health clinic of the Regional clinical mental hospital №3 in Kharkov during the period from 2012 to 2014. The intervention group consisted of 80 patients with the diagnosis 50.0 within 6 and 16 y - all of them were patients that agreed to participate in the research and were under treatment within named period of time. The age of the patients is explained by the most frequency of manifestation of the onset among all age categories. All the examined were female; it’s connected with the small percentage of men among people with anorexia, and due to the fact that men with anorexia turn to the specialists very seldom. Within the given period there wasn’t any male patient under treatment with the diagnosis F 50.0.
The main criteria of the selection of patients were the following: 1) presence of unhealthy assurance of their own excess weight; 2) purposeful activities on the improvement of the “physical defect”; 3) objective weight loss from 20%; 4) conscious strict restrictions in food as well as different violations of ways of food acceptance (eating standing, cutting food into small pieces) [4]. The following methods have been used: clinic-psychopathological, clinical follow-up, pathopsychological, instrumental (EEG has been used, because CT and MRI don’t reflect functional derangements of nervous system) [13].
For the treatment were used the following methods:
1) on the first stage pathogenic and symptomatic remedies for stabilization and improvement of somatic state of patients. The therapy was chosen for each patient individually, sedatives, as well as neuroleptics (the choice of doze depended on the severity of the somatic state of the patients and nosologic belonging);
2) the therapy on the second stage corresponded to the nosology - if depressive, anxious, phobic, obsessive features prevailed, than against the background of continuing systemic therapy dozes of neuroleptics were gradually increased, and according to the indications tranquilizers or anti-depressants were added [14-20].
If the disease pattern contained fixed ideas, symptoms of dysmorphophobia secondary to schizoid premorbid state, it was also necessary to add neuroleptics or to combine neuroleptics of different groups [21-27].
Individually for each person a psychotherapy of the most opportunistic and appropriate type was conducted as well as family therapy according to the indications [24, 28-31].
RESULTS
Examination of the psychopathological structure and varieties of clinical implications of anorexia nervosa of the patients included into the intervention group of the mentioned age has revealed their variety and made it possible to single out the clinical peculiarities of each case in terms of the severity and structure of dysmorphic ideas together with obsessive phobic and affectional disorders.
It was significant for the patients with anorexia nervosa developing in the childhood and adolescence that there was a specific premorbid habit (table 1.) characterized by combination of schizoid, hysterical, epileptic of anxious character types with features of perfectionism.
In the depressive feelings anxious and obsessive fears of overeating were predominant, there was fear of possible body-weight increase (so called “overweight”).
On the electroencephalogram all 80 patients had a steady alpha-activity, on the background of which in comparison with normal quantities it’s figured
27
2015 | No 2 | VOLUME 1 | ISJM
ORIGINAL PAPERS
Type of character Patients with indicated type of character Patients with perfectionistic features
Patients % Patients %
Schizoid 18 22.5 11 61.1
Hysterical 29 36.25 19 65.5
Epileptic 14 17.5 13 92.8
Anxious 19 23.75 16 84
Table 1. Allocation of the types of character
Diagram 1. Features of the patients’ response to therapy
out that 49 patients (61.25% of the examined) have a paroxysmal activity that is identified in the electroencephalogram as a symptom of dysfunction of stem-diencephalic structures of the brain.
On the results of the clinic-psychopathological method we have found out that 28 patients (35%) have hereditary load of anamnesis as for violation of eating behavior, 11 patients have psychiatric or psychological problems in their families (13.75%). During the monitoring over time first of all drew attention expressional and affective manifestations, especially reactions on the therapy that is conducted. As a result 8 people (10%) had strongly negative reaction to the very fact of the therapy, negative -23 people (28.75%), indifferent - 24 people (30%), formally positive - 19 people (23.75%), positive - 6 people (7.5%) (diagram 1).
On the results of the pathopsychological research all the patients indifferently of their emotional state and
age showed cautious attitude to the analysis of their cognitive abilities, 70 people (90%) out of 80 in the conversation used short answers, the speech of 60 patients (75%) was characterized by monotony, poor mimic, inarticulation (46 people (57.5%)) which was regarded as signs of extreme asthenization. The investigation of cognitive activity hasn’t shown serious violations, but during the tests the patients quickly got tired, in 15 minutes started to make mistakes 13 people (16.25%), in 20-25 minutes started to make mistakes another 25 people (31.25%), and in 30 minutes 71 patient had mistakes (88.7%), which was regarded as a fatigue again on the background of asthenization. Also we noted that 62 patients (77.5%) had difficulties with concentration and attention switch. All the examined had memory within normal limits.
The policy of disease management of the patients included 2 stages of treatment.
