Anorexia nervosa

"The Eating Disorder Service at the Children's Hospital at Westmead (CHW) in Sydney, provides comprehensive inpatient and outpatient treatment for children and adolescents with eating disorders. In 2003 the Maudsley Model of family based treatment for anorexia nervosa was introduced to support outpatient care. This has resulted in positive changes in the dynamics of the eating disorder team, a change in the philosophies that underpin the program and the experience of families that consult the service. There has also been a significant decrease in readmission rates. Our experience with the model has resulted in requests to provide training to other clinicians around Australia and a number of ongoing consultative relationships have followed. Implementation of the Maudsley model at CHW is described, followed by an overview of the theory and a summary of the key changes and challenges since moving in this new direction in 2003."

"Would anorexia have so quickly become part of Hong Kong’s symptom repertoire without the importation of the Western template for the disease? It seems unlikely. Beginning with scattered European cases in the early 19th century, it took more than 50 years for Western mental-health professionals to name, codify and popularize anorexia as a manifestation of hysteria. By contrast, after Charlene fell onto the sidewalk on Wan Chai Road on that late November day in 1994, it was just a matter of hours before the Hong Kong population learned the name of the disease, who was at risk and what it meant."

"Clinical observation has long suggested a link between personality and eating disorders. Research has consistently linked anorexia (particularly when the patient does not also have bulimic symptoms) to personality traits such as introversion, conformity, perfectionism, rigidity, and obsessive-compulsive features. The picture for bulimia is more mixed. Traits such as perfectionism, shyness, and compliance have consistently emerged in studies of individuals with bulimia or with anorexia, although research has often found bulimic patients to be extroverted, histrionic, and affectively unstable."

"Circulating concentrations of leptin are exceedingly low during the acute stage of anorexia nervosa. Which symptoms result from these diminished concentrations must be clarified. Furthermore, research is required to evaluate whether or not a too rapid weight gain might induce a physiological counter-regulation which would predispose to renewed loss of weight."

"Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic."

"Published photographs of models that have been modified “in order to narrow or widen the silhouette” should be labelled as “photograph touched up”. Those who failed to comply could face a fine of up to €37,500, or 30% of the value of the advert featuring the model. An earlier version of the bill also made it an offence punishable by up to a year’s imprisonment to encourage excessive thinness, a measure aimed at “pro-ana” websites that extol or promote anorexia or bulimia. Catherine Lemorton, president of the government’s social affairs committee, said many of those who ran such sites “suffered themselves with eating problems” and might be damaged further by the threat of prison. When the law was first introduced to the house in April this year, Marie-Rose Moro, a psychoanalyst and psychiatrist, said the law would solve nothing. “It would be better to provide more resources to care for anorexic patients,” she said, adding that there should be “more awareness to eating disorders in society”. Modelling agencies also attacked the law. “It’s very serious to conflate anorexia with the thinness of models and it ignores the fact that anorexia is a psychogenic illness,” Isabelle Saint-Felix, secretary general of Synam, which represents around 40 modelling agencies in France, told AFP. In France, an estimated 30,000 to 40,000 people – almost all of them adolescents – suffer from anorexia nervosa, an eating disorder with a high mortality rate."

"Tumors of the hypothalamic-pineal region may present with a wide variety of symptoms, including disturbed eating. We present a case where such a tumor was misdiagnosed as anorexia nervosa."

"Organic disorder should always be considered before making a diagnosis of anorexia nervosa, particularly if the presentation is atypical."

"Social media have become a significant means for peer-related communication, self-presentation, and identity management. So-called eating disorder websites that propagate a drastic thin ideal and unhealthy eating behaviors have triggered a debate about the harmful facets of social Internet activity. Little research has addressed the language that is used by the authors of these websites. The present study focuses on personal weblogs, a popular form of mostly text-based, diary-like, online journals. We compared 31 pro–eating disorder blogs, 29 recovery blogs, and 27 control blogs by the means of computerized quantitative text analyses. The language of pro–eating disorder blogs featured lower cognitive processing, a more closed-minded writing style, was less emotionally expressive, contained fewer social references, and focused more on eating-related contents than recovery blogs. A subset of 12 language indicators correctly classified the blogs in 84% of the cases. The distinct language patterns appear to reflect the psychological conditions of the blog authors and provide insight into their various stages of coping."

"In their world, there is a size zero, and it’s a status symbol. The chronic dieters have been as it since they were eight and nine years old. “Epidemic of eating disorders” is old stuff; being preached to about it turns them right off. Their world is one in which the anorexics swap starvation diet tips on the Internet, participate in group fasts, offer advice on how to hide your “ana” from family members, and share inspirational photos of emaciated models. But full-blown anorexia has never been the norm among teenage girls; the real epidemic is among the girls with seemingly healthy eating habits, seemingly health bodies, who commit or work their butts off as a result form of anti-fat maintenance."

