Anorexia nervosa - Causes, symptoms and treatment. MF.

This disease occurs mainly in girls in the puberty period, less often in young women and boys. It manifests itself as an obsessive unreasonable fear of overweight, which causes a sharp restriction of nutrition, as well as a violation of the adequate perception of one's body.

Anorexia nervosa is a disease whose main manifestation is the refusal of food associated with changes in the neuroendocrine system.

Symptoms of anorexia nervosa

Four stages of the development of anorexia nervosa can be identified:

1) primary, initial .

Lasts from 2 to 4 years. For him, the syndrom of dysmorphomania is a delusional or overvalued idea of ​​discontent with one's own appearance, the idea of ​​a relationship, depression and the desire to correct an imaginary defect. Teenagers might not like either their "recovered figure" as a whole, or individual parts of the body, "round cheeks", "fat stomach", "rounded hips."The emergence of discontent with one's own appearance coincided, as a rule, with a real change in the forms of the body, typical for pubertal age. Thoughts about excessive completeness can be either overvalued or delusional( not susceptible to dissuasion).A painful conviction of excessive fullness can sometimes be combined with the presence of a pathological idea of ​​other imaginary or extremely over-estimated shortcomings in appearance( the shape of the nose, ears, cheeks, lips).

The idea of ​​a relationship with of anorexia nervosa is very rudimentary. The determining factor in the formation of the syndrome is most often the disparity of the patient, in his opinion, with his own "ideal" - the literary hero or the person of the nearest environment with the desire to imitate him in everything and above all to have a similar appearance and figure. The opinion of others about the appearance of the patient is of much less importance to him. At the same time, the heightened sensitivity and vulnerability of adolescents leads to the fact that careless remarks by teachers, parents, and peers become the trigger mechanism of the desire to "correct" a physical defect.

Affective disorders( mood disorders) - for this pathology, also have features. Depressive disorders in general are less pronounced and at more distant stages are closely related to the degree of effectiveness of the appearance correction performed by patients.

The number of features of dysmorphomania in anorexia nervosa should be attributed to the fact that the possibility of correcting an imaginary or actual physical defect is in the hands of the patient himself and he always in one way or another realizes it.

2) the anorectic stage of begins with an active desire to correct the appearance and conditionally ends with a weight loss of 20-50% of the initial mass, the development of secondary somatoendocrine changes, oligoamenorrhea( reduced menstruation in girls) or amenorrhea( complete cessation).

Methods of weight loss can be very diverse and carefully concealed at the beginning of correction of excessive fullness. At the initial stage, the greater physical exertion, active sports, the patients combine with the restriction of the amount of food. By reducing the amount of food, the patients at first exclude a number of foods rich in carbohydrates or proteins, and then begin to observe a severe diet and eat mostly milk and vegetable food. With discontent with such parts of the body as the abdomen, thighs, patients simultaneously with a strict diet until exhaustion are engaged in specially designed physical exercises - they do everything standing up, walk a lot, shorten sleep, pull the waist with belts or cords so that food "is absorbed more slowly."Exercises such as "fold - bend" with increasing weight loss are sometimes so intense that they lead to trauma of the skin in the area of ​​the sacrum, shoulder blades, along the spine, at the waist. Feelings of hunger may be absent in the early days of food restriction, but more often it is sufficiently expressed already in the early stages, which significantly hampers the actual refusal of food and requires the patient to seek other ways of losing weight. These include the use of laxatives, often in very large doses, less often the use of enemas. These measures can lead to weakness of the sphincter, prolapse of the rectum, sometimes very significant.

Another very common way to lose weight when you are hungry is artificially induced vomiting. The choice of this method is often of a conscious nature, although sometimes the patients come to it by accident: unable to resist the desire to eat, they immediately eat a lot of food, and then because of overfilling the stomach can not hold it. The resulting vomiting and leads the patients to the thought is in sufficient quantity and quickly to get rid of food until it has absorbed, with the help of artificial vomiting. Initially, some patients chew, and then spit food, forcing the room with bags and jars of chewed food.

