HEALTH SCIENCE JOURNAL

Volume 6, Issue 2 (April June 2012)

_REVIEW_

Contribution of social and family factors in anorexia nervosa

Greta Wozniak1, Maria Rekleiti2, Zoe Roupa3
1. MD, PhD, Nursing Department, Applied University of Larissa, Greece
2. RN, MSc, General Hospital of Korinthos, Greece
3. RN, MD, PhD, Professor Coordinator for the Nursing Program School of Sciences, European
University, Cyprus

ABSTRACT
Background: Anorexia nervosa is probably the most substantial eating disorder, with basically unknown
causes, centered on psychological factors and affected by many social, biological and cultural ones. The
aim of this study was to emerge the complex issues regarding the treatment, the early intervention and the
prevention of the anorexia nervosa.
The method f this study included a search of the literature in several databases (Medline, EMBASE and
CINAHL) to identify articles related to anorexia nervosa. Results: Patients with anorexia nervosa develop
a refusal in ingestion of food, maintaining a distorted self-perception of their body, considering themselves
as overweighed. The diagnosis even though is made according international established criteria, varies
among the patients taking into consideration additional factors like family and social environment. As the
patients refuse to admit the seriousness of their condition, they seek for medical assistance when
disorders appear in vital organs, due to de-nutrition. In most cases hospitalization is necessary and
includes a suitable diet program and medication treatment.
Conclusions: Psychological therapy is a basic part of the treatment, in long-term basis and is employed by
behavior therapy and the patient's support. Advising the public and especially parents with children in
adolescence, where usually anorexia nervosa occurs, is necessary as the prevention and the early diagnosis
is the best treatment.

Keywords: Anorexia nervosa, treatment, prevention.

CORRESPONDING AUTHOR
Greta Wozniak, MD, PhD
Applied University of Larissa
Larissa, GREECE,
Phone: +30-2410 684252
Fax: +30-24210 - 72462
E-mail: greta@med.uth.gr

INTRODUCTION

D
isorders in food injection have last years due to the constantly increased
raised the interest of scientists the number, mainly of women, that report

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severe behavioral problems regarding the melancholy and usually appears to

7
food. Two clinical syndromes appear in sexual immature females.
adolescent and adult age: Anorexia Anorexia nervosa is more commonly
Nervosa and Bulimia nervosa.1 appeared during the recent decades
Anorexia nervosa appears at a rate of 80- comparing with former ones, and
85%, in young women at the age of 12- reported in females in preadolescence
25 years old, in the middle and upper age and males. Epidemiological data
socio-economic status, in whose report that eating disorders climb up to
profession a good appearance and 4% in adolescent females and anorexia
thinness are considered as a professional nervosa is estimated that appears at 0.5-
and especially desirable requirement, 1% in the same group. It occurs 10-20
while the small male percentage that times more in females than in males and
suffer from anorexia nervosa with mainly at developed countries, (western
compulsive exercising.2,3 Although countries).8
anorexia nervosa is described as primary, Study results show that anorectic
many patients may suffer from medical children come from families that have
disorders, psychosis, neurosis, lost a member, they have been abussed.9
personality disorders and depressive Respective studies reach the conclusion
inclination with lack of emotional that the 1/3 of the anorectic patients
expression.4 have been sexual abused during
Anorexia nervosa is characterized by childhood and they seem to have
severe and serious disorders of self- common characteristics with sexual
perception of their body and the abused victims, like low self-esteem,
determined pursuit of thinness.5 It was feelings of shame and a negative attitude
described for the first time by Morton in towards their body and the opposite
1689, and was a subject of study in the sex.4
middle of last century, as a form of Although the mental, social and physical
hysteria. At first the disorder was consequences are particular serious, the
described as a hereditary abnormality of scientific studies are few and there is a
the central neurological system that considerable delay in elaboration of
appears only to young females6. In 1883 proof based approaches, especially for
Huchard established the term "anorexia children and adolescents, in spite the
nervosa" and Freud (1895) suggested fact that eating disorders occur to this
that anorexia is associated with age groups.10-12

