Anorexia nervosa as a pathological prototype of femininity
Anorexia nervosa is primarily an internalizing disorder because the morbidity is turned inward. I understand that this could be disagreed with. Indeed, hypophagia (self starving) could be stated to consist of an externalizing behavior, with a bellicose intent or an attention-seeking unconscious motive. And there is even a form of the disease which comprises much disruptive behavior: indeed, bulimia is a form of anorexia nervosa characterized by cycles of food bingeing and vomiting and laxative abuse and dangerous dieting, kleptomania, sexual promiscuity, drug abuse and alcoholism, emotional lability, all reminiscent of episodic dyscontrol disorder. My topic here will limit itself to the so called "restricting" form of anorexia consisting basically of self starving. This type of anorexia is the more common form. The restricting anorexic is typically extremely well considered by the family and school. She is a model child up until her hypophagia (self starving), and even this goes unnoticed for a long period of time. There is no acting out, no impulsive destructiveness, no attention-seeking behavior, no hostility at all. About 40% are clinically depressed at one or another point in or around their anorexic "career", including quite frequently before the hypophagia. A similar number manifest signs of the obsessive-compulsive syndrome other than the obsession for thinness and compulsive dieting (excessive cleanliness, ritualisms, complex recurrent ruminations having to do with mind control, etc.). Restricting anorexics are sexually turned off (delibidinized) if they have ever been turned on at all, and loathe the rotundness of the feminine shape. Anorexia nervosa is stress-related: it happens more often in stressed families (especially the type of stress associated with the ideology of over-achievement) and it is aggravated by stressors which can be pegged in time (sudden financial strain, death of a parent, parental divorce or conflict, etc.). One of the most spectacular maladjustments in anorexia nervosa is the body image disturbance. Restricting anorexics see themselves as despicably fat even when they are cadaverically thin.
Body image distortion in restricting anorexics
Figure 12. My student Colette Jodoin completed her PhD on the neuropsychology of anorexia nervosa several years ago. One of the issues that interested her was the distortion of body image. She presented various cards to schoolgirls who scored in the pathological range on an anorexia scale. The girls were simply asked to rate which card best represented their true physiognomy (body shape) and which card represented their ideal body shape. Elaborate anthropometric measurements of the girl's bodies were taken. It was found that these “pre-anorexic” girls selected appropriate models to represent their true physiognomies. However, their selections of “ideal” physiognomies corresponded to the cadaverically thin models, a finding which differed significantly from selections of normal controls.
The endocrinological profile is complex and is still far from being completely understood. The hypothalomo-hypophyso-adrenal axis is certainly out of whack. Anorexic adolescents have amenorhea (retarded menses), lanugo (downy infantile body hair), bradycardia (slow heart beat) and poor thermoregulation (overly sensitive to temperature changes).
The neurological and neuropsychological profiles are all suggestive of a right hemisphere disorder. First, depression itself is more a right than a left hemisphere disorder. The electroencephalographic, neuropsychological and brain imaging research are all concordant in supporting this point of view. Also, electroconvulsive therapy is more effective for depression when applied to the right than the left temporal area. Second, body image disturbance is also more often a right than a left hemisphere disturbance. Less is known about hemispheric asymmetry in the etiology of this particular disorder than is the case for depression. Nevertheless, it has been observed that when the etiology is migrainous or epileptic, the focus is far more often on the right side. Symptoms of neurologically-caused body image distortion are more often observed on the left side of the body -suggesting again a right hemisphere pathology. Third, when electroencephalograms of anorexics shows an asymmetry of disturbance (a small minority of cases) the abnormality is virtually always worse on the right side of the brain. In a review of such cases which I published with my student Marie-Josée Chouinard, we found this in 19 out of 21 cases. Fourth, metabolic brain imaging of anorexics has revealed more abnormality on the right side. Fifth, neuropsychological evaluation has consistently revealed a pattern of preserved verbal abilities and mildly "impaired" visuospatial abilities, a profile more compatible, of course, with right hemisphere disturbance. Not much useful information has been found concerning neurotransmitter physiology in anorexia nervosa. Of course it is well accepted that serotonin has a lot to do with appetite. And indeed the only drug treatment that has ever so minimally surpassed the placebo effect in this disorder is tricyclic antidepressants, i.e., serotonin agonists.