At earlier stages, the vomiting is accompanied by characteristic vegetative manifestations and gives patients unpleasant sensations. Later, with frequent vomiting, this procedure is simplified: it is enough for patients to make an expectorant movement or simply tilt the body, push the epigastric region and all the eaten food is thrown out without painful vegetative manifestations. Patients call it "regurgitation".First, they carefully compare the amount of food eaten and vomit, resort to repeated washing of the stomach - after the first vomiting, drinking up to 2-3 liters of water, in some cases it is done using a probe. Artificially induced vomiting in a number of patients is inextricably linked with bouts of bulimia. Bulimia is an insurmountable hunger, almost no sense of satiety, while patients can absorb a very large amount of food, often even a little edible.

Thus, the pathology of eating behavior is formed in the following sequence: in the beginning, patients go shopping and "visually gorge", with the same purpose they are trying to cook food, while experiencing great pleasure, lick the remnants of food from knives and spoons. A characteristic feature of these patients is often the desire to "feed" relatives, especially younger brothers and sisters. The next stage in the fight against hunger is chewing and spitting, then - artificially induced vomiting, in a series of observations later associated with bouts of bulimia.

All day sick people go hungry, constantly thinking about food, imagining all the nuances of the upcoming meal. Thus, thoughts about eating become obtrusive. Having bought a large number of products, and sometimes stealing them, the patients return home, set the table, often serve it nicely, and start eating with the most delicious food to enjoy. However, they can not stop and eat all the food that is in the house. Loss of sense of proportion, control over the quantity and quality of the eaten is very characteristic of bulimia. Some patients prepare themselves whole tanks of inedible food to provide "zhor."Eating a huge amount of food, patients experience euphoria, they have vegetative reactions. After this, they artificially induce vomiting, wash the stomach with plenty of water. There comes a feeling of "bliss", an unusual lightness in the whole body, reinforced by the belief that the body is completely freed from food( light washings without the taste of gastric juice).

Passive methods of weight loss include the use of a number of medications that reduce appetite, as well as psychostimulants, in particular sidnokarba. In order to lose weight, patients begin to smoke a lot, drink large amounts of black coffee, use diuretics.

An important place in the clinical picture of the disease is occupied by hypochondriacal disorders. Secondary gastroenterocolitis, omission of almost all internal organs and, first of all, gastroenteroptosis, which develop as a result of restriction in eating or inappropriate eating behavior, are accompanied by pain in the stomach and in the bowels after meals, with persistent constipation. There is a fixation of patients on unpleasant sensations in the gastrointestinal tract. Typical for this stage of anorexia nervosa fear of eating is due not only to the fear of getting better, but also the possibility of the appearance of painful sensations in the epigastric region. Psychopathological disorders of this period include peculiar obsessions. They are inextricably linked with dysmorphomaniac experiences and are manifested in the form of an obsessive fear of eating, waiting for the appearance of a feeling of severe hunger, the need to induce vomiting, as well as obsessive counting of calories contained in the eaten food.

Despite the significant weight loss in patients there is practically no physical weakness, they remain very mobile, active, efficient. The clinical picture of the disease in the anorectic stage often includes also vegetative disorders in the form of attacks of suffocation, palpitation, dizziness, intense sweating, which occur several hours after eating;

3) cachectic.

During this period of illness in the clinical picture, somatoendocrine disorders predominate. After the onset of amenorrhea, weight loss is greatly accelerated. Patients completely lack subcutaneous fatty tissue, dystrophic changes in the skin, muscles, develop myocardial dystrophy, as well as bradycardia, hypotension, acrocyanosis, a decrease in body temperature and skin elasticity, a decrease in blood sugar, and signs of anemia. Patients quickly freeze, there is increased fragility of the nails, hair falls out, teeth are destroyed.

As a result of prolonged eating disorders, as well as( in a number of patients), special clinical behavior of the gastritis and enterocolitis is heavier. At this stage, physical activity, characteristic of earlier stages of anorexia nervosa, is significantly reduced. The leading place in the clinical picture is asthenic syndrome with a predominance of adynamia and increased exhaustion.

In the period of severe cachexia, patients completely lose their critical attitude to their condition and continue to persist in refusing to eat. Being extremely depleted, they often claim that they have excess body weight or are satisfied with their appearance. In other words, there is a delusional attitude towards one's appearance, which, apparently, is due to a violation of the perception of one's own body.

As cachexia increases, patients become inactive, lie in bed, they have persistent constipation, and blood pressure is significantly reduced. Expressed water-electrolyte shifts can lead to the development of painful muscle cramps, sometimes polyneuritis( alimentary polyneuritis) is possible Such a condition without medical care can be fatal. Usually in a state of severe cachexia according to vital signs, often violently, because patients do not understand the seriousness of their situation,they are hospitalized.

4) the stage of reduction of anorexia nervosa.

In the period of excretion from cachexia, the leading place in the clinical picture belongs to asthenic symptoms, fear to recover, fixation on pathological sensations from the gastrointestinal tract. With a slight increase in body weight, dysmorphomania is again actualized, there is a desire for "correction" of the appearance, and depressive symptoms increase. As the physical condition improves, the physical weakness quickly disappears, the patients again become extremely mobile, seek to perform complex physical exercises, can resort to large doses of laxatives, after feeding try to induce vomiting. All this requires careful supervision of patients in the hospital. For 1-2 months with proper treatment, patients completely exit cachexia, gaining from 9 to 15 kg, but the normalization of the menstrual cycle requires a much longer time( 6 months from the beginning of intensive treatment).Before the recovery of menstruation, the mental state is characterized by mood instability, periodic actualization of dysmorphic phenomena, explosiveness, a tendency to hysterical forms of response. During the first 2 years, severe relapses of the syndrome that require in-patient treatment are possible. This stage should be considered as a reduction of the syndrome.

Along with the typical variant of anorexia nervosa, there are varieties of this pathology in clinical practice, with the symptomatology being the most different from the typical at the preanorectic stage. This primarily concerns the reasons for refusing to eat, which can have delusional motives that do not concern the appearance of the patient. Most often this hypochondriac delirium( "not so digestible food", contained in the food substances "break metabolism, spoil the skin," etc.).Self-restriction in food may be due to fear of suppressing food or fear of vomiting in a public place in the presence of a fixed vomiting reaction. Despite significant weight loss due to the restriction of food intake, these patients rarely have amenorrhea. Depletion, as a rule, does not reach cachexia. At the same time, in more remote stages of the disease, a special attitude to one's appearance can be formed without the desire to recover, despite the lack of body weight.

Causes of anorexia nervosa

A number of conditions, both social and biological, are needed to form a syndrome of anorexia nervosa. An important role in the development of anorexia nervosa belongs to heredity, exogenous hazards in the first years of life, personality characteristics, and micro-social factors( the role of the family).

Depletion, depressive states, stresses, aversion to food.

Over the past 20 years, the number of patients with anorexia nervosa has increased in economically developed countries. With a frequency of 1 out of 90 cases, anorexia nervosa occurs among girls aged 16 years and older.

How anorexia nervosa develops

The disease is common among adolescent girls who lose at least 15% -40% of normal body weight. The loss of body weight is caused by the patient himself due to the refusal of food, which "fills".Patients induce vomiting, take laxatives, exercise a lot, use suppressing appetite or take diuretics. The perception of one's body is distorted, horror arises before obesity, the patient considers only low weight acceptable for himself. At the same time, exhaustion, poor tolerance of cold and heat, chilliness, lowering of blood pressure, disappearing of menstruation, growth of the body stops, the patients are aggressive, poorly oriented in the surrounding environment.

Treatment of anorexia nervosa

Most patients consult a doctor before the onset of severe malnutrition. In such cases, recovery can occur spontaneously without medical intervention. In severe cases, medical care includes compulsory inpatient treatment, the prescription of drug therapy, psychotherapy of the patient and family members, the restoration of a normal diet with a gradual increase in calorie content of food.

Schematically, the treatment can be divided into two stages:

Stage I, is aimed at improving the physical state, its goal is to suspend weight loss, eliminate the threat to life, remove the patient from the state of cachexia.

II stage involves the treatment of the underlying disease using pharmacological agents and various methods of psychotherapy. Regularly, patients need to be reminded that the realization of their aspirations related to study, work, position in the family and society is largely dependent on their own efforts in the fight against pathological fixation on their appearance and nutrition. They need to clarify that socially useful activities should distract them from excessive preoccupation with their bodies and help avoid re-weight loss.