"[A]norexia nervosa, which often manifests itself after an episode of sexual abuse or humiliation, can be seen as at least in part a defense against the “femaleness” of the body and a punishment of its desires. Those desires (as I argue in “Hunger as Ideology”) have frequently been culturally represented trough the metaphor of female appetite. The extremes to which the anoretic takes the denial of appetite (that is, to the point of starvation) suggests the dualistic nature of the construction of reality: either she transcends body totally, becoming pure “male” will, “or” she capitulates utterly to the degraded female body and its disgusting hungers. She sees no other possibilities, no middle ground."

"The feminist perspective has never questioned the reality of the anoretic’s disorder or the severity of her suffering."

"At one end of this continuum we find anorexia and bulimia, extremes which set into play physiological and psychological dynamics that lead the sufferer into addictive patterns and medical and emotional problems outside the “norms” of behavior and experience. But is is not only anoretics and bulimics whose lives are led into “disorder.” This is a culture in which rigorous dieting and exercise are being engaged in by more and younger girls all the time-girls as young as seven or eight, according to some studies.(32) These little girls live in constant fear- a fear reinforced by the attitudes of the boys in their classes-of gaining a pound and thus ceasing to be “attractive.” They jog daily, count their calories obsessively, and risk serious vitamin deficiencies and delayed reproductive maturation. We may be producing a generation of young, privileged women with severely impaired menstrual, nutritional, and intellectual functioning."

"The search for distinctive patterns, profiles, and abnormalities underlying anorexia nervosa and bulimia is thus not, as man researchers claim, “conceptually” demanded; a myriad of heterogeneous factors, “family resemblances” rather than essential features, unpredictable combinations of elements, may be at work in determining who turns out to be most susceptible. It may be, too, that patterns and profiles could one be assembled but are now breaking apart under the pressure of an increasingly coercive mass culture with its compelling, fabricated images of beauty and success."

"[F]rom it’s nineteenth-century emergence as a cultural phenomenon, anorexia has been a class-biased disorder, appearing predominantly among the daughters of families of relative affluence. The reasons for this are several. Slenderness and rejection of good have, of course, very different meanings in conditions of deprivation and scarcity than in those of plenty. Demonstrating an ability to “rise above the need to eat imparts moral or aesthetic superiority only where others are prone to overindulgence. Where people are barely managing to put nutritious food on the table, the fleshless, “dematerialized” body suggests death, not superior detachment, self control , or resistance to parental expectations. Moreover, the possibility of success in attaining dominant ideals (for example, that of the glamorous superwoman so many anoretics emulate) depends on certain material preconditions which economically struggling women lack; hence, they may be “protected” (so to speak) against eating disorders by their despair of ever embodying the images of feminine success that surround them."

"The decoding of slenderness to reveal deep associations with autonomy, will, discipline, conquest of desire, enhanced spirituality, purity, and transcendence of the female body suggests that the continuities proposed by Rudolph Bell between contemporary anorexia and the self-starvation of medieval saints are not so farfetched as such critics as Brumberg have claimed. Brumberg argues that attempts to find common psychological or political features in the anorexia of medieval saints and that of contemporary women founder on the fact that anorexia mirabilia was centered on a quest for spiritual perfection, “while the modern anoretic strives for perfection in terms of society’s ideal of physical rather than spiritual beauty.” But Brumberg here operates on the assumption-an assumption challenged by the essays in this volume-that there is such a thing as purely “physical” beauty. Granted, the medieval saint was utterly uninterested in attaining a slender appearance. But it does not follow that the contemporary obsession with slenderness is without deep “spiritual” dimensions, and that these cannot share important-that is, illuminating-affinities with the ascetic ambitions of medieval saints. Here, one anoretic explicitly makes the connection: “I felt like one of those early Christian saints who starved themselves in the desert sun.” This is not to say that meaning of self-starvation for the fasting nuns of the Middle Ages can be simply equated with its meaning for adolescent anoretics of today. But in the context of enduring historical traditions that have dominantly coded appetite, lack of will, temptation, and, indeed, the body itself as female, surely we would expect that women’s projects to transcend hunger and desire would reveal some continuous elements."

"The shallow and unanalyzed conception of slenderness as merely “an external body configuration “rather than” an internal spiritual state,” an ideal without psychological or moral depth, still predominates in the literature on anorexia and bulimia. Why? One explanation is that so long as eating disorders remain situated within a medical model, those who are entrusted with the conceptualization of anorexia and bulimia will be medical professionals who have little experience in or inclination toward cultural interpretation and criticism. But more important is the fact that to begin to incorporate such interpretation and criticism within the medical model would be to transform that model itself."

