An Exploration of the Aetiology, Pathophysiology and Treatment of Anorexia Nervosa in Western and Traditional Chinese Medicine
The media in the UK and throughout the developed world devotes vast amounts of coverage to exploring all aspects of our eating habits; at one end of the scale there is obesity, and at the other, disorders of weight restriction, for example anorexia nervosa (AN). The World Health Organisation ([WHO], 2006) predicts that by 2015 there will be 700 million obese adults globally; where body mass index (BMI) exceeds 30, almost double their own projection for 2005. In parallel, children as young as eight have been diagnosed with AN (Rose, 2007). Blame for these confusing and apparently contradictory attitudes towards eating has been apportioned to, amongst others, governments, parents, the fashion industry, the internet, fast food companies and the media.
Alarming facts surround eating disorders; according to Beating Eating Disorders ([BEAT], 2007a) a UK eating disorders charity, 1.1 million people are directly affected by eating disorders in the UK. Bennett (2007) states that roughly one percent of teenagers aged 16 to 18 has AN, an increase of 40% since 1990. Astonishingly, having an eating disorder is seen by some young people as a badge of honour with terms such as ‘wannarexia’ endorsing AN as a quick fix solution for weight loss (Cohen, 2007). Most disturbingly, AN has the highest mortality of any psychiatric disorder (Hoek, 2006, cited by Morris & Twaddle, 2007, p. 894).
A thorough review of published material covering the aetiology, pathophysiology and treatment of AN in traditional Chinese medicine (TCM), exposed a dearth of available material on the disorder. For example, a search of pubmed using keywords AN and acupuncture or Chinese medicine returned less than 20 items, mostly of poor quality. This paper aims to summarise existing Western medical and TCM thinking on AN, discuss themes of central importance in the disorder and extend the understanding of AN within TCM.
Anorexia Nervosa in Western Medicine
In 1873 the French physician Lasègue and the British doctor Gull independently published articles that for the first time formally described the disorder of anorexia nervosa (Vandereycken & van Deth, 1994). Gull named the illness, meaning nervous loss of appetite, and ruled out organic disease as a cause. Lasègue explored its sociological roots amongst the Victorian middle classes (Brody, 2007).
According to Gordon (2004), numerous epidemiological studies have documented increases in the incidence of AN and bulimia nervosa (BN) through the 1970s, 1980s and 1990s. Explanations for this increase include a rise in sufferers seeking help for AN, improved detection and changes in diagnostic practice (Fairburn & Harrison, 2003). However, Currin, Schmidt, Treasure and Jick (2005) concluded that the incidence of AN in the UK was stable between 1988 and 2000 and measured primary care incidence rates for AN in 2000 at 4.7 per 100,000 population. AN is not a common condition, BEAT (2007b) quotes a prevalence rate of between 1% and 2% among young adult women. 80%-90% of AN sufferers are female (Morris & Twaddle, 2007) and this ratio has been supported across almost every epidemiological study (Gordon, 2004). Ogden (2003, p. 183) cites Buckley, Freyne and Walsh (1991) as finding that AN in males is on the increase within groups where low body weight is required; for example models, jockeys and dancers.
Morbidity and mortality of AN is amongst the highest of all functional psychiatric disorders due to malnutrition, purging behaviour and suicide (Claudino et al., 2007). AN has a multifactoral aetiology thought to involve genetics, personality traits of perfectionism and compulsiveness, anxiety disorders, family history of depression and obesity, and peer, family and cultural views of appearance (Yager & Andersen, 2005).
Prior to the 1990s, the aetiology of eating disorders was widely considered to be linked to societal obsession with thinness and female gender dynamics, but this view shifted after twin and family studies uncovered a genetic component (Collier & Treasure, 2004). One clinic sample found a concordance rate for AN of 55% in monozygotic twins and 5% in dizygotic twins, thus reinforcing the heritability of AN (Treasure & Holland, 1989), although Fairburn and Harrison (2003) caution that such samples are potentially biased. Opinion on whether there is a cultural predisposition to AN appears to have shifted. Treasure (2001) stated that this was true in the West owing to the value placed on slimness. However, AN has been observed in every non-Western region of the world and Keel and Klump (2003) concluded it is not bound to culture, as is the case with BN. Schmidt and Treasure (2006) concur with this view and explain the central psychopathology of AN as motivated eating restraint.
The role of gender in eating disorders is poorly understood. Female biology; a higher tolerance for food deprivation, vulnerability to emotional stress during puberty (Gordon, 2004), and fat development during maturation (Crisp, 1980) may explain the elevated incidence in women. Puberty is the time of highest risk for development of anorexic behaviours (Schmidt, 2005). There is strong female bias in terms of cultural attitudes towards body weight, with gender-specific ideals at polar opposites (Davis & Scott-Robertson, 2000). However, AN can develop without weight and shape concerns (Schmidt, 2005).
The view that neurobiological vulnerabilities contribute significantly to the pathogenesis of AN is gaining acceptance (Kaye, 2007) and understanding how these interplay with genetic and environmental influences could help unravel the mystery of AN (Treasure, 2007).
There is limited understanding of the individual causal processes in AN and how they interact and vary in its development and maintenance. Research has looked at the role perinatal factors play in the pathogenesis of eating disorders, and in AN both pregnancy and neonatal complications may have an independent role in the development of the disorder (Favaro, Tenconi, & Santonastaso, 2006). A study by Procopio and Marriott (2007) linked in-utero over-expression of oestrogen to AN, concluding that intrauterine exposure to sex hormones might affect the risk of developing AN in adult life. In recognition of the role that neurobiological vulnerabilities could have in eating disorders, evidence has shown that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood and impulse control in AN and BN (Kaye, 2007).
The psychological mechanisms involved in the development and maintenance of eating disorders have two main origins; a need to feel in control of life which gets displaced onto controlling eating (Fairburn, Shafran, & Cooper, 1999) and an over-evaluation of shape and weight in those who have been sensitised to their appearance (Fairburn & Harrison, 2003).
AN has high comorbidity with other psychiatric conditions, including depression, anxiety disorders and obsessive-compulsive disorder (Yager & Andersen, 2005). Studies support observations that AN is found in families with obsessive, perfectionist and competitive traits, and possibly autistic spectrum traits (Morris & Twaddle, 2007). Wade, Bulik, Neale, and Kendler (2000) found evidence of a shared genetic liability for depression and AN. Finally, AN can be viewed as a form of addiction where the sufferer is locked into a compulsive cycle (Giddens, 2007).
According to Nicholls and Viner (2005), AN and BN are characterised by a morbid preoccupation with weight and shape which manifests through distorted or chaotic eating behaviour; According to Treasure (2001) AN is characterised by a pre-occupation with maintaining weight below that which is normally compatible with health. Although weight and BMI are important measures of risk in AN, guidelines issued in the UK (National Institute for Clinical Excellence [NICE], 2004, p. 10) stress that they should not be considered sole indicators.
The diagnosticand statistical manual of mental disorders ([DSM IV] American Psychiatric Association, 1994) identifies two types of AN: restricting and binge-purge. Restricting AN is characterised by severe restriction of food intake frequently accompanied by excessive exercise. With binge-purge AN a large volume of food is consumed in a short period of time with compensatory factors such as vomiting or laxative abuse. Russell (1985) was the first to observe the rising incidence of the binge-purge subtype within AN and there is mounting evidence that restricting anorexia should be considered a distinct and separate phenotype (Schmidt & Treasure, 2006).
According to Brody (2007) clinical signs of AN can manifest as a disturbed relationship with mother and father, distortions of body image, hyperactivity, the wish to be or to feel in control, asceticism and depression.
Kaye (2007) writes, with regard to AN, that the "lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions” (p. 1). AN takes an average of 5-6 years from diagnosis to recovery (Morris and Twaddle, 2007), and up to 30% of patients never recover (Lowe et al., 2001). Short term structured treatments such as cognitive behavioural therapy (CBT) and interpersonal psychotherapy, effective in other eating disorders, have not helped patients with AN and longer term therapies that incorporate motivational enhancement techniques are recommended (Morris & Twaddle, 2007). According to Eisler et al. (2000) family based therapy is the only well researched intervention that has a beneficial impact on AN; however Bulik, Berkman, Brownley, Sedway and Lohr (2007) state that its efficacy is limited to younger, non-chronic patients.
The evidence base for treatment of AN with medication is poor (Attia & Walsh, 2007). Well documented benefits of antidepressants in BN do not extend to AN and the harmful effects of drug therapy on severely malnourished patients is a consideration (Morris & Twaddle, 2007). Hospital admission for acute cases of AN is strongly correlated with poor outcome (Ben-Tovim et al., 2001).
In summary there are many unanswered questions surrounding the aetiology, pathophysiology and treatment of AN in Western medicine. The principal risk factors have been identified but how they interact is not clear. Gaps in knowledge about the disease mechanism of AN impact on treatment efficacy, and the high comorbidity of AN with other psychiatric disorders has had more of an influence on treatment decisions rather than research specific to AN.
Anorexia Nervosa in Traditional Chinese Medicine
Historical and Cultural Context
Chinese medicine has origins in shamanism where disease was thought to be the result of demons or evils invading the body (Flaws & Lake, 2001). An image of someone being engulfed by demons is an accurate metaphor for eating disorders (McIntire, n.d.). Chinese philosophy has shaped beliefs about mental illness and these are firmly entrenched in Chinese culture (Wong, Tsui, Pearson, Chen, & Chiu, 2004). Confucianism promoted the concept of social order and harmony based upon ‘right action’, the observance of rituals and the traditional social hierarchy (Zhang & Rose, 1999). Traditionally psychological disturbances have carried a stigma within Chinese society (Ng, 1991).
In Chinese culture there is a belief that mental illness is punishment for the sins of a family’s ancestors and generates high levels of stigma (Furnham & Wong, 2007). Flaws and Lake (2001, p. 9) cite Kleinman and Kleinman (1985) in describing dysphoric emotion as shameful to both self and family within Chinese culture; for this reason it was not revealed beyond the family and was seen to overlap with highly stigmatised mental illness. Mental illness is viewed as a threat to social order through its unpredictability (Yang, 2007).
TCM somatises the psychoemotional, and behavioural disorders are seen only in the context of physiological dysfunction (Ng, 1991). This is further perpetuated by linking excessive emotions to physical pathology and administering treatment with somatic therapies such as acupuncture and herbs (Flaws & Lake, 2001).
Against this cultural background, no evidence has been found to suggest that AN was identified or discussed in classical Chinese medicine. In Chinese texts anorexia is seen as a symptom corresponding to lack of appetite and not considered an autonomous illness (Rossi, 2007). Classical texts discussed loss of appetite as a symptom and in the Jin dynasty (282 CE) Mi Huang-fu wrote that for irritability, no desire for food, and ever growing silence, needle the foot taiyin (Flaws & Lake, 2001).
Epidemiology in China
According to Lee, Chiu and Chen (1989), no papers on AN were published in the two major Chinese psychiatric journals and there were no reports of AN in Chinese subjects born and living in a Chinese community. However, in 1990 a clinical report was published on nine cases of AN in China (Song & Fang, 1990). Ma (2007) stated that AN "has become a rising mental health problem in Chinese societies” (p.409). The initial claim that there was a lack of published material on AN could be due to the cultural taboos surrounding open discussion of mental illness.
Jing is the blueprint for life; it is the foundation of the human and what makes us unique, it is the combination of the paternal (yang) and maternal (yin) essence. Jing is our genetic and karmic endowment, that is "all that we bring to this life from past lives and ancestors” (Jarrett, 2004, p. 43). Jing represents the physical and emotional inheritance from our parents. In the aetiology of AN serious emotional disharmony in a parent could transmit to the jing of the child. Jing is the basis for shen and is responsible for the development of the deepest awareness and wisdom (Kaptchuk, 2000). The shen can therefore be influenced by the inherited emotional past.
Jing is responsible for growth and development which is distorted in AN, both in terms of the physical and emotional. For women the second seven year cycle is a vulnerable time and the emotional conflicts of puberty could be a catalyst for the onset of AN (Ross, 1995). No sources validate the existence of comparable pubertal vulnerabilities in the second male developmental cycle. Through food deprivation sufferers could be seen to be avoiding maturing into adults, preferring to remain immature (L. M. Lee, personal communication, November 21, 2007) and this will compromise the growth cycle governed by jing. The anorexic has difficulty nourishing themselves due to a lack of mental and emotional nourishment in the past, with the desire for weight loss to avoid growth and maturity (Gascoigne, 2001).
Emotions become causes of disease when they take over the mind and are long lasting or intense. In the fourteenth century Zhang Zi-he discussed illness caused by extremes of emotion and described a case of not eating due to great anger (Flaws & Lake, 2001). In Chinese medicine emotions are physiological events; a response of the shen to external stimuli (Rossi, 2007). People can lose their appetite if they are anxious, angry or unhappy and in extreme cases this can lead to AN (Hicks, Hicks, & Mole, 2004).
Ross (1995) concludes that a lack of love forms the basis for eating disorders; attributing this to pain and unease from separation of the ego from the love of the self. Central themes of a lack of love for oneself (L. Jarrett, personal communication, November 15, 2007) and separation (F. Turner, personal communication, December 14, 2007) have been identified as being common in AN.
Disturbed family relationships may have a role in AN (Ross, 1995). The relationship with the mother is of central importance as the provider of nourishment, both physical and emotional, to the child. The mother is the embodiment of the earth element. The mother helps us connect to the world and foster our own identities (Hicks et al., 2004); this sense of self is lacking and could even be considered to be pathological in AN.
The modern Chinese translation of AN is ‘disease of being fed up with eating’ (Lee et al., 1989) and like the English name it is a misnomer. Food has a pivotal role in Chinese culture, not only to satisfy hunger and for pleasure, but also as provision against disease (Zhang & Rose, 1999). In AN the reduced intake of food not only compromises calories but the protective properties provided by food.
Flaws and Lake (2001) identify three mechanisms in psychological disease; malnourishment, harassment by heat and blockage and obstruction. In the case of AN malnourishment, both physical and emotional, could be seen as the principal mechanism involved, both as a cause of disease and in explaining its maintenance.
The shen relies on pre-natal jing from the kidneys for its basis and post-natal qi from the spleen for nourishment. If the spleen is weakened, through poor diet, it cannot adequately nourish the shen. Insufficient eating causes deficiency of qi (yang) and blood (yin) and compromises the spleen’s transporting and transforming function. Over time, for example in AN, a destructive pattern is established where a weakened spleen fails to absorb nutrients from food that is eaten and malnourishment prevails. This has severe consequences for the production of qi and blood in the body and ostensibly for nourishment of the shen. After two years of having an eating disorder the body is irreversibly damaged (L. Jarrett, personal communication, November 15, 2007).
Heart spirit malnourishment from blood deficiency can arise in AN and in women is further exacerbated by the loss of blood through menstruation (Flaws & Lake, 2001). The support that the heart relies upon the spleen and kidneys to provide the shen is reflected in the cosmological arrangement of the five elements. The malnourishment that persists in AN will ultimately affect all the zangfu and vital substances and cause a wide range of signs and symptoms. The zangfu and emotional state are inextricably linked; in AN a pernicious pathological cycle is established.
Excessive emotional force will alter the physiological movements of qi and therefore cause illness (Rossi, 2007). The liver with its responsibility for ensuring the free flow of qi, and therefore emotions,and housing the hun is implicated in AN. If emotions become pathological they will cause stagnation of qi and eventual depletion of vital substances. Long term qi stagnation can give rise to blood stasis, heat, fire and phlegm which can harass the mind (Maciocia, 2008). The liver is important in AN owing to its role in filling the chong vessel and regulating menstruation (Larre & Rochat de la Vallee, 1997).
