Anorexia nervosa is generally regarded as a psychiatric disorder characterized by abnormal eating behaviors that may lead to an  extreme weight loss and serious medical consequences. It is a relentless pursuit of thinness.   Its etiology is unknown, and may be irrelevant, since its management does not depend on its etiology. We shall therefore study its evolution within a framework described elsewhere.

Disease indicator

The refusal to eat is one component of a complex disease. It is  called here disease indicator. It is not the disease itself. It is the best solution created by WOB in order to  maintain the patient's life.  This may come as a surprise since the patient  virtually fades away.  Despite her hunger she refuses to eat. One is inclined to regard her behavior as a psychiatric disorder. Obsession with food, self mutilation,  or an obscure neurosis. In reality Anorexia Nervosa is a misnomer. It obviously is not  a loss of appetite,  since the girl is hungry and starving, and it does not originate in the nervous system. It ought therefore be called.  Pernicious  (self inflicted) Anorexia  (PA).

Mind-PA and WOB-PA

We shall distinguish between Mind-PA and WOB-PA. There are two kinds of Mind-PA. 1. A benign Mind-PA, like the pursuit of a Barbie figure, or the dream to become a gymnast like Nadia Comaneci (www.nadiacomaneci.com), and 2. A malignant Mind-PA, which results from a biased attitude of the society to PA, which  regards it as abnormal,  and attempts to correct it by force feeding.

PA is first of all a WOB solution and we wonder what drives it?  The forthcoming arguments will be illustrated  with an attractive hypothesis by R. Wheatland according to whom PA is driven by a relative adrenocortical insufficiency.

PA proceeds through three phases:

1. Full compensation when adrenocortical hormone is adequate, and patient feels healthy.
2. Decompensation, when adrenocortical hormone is inadequate, and patient is forced to starve, and reduce weight. Accompanied by amenorrhea or loss of secondary sex characteristics  in males.
3. Total  decompensation, which results from complications of prolonged starvation, e.g., pancytopenia, or cardiovascular complications, like dysrhythmias

Full compensation

Suppose that the child suffers from a relative adrenocortical insufficiency.  As long as it is small, his adrenal produces enough  hormones to keep it healthy. At puberty the delicate balance is offset. The growing body demands more adrenocortical hormones, which the adrenal fails to supply and the child  enters a phase of decompensation..

Decompensation

Starts at puberty when WOB fails to supply enough  hormone for the rising demand by the growing body.  As the body grows relative hormone deficiency deepens, and an intercurrent disease may initiate an Addisonian crisis.  The clinical manifestation of PA are an attempt by WOB to minimize the threat of an acute adrenocortical deficiency. It stops estrogen production (amenorrhea), and so retards growth.  It informs the mind to eat less and select food with low caloric value, which is expressed by strange eating habits, and division of foods into "good/safe" and "bad/dangerous" categories.

Total decompensation

Pancytopenia due to prolonged starvation. Vitamin deficiencies,  Cardiac dysrhythmias, etc.

Physician

Physician has two main responsibilities: To help where WOB failed, and to improve patient's quality of life. All this without interfering too much with WOB solutions. He has to work out a compromise between  WOB and mind demands. Since patient cannot be cured the main objective is to slow down disease progression.

PA-Yogi

The first task of the physician is to study patients who live with PA in peace and good health,  called here PA-Yogis. The Yogi suffix signifies patients who live in peace with their disease. What is their secret and how do they mange? Their knowledge might be applied to other patients. Since physicians are too busy and lack time to observe patients,  PA patients are advised to join support groups where they may learn  from the experience of  PA-Yogis.

Malignant Mind-PA

Once a patient realizes the nature of his condition he ought to realize that his/her life has changed  and his mission is to become a PA-Yogi. First she ought to learn how to handle society prejudice. Her misery induced by societal bias, triggers psychological  defense  which requires adrenocortical hormones (stress) and deepens the relative deficiency. The patient might  benefit from meditation, which has two advantages.   It helps her to ignore the society and focuses her effort on handling  WOB-PA.  Both conserve hormones. 

Slim is chic

For a PA-Yogi 'slim is chic'. Since his adrenal is sluggish, he has to reduce weight until  hormone production covers his needs.  The correct weight is determined by WOB.  As long as he is relatively overweight, WOB will complain and make him feel sick as if saying: " continue reducing weight  until I can meet your demands." When attaining the correct weight  he  feels healthy,  since WOB will stop complaining. This is the meaning of living with a disease in good health. Throughout this difficult endeavor he will be assisted by his physician, whose  task among other, is to design a low calories  diet, rich in vitamins and minerals.

Sport.

Muscle building should not be advised since raising the demand on hormone. Instead the patient ought  to pursue an aerobic activity, which trains the organism to utilize adrenocortical hormones more efficiently.

Hormone replacement

Low doses of cortisol supplements may slow down disease progression. Yet how small such doses ought to be? External hormone supplement has two disadvantages: 1. It   curtails internal hormone production, aggravating the internal deficiency., 2. It enhances body growth, and deepens the relative deficiency.  Hormone replacement ought therefore be the last resort, like during acute intercurrent diseases.

What drives PA?  The growing body regenerates all its tissues  why does it fail in PA? In the past chronic adrenal deficiency was  driven by tuberculosis.  Today  the culprit might be viral, or a fungus. Or, might the culprit hit only the pituitary?  Only WOB knows!

References

1. R. Wheatland Alternative Treatment Considerations in Anorexia Nervosa
Med Hypotheses 2002;59 (6):710-5 http://www.query.com/terp/index.html