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In recent years, it seems that the public has begun to pay more attention to eating disorders. This trend could be a consequence of the heightened nutrition and fitness craze that the 1990's has brought about, or possibly a result of more intense and conclusive research studies. More clearly defined definitions of anorexia and bulimia in the DSM-IV may also have contributed to better diagnosis of eating disorders.
Anorexia nervosa is a disorder that in the majority of cases will start when the patient is a teenager. The mean age at onset is figured to be about 17 years of age. The distribution of cases appears 'to be asymmetrical with a skewness towards the higher ages (Theander, 1996).
Recently, child psychiatrists have begun to recognize increasing cases beginning in childhood (McCune & Walford, 1991). While refusal to eat and loss of weight are common symptoms in child psychiatric practices, similarities between these anoretic states and the syndrome of anorexia nervosa are slight (Hawley, 1985). While severity of illness is usually associated with worse outcome, age of onset for anorexia can play a critical role in future outcome. Premenarcheal anorexia nervosa has serious implications for the progress of puberty which may in turn, have detrimental effects on the youngsters (Bryant-Waugh, Fosson, Knibbs, & Lask, 1987). It is important that pediatricians, psychiatrists, educators, and parents are able to identify this disorder at early ages. The purpose of the following sections of this paper are to help familiarize readers with signs and symptoms which may aid in identification of anorexia leading to an early diagnosis.
Girls with anorexia nervosa may display some of the following symptoms
as described by the Diagnostic and Statistical Manual IV:
|Refusal to maintain body weight at or above a minimally normal weight for age and height (body weight at or below 85% of the normally prescribed range for age and height)|
|Intense fears of gaining weight or becoming fat, even though underweight|
|Disturbances in the perception of the shape or size of body|
|Denial of the seriousness of current low body weight -Absence of at least three consecutive menstrual cycles in postmenarcheal females (amenorrhea)|
|Weight loss is most commonly achieved through reduction in total food intake|
|Increased or excessive exercise |
While children must meet the criteria listed in the DSM-IV for diagnosis of anorexia, a description of the signs which are commonly seen in the development of an eating disorder may help one understand the thoughts and emotions that surround many young girls on a daily basis. Becoming familiar with these signs may allow untrained observers to identify the possible development of an eating disorder in its early stages. Early identification and referral to psychological services will increase the young girl's likelihood of a more favorable prognosis (Romeo, 1996).
In the initial stages of anorexia, a youngster may notice that her clothes feel a little snug or her face looks a bit chubbier in the mirror. The scale in the bathroom may confirm her assumption that she has gained a little weight. The only solution to this new found flaw is a diet. The girl may announce that she is going on a diet. Most people will applaud this initial decision, realizing that everyone could stand to cut the junk food out of their diet. As the young girl begins to think more about her new diet, questions will begin to run through her mind. How many calories are in this? What foods should she eat? How much food should she eat? Books on nutrition and dieting are common reference points for youngsters as they attempt to formulate their diet plan. Certain foods become forbidden because they contain too much fat or are high in calories while other foods are labeled "safe". The young girls diet will become an accumulation of only these "safe" items.
Exercise habits will continue to increase. The two mile workout will escalate to four miles. Spare time is used for repetitions of sit-ups or jumping jacks because it can not hurt to burn those extra calories Besides, any book concerning dieting encourages exercise to lose weight.
Conversations with friends often revolve around diet or the body shape of other people. Classmates are constantly talked about and their figures analyzed and compared with others. These discussions reinforce the young girl's diet because she does not want to be criticized for her appearance. Actresses and models seen in magazines and movies are all thin and attractive. These glorified figures only enhance a youngster's desire to be thin.
At first the young girl is complimented on her weight loss and the slenderness
of her appearance by friends and family. She is praised on the success
of her diet and considers it an achievement. As the youngster becomes to
thin, she actively resists suggestion that she must gain weight. The girl
believes that others are simply jealous of her appearance for she is convinced
that she still looks too fat. The youngster will not eat more for fear
of gaining weight.
While key factors in the involved in the development of anorexia nervosa have been identified, it is now time to take a look at the youngest victims. Although early onset cases are rare in comparison to other age groups, the limited research should is not a good reason to forget this subgroup. Early onset anorexia may be defined by using either an age limit or by using menarche as a biological age limit. Chronological age limits are usually set at fourteen years, before individuals show any outward sign of puberty (Bryant-Waugh et al., 1987). Biological markers identify early onset anorexia by deliberate self starvation before menarche. This factor is often considered a cause of under diagnosis in youngsters because missed menstrual cycles is a key component in identifying anorexia. The role of anorexia in delaying menarche is well established (Bhat, Crisp, Gowers, & Joughin, 1991).
Younger children are often more emaciated than those person's with a
later onset of anorexia as a result of less initial body fat. Although
early onset cases are often severe, these youngsters do not seem to resort
to such dramatic abstinence or laxative abuse (Bhat et al., 1991).
While depression is a common problem during the course of anorexic episodes, it has been speculated that the eating disorder is primary and although depressive feelings are an integral part of the disorder, they are not a cause of it (Rastam, 1992). This finding is supported by observed cases of early onset anorexia. Through the use responses by 250 subjects on the Beck Depression Inventory, various scales on the Symptom Checklist 90, and the Eating Disorder Inventory, Halmi, Heebink, and Sunday (1995) concluded that young patients with anorexia had less depression than older patients. Chee, Mynors-Wallis, and Treasure (1990) also agree that late onset cases are more likely to be complicated by coexisting depression.
Past research has alluded to negative life events as precipitants of anorexia nervosa. Recently though, Byram, Gowers, North, and Weaver (1996) performed a study that was unable to find a significant relationship between the development of anorexia and negative life events. The results of their study found that less than one-half of the subjects with anorexia revealed a moderately negative life event in the year proceeding the onset of illness and only one-quarter revealed a severely negative life event. These responses were consistent with that of controls (Byram et al., 1996).
In the case of early onset anorexia, correlations have been made between the onset of the disorder and greater fears concerning maturity. Typical premenarcheal cases seem to be associated with anxieties about pubertal development. It has been argued that represents a maladaptive biological response to the growth changes of puberty (Bhat et al., 1991).
Other findings attribute the early onset of anorexia nervosa to a struggle
for self control and autonomy. Younger patients may be influenced by
family conflicts concerning the child's emerging adolescence. Some
children may attempt to resolve conflicts by focusing controversy on food
and control of intake (Bryant-Waugh, et al., 1987). Halmi et al. (1995)
suggest that various psychological discrepancies in childhood such as increasing
autonomy, separation, peer and social pressure, as well as emerging physical
maturity and sexual interests may proceed and prolong early onset anorexia.
An early age of onset of anorexia has been associated with a poor outcome (Halmi, et al,., 1995). Consistent with all cases of anorexia though, severity of the illness also effects outcome. when treating young anorexia patients, there are many risks involved if the disorder is allowed to run a long or chronic course (Theander, 1996).
Treatment should take into account the patient's growth rates and pubertal development as well as age (Bhat et al., 1991). While individual counseling has helped improve the youngster's well being, more recent findings consider additional family treatment to be helpful. Because young anoretic patients seem to have been considerably influenced by family conflict, outcome can be improved by family therapy (Halmi et al., 1995). In a person with early onset anorexia, it is not only the sufferings of the patient and her family that call for intensive treatment, but it is the risk of retarded body length, underdeveloped breasts, and a hampered development of mature personality (Theander, 1996).
Bhat,A., Crisp, A. H., Gowers, S. G., & Joughin, II. (1991).
Premenarcheal Anorexia Nervosa. Journal of Child Psychology and
Psychiatry, 32, 515-524.
Bryant-Waugh, R., Fosson, A., Knibbs, J., & Lask, B. (1987). Early
Onset Anorexia Nervosa. Archives of Disease in Childhood, 62,
Byram, V., Gowers, S. G., North, C. D., & Weaver, A. B (1996) Life
Event Precipitants of Adolescent Anorexia Nervosa. Journal of Child
Psychology and Psychiatry, 37, 469-477.
Chee, Deborah, Mynors-Wallis, Laurence, & Treasurer Janet. (1992).
Life Events and Anorexia Nervosa: Differences Between Early and Late Onset
Cases. International Journal of Eating Disorders, A, 369-375.
Halmi, Katherine A., Heebink, Denise M., & Sunday, Suzanne, R. (1995).
Amorexia Nervosa and Bulimia Nervosa in Adolescence: Effects of Age and
Menstrual Status on Psychological Variables. Journal of -the American
Academy of Child and Adolescent Psychiary, 34, 378-382.
Hawley, Richard. (1985). The Outcome of Anorexia Nervosa in Younger
Subjects. British Journal of Psychiatry, 146, 657660.
McCune, Noel & Walford, Geraldine. (1991). Long-Term outcome in
Early-Onset Anorexia Nervosa. British Journal of Psychiatry, 159,
Rastam, Maria. (1992). lmdrexia in 51 Swedish Adolescents: Premorbid Problems and Comorbidity. Journal of the American Academy of Chlld and Adolescent Psychiatry, 11, 819-827.
Romeo, Felicia.(1996). Educators and the Onset of AnorexiaNervosa in
Young. Education, 117, 55-60.
Theander, Sten. (1996). Anorexia Nervosa with an Early Onset: Selection,
Gender, Outcome, and Results of a Long-Term Follow-Up Study. Journal
of Youth and Adolescencg, 25, 419428.
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