If there is any doubt in the readers' mind that there are biological determinants of anorexia nervosa, then a review of the genetics of the disorder will surely do the trick. Several studies have been carried out on family pedigrees of patients with anorexia nervosa. The disease certainly does run in families. The disease is probably polygenic (like most psychopathologies) because a) the pattern of transmission is incompatible with a Mendelian (single gene) model (25% of descendants present the trait if the gene is recessive or 50% if the gene is dominant), and b) there is a spectrum of disorders in the family tree. Right after anorexia, depression is the most frequently noted disorder, followed by the obsessive-compulsive syndrome. Family studies are important for genetics, but they are not as important as twin studies. Indeed, it is always conceivable that a disorder like anorexia runs in families simply because stress or some other anorexia-inducing set of lifestyle variables also runs in families. Because homozygotic twins share 100% of their genes, and dizygotic twins share 50%, the comparison of concordance rates (for anorexia for example) in the two types of twins tells us a great deal about the extent to which a disease is hereditary. And we are far less likely to be tempted to explain a DIFFERENCE in the concordance rates by a DIFFERENCE in lifestyle variables. If the identical twins have very high concordance, and the fraternal twins have much lower concordance, then a trait is likely to be strongly inherited. In fact, the comparison of these two types of twins can actually generate a quantitative estimate of the proportion of a trait that is hereditary (as opposed to environmentally determined). Only recently has a large series of such twin pairs been studied for anorexia. At least one twin of each pair had to have anorexia to be included in the study. The authors found that the heritability was amazingly high (80%), higher than most biological traits such as blood cholesterol level, serotonin physiology, life expectancy, etc.
1) it is an internalizing disorder
2) it is a stress-related disorder
3) the main co-morbidity (depression) is female-prevalent
4) its' onset is around puberty and adolescence
5) it is certainly influenced by hormonal changes occurring at that time
6) morbidity is centered around female-typical concerns such as body appearance
7) the sex drive is abnormally low
8) the right hemisphere is more affected than the left
9) visuospatial functions are more affected than the verbal
10) more evidence points to serotonin mediation of the disorder than to mediation by any other neurotransmitter
A vignette on a case of anorexia nervosa
Alessi and his colleagues described case AD in a 1989 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. At age nine, her 25-pound (35%) weight loss (bringing her to 52 pounds) brought her to medical attention. This is a very early onset and a severe expression of the disorder. She was extremely concerned with being fat, had lost interest in outside activities and friends, suffered energy loss, couldn’t concentrate and was suicidal. She had been a very sociable straight-A student. Her parents unsuccessfully tried to prevent her from dieting. She did not binge and purge (bulimia), and no use of laxatives or dieting pills was noted, but she often voluntarily vomited her food. She had been very anxious about preschool (separation anxiety). She belonged to an over-achieving perfectionistic family. She was hostile to medical intervention and even more so to psychotherapy -which was nevertheless imposed, in addition to coercive feeding with careful surveillance. She scored very high on tests of depression and of eating disorder. She had an IQ of 130 despite her poor health at the time of testing, which was during her hospitalization. Several of her hormones were in a state of imbalance. The treatment was effective in producing weight gain, redressing her hormonal imbalances, and lifting her depression.
Body image distortion in restricting anorexics
Figure 12. My student Colette Jodoin completed her PhD on the neuropsychology of anorexia nervosa several years ago. One of the issues that interested her was the distortion of body image. She presented various cards to schoolgirls who scored in the pathological range on an anorexia scale. The girls were simply asked to rate which card best represented their true physiognomy (body shape) and which card represented their ideal body shape. Elaborate anthropometric measurements of the girl's bodies were taken. It was found that these “pre-anorexic” girls selected appropriate models to represent their true physiognomies. However, their selections of “ideal” physiognomies corresponded to the cadaverically thin models, a finding which differed significantly from selections of normal controls.
The endocrinological profile is complex and is still far from being completely understood. The hypothalomo-hypophyso-adrenal axis is certainly out of whack. Anorexic adolescents have amenorhea (retarded menses), lanugo (downy infantile body hair), bradycardia (slow heart beat) and poor thermoregulation (overly sensitive to temperature changes).