On the first stage a consecutive complex treatment
ISJM | VOLUME 1 | No 2 | 2015
28
ORIGINAL PAPERS
in hospital environment aimed to remove the weight deficit of body according to the age norm and to stop further weight loss, and to normalize the main somatic markers.
The therapy on the second stage - according to the nosological sign is defined directly by the structure and causes of such state of the patients.
Apart from the pharmacotherapy the patients were treated all this time with the psychotherapy oriented to the correction of the patient’s opinion about the ideal weight and the ways to get it, help in the formation of the idea about rational nutrition, understanding by the patients psychological motives of pathological eating behavior.
According to the results of the theraphy on the first stage, an average duration ranges from 2 to 4 months, 17 patients had the metabolism indices - blood glucose level, glucose tolerance, protein fractions, beta-lipoproteids, level of electrolytes in blood, and the state of acid-base metabolism compensated on 90100%, 33 patients - on 70-83%, 28 patients- 50-69%, 2 patients - 49 % and less. On the background of taking sedatives and neuroleptics it was possible to observe that all the patients approximately in equal measure had a persistent decrease of dysmorphophobic ideas, anxiety, and absence of affective disorders. The effectiveness of the psychotherapy began to be evident no sooner than in 1,5 months after it’ beginning and also confirmed the result of neuroleptics and sedatives stated above.
Moving to the second stage was realized gradually according to the normalization of the indicants of the basal metabolism - the elements of pathogenic therapy were discontinued, became possible more exact correction of the doze of neuroleptics and decrease of the doze of sedatives, including on the background of the continuing psychotherapy.
DISCUSSION AND CONCLUSION
Syndrome of anorexia nervosa of the patients which in the premorbid had features of perfectionism, anxious and hysterical features, besides that combined with anxious depression with domination of dysmorphophobia.
Analysis of the electroencofalogram of the patients
with an anorexia nervosa syndrome has shown some peculiarities of the deviations that can be an additional criterion for the diagnosis and prognosis of the disease and when revealing the indicated changes on the EEG of the patients will let us have a suspicion concerning the patient’s anorexia.
The treatment of the patients with anorexia nervosa syndrome needs a complex approach taking into consideration not only nosological belonging of the syndrome, but also the stages of its dynamics. An approximate duration of the treatment is 3-6 months. The two-stages therapy used has shown an good result over time, however the problem of recurrences hasn't been solved yet taking into consideration that the prescription of pharmacological correction with neuroleptics or other substances is not recommended due to the absence steady psychopathological disorders and prophylactic using such solutions correlates with a big amount of bad effects and thus inappropriate of a life-long treatment for solving the problem of recurrences.
In this question the biggest significance has psychotherapy with maximum possible determination of the real causes of the disease, elimination when possible of the effects of painful memories, stresses which happened in the past, etc. High hopes are put on family psychotherapy. The innovation offered on the basis of results of the research is the medical examination of the patients with such nosology. It is connected with incomplete correction of the current state - not all of the patients have the possibility to recover the level of health according to their age norms, as well as they can’t get rid of dysmorphophobic ideas, obsessive ideas, etc, that can be the background for appearance of diseases, risk of recurrences, controlling the further dynamics of the patient’s state - physical as well as psychical and psychological. It will also allow to quickly react to possible breakdown of patients’ health and to immediately hospitalize them for the medical treatment that can help to decrease the mortality rate and contribute to the common improvement of the quality of life and health status among all examined patients.
ACKNOWLEDGEMENTS
The authors thank PhD, assistant professor of
29
2015 | No 2 | VOLUME 1 | ISJM
ORIGINAL PAPERS
Department of Psychiatrics, Narcology and Medical psychology of Kharkov National Medical University Samardakova GA, for her review of the manuscript and valuable suggestions.
REFERENCES
1. Korkin MV, Tsyvilko MA, Marilov VV. Nervnaya anorexia (Anorexia nervosa). 1986, pp 10-15.
2. 2. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-2015-WHO Version for. Available from: http:// apps.who.int/classifications/icd10/browse/2015/en#/ F50.0 [accessed on April 14, 2015].
3. Frederique R. E. Smink, Daphne van Hoeken, Hans W. Hoek. Epidemiology of Eating Disorders: Incidence, Prevalence and Mortality Rates. Curr Psychiatry Rep. 2012; 14(4): 406-414.
4. Sokolovsky SR. Quantum Sati’s. Osnovy psihologii zdorovya (Quantum Sati’s. Fundamentals of Health Psychology). 2008, pp 67-70.
5. Kittel R, Brauhardt A, Hilbert A. Cognitive and emotional functioning in binge-eating disorder: A systematic review. Int J Eat Disord. 2015 May 26.
6. Bannatyne A, Stapleton P. Educating Medical Students About Anorexia Nervosa: A Potential Method for Reducing the Volitional Stigma Associated With the Disorder. Eating Disorders. The Journal of Treatment and Prevention. 2015; 23 (2): 115-133.
