Anorexia Nervosa is an eating disorder that is familiar to the public. It is shown on television, movies, and the news as an emaciated teen and young adult white women engaging in activities like refusing to eat, obsessively counting calories of everything they consume, and self-inducing vomiting when they are forced to eat something “bad” or too high in calories. However, Anorexia Nervosa can affect people of any age, gender, race, or ethnicity. People have been experiencing the symptoms of Anorexia Nervosa for hundreds or thousands of years according to historians.
Anorexia Nervosa often begins in the teen years, although the incidence among children and older adults has been increasing (National Eating Disorders Association, 2018). The stereotype of the emaciated appearance is not necessarily how an individual with Anorexia Nervosa will present and a large segment of mental health professionals have been lobbying to remove the low body weight requirement from the DSM-5 diagnosis criteria.
According to the DSM-5, to be diagnosed with Anorexia Nervosa an individual must:
· Restriction of energy intake relative to requirements leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
· Intense fear of gaining weight or becoming fat, even though underweight.
· Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight (Diagnostic and statistical manual of mental disorders: DSM-5, 2017).
If an individual meets the criteria for Anorexia Nervosa except being underweight then it is labeled as Atypical Anorexia, although there has been no medical or psychological difference shown between Atypical Anorexia and Anorexia Nervosa.
Anorexia Nervosa is a bio-psycho-social illness that often makes the cause complex and hard to pin down. Eating disorders like Anorexia Nervosa tend to run in families and they have a significant genetic component. Individuals with certain temperaments and personality traits are also more prone to develop Anorexia Nervosa (Causes of Anorexia, 2020). The traits of obsessive thinking, perfectionistic tendencies, sensitivity to reward and punishment, emotional instability, hypersensitivity, impulsivity, and rigidity are all believed to be inherited (McGuire, 2017).
From the psychological perspective individuals with Anorexia Nervosa tend to be high-achieving perfectionists. This enforces their obsessive drive to be the “best dieter” or the “thinnest.” They also have low self-directedness that often conflicts with their beliefs and values which can lead to them hiding their illness and presenting as “healthy” to friends and loved ones. These individuals also tend to be inflexible and maintain certain rules regarding food, exercise, or rituals (Causes of Anorexia, 2020).
There is also a social component to Anorexia Nervosa. Today’s culture glorifies thinness, at times even at the expense of health. With the media portraying thin as the beauty standard many individuals with Anorexia internalize that narrative. Women especially are constantly receiving messages through media and advertising about diets, exercise programs, etc. that can lead to distorted body image and damaged relationships with both food and movement (Causes of Anorexia, 2020).
Researchers at Mayo Clinic have determined that environmental factors make up 30-50% of the role of developing an eating disorder and genetic factors contribute 50-70%. When an individual suffers from an eating disorder, there are physical mechanisms that cause physiological and neurological changes. This leads to the patient becoming more committed to their disorder. These changes, often due to methylation, also can change the inheritability of the disorder if the individual has children afterward (McGuire, 2017).
For treating Anorexia Nervosa current standard of care is family-based therapy and nutrition counseling. For severe cases, inpatient treatment is typically recommended. During inpatient treatment the patient is monitored around the clock to ensure that any medical complications that arise can be addressed in a timely manner and their caloric intake is closely monitored while they go through counseling and other treatments. Acupuncture is potentially beneficial as an adjunct therapy to treat Anorexia Nervosa. It has been shown to decrease anxiety and perfectionism which increase the patient’s quality of life (Fogarty, 2010).