The neurological and neuropsychological profiles are all suggestive of a right hemisphere disorder. First, depression itself is more a right than a left hemisphere disorder. The electroencephalographic, neuropsychological and brain imaging research are all concordant in supporting this point of view. Also, electroconvulsive therapy is more effective for depression when applied to the right than the left temporal area. Second, body image disturbance is also more often a right than a left hemisphere disturbance. Less is known about hemispheric asymmetry in the etiology of this particular disorder than is the case for depression. Nevertheless, it has been observed that when the etiology is migrainous or epileptic, the focus is far more often on the right side. Symptoms of neurologically-caused body image distortion are more often observed on the left side of the body -suggesting again a right hemisphere pathology. Third, when electroencephalograms of anorexics shows an asymmetry of disturbance (a small minority of cases) the abnormality is virtually always worse on the right side of the brain. In a review of such cases which I published with my student Marie-Josée Chouinard, we found this in 19 out of 21 cases. Fourth, metabolic brain imaging of anorexics has revealed more abnormality on the right side. Fifth, neuropsychological evaluation has consistently revealed a pattern of preserved verbal abilities and mildly "impaired" visuospatial abilities, a profile more compatible, of course, with right hemisphere disturbance. Not much useful information has been found concerning neurotransmitter physiology in anorexia nervosa. Of course it is well accepted that serotonin has a lot to do with appetite. And indeed the only drug treatment that has ever so minimally surpassed the placebo effect in this disorder is tricyclic antidepressants, i.e., serotonin agonists.
If there is any doubt in the readers' mind that there are biological determinants of anorexia nervosa, then a review of the genetics of the disorder will surely do the trick. Several studies have been carried out on family pedigrees of patients with anorexia nervosa. The disease certainly does run in families. The disease is probably polygenic (like most psychopathologies) because a) the pattern of transmission is incompatible with a Mendelian (single gene) model (25% of descendants present the trait if the gene is recessive or 50% if the gene is dominant), and b) there is a spectrum of disorders in the family tree. Right after anorexia, depression is the most frequently noted disorder, followed by the obsessive-compulsive syndrome. Family studies are important for genetics, but they are not as important as twin studies. Indeed, it is always conceivable that a disorder like anorexia runs in families simply because stress or some other anorexia-inducing set of lifestyle variables also runs in families. Because homozygotic twins share 100% of their genes, and dizygotic twins share 50%, the comparison of concordance rates (for anorexia for example) in the two types of twins tells us a great deal about the extent to which a disease is hereditary. And we are far less likely to be tempted to explain a DIFFERENCE in the concordance rates by a DIFFERENCE in lifestyle variables. If the identical twins have very high concordance, and the fraternal twins have much lower concordance, then a trait is likely to be strongly inherited. In fact, the comparison of these two types of twins can actually generate a quantitative estimate of the proportion of a trait that is hereditary (as opposed to environmentally determined). Only recently has a large series of such twin pairs been studied for anorexia. At least one twin of each pair had to have anorexia to be included in the study. The authors found that the heritability was amazingly high (80%), higher than most biological traits such as blood cholesterol level, serotonin physiology, life expectancy, etc.
1) it is an internalizing disorder
2) it is a stress-related disorder
3) the main co-morbidity (depression) is female-prevalent
4) its' onset is around puberty and adolescence
5) it is certainly influenced by hormonal changes occurring at that time
6) morbidity is centered around female-typical concerns such as body appearance
7) the sex drive is abnormally low
8) the right hemisphere is more affected than the left
9) visuospatial functions are more affected than the verbal
10) more evidence points to serotonin mediation of the disorder than to mediation by any other neurotransmitter
A vignette on a case of anorexia nervosa
Alessi and his colleagues described case AD in a 1989 issue of the Journal of the American Academy of Child and Adolescent Psychiatry. At age nine, her 25-pound (35%) weight loss (bringing her to 52 pounds) brought her to medical attention. This is a very early onset and a severe expression of the disorder. She was extremely concerned with being fat, had lost interest in outside activities and friends, suffered energy loss, couldn’t concentrate and was suicidal. She had been a very sociable straight-A student. Her parents unsuccessfully tried to prevent her from dieting. She did not binge and purge (bulimia), and no use of laxatives or dieting pills was noted, but she often voluntarily vomited her food. She had been very anxious about preschool (separation anxiety). She belonged to an over-achieving perfectionistic family. She was hostile to medical intervention and even more so to psychotherapy -which was nevertheless imposed, in addition to coercive feeding with careful surveillance. She scored very high on tests of depression and of eating disorder. She had an IQ of 130 despite her poor health at the time of testing, which was during her hospitalization. Several of her hormones were in a state of imbalance. The treatment was effective in producing weight gain, redressing her hormonal imbalances, and lifting her depression.
.jpg)
No comments