7. Brukhin AE, Souleimanov RA, Artemieva MS. Particularites des troubles du development et du comportement sexuel dans l’anorexie mentale. Revue medicale Suisse. 2011; 7 (287): 633-680.
8. Korkina MV. Social’nie faktori i rasstroistva pichevogo povedeniia (Social factors and eating disorders). 2009, pp 332-338.
9. Dingemans AE, van Furth EF. EDNOS is an eating disorder of clinical relevance, on a par with anorexia and bulimia nervosa. Tijdschr Psychiatr. 2015; 57 (4): 258-64.
10. Hudson JI, Hiripi E, Pope HG, Kessler RC. The prevalence and correlates of eating disorders in ISJM | VOLUME 1 | No 2 | 2015
the National Comorbidity Survey replication. Biol Psychiatry. 2007; 61 (3): 348-358.
11. Striegel-Moore RH, Bulik CM. Risk factors for eating disorders. Am Psychologist. 2007; 62: 181198.
12. Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P, Pedersen NL. Prevalence, heritability, and prospective risk factors for anorexia nervosa. Arch Gen Psychiatry. 2006; 63 (3): 305-312.
13. Steinglass J, Walsh BT, Stern Y Set shifting deficit in anorexia nervosa. J Int Neuropsychol Soc. 2006; 12 (3): 431-435.
14. American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry. 2006;163(7 Suppl):4-54.
15. Meehan KG, Loeb KL, Roberto CA, Attia E. Mood change during weight restoration in patients with anorexia nervosa. Int J Eat Disord. 2006; 39 (7): 587-589.
16. Lock J, le Grange D, Forsberg S, Hewell K. Is family therapy useful for treating children with anorexia nervosa? Results of a case series. J Am Acad Child Adolesc Psychiatry. 2006; 45 (11):1323-1328.
17. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, Pike KM, Devlin MJ, Woodside B, Roberto CA, Rockert W. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA. 2006; 295 (22): 2605-2612.
18. Kaplan AS, Howlett A. Pharmacotherapy for anorexia nervosa. The Treatment of Eating Disorders: A Clinical Handbook. 2010, pp 175-186.
19. Gowers SG, Clark A, Roberts C. Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled
trial. Br J Psychiatry. 2007; 191: 427-435.
20. Olmsted MP, McFarlane TL, Carter JC, Trottier K, Woodside DB, Dimitropoulos G. Inpatient and day hospital treatment for anorexia nervosa. The Treatment of Eating Disorders:
30
ORIGINAL PAPERS
A Clinical Handbook. 2010, pp 198-212.
21. Mehler PS, Birmingham CL, Crow SJ, Jahraus JP. Medical complications of eating disorders. Overview of Eating Disorders: A Clinical Handbook. 2010, pp 66-80.
22. Keel PK, Haedt A. Evidence-based psychosocial treatments for eating problems and eating disorders. J Clin Child Adolesc Psychol. 2008; 37 (1): 39-61.
23. Clarke TK, Weiss AR, Berrettini
WH. The genetics of anorexia nervosa. Clin Pharmacol Ther.2012;91(2): 181-8.
24. Cook-Darzens S, Doyen C, Mouren MC. Family therapy in the treatment of adolescent anorexia nervosa: current research evidence and its therapeutic implications. Eat Weight Disord. 2008; 13 (4): 157-70.
25. Espindola CR, Blay SL. Anorexia nervosa
treatment from the patient perspective: a metasynthesis of qualitative studies. Ann Clin Psychiatry. 2009; 21 (1): 38-48.
26. Ferri: Ferri’s Clinical Advisor, 2013, 1st ed. Anorexia Nervosa. St. Louis, MO: Mosby. 2012.
27. KishiT,KafantarisV,SundayS,SheridanEM,Correll CU. Are antipsychotics effective for the treatment of anorexia nervosa? Results from a systemic review and meta-analysis. J Clin Psychiatry.2012; 73 (6): 757-66.
28. Loeb KL, Walsh BT, Lock J, le Grange D, Jones J, Marcus S, Weaver J, Dobrow I. Open trial of family-based treatment for full and partial anorexia nervosa in adolescence: evidence of successful dissemination. J Am Acad Child Adolesc Psychiatry. 2007; 46 (7): 792-800.
29. Lozano GA. Ob e sity with sexually sel ected anorexi a nervosa. Med Hypotheses. 2008; 71 (6): 933-40.
30. Papadopoulos FC, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa.BrJ Psychiatry. 2009; 194 (1): 10-7.
31. Williams PM, Goodie J, Motsinger CD.
Treating eating disorders in primary care. Am Fam Physician.2008;77(2): 187-95.
31
2015 | No 2 | VOLUME 1 | ISJM