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Volume 6, Issue 2 (April June 2012)
The social conventions and the emphasis mother associated with the occurrence
to external appearance, that influences of the disorder to children and especially
mainly young people, are factors to adolescent females.13
associated with eating disorders in Psychical theory
addition with advertisement and the According to Bruch (1982) the psychical
contribution of mass media projecting factors associated with the appearance of
anorectic models as the only way to the disorder are:
success, the non-acceptance of other 1. Adolescent crisis and new experiences,
values like educational, cultural, social as inclinatory factors
enlarge the problem. The modern society 2. Raising a child that is only ostensibly
enervates family bonds and reduces the "normal". They usually hide behaviors
time spent between parents and children, with lack of recognition, enhancement
setting new priorities, altered from those and confirmation of child's abilities.
of previous generations. 3. The preponderant psychological
Purpose of this study is to highlight the mechanism, which is the complete
complex issues concerning the control of the body, as an effort to
treatment, the early intervention and the maintain a level the dominance over
prevention of the anorexia nervosa. their selves.14
Etiology of anorexia nervosa and Social-Psychological factors
associated factors Many scientists ascribe the disorder to
The causes of anorexia nervosa are multi psychological and social mechanisms.
factored and there are many relative They believe that anorexia nervosa
theories from the scientific community. seems to be a reaction to the demands of
It is supported that the disorder is adolescence for more independence and
caused by a coalescence of biological, increased social and sexual activity. In a
social-cultural and psychological - way, patients through the disorder
psychical factors. There also the view replace the normal adolescent quests
that the causes of anorexia nervosa are with the constant concern of food and
only psychical or that there is no clear control of their body weight. They report
evidence regarding the exact that there are troubled relationships
pathogenesis that induces the disorder. between parents and the anorectic
But all scientists agree at the significant children try to draw their attention. In
role of the family and particularly the patients' family history are mentioned

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Technological Educational Institute of Athens

cases of depression, alcoholism, and the causes of anorexia nervosa. They

15
eating disorders. believe that the importance of
Biological factors psychological, social and biological
1. Heredity: Anorexia nervosa is reported factors varies to each individual.
in significally higher frequency among Biological factors may be associated with
individuals that are biological related to hormonal changes that occur during
anorectic patients and in genetic level adolescence. Psychological mechanisms
there are evidence that it is occurred at a may be involved in the changes in
rate of 50% between identical twins and, personality and behavior during the
at rate of 10% in fraternal twins or twin human life and social factors may be
sisters. related with the idealization of thinness,
2. Neurochemical factors. Biological that plays a powerful role in our
theories are focused in the function of culture.18,19
hypothalamus, where, based on
observations and clinical results, there is Beginning and probability of prognosis
a protogenic dysfunction. Over-secretion of anorexia nervosa
of cortisol is detected to malnutrition Few data are available by researchers
and depression. There are increased regarding the onset of the disorder. 85%
corticotropin CRG levels and it is of the incidence is detected between 13-
released to cerebrospinal fluid of these 20 years of age, with adolescence being
patients. Also amenorrhea is reported the most critical period of lifetime, and
before the occurrence of weight loss. An the probability of developing the
increased level of ceretonin in brain disorder after the age of 40 almost non-
reduces the appetite, and leptin seems to existent, also the beginning of the
have an important roll in regulation of disorder is often associated with a
fat sites in the body, and as a result to stressful event. The prognosis of the
the regulation of appetite. Anorexics disorder is extremely difficult to be
have lower leptin levels in blood that are defined, as it is influenced by the
increased with the temperature rise.16,17 structure of personality. Persons that are
Theory of unknown etiology hysteric, with intense obsessions, and a
Group of scientists support the view that bad background of maternal
anorexia nervosa is an open question in relationship, are very likely to develop
medicine and there is no psychiatric the disorder in future. Also individuals
theory to support sufficiently by its own with family history of anorexia nervosa,

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Volume 6, Issue 2 (April June 2012)
or with medical history of serious anorexia nervosa are discriminated to
20,21
diseases are at the same risk. medical complications of the disorder,
including hypokalemia,
Progress and prognosis of anorexia bronchopneumonia, cardiac arrhythmia,
nervosa coronary disease, pancreatitis, necrotic
Anorexic patients ask for medical advice colitis and suicides.25
long after the appearance of very serious
symptoms, many of them unwillingly, Symptoms and behavior characteristics
after their family encouragement. The The self-enforcement starvation of the
progress of the disease varies, from patients, who are not having disorders in
immediate recovery after the treatment, appetite, and are visibly obvious, causes
to unsteady progress of weight recovery the symptoms of the disorder by
with recurrences, and to constant fatal behavioral and physical changes.
aggravation. Studies report that the 1/3 Behavior of anorexic
of the patients is cured, at the 1/3 there Anorexic persons have a disorder image
health condition is improved and at 1/3 of the normal weight and shape of the
the disorder becomes chronic.22 body and they consciously chose ways
Generally the prognosis is not good. The for weight loss that gradually lead to
extended duration of the disease, dying. They seem to have obsessive
depression, frequent vomits and the characteristics, high sense of duty and
excess weight loss are negative morality and an inclination to
prognostic points, including hospitalized independence. At the beginning they are
treatment, sensitivity to various diseases, intensively busy preparing their meals,
and family with intense and they avoid high calorie foods, weight
23
psychopathology. As positive at least four times daily, and follow strict
prognostic points are considered the exhausting diets.26 After a while they are
reduction of stress, a strongly supportive entering the second phase, where their
family and friendly environment, and behavior constantly changes, the family
also strongly structured personality.3 begin to realize the problem, although
The mortality of the hospitalized patients patients still deny it and refuse any
is more 10% due to either excess weight conversation about it, as a result there
loss or inanition or to suicide attempts.24 are daily conflicts within family
The causes of death in patients with members, and gradually they become

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 Quarterly scientific, online publication by Department of Nursing A,
Technological Educational Institute of Athens

isolated. Their interest for any kind of

activity is lost and reduced, their ability Diagnosis of anorexia nervosa
to concentrate is reduced as well as their The patents with anorexia nervosa seem
sexual activity. The patients adopt a to have a certain behavior regarding the
contrary behavior, obstinacy, laziness, shape and weight of their body.
emotional instability and detachedness.27 Diagnosis of anorexia nervosa is based
Physical symptoms on diagnostic criteria established by
Abrupt weight loss at a rate of 25% of American Psychiatric Association (DSM-
the normal body weight, initially in IV) that are in valid worldwide and are
males causes delay in stature and referred to psychopathological
pubescence and in females amenorrhea, symptoms and signs and to evidence of
and in both sexes reduced thyroid endocrinologic disorders (Table 2). 33
metabolism. In continue occurs the
deterioration of bodys shape, Treatment approaches of anorexia
depression, intense xerodermia, nervosa
intolerance of high and low temperature. There are two main aims in the
Gradually heads hairs are getting treatment of anorexia nervosa. The first
thinner and the presence of lanugo (hair is to rehabilitate the state of nutrition.
that looks like neonatal lint) becomes For anorexic patients this means to
obvious on face, shoulder blade and regain the body weight to normal levels.
hands as well as inflation and The second aim is to alter the
inflammation of salivary glands. As pathological behavior of eating, so that
organism tries to adapt with low intake the body weight is preserved to normal
of energy, appears a variety of organic limits and to control the use of laxatives
disorders, such as bradycardia, and other pathological behaviours.34
arrhythmias and decrease of arterial Usually anorexia is treated in an
blood pressure having as result periods outpatient setting. Evidence for
of hypotension. It exceeds anemia, hospitalization is a severe weight loss
dental problems, hands and legs and emaciation, hypotension,
formicary, inflexibility, stress and hypothermia, electrolyte disorders,
upheaval, insomnia and early awakening. presence of suicidal ideation or
During laboratory testing the endocrine psychosis, and the failure outpatient
disorders become obvious by disorders at treatment.
hormonal prices (Table 1).30-32 The treatment approach is a