"Presently, little research has been conducted on the use of manual restraint within child and adolescent settings. However, even less research has been conducted on the use of manual restraint for CNF of patients with AN within inpatient eating disorder settings."

"AN is an eating disorder characterised by an extremely low body weight, a severe restriction of food, a strong desire to be thin, and an intense fear of gaining weight (National Institute of Mental Health, 2018). Under relevant mental health legislation, patients with AN can be administered CNF in extreme cases when they are presenting with very low body weight, and refusing to eat and/or drink (Fuller et al., 2019; Royal College of Psychiatrists, 2014). In the rare case when a patient is resistant to nasogastric feeding, staff members may administer manual restraint to ensure the safety of themselves and the patient during feeding (Fuller et al., 2019, 2020; Neiderman et al., 2001). Within the UK, manual restraint in this context may be used in the absence of other restrictive practices (e.g., seclusion), and may involve holding the patient’s arms, legs and head in a safe position, in order to allow for the safe passing of a nasogastric tube and subsequent feeding (Fuller et al., 2019; Neiderman et al., 2001). Feeding in the context of active resistance is a rare event and raises ethical, legal and clinical issues for all those involved (National Collaborating Centre for Mental Health, 2004). Despite the wealth of research that exists on the treatment of AN, we could only locate one published qualitative study that explored the experience of CNF in the context of AN, including the experience of CNF under manual restraint (Neiderman et al., 2001). In this qualitative survey study exploring children and adolescent patients’, and their parents’ experiences of nasogastric feeding, the authors summarised patients’ nasogastric feeding experiences into two main categories: “I regretted it at the time but think that it was necessary” and “I hated it then and hate it now”."

"An Unpleasant Practice Administering manual restraint for CNF of young persons with AN was an unpleasant practice for all nursing assistants, and this was evidenced by the numerous reported adverse physical, psychological and interpersonal outcomes. Some felt that they did not receive enough support from the eating disorder organisation in managing these outcomes. Six subthemes are reported. Emotional distress. Despite recognising the necessity of CNF under manual restraint for young persons with AN who were refusing all foods and/or fluids, seven of the eight nursing assistants described the emotional distress they experienced as a result of administering manual restraint."

"Becoming desensitised and sensitized Despite the physical and emotional challenges that encapsulated participants’ experiences of administering manual restraint for CNF of young persons with AN, and unlike the “Importance of coping” theme which described participants’ conscious attempts to cope with the procedure, five of the eight nursing assistants reported becoming emotionally desensitised to the practice over time."

"The purpose of this phenomenological study was to explore nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. The findings paint a physically and emotionally distressing picture of the participants’ experiences and provide valuable insight into the experience of applying manual restraint for CNF of patients with AN. It is clear from the analysis that administering manual restraint for CNF of young persons with AN was a distressing practice for nursing assistants."

"By far the most prevalent finding in this study concerned the adverse physical outcomes that pervaded nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN."

"It is critical that relevant eating disorder services prioritise the use of psychological interventions, and alternatives to CNF interventions under manual restraint where practically possible, given the highly distressing impact this practice may have on both nursing staff and patients. This can include offering a range of psychological interventions (e.g., art, family, individual and group therapy, etc) and dietary choices to patients (e.g., diverse food types, liquid supplements, etc), with such options frequently being re-communicated to patients who refuse them. The provision of staff training in communication and trauma-informed approaches may help nursing staff develop improved therapeutic relationships with patients (Maguire & Taylor, 2019), which in turn may have an impact on patients’ receptiveness towards staff support, their willingness to accept dietary intake, and in turn, their recovery from AN (Sly et al., 2013). CNF interventions under manual restraint should only be used as a last resort after exhaustive unsuccessful attempts have been made to offer oral dietary intake to patients, and there is a clinical need for feeding. This is particularly important for patients who present with ongoing refusal of significant dietary intake, where there may be a risk of the habitual use of manual restraint for CNF as a first resort intervention rather than a last resort. The findings of this study can be used as a useful source of information for relevant eating disorder services, to illustrate the potential adverse physical, psychological and interpersonal challenges that administering manual restraint for CNF of patients with AN, could pose to their nursing staff."

"To our knowledge, this study is the first to explore nursing assistants’ experiences of administering manual restraint for CNF of patients with AN,and makes a substantial contribution to the limited literature on this practice. The findings highlight that the use of manual restraint for CNF of young persons with AN is a highly physically and emotionally distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings."