ANOREXIA (anorexia; the Greek negative an-and orexis prefix — appetite) — total absence of appetite at the objective need for food.
And. it is caused by organic or functional disturbances of activity of the center of appetite at the level of a hypothalamus or the highest analyzers in bark of hemicerebrums (see. Food center ). Primary organic lesions of these structures at strokes, tumors, injuries and inflammations of a brain are combined usually with heavy psychological disturbances against the background of which value judgment of appetite is impossible. Most often And. accompanies organic diseases of closed glands and is an important symptom of a pituitary cachexia (see) and adrenal insufficiency at addisonovy disease (see). Apparently, reactions of pituitary and adrenal system participate also in formation of functional disorders of appetite at different morbid conditions.
Long And. — usually a symptom of diseases, heavy on the forecast, but many morbid conditions are followed passing And., especially in acute stages and in phases of an aggravation or the culmination of a disease.
Except And., connected with organic neuroendocrinopathies, by pathogenetic options it is possible to allocate intoksikatsionny, dispeptic, neurodynamic, neurotic and psychogenic And. The last form pathogenetic is heterogeneous therefore allocation in an independent form of the peculiar morbid condition designated as psychological is almost important And.
Intoksikatsionny anorexia it is connected with disturbance of normal excitability of the food center owing to acute poisonings or hron. intoxications, including at long debilitating diseases (tuberculosis, malignant tumors). Regarding cases, napr, at hron. poisonings with vapors of mercury, And. it is caused by preferential direct damaging effect of poison on a thalamus and hypothalamic area and bark of parencephalons (see. Mercury ). At toxic damage of many systems, including digestive and closed glands (intoxication compounds of mercury, bacterial toxins, medicines), the leading link in development And. it is difficult to allocate. Alcoholics and smokers have a pathogeny And. has the mixed nature (intoxication of a nervous system, alcoholic defeats of the alimentary system, endocrinopathy at hron. nicotinism).
At acute poisonings and in acute stages of infectious diseases passing And., as well as the thirst increased during this period, has protective character since dezintoksikatsioiny systems of an organism and first of all anti-toxic functions of a liver during this period are overstrained.
At hron. infectious and oncological diseases And. aggravates the available disturbances of exchange, vitamin and fermental deficiency, reduces adaptation opportunities of an organism that worsens the course of the main disease.
Dispeptic anorexia accompanies diseases of the digestive system and in most cases has the uslovnoreflektorny nature (if meal causes pains, a meteorism, nausea and other dpspeptichesky phenomena).
Also changes of receptors of the alimentary system matter, at dysfunctions the cut is broken formation of appetite in an initial phase of meal and content by food. Such origin has And., observed sometimes at patients hron. gastritis with an akhiliya (obligate dependence between gastric secretion and appetite is not established). Genesis is not absolutely clear And. at a carcinoma of the stomach, when And. and even a fastidium can appear before other dispeptichesknkh of complaints and symptoms of the general intoxication that matters for early diagnosis of cancer.
At already available digestive disturbances and deficit of food at patients with hron. diseases of the alimentary system oppression of appetite significantly worsens the forecast of a disease. In such cases And. demands vigorous treatment.
Neurodynamic anorexia it is connected with features of nervous activity at stressful situations and develops owing to extraordinary pain stimulations at a myocardial infarction, renal and hepatic gripes or owing to disorganization of a metabolism and nervous activity at shock, peritonitis. And. does not treat the leading symptoms of the specified morbid conditions and it is mediated probably by reciprocal braking of the center of appetite at overexcitation of separate structures of limbic system. The same mechanism (reciprocal braking) should be assumed also at And., accompanying excitement of the emetic center. In particular, at toxicosis of pregnancy And. it is closely connected on time with an emetic reflex (on meal, its smells).
Neurotic anorexia is explained by close connection of activity of the food center with a functional condition of bark of parencephalons: superexcitation of bark and strong emotions (especially negative) suppress appetite. Neurotic component often defines stability dispeptic or intoksikatsionny And., arising against the background of a somatopathy. Actually neurotic And. it is not connected with a somatopathy at all or does not correspond to its weight and develops or against the background of neurosis or as independent specific neurosis. To development And. against the background of neurosis the irregularity and monotony of food, negative emotions on a situation promote, in a cut of people eats, fear of meal because of fear of «intoxication» at locks etc. Separately described psychological And. (see below) begins with fear of completeness.
The greatest number of complaints at any forms A. it is connected with lack of appetite, however the possibility of false complaints at hysterical neurosises demands for recognition And. identifications of the accompanying and related symptoms.
Signs And. are combined with signs of a basic disease. Along with loss of appetite complaints to weakness, weight loss, fatigue, apathy are noted. At long And. gradually objective symptoms of insufficiency of food develop: weight reduction of a body, falling of turgor of fabrics, disappearance of a hypodermic fatty layer also, at last, occurs exhaustion with reduction of muscle bulk. Early, especially at dispeptic And., symptoms of a vitamin deficiency appear (see). Standard metabolism and temperature of skin at such patients are lowered. Sexual functions decrease, at women the menstrual cycle falls apart. Skin and mucous membranes dry, it is frequent with trophic changes. The tone of muscles is weakened. Language is laid over, the stomach is pulled in, off-flavor from a mouth, defecation rare and complicated is noted. Arterial pressure is lowered, at rest it is noted bradpkardpya, and at an exercise stress — inadequate increase of pulse. In blood decrease in hemoglobin and crude protein of plasma is observed. The bystry psychoemotional exhaustion, a tendency to a depression is noted.
Treatment is carried out against the background of therapy of a basic disease. Reorganization of the regime of the patient, a variety of dishes, physiotherapy exercises is necessary. At intoksikatsionny, neurotic and if there are no contraindications, then and at dispeptic And. appoint orexigenic seasonings, bitters from a wormwood, a centaury, mix of bitter herbs on 15 — 20 drops of a pla fortified wine on 20 — 40 g before food. At a heavy current of Ampere-second exhaustion of the patient showed a preliminary bed rest, polyvitamin therapy, anabolic hormones — methandrostenolone (Nerobolum) inside on 10 — 15 mg a day or 2,5% Solutio oleosa Nandrolonum-fenilpropionata (nerobolil) on 1 ml intramusculary each 7 days, massage of a body. In hard cases use of insulin on 8 — 16 PIECES before a breakfast is justified. At neurotic forms A. the psychotherapy supported by purpose of psychopharmacological means — the inhibitors of a monamnnoksidaza, chlordiazepoxide, diazepam, meprobamate, phenobarbital selected in individual dosages depending on the accompanying displays of neurosis has major importance (phobias, apathy, alarm, etc.). In exceptional cases there is a need for artificial nutrition (see) and parenteral administration of saline solutions.
Anorexia psychological — the morbid condition which is shown in conscious restriction of food for weight loss and in the accruing exhaustion. It is for the first time described in 1873. W. Gull which offered the term «anorexia nervosa» and in 1874 Lassgom (E. S. Lasegue). Meets rather seldom (frequency of hospitalization makes 0,5 on 100000 population a year). In the last decades growth of number of patients is noted. A ratio among sick persons men's and female about 1:10. The disease arises aged from 15 up to 23 years more often. Clinic: there is supervaluable or persuasive idea of excess completeness with aspiration to weight loss is more rare. The increasing restriction in food which is usually hidden from people around is observed other measures to weight loss are undertaken: a concentrated study sport, physical work, artificial calling of vomiting after food, reception of laxatives. Appetite is not broken in the beginning, and the feeling of hunger can even be increased in this connection from time to time there is an overeating. Further appetite and feeling of hunger decrease. Rather quickly body weight falls (for 10 — 50% of initial) and other symptoms of the somatic disturbances connected with develop And. The accompanying mental disturbances are not identical. Mood swings from raised to lowered, the increased physical activity, hypochondria are more often noted. The alarming state, persuasive fears, the aspiration to examine the body in a mirror are less often observed. In more remote period the lowered mood prevails. The course of a disease usually continuous — from 2 to 6 years and more. The etiology of a disease is not quite clear. The point of view about an etiological role of the emotional conflicts is widespread. The great value in an origin of a disease is attached to features of the personality (line of a paranoyalnost), and also the wrong education (excessive guardianship from mother). The most important condition of developing of a disease — a disgarmonicheska the proceeding pubertal period. Syndromal qualification is various. One authors recognize independence of a syndrome nervous And., others carry it to manifestations of dismorfofobpchesky, hypochiondrial, depressive, obsessivny syndromes, conditions of depersonalization. The nosological provision of a disease is controversial: more popular belief in its belonging to psychogenias, in particular to psychosomatic diseases and neurosises; in the USSR usually is considered as a special form of a reactive state at pubertal age.
Psychological And. it is necessary to differentiate with similar states — disturbance of appetite at various neurosises, and also with anorexia at organic neuroendocrinopathies at which disorder of appetite is not combined with aspiration to weight loss. Differential diagnosis with a similar syndrome at schizophrenia is difficult. Differential diagnosis is helped by existence of specific changes of the personality and more expressed dismorfofobichesky symptoms at schizophrenia. From psychological And. it is also necessary to distinguish failure from food for crazy motives at patients with psychoses. Forecast of a disease generally favorable: from 1/2 to 2/3 patients completely recover. Exceptional cases of death owing to a cachexia are known. The long-term course of a disease can lead to pathological development of the personality. Heavier forecast at males. Treatment shall be carried out in a hospital with isolation from the family in the beginning. Suralimentation high-calorific food in combination with small doses of insulin, rational psychotherapy and psychotropic drugs (aminazine, a haloperidol, Tisercinum, Seduxenum) is appointed.
Anorexia at children
is More often observed decrease, is more rare — total absence of appetite.
At newborns And. can be a consequence of organic lesions of a brain — inborn pl connected with intracraneal hemorrhage at a birth trauma, a consequence of inborn defects of exchange (aminoatsidopatiya), and also a consequence of intoxication at the general diseases (sepsis, otitis, pneumonia, pyelonephritis etc.).
And. accompanies many endocrine diseases with disbolism. At the same time changes of appetite can be selective, representing in some cases reflection of compensation of exchange disturbances. This selectivity allows to assume a specific type of disturbances of exchange sometimes. Reason And. there can be disturbances of flavoring reception owing to diseases of a nasopharynx (adenoid vegetations, adenoidites, etc.), reception of medicines, bitter and off-flavor of drugs that needs to be considered at the choice of a form of medicine. As reception of many drugs is combined with food, the negative reflex on food develops. Dysbacteriosis and disturbances of gastric and intestinal secretion at enteral use of antibacterial agents can also be
A. U cause of children of preschool age And. often develops at uniform food and insufficient content of vitamins (C, groups B). Excess of separate food ingredients (proteins, fats, is more rare than carbohydrates) leads to braking of appetite.
And. at a gipervptaminoza of D it is caused by balance upset of calcium and water. It is more often observed at children aged about one year and expressed by total failure from food and vomiting (see. Hypervitaminosis ).
A foreground among other options A. occupy its neurotic forms children, and quite often neurotic component supports And. other nature. So, in the postinfectious period the loss of appetite which arose at initial toxicosis is supported by reception of medicines, and attempts of parents to violently feed children fix a negative conditioned reflex. And. often arises at violent feeding of the child, at an overfeeding, at introduction to a food allowance of new types of food (e.g., at purpose of a feeding up). The attempt of mother to violently feed the child to recover his weight, causes in the beginning negativism which on the second year of life quite often turns into a resistant negative conditioned reflex. Derivation from food or threat can strengthen A. Appetit decreases at children when they before food receive sweets of a pla excessive amount of milk, a cut it is used as drink. The unstable house situation, haste during the feeding, excessive persistence of parents, nervousness of the child at visit of kindergarten, school, and also the wrong education, feeding of the child who is carried away by a game become the reason functional And. At the same time the food stereotype is broken and reflex decrease in gastric secretion is noted, symptoms of neurosis appear. Only in process of growth of the child, consolidation of skills of meal and elimination of defects of education excitability of the food center and degree amplifies And. decreases.
The peculiar syndrome designated as psychological And. (see above), develops at children in before - and the pubertal period. At this form A. after primary failure from food the secondary hypopituitarism with decrease in activity of an adenohypophysis, weakening of a number of its functions develops (gonadotropic, thyritropic, adrenocorticotropic). At a psychological form A. it is necessary to exclude a mental disease and primary damages of a hypophysis and a diencephalon.
Treatment is begun with examination and elimination of the reason of A. Nuzhno to check a diet of the child. Observance of the correct day regimen with sufficient stay in the fresh air, creation of a quiet situation is necessary during feeding. Rational feeding by the mixed food, restriction of milk, prohibition of sweets and reception of any food in intervals between feedings is recommended. It is possible to vary food at children of advanced age. At And. at the children having the lowered gastric secretion use of the dishes stimulating secretion (beef-infusion broths, hot and salty spices), appointment salt to - you and pepsin, and also an abomin (on 0,1 and 0,2 g is reasonable during food), Pancreatinum (on 0,25 — 0,5 g during food), to children of the first three years of life — an apilak, anabolic hormones (especially if And. is followed by a hypotrophy). In particular, appoint methandrostenolone (Nerobolum) on 0,1 mg to 1 kg of weight of the child a day. Sometimes purpose of mineral waters, and to children of more advanced age — bitters, etc. helps. In hard cases appoint transfusions of plasma and other blood preparations. Feeding via the probe — a last resort.
Bibliography: Azerkovich N. N. of Anorexia nervosa (mentalis), Zhurn. neuropath, and psikhiat., t. 62, No. 7, page 1105, 1962, bibliogr.; Korkina M. V. Nervous anorexia neprotsessualyyuy the nature, in book: A wedge, dynamics of neurosises and a psychopathy, under the editorship of V. V. Kovalyov, page 128, L., 1967; Lebedinskaya K. S. Nervous anorexia, Zhurn. neuropath, and psikhiat., t. 67, No. 5, page 773, 1967; Bliss E. L. a. Hardin Branch C. H. Anorexia nervosa, its history, psychology and biology, N. Y., 1960, bibliogr.; Dally P. Anorexia nervosa, L., 1969, bibliogr.; Theander S. Anorexia nervosa, Copenhagen, 1970, bibliogr.
And. at children — Kossyura M. B. To a question of the mechanism of development of persistent anorexia in children, Pediatrics, No. 5, page 58, 1962; Krasnogorsk N. I. Works on studying of higher nervous activity of the person and animals, t. 1, page 275, M., 1954; Novlyanskaya K. A. About one of forms of long pathological reactions at pubertal age (anorexia nervosa at teenagers), Zhurn. neuropath, and psikhiat., t. 58, No. 7, page 861, 1958; Sukhareva G. E. Clinical lectures on psychiatry of children's age, t. 2, page 187, M., 1959; Ugolev A. M. and Kassil V. G. Physiology of appetite, in book: Food of the healthy and sick child, under the editorship of M. I. Olevsky and Yu. K. Polteva, page 45, M., 1965; Usoltcev A. N. Nervous anorexia, Vopr. okhr. mat. also it is put., t. 10, No. 7, page 54, 1965, bibliogr.
V. P. Zhmurkin; V. V. Kovalyov (psikhiat.), A. V. Mazurin (ped.).