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Volume 6, Issue 2 (April June 2012)
combination of behavior therapy and The modern social models idealize
35,36
supportive psychotherapy. It is very women with low body weight, with
important the approaching way of the result the increasing number of incidents
person, in order to develop positive of anorexia nervosa, especially among
behavior. This includes the learning of adolescents. Long-term aim should be
behavior, and then follows de learning the reducing effects of eating disorders
and relearning, without seeking the and the associated risk factors.
causes of the previous pathologic Scientists emphasize the need of
behavior. The aim of this behavior encouraging the patients to seek therapy
treatment is to restore the normal way of and to treat them with understanding,
37
eating. while the goals and limits of treatment
In hospitalized treatment a strict are attainable. Also, they suggest specific
protocol is followed to anorectic patients instructions regarding the level of the
in order to gain a certain weigh daily, needed treatment to psychological and
regarding the intakes and outtakes of behavioral issues that characterize
calories, and there is a close monitoring anorexia nervosa. All the medical
till 2 hour after the meal, to avoid professionals should realize that the
induced vomiting to patients with excess recovery of the disorder is a slow
weight loss. procedure.
The financial cost for this kind of
Conclusions disorders is high and onerous for the
Although there is a significant progress families of the patients. Beside the long
in treatment of anorexia nervosa, the period of time, there are many variations
conclusions, of the few studies during in the force of the disease, and many
the last decade, have showed a times hospitalization is necessary and
wackiness in research, as it seems that treatment is common to engage a
the ways of developing prevention and multidisciplinary team of professionals
treatment programs of anorexia nervosa for the patients and their families.
are not connected with the risk factors Anorexia nervosa is a psychiatric disease
and the necessity of finding a treatment with high mortality rates in young
approach that combines the traditional patients. It is need the state to organize
methods of therapy with new ones, and units for patients with eating disorders
this due to limited knowledge. and to fully cover treatment and

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Technological Educational Institute of Athens

hospitalization. The public information is 6. Silverman JA. Richard Morton's

essential and especially to parents with second case of anorexia nervosa:
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7. Habermas T. The psychiatric
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Technological Educational Institute of Athens

ANNEX

Table 1: Abnormalities in Anorexia Nervosa

FUNCTIONAL FINDINGS
SYSTEM

Endocrine - Normal thyroid gland

metabolic

Normal TSH*

Decreased T3 and BMR

Increased serum cholesterol

Normal pelvic examination results

Decreased FSH, LH, response to LHRH

Decreased estrogen production

Increased cortisol and urine free cortisol

ACTH normal or increased

Decreased suppressibility by dexamethasone

Decreased serum insulin and RBC insulin bitting GTT flat or diabetic

Salt and water balance maybe abnormal

Deficient ADH

Normal or increased serum GH

Decreased GH response to glucagon, propranolol, TRH and levodopa

Decreased, increased or normal serum Ca ++ and PTH

Hematologic Anemias

Leucopenia

Thrombocytopenia

Miscellaneous Increased ESR (mild)

Decreased serum albumin

Changes in serum globulins

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Table 2. Diagnostic criteria DSM-IV for anorexia nervosa (APA, 1996)

DIAGNOSTIC CRITERIA DETERMINATION

The refusal to maintain body weight at or above

a though the person is underweight
A) Restrictive type

) Hyper-appetite/ Purgative type

Excessive fear of weights increase or fear of fat

although the individual is thin

Grossly distorted self-perception regarding the

weight or the shape of the body.

Amenorrhea, for at least three consecutive

periods.

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