anorexia nervosa

Definition

Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The name comes from two Latin words that mean nervous inability to eat. In females who have begun to menstruate, anorexia nervosa is usually marked by amenorrhea, or skipping at least three menstrual periods in a row. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (1994), defines two subtypes of anorexia nervosa—a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. DSM-IV defines a binge as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Description

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of DSM in 1980. It is, however, a growing problem among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder, and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5–1% of caucasian female adolescents. Over 90% of patients diagnosed with the disorder as of 1998 are female. It was originally thought that only 5% of anorexics are male, but that estimate is being revised upward. The peak age range for onset of the disorder is 14-18 years, although there are patients who develop anorexia as late as their 40s. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and social classes in the United States.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

— Rebecca J. Frey

A psychophysiological disorder usually occurring in young women that is characterized by an abnormal fear of becoming obese, a distorted self-image, a persistent unwillingness to eat, and severe weight loss. It is often accompanied by self-induced vomiting, excessive exercise, malnutrition, amenorrhea, and other physiological changes.

[New Latin anorexia nervōsa : anorexia, anorexia + nervōsa, feminine of nervōsus, nervous.]

A psychiatric disorder in which a dramatic reduction in caloric intake consequent to excessive dieting leads to significant bodily, physiological, biochemical, emotional, psychological, and behavioral disturbances. Anorexia nervosa is typically an illness of adolescent females: 90% of all cases begin in girls who are between 12 and 20 years of age. Nevertheless, this disorder can also occur in males, in prepubertal girls, and in women well into their third decade. Moreover, if the illness becomes chronic, it can persist into mid-life and beyond. Anorexia nervosa literally means “nervous loss of appetite” but appears to have little to do with such. Rather, there is usually a conscious decision made by a teen-age girl, most commonly around the ages of 14 or 18 years, to embark upon a diet. The amount of weight lost can vary considerably. The usual criterion for making a diagnosis of anorexia nervosa is a weight change of at least 25% from premorbid weight (to at least 15% below ideal weight in persons who were overweight at the onset). But this figure should be viewed as only a rule of thumb. In addition to these core disturbances, there is an array of associated symptoms and practices that characterize most persons with anorexia nervosa. Amenorrhea (absence of menstruation); increased physical activity; insomnia; use of emetics, cathartics, and diuretics; difficulty in recognizing satiation; and obsessional thinking and depression. The course and prognosis of anorexia nervosa is highly variable. While a high recovery rate, perhaps above 67%, is found in those persons whose illness begins acutely in their early teens and who quickly receive treatment, the outlook is considerably bleaker in those persons who develop the disorder later, who do not receive early treatment, and who develop bulimia.

Perhaps as many as 40–50% of anorectic patients whose illness persists for more than 1–2 years will develop the additional eating disturbance known as bulimia. Literally meaning “oxhunger,” bulimia refers to binge eating or compulsive overeating wherein thousands of calories are consumed in a relatively brief period of time (for example, 2 h). The binge characteristically involves carbohydrates and will usually culminate in self-induced vomiting. The precise nature of the relationship of bulimia to anorexia nervosa remains unclear. Not all anorectics become bulimic and not all bulimics were anorectic. But dieting is common as a precursor to bulimia, and high premorbid weight and chronicity of weight loss seem to predispose the anorectic to developing bulimia.

Although there is a broad range of symptoms, personality styles, precipitants, and outcomes that characterize anorexia nervosa, there is no simple explanation of its origins. In one widely accepted conception, the illness is viewed as a desperate struggle by the vulnerable female adolescent to establish a sense of identity separate from that of her domineering, overbearing, controlling, and intrusive mother. There is considerable emphasis on viewing the family system as the matrix in which the illness develops and for which the illness must have significance. Anorexia is viewed as both a response to the lack of “living space” that the adolescent experiences and as a defense against the threats to the stability of the family system that the girl's normal development implies. Development of anorexia is thus a function of both individual and family. It should be noted, however, that these formulations suffer from a common problem. They are based on assessments of anorectic patients—and their families—after the illness has become established. Thus, these theories cannot very well differentiate among predisposing, precipitating, and sustaining factors.

There are numerous physical, physiological, and biochemical changes that reflect primarily, although not solely, the ravages of starvation. In addition to the general bodily emaciation they manifest, anorectic individuals show brittle nails, thinning hair, cold extremities, a slow pulse, a small heart, and a hypometabolic state. In anorectic women who also binge and vomit, tooth decay and enlargement of the salivary glands are common. A mild-to-moderate anemia and a diminished white blood cell count develop with progressive malnutrition. Diabetes insipidus can also occur in advanced cases. In addition, abnormalities in glucose tolerance and blood electrolytes have been observed. Particularly in women who vomit, the blood potassium level can be significantly low. See also Malnutrition.

Because of the prominence of amenorrhea in its symptomatology, there has been a long-standing interest in the endocrinology of anorexia nervosa. A number of reliable hormonal abnormalities have been documented. Most prominent among these are diminished hypothalamic-pituitary-gonadal axis function and elevated hypothalamic-pituitary-adrenal axis function. Reversal of these endocrine aberrations usually occurs with clinical improvement, although considerable time may be required for full normalization.

As with virtually all psychiatric conditions for which the etiology is unknown and where no single empirically effective treatment exists, the therapeutic approaches to anorexia nervosa are diverse and reflect the different disciplines, training biases, and experiences of their proponents. Individual, insight-oriented psychotherapy directed toward increasing confidence in identifying and accepting bodily feelings, and understanding the sources of one's low self-esteem and poor sense of self, has generally been the essence of treatment for nonhospitalized individuals, particularly before chronicity has set in. Individual psychotherapy still remains a critical part of any approach to treatment, but the recovery rate can be increased, perhaps beyond 80%, by the inclusion of regular family therapy as part of the treatment approach. In the hospital, the first priority of treatment is directed toward correcting the biological abnormalities created by the extreme dieting (and, when present, the vomiting). If the individual appears unable or unwilling to resume adequate caloric intake, despite firm but supportive nursing and concomitant individual and family psychotherapy, more extreme measures may have to be instituted, including behavior modification or intravenous hyperalimentation. There is some evidence that, particularly in anorectics who are also characterized by depression and bulimia, antidepressant or possibly anticonvulsant medication may be helpful in damping down the binging and thereby gradually normalizing eating behavior in general. See also Psychopharmacology; Psychotherapy.

A psychological disturbance resulting in a refusal to eat, possibly with restriction to a very limited range of foods, and often accompanied by a rigid programme of vigorous physical exercise, to the point of exhaustion. Anorectic subjects generally do not feel sensations of hunger. The result is a very considerable loss of weight, with tissue atrophy and a fall in basal metabolic rate. It is especially prevalent among adolescent girls; when body weight falls below about 45 kg there is a cessation of menstruation. See also bulimia nervosa.

Anorexia nervosa is usually abbreviated to anorexia, and is sometimes referred to as self-starvation syndrome. It is a potentially fatal eating disorder in which there is a loss of appetite or desire for food, leading to severe loss of body weight. Clinical diagnosis is usually based on the following criteria:

• weight less than 85 per cent ideal weight
• intense fear of becoming obese, even when underweight
• disturbance of body image (i.e. feeling fat even when thin)
• in women, cessation of periods for three or more consecutive cycles when not on the contraceptive pill.

Anorexia is often associated with other eating disorders, such as bulimia nervosa. Although it can affect adults, both male and female, it occurs most frequently in adolescent girls. Anorexics are ten times more likely to be female than male.

Anorexia is now recognized as a serious psychological illness and is on the increase in Western societies (one estimate gives a 360 per cent increase over the last 9 years). Anorexics are usually emotionally disturbed and have a distorted body image. They are often convinced that they should be thinner even when their body weight is well below average. They will go to extreme lengths to restrict eating and to lose weight because they have a phobia about becoming obese. This phobia is expressed as an intense fear of gaining weight even when they are dangerously underweight.

There are many suggested causes of anorexia. It has been linked to dietary problems in early life, parental obsessions with food, problems within the family, and rejection of adult sexuality. Some psychologists see the relentless pursuit of thinness as a desire to be autonomous, to have control over one's own body, and to gain an identity. It is also seen as an attempt constantly to please others. Anorexia has been linked with participation in certain types of sports. Gymnasts, distance runners, and dancers are believed to be prone to eating disorders because of the pressure on them to remain slim, but it is generally agreed that these disorders rarely develop into the full condition. Some sport psychologists and sports nutritionists believe that high levels of physical activity can lead to the development of anorexia nervosa. They contend that strenuous exercise can suppress appetite resulting in a reduced food intake and weight loss. Many people who perceive themselves as being overweight exercise in order to slim. Any weight loss associated with their activity encourages them to exercise even more. This may initiate a cycle of exercise and weight loss that can lead to anorexia. However, although excessive exercise may contribute to anorexia, most experts believe that it is only one contributory factor, and does not explain the majority of cases.

Whatever the cause, the effects of anorexia are dramatic and potentially very dangerous. The persistent anorexic becomes malnourished, may suffer a variety of medical complications (including hair loss, cessation of periods, and cardiovascular abnormalities), and risks death due to starvation. One recent study reported a mortality rate of 6.6 per cent during a ten-year follow-up period.

Anorexia is much more than dieting gone wrong. It requires medical treatment and may respond to psychotherapy. The more chronic the condition, the more difficult it is to treat. If treated early, most of the physical symptoms can be corrected through adequate nutrition and the gradual restoration of normal weight. However, the underlying psychological problems may be more resistant to treatment.

A psychoneurotic disorder characterized by a prolonged refusal to eat, resulting in emaciation, amenorrhea in women, emotional disturbance concerning body image, and an abnormal fear of becoming fat.

Definition

Anorexia nervosa is an eating disorder characterized by unrealistic fear of weight gain, self-starvation, and conspicuous distortion of body image. The name comes from two Latin words that mean "nervous inability to eat." In females who have begun to menstruate, anorexia nervosa is usually marked by amenorrhea, or skipping at least three menstrual periods in a row. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV (1994), defines two subtypes of anorexia nervosa—a restricting type, characterized by strict dieting and exercise without binge eating—and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and the use of laxatives or enemas. DSM-IV defines a binge as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Description

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of DSM in 1980. It is, however, a growing problem among adolescent females and its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder, not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5-1% of Caucasian female adolescents. Over 90% of patients diagnosed with the disorder as of 1998 were female. It was originally thought that only 5% of anorexics are male, but that estimate is being revised upward. The peak age range for onset of the disorder is 14-18 years, although there are patients who develop anorexia as late as their 40s. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is also changing. More recent studies indicate that anorexia is increasingly common among women of all races and social classes in the United States.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, loss of kidney function, osteoporosis, anemia and other abnormalities of the blood.

Causes & Symptoms

Anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors. While the precise cause of the disease is not known, it has been linked to the following:

Social Influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on women's looks. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational Goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

Genetic and Biological Influences

Women whose biological mothers or sisters have the disorder appear to be at increased risk.

Psychological Factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been interpreted as:

• A rejection of female sexual maturity. This rejection is variously interpreted as a desire to remain a child, or as a desire to resemble men as closely as possible.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and non-threatening as possible. This hypothesis reflects the idea that female passivity and weakness are attractive to men.
• Overemphasis on control, autonomy, and independence. Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionists and "driven" about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction. In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male Anorexics

Although anorexia nervosa is still considered a disorder that largely affects women, its incidence in the male population is rising. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Moreover, homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard "attractive" weight for heterosexual males.

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Most anorexics deny that they are ill and are usually brought to treatment by a family member.

Anorexia is usually diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea (failure to menstruate) in females, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15% below normal, with some allowance for body build and weight history.

The doctor will rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Alternative treatments should serve as complementary to a conventional treatment program. Alternative therapies for anorexia nervosa include diet and nutrition, herbal therapy, hydrotherapy, aromatherapy, Ayurveda, and mind/body medicine.

Nutritional Therapy

A naturopath or nutritionist may recommend the following:

• avoiding sweets or baked goods
• following a nutritious and well-balanced diet (when patients resume eating normally)
• gaily multivitamin and mineral supplements
• zinc supplements. (Zinc is an important mineral needed by the body for normal hormonal activity and enzymatic function)

Herbal Therapy

The following herbs may help reduce anxiety and depression which are often associated with this disorder:

• chamomile (Matricaria recutita)
• lemon balm (Melissa officinalis)
• linden (Tilia spp.) flowers

Aromatherapy

Essential oils of herbs such as bergamot, basil, chamomile, clary sage and lavender may help stimulate appetite, relax the body and fight depression. They can be diffused into the air, inhaled, massaged or put in bath water.

Relaxation Techniques

Relaxation techniques such as yoga, meditation and t'ai chi can relax the body and release stress, anxiety and depression.

Hypnotherapy

Hypnotherapy may help resolve unconscious issues that contribute to anorexic behavior.

Other Alternative Treatments

Other alternative treatments that may be helpful include hydrotherapy, magnetic field therapy, acupuncture, biofeedback, Ayurveda and Chinese herbal medicine.

Allopathic Treatment

Treatment of anorexia nervosa includes both short-term and long-term measures, and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out treatment plan.

Hospital Treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40% or more below normal, or weight loss over a three-month period of more than 30 pounds
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or by over-feeding (hyperalimentation techniques).

Outpatient Treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented, and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50% of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants, anti-anxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is still debated. However, at least one study of Prozac showed it helped the patient maintain weight gained while in the hospital.

Expected Results

Figures for long-term recovery vary from study to study, but the most reliable estimates are that 40-60% of anorexics will make a good physical and social recovery, and 75% will gain weight. The long-term mortality rate for anorexia is estimated at around 10%, although some studies give a lower figure of 3-4%. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families.

Resources

Books

"Anorexia Nervosa." In Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: The American Psychiatric Association, 1994.

Baron, Robert B. "Nutrition." In Current Medical Diagnosis & Treatment edited by Lawrence M. Tierney, Jr., et al. Stamford, CT: Appleton & Lange, 1998.

The Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Fife, WA: Future Medicine Publishing, 1995.

Cassell, Dana K., with Felix E. F. Larocca. The Encyclopedia of Obesity and Eating Disorders. New York: Facts on File, Inc., 1994.

Herzog, David B. "Eating Disorders." In The New Harvard Guide to Psychiatry. Edited by Armand M. Nicholi, Jr., Cambridge, MA, and London, UK: The Belknap Press of Harvard University Press, 1988.

Kaplan, David W., and Kathleen A. Mammel. "Adolescence." In Current Pediatric Diagnosis & Treatment. Edited by William W. Hay, Jr., et al. Stamford, CT: Appleton & Lange, 1997.

Mitchell, James E. "Anorexia Nervosa: Medical and Physiological Aspects." In Handbook of Eating Disorders. Edited by Kelly D. Brownell and John P. Foreyt. New York: Basic Books, Inc., 1986.

The Medical Advisor: The Complete Guide to Alternative & Conventional Treatments. Richmond, VA: Time Life Education, 1997.

"Physical Conditions in Adolescence: Anorexia Nervosa." In The Merck Manual of Diagnosis and Therapy, vol. II. Edited by Robert Berkow, et al. Rahway, NJ: Merck Research Laboratories, 1992.

Pipher, Mary. Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Ballantine Books, 1994.

Organizations

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. (212) 734-1114.

National Institute of Mental Health Eating Disorders Program, Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. (301) 496-1891.

Other

Eating Disorders Home Page.

[Article by: Mai Tran]

Definition

Anorexia nervosa is an eating disorder characterized by self-starvation, unrealistic fear of weight gain, and conspicuous distortion of body image.

Description

The term anorexia nervosa comes from two Latin words that mean "nervous inability to eat." Anorexics have the following characteristics in common:

• inability to maintain weight at or above what is normally expected for age or height
• intense fear of becoming fat
• distorted body image
• in females who have begun to menstruate, the absence of at least three menstrual periods in a row, a condition called amenorrhea

There are two subtypes of anorexia nervosa: a restricting type, characterized by strict dieting and exercise without binge eating; and a binge-eating/purging type, marked by episodes of compulsive eating with or without self-induced vomiting and/or the use of laxatives or enemas. A binge is defined as a time-limited (usually under two hours) episode of compulsive eating in which the individual consumes a significantly larger amount of food than most people would eat in similar circumstances.

Demographics

Anorexia nervosa was not officially classified as a psychiatric disorder until the third edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. It is, however, a growing problem in the early 2000s among adolescent females. Its incidence in the United States has doubled since 1970. The rise in the number of reported cases reflects a genuine increase in the number of persons affected by the disorder and not simply earlier or more accurate diagnosis. Estimates of the incidence of anorexia range between 0.5 percent and 1 percent of Caucasian female adolescents. Over 90 percent of patients diagnosed with the disorder as of 2001 are female. The peak age range for onset of the disorder is 14 to 18 years. In the 1970s and 1980s, anorexia was regarded as a disorder of upper- and middle-class women, but that generalization is as of 2004 also changing. Studies indicate that anorexia is increasingly common among females of all races and social classes in the United States.

Causes and Symptoms

While the precise cause of the disease is not known, anorexia is a disorder that results from the interaction of cultural and interpersonal as well as biological factors.

Social Influences

The rising incidence of anorexia is thought to reflect the present idealization of thinness as a badge of upper-class status as well as of female beauty. In addition, the increase in cases of anorexia includes "copycat" behavior, with some patients developing the disorder from imitating other girls.

The onset of anorexia in adolescence is attributed to a developmental crisis caused by girls' changing bodies coupled with society's overemphasis on female appearance. The increasing influence of the mass media in spreading and reinforcing gender stereotypes has also been noted.

Occupational Goals

The risk of developing anorexia is higher among adolescents preparing for careers that require attention to weight and/or appearance. These high-risk groups include dancers, fashion models, professional athletes (including gymnasts, skaters, long-distance runners, and jockeys), and actresses.

Genetic and Biological Influences

Girls whose biological mothers or sisters have or have had anorexia nervosa appear to be at increased risk of developing the disorder.

Psychological Factors

A number of theories have been advanced to explain the psychological aspects of the disorder. No single explanation covers all cases. Anorexia nervosa has been given the following interpretations:

• Overemphasis on control, autonomy, and independence: Some anorexics come from achievement-oriented families that stress physical fitness and dieting. Many anorexics are perfectionists who are driven about schoolwork and other matters in addition to weight control.
• Evidence of family dysfunction: In some families, a daughter's eating disorder serves as a distraction from marital discord or other family tensions.
• A rejection of female sexual maturity: This rejection is variously interpreted as a desire to remain a child or as a desire to resemble males.
• A reaction to sexual abuse or assault.
• A desire to appear as fragile and nonthreatening as possible: This hypothesis reflects the idea that female passivity and weakness are attractive to males.
• Inability to interpret the body's hunger signals accurately due to early experiences of inappropriate feeding.

Male Anorexics

Although anorexia nervosa largely affects females, its incidence in the male population is rising in the early 2000s. Less is known about the causes of anorexia in males, but some risk factors are the same as for females. These include certain occupational goals and increasing media emphasis on external appearance in men. Homosexual males are under pressure to conform to an ideal body weight that is about 20 pounds lighter than the standard attractive weight for heterosexual males.

When to Call the Doctor

A healthcare professional should be contacted if a child or adolescent is suspected of having anorexia nervosa or displays early signs of the disorder, such as the following:

• fear of gaining weight
• distorted body image
• recent weight loss
• restrictive or abnormal eating patterns such as skipping meals or eliminating once-liked foods
• preoccupation with food and dieting
• compulsive exercising
• purging behaviors such as vomiting or using laxatives
• withdrawal from friends and family
• wearing baggy clothes to hide weight loss

Diagnosis

Diagnosis of anorexia nervosa is complicated by a number of factors. One is that the disorder varies somewhat in severity from patient to patient. A second factor is denial, which is regarded as an early sign of the disorder. Many anorexics deny that they are ill and are usually brought to treatment by a family member.

Anorexia nervosa is a serious public health problem not only because of its rising incidence, but also because it has one of the highest mortality rates of any psychiatric disorder. Moreover, the disorder may cause serious long-term health complications, including congestive heart failure, sudden death, growth retardation, dental problems, constipation, stomach rupture, swelling of the salivary glands, anemia and other abnormalities of the blood, loss of kidney function, and osteoporosis.

Most anorexics are diagnosed by pediatricians or family practitioners. Anorexics develop emaciated bodies, dry or yellowish skin, and abnormally low blood pressure. There is usually a history of amenorrhea in female patients, and sometimes of abdominal pain, constