Obesity is one of the major illnesses of the western world; yet in the midst of plenty exists an illness that is just the reverse.

Anorexia nervosa, or what has been called The Twiggy Syndrome is a disorder of affluent societies and is more common in wealthy, intelligent, high-achieving families.

Although it has undoubtedly occurred before, this disorder was first described about 100 years ago.

It usually affects young girls just out of puberty or in their late teens or early 20s. Occasionally, it can occur in girls before puberty, or even in young boys.

In anorexia nervosa there is a disturbance of eating. Although the word anorexia means loss of appetite, there is really no loss of appetite but a refusal of food and a preoccupation with dieting and with weight.

This disturbance of the control of food appears to be the primary problem and not a result of some other psychological disturbance.

The girls affected are usually obsessive-compulsive in personality, perfectionist, conscientious, hard-working, and rigid in outlook. Many give an outward appearance of confidence but most are consumed with self-doubt and feelings of inferiority. They lend to withdraw and to be isolated from their peers.

Many cases seem to follow some sexual difficulty. This may only be the development of sexuality thal conics with puberty or it may follow episodes of petting or intercourse which the girl cannot handle psychologically.

When the family is examined it is often found that there is a disturbance in family relationships. The outward appearance may be one of family harmony but beneath this calm lies well-controlled hostility.

The mothers are usually domineering and rigid in outlook; both parents are intense and seek affection and approval from the girl to compensate for their hostility to each other.

Many theories have been advanced for the cause of this disorder, but at the moment there is no proof that is convincing. The Freudian theory sees this as a rejection of sexuality or of pregnancy. Other psychiatrists see it as part of the obsessive-compulsive personality disorder, or of depression. Whatever the cause, the treatment is difficult.

There does appear to be a disturbance in the body image that the girl has of herself. A few start off being overweight, many are of normal weight, a few are underweight.

Despite the fact that the girl is obviously underweight to all other observers, she may insist that she is “just right” or “not too thin.”

Food is rejected, dieting becomes the all-important thing. At this time the girl’s parents may commence nagging her to eat more. To avoid this she may dawdle over meals or state that she has already eaten at school or with a friend. If she is made to eat she may go to the bathroom and make herself sick or else take regular and large doses of laxatives so that diarrhea is caused. She may exercise to excess in an attempt to “burn up” more weight.

Now when diuretic tablets are so widely prescribed, she may take these to excess in an effort to lose fluid, and so, weight.

When the weight falls well below what is ideal, there is a disturbance of menstrual function. The periods usually stop and it is this symptom that often prompts either the girl or her mother to go to the doctor.

Some researchers believe that the stopping of the periods is due to emotional factors, others believe it is due simply to the reduction in weight and follows the same pattern as in those who are undernourished due to famine or war. The pituitary, that master gland at the base of the brain, appears to shut down and no longer sends out its stimulatory hormones to the ovaries.

Mild cases of anorexia nervosa may be treated at home by an informed general practitioner, particularly if he has a good relationship with that family.

The more severe cases will require admission to the hospital. They are perhaps better in a psychiatric ward or hospital rather than a general hospital. Most will respond to encouragement and supervision of meals rather than to forced feeding.

However if the weight loss is extreme and the general physical condition is poor then intravenous feeding may be necessary. Girls suffering from anorexia nervosa are often demanding and manipulative in hospitals and experienced psychiatric nurses may handle them better than general trained nurses.

Apart from the attention to the physical state, the emotional side of this disorder needs treatment. The girl herself may need intensive psychotherapy. Often the family, especially the parents, may also need counseling, and it may be better in these cases for the parents to have a different therapist to the girl herself.

Anorexia nervosa rarely results in death now unless as a result of suicide, but associated depression is not unusual.

Many young girls, concerned with their awakening interest in boys and in their appearance and attractiveness to the opposite sex, may diet and try to emulate some model, actress, or pop star. This is normal and the loss of puppy fat of the pubertal years is to be encouraged.

Parents should however be wary of the girl who appears to have gone too far. Anorexia nervosa is not common. Most teenagers are normal and their fads and fancies are also normal. Unfortunately this disorder usually happens to girls who have a disturbed family life and so it may not be recognized or acted on by the parents until it has developed into a severe problem. Sometimes it may fall to a teacher to recognize this condition and advise the parents to seek help.

As in many emotional problems, particularly behavior problems, it is not a question of seeking to blame some family members for the problem. What is necessary is for all members of the family to realize that the family relationship is sick and they may need counseling too.

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