Acupuncture for treating Anorexia Nervosa was shown to be effective with twice-weekly treatments for three weeks and then weekly for three more weeks for a total of nine treatments over six weeks. The points they found effective for treating Anorexia Nervosa include Hegu (LI4), Zusanli (ST36), Neiguan (PC6), Taichong (LV3), and Yanglingquan (GB34). These points were used because acupuncture has been shown to decrease limbic system activity which has an important impact on depression, mood, fear, and defensiveness. According to Fogarty et al, the therapeutic relationship developed during the treatments was also important for the patients. Empathy, non-judgment, acceptance, and positive regard from the practitioner were important for the patients (Fogarty, 2013)
When using acupuncture to treat patients with Anorexia Nervosa there are additional considerations to take into account. Patients with Anorexia Nervosa tend to become chilled during treatment, so ensuring that a table warmer, blankets, and/or heat lamp is used during treatment is essential. Heavy needling can worsen anxiety, depression, or other comorbidities for these patients, so it is recommended to use low gauge thin needles. Deep needling is also contraindicated for this patient population if they are presenting as underweight. Anorexia Nervosa patients may have difficulty lying still for long periods of time. This may be due to blood and/or yin deficiencies or they may view the lack of movement as increasing potential for weight gain. Long needle retention times should also be avoided with these patients as it may deplete their already deficient qi and lead to poor outcomes (Fogarty, 2015).
For treatment of Anorexia Nervosa, I would refer out to or work collaboratively with a counselor, psychiatrist, or psychologist who is experienced with family-based therapy, as well as mirror therapy as those two modalities, have been shown to have the highest level of effectiveness for treating Anorexia Nervosa and the most chance for a full recovery. As a chiropractor I would equipped to help with adjunctive therapies as well as to manage some of the physical symptoms and side-effects of both the Anorexia Nervosa itself and the recovery from it.
I would have the patient come in twice a week for 3 weeks, then weekly thereafter. We would discuss any new symptoms and how the treatment is going so far to see if there were any new issues to address. They would be put on glutamine, magnesium, digestive enzymes, and potentially an HCL with Betaine to help renew optimal gastrointestinal function. They would also need to be evaluated for cardiac issues, hiatal hernia, and malnutrition. Based on the results of those evaluations they may need additional supplementation. They would receive gentle mobilizations at each treatment, eventually getting HVLA adjustments as their nutritional status normalized. They would also receive visceral manipulation to help address the gastroparesis and low intestinal motility that are often side effects of anorexia.
For acupuncture, they would receive no more than 11 points for each treatment. The points would include Hegu (LI4), Zusanli (ST36), Neiguan (PC6), Taichong (LV3), and Yanglingquan (GB34) each treatment as those points had been shown in Fogarty’s study to be effective. Additional points would be used based on their symptoms that day. In Traditional Chinese Medicine, Anorexia Nervosa can be caused by Spleen Blood Deficiency, Spleen Qi Deficiency, Spleen and Stomach Damp-Heat, Stomach Food Stagnation, and Stomach Qi Deficiency.
Hegu (LI4) is the Yuan source point of the Large Intestine channel. It strongly moves the Qi and Blood and would help clear the stagnation that may be underlying the Anorexia Nervosa. Zusanli (ST36) tonifies Qi and/or blood. It is also useful for anything that involves the stomach and/or spleen. Zusanli (ST36) is a point that can also help with the common comorbidities of Anorexia Nervosa such as anxiety, depression, and insomnia. Neiguan (PC6) helps with Qi stagnation, insomnia, and many of the side effects a patient with Anorexia Nervosa in recovery may experience such as stomach pain, nausea, stress, and poor memory. Taichong (LV3)is another point that is good for stagnation. It tonifies Yin which is lacking in individuals with Anorexia Nervosa. It also helps with nausea, constipation, and diarrhea with undigested food. Taichong (LV3) is a calming point that can help with anger, insomnia, irritability, and anxiety. Since Taichong (LV3) and Hegu (LI4) are both used in this treatment and they are the four gates they will have a powerful effect on the flow of Qi and Blood. Yanglingquan (GB34) helps with many digestive issues such as nausea, vomiting, and indigestion. It can also help with gallstones which may be a side effect of Anorexia Nervosa.
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