Chapter 8 of the Ling Shu states "heart and mind with frightened and distressed thoughts and anxiety can result in injury to the spirit. When the spirit is injured, it can result in fear and loss of self. There is a breakdown of the tissue and a stripping of the flesh.” (Wu, 2002, p. 39-40). This passage illustrates the effect of fear on the spirit and how this can lead to a loss of self-identity and a separation of the physical and emotional; both characteristic in AN.
From an elemental perspective the earth and fire elements are implicated in AN (L. Jarrett, personal communication, November 15, 2007). Someone born as an earth constitutional factor (CF) will be less able to receive nourishment and care from the mother and the balance of their relationship will be affected (Hicks et al., 2004). There is a tension within the earth element between giving to others and taking away and the anorexic personifies this through contradictory acts of generosity and hoarding (Franglen, 2001).
The chong and renmai can be implicated in AN (A. M. Lavin, personal communication, January 18, 2008). Magidoff (1999) states that "the chong involves more of a sense of self, while the ren involves more love of self” (p. 5). This has resonance in AN; as discussed there is little sense of self, the person is literally disappearing and low self-esteem prevails.
AN pertains to the traditional disease categories of fear and fright and anxiety and thinking in TCM (Flaws & Lake, 2001). The former refers to "fear of something which is not currently present but which causes fear about the future” (Flaws & Lake, 2001, p. 125). Fear is related to a kidney or jing deficiency. Susceptibility to fear and fright could be caused by qi and blood deficiency particularly affecting the heart and spleen, or to gallbladder deficiency, due to spleen weakness, leading to phlegm formation, and liver qi stagnation (Flaws & Lake, 2001).
Excessive and obsessive thinking are the hallmarks of a weakened spleen and a characteristic of AN, Jarrett describes this as being caught up in one’s own process (personal communication, November 15, 2007). Maciocia (2008) links anxiety to blood deficiency, worry and pensiveness; implicating the spleen and heart. AN can be diagnosed as deficient spleen qi and deficient heart fire (Ross, 1995). The mind consumes the most energy; excessive thinking deprives organs of energy, in quantity and quality, and drains yin especially of the heart and kidney (Hammer, 2005). Pathological emotions disturb the shen, hun and po and imbalances of these spirits alter the harmony of the zangfu and of qi and blood (Maciocia, 2008).
Rossi (2007) views the central pathology of AN as insufficiency of yin; the mutually harmonious relationship between yin and yang is broken; there is opposition without reciprocation which "manifests in anorexia (sic.) as a spirit-yang that denies the body-yin, like a flame that burns matter.” (p. 227). This illustrates how the spirit affects the physical through obsessive emotional churn.
Rossi (2007) states that "there is no specific pattern of anorexia; in order to classify it we follow the normal diagnostic methods and consider its primary symptoms” (p. 226). Others suggest treatment for AN should aim to develop the connection with the inner self and as well as strengthening the spleen to support heart fire (Ross, 1995). Hicks et al. (2004) describe the case of an anorexic patient who responded well to tonification of the fire element during acupuncture treatment.
An article by Yu (2004) claimed that acupuncture had been used successfully to treat AN, but further evidence to substantiate this statement could not be found. Research has been conducted into the use of electroacupuncture for the treatment of AN and BN as it may counter some physiological effects of gastric distension, thereby increasing appetite (Mayor, 2007). The author’s research supports the effectiveness of acupuncture in alleviating digestive symptoms associated with AN (N. McIntire, personal communication, November 30, 2007).
A review by Birmingham and Sidhu (2007) found no RCTs for the treatment of AN with complementary therapies and suggests further investigation is needed. However, a recent Australian study concluded that acupuncture could have value as an adjunct therapy in the treatment of eating disorders, including AN, by helping to improve quality of life (Fogarty et al., 2010).
AN is not recognised as a distinct disease pattern in TCM. The aetiology can be understood in terms of the influence of jing and emotions. Malnourishment impacts on the physical, compromising the vital substances and zangfu, and emotional being producing disharmony and separation on many levels. Knowledge on the treatment of AN in TCM is limited and generalisation is challenging given its varying expression in individuals. However, the holistic values of TCM strengthen the case for its wider use.
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