As discussed in Chapter 1, AN usually begins in adolescence; however, it is now known that AN can be identified in children as young as six, and such childhood cases of AN are being increasingly reported. Since diagnosis of AN in children has been quite rare and controversial, care must be taken to rule out the presence of another primary causal condition. Perhaps in part as a result of such caution, diagnosis of AN in children is frequently delayed. This is highly unfortunate, for the condition can have devastating effects if undetected in pre-pubescent children, permanently damaging growth and development; early diagnosis and competent treatment are vital.
The incidence of childhood AN is not known; however, it has become clear that, while the disorder is less common in children than in adolescents or adults, the numbers are rising. A common finding with childhood AN is the relatively high percentage of boys who have the disorder. In adults with AN, men account for only 5–10 per cent of cases, whereas in children boys have been reported to account for between 20 and 25 per cent. It is not yet clear if this is a definite gender difference or whether younger boys are simply more likely to come to medical attention than girls of the same age. One interesting difference has emerged in that while the girls tend to say they want to be thin for aesthetic reasons, the boys often give reasons of health and fitness.
Physical deterioration is more rapid in children, possibly because they have less fatty tissue in their bodies. However, this may appear to be a problem of growth or failure to reach puberty, rather than the more obvious weight loss characteristic of adolescent AN. Depressive symptoms appear earlier and more commonly in childhood AN, possibly as a result of the faster rate of deterioration, and anorexic symptoms escalate with weight loss, creating a vicious circle. While the core features (behavioral and psychological) of the condition are similar to those in adolescents and adults, bingeing and laxative abuse are less common among children.
It is possible that childhood AN may represent a more biological/genetic form of the disorder. Prognosis in this group is comparatively poor. Only two-thirds make a full recovery, the remainder continuing to experience difficulties. Persistent amenorrhea occurs in about 30 per cent of this group, and long-term repercussions include delayed growth, infertility and osteoporosis.
Physical complications include:
Psychological complications include:
Social/familial complications affect:
Weight loss or the failure to gain weight accompanied by food refusal may indicate a number of different conditions. The following checklist should be helpful.
The child’s school may be able to provide important information about the child’s eating habits and her academic, social and emotional competence. However, if the school is involved, remember that the staff may also have little experience of AN.
The Great Ormond Street Hospital for Children operates the following diagnostic checklist to assist in identifying children with AN. A child is diagnosed with AN if he/she shows:
1 Determined food avoidance.
2 Weight loss or failure to gain weight during the period of pre-adolescent growth (10–14 years) in the absence of any physical or other mental illnesses.
3 Any two or more of the following:
(a) preoccupation with body weight;
(b) preoccupation with energy intake;
(c) distorted body image;
(d) fear of fatness;
(e) self-induced vomiting;
(f) extensive exercising;
(g) purging (laxative abuse).
Many pre-pubescent children are now diet-conscious, often internalizing their mothers’ dieting and media messages. AN can start in the absence of overt dieting (for example, after an episode of viral illness causing loss of appetite), or as a diet with a friend. How can early AN be distinguished from ‘normal’ dieting?
Treatment of AN is always a lot more complex than simple weight restoration, and this is especially so for children, for whom the family system has a relatively important influence.
For all children with AN – that is, all those under 18 years – the family will be involved in treatment. Formal family therapy is not necessarily the preferred choice; family counselling may do just as well. For those families that do not feel comfortable with family counselling or family therapy, parental counselling alongside individual psychotherapy for the child is just as effective and may be preferred. Whatever option is taken, it is important that the family receives support, guidance and education, since AN can have a devastating effect on family functioning.
Individual psychotherapy is a valuable adjunct to family or parental counselling in children with AN, but is not a replacement for it. There is no consensus regarding which type of individual therapy should be used; it is possible that therapist empathy, continuity and a developmental approach may be more important than the type of therapy itself. Emotional change takes longer to bring about than weight change, so long-term therapy may be needed.
Physical treatments and drug treatment may also be used. No drugs directly affect the course of the AN, but some may help with particular symptoms. If depression coexists with AN, low doses of antidepressants, taken with food, may help. If the child suffers delayed gastric emptying, a drug may be prescribed to help this.
Dietary treatment is obviously important as a major goal in the treatment of children with AN is weight restoration. This is especially important in children on the brink of puberty, as growth potential is continually being lost. If the child has reached a very low weight, a skilled refeeding programme must be implemented and the advice of a dietician should be sought; in less extreme cases a high-energy balanced diet using the portion system (see Part Two, Step 5) is advisable. Vitamin supplements are rarely necessary. Food supplements may be useful, especially in severe cases where food refusal is marked, and also if the child’s weight is low but stable and the child is refusing further normal food. However, they should be used in addition to, not instead of, a normal mixed diet.
Hospitalization is likely to be necessary if the child’s weight has fallen to less than 70 per cent of the normal level for age; if there are physical complications (e.g. dehydration, circulatory failure or persistent or bloody vomiting); or when there is depressed mood or other psychiatric disturbance in the child or parents.
AN is considerably less prevalent in men than in women; men account for only about 5 per cent of cases. Apart from a few obvious sex-related differences in symptoms (e.g. amenorrhea occurs only in women), on the whole there appear to be few differences between the sexes in terms of the physical features of the disorder. Weight loss, emaciation, hormonal changes and starvation-related symptoms are found in both males and females. Men also display the characteristic fear of fatness, refusal to maintain normal weight and rigidity in thinking.
However, there are three major factors that do differentiate men and women with AN:
On the whole, most men who develop AN are more obsessed than women with the exercise component. They are often compulsive exercisers, spending long hours each day jogging or doing press-ups and other exercises. While they are often as obsessed about their diet as women, they do not often show the same interest in cooking and recipes. While bingeing, vomiting and anxiety eating are as common in male AN as female AN, there is often less laxative abuse.
Certain features common in men with AN include conscientiousness and obsessionality as children: these applied to approximately a third of one group studied, while a similar proportion described dietary problems, either obesity or finicky eating habits. The presence of significant life events also appears common in the year preceding the onset of the disorder. Identifiable triggers were often related to a change in circumstances, whether through the death or departure of a loved one or a move to a new city.
Men, just like women, are strongly influenced by cultural pressure regarding appearance and roles. Over the years the pressures and expectations imposed on men by society have changed. While the traditional emphasis on strength and power is still propagated through tough, fighting, hero types in films such as Rambo, contemporary trends also require high levels of career success with less regard for personal relationships. Yet it is also seen as important to have a partner. Thus men are subject to conflicting demands: on the one hand to show power and strength, reflected in career and appearance, and on the other to acknowledge and express emotional needs. Internal conflict may result.
AN has been found to be markedly more prevalent among male body-builders than among other male groups (2.8 per cent; far higher than the 0.02 per cent reported among men overall). A recent study of athletes who abuse anabolic steroids has revealed the existence of a new body image disturbance referred to as a ‘reverse’ form of AN. The disorder, which may be associated with the abuse of the drug, is characterized by a fear of being too small, and by perceiving oneself as small and weak, even when one is actually large and muscular.
In all points except the reversal of self-perception and associated symptoms, ‘reverse’ AN in body-builders closely resembles AN. The implication is that this body image disturbance may reflect the cultural expectations of the group, just as ‘normal’ AN may for the young women whom it primarily affects. AN in young women has often been attributed to the increasing cultural pressures for slimness. Reverse AN may be an analogous response of young men to the influence of media pressure to be strong and muscular, as propagated through the gym subculture scene, in bodybuilder magazines, and in Hollywood movies.
Contrary to popular thought, AN is not restricted to the young; it can start at any time in the life cycle, including during old age. Criteria for the diagnosis of late-onset AN are the same as those for adolescent AN; self-induced starvation and a morbid fear of fatness, along with denial of the seriousness of the low body weight. Since most of these cases occur during or after the menopause, amenorrhea is not relevant. The pattern of this disorder varies greatly: in some it follows a lifelong preoccupation with weight and dieting, whereas in others there may have been no previous eating disorders.
Eating disorders are becoming more common in the elderly. Two reasons have been put forward to explain this increase. First, there has been a dramatic increase in the incidence of eating disorders in the last 30 years. Since at least 20 per cent of these disorders are chronic, and not all of those affected recover by the end of their reproductive life, some are likely to still have AN in their old age. Second, it is possible that even elderly women are beginning to succumb to the social pressures to be slim.
The diagnosis of AN in elderly patients may be more complex than in younger people, for a number of reasons. Elderly patients may be more reluctant to discuss psychological issues, eating habits or sexual issues. In some cases weight loss may have been initiated by coexisting medical or psychiatric disorders, but sustained by the individual thereafter. Weight loss may also be a symptom of one or more of the serious medical conditions that become more common during and after the forties, or be associated with major depressive symptoms, common in later years; in the latter case, there is no weight preoccupation or fear of fatness driving the weight loss. In any event, unexplained weight loss in an elderly person needs careful investigation, and eating disorders should be considered among the possible causes.
As is common with eating disorders in younger individuals, many older people with AN also have other psychiatric problems, particularly anxiety, depression and perfectionism. Overly controlled personalities are often vulnerable, especially to remembered childhood neglect or emotional distress. It seems that childhood experiences of being teased or abused remain salient and sensitive issues for some, and may manifest in an eating disorder when memories are exacerbated by a change in situation or circumstances, for example through the loss of a spouse or close friend.
There seems to be evidence that developmental milestones or phase-of-life events may serve as stressors for vulnerable women at any age, triggering AN as a maladaptive response. Younger patients report that rigorous dieting gives them an enhanced feeling of control when going through periods of loss and uncertainty. In later life, eating disorders may represent a reaction to continuing interpersonal loss – children leaving home, retirement from a job, or the death of friends or a spouse – and a similar perceived need to exercise control over some area of life.
It is important to view AN in its context. Its incidence among older women may be increasing as pressure mounts to retain physical attractiveness and sexuality. It has been suggested that some elderly women may become obsessed with thinness as a way of trying to avoid the ageing process. This particular motivation apart, the picture of AN in the elderly closely resembles that seen in younger people. Indeed, the fear of ageing and loss of sexual power and attractiveness may be as traumatic for older women as the teenage fear of not attaining the necessary perceived standards, and may be dealt with by similar psychological mechanisms (though the experience of sexual conflicts often relevant in adolescent AN does not appear pertinent in AN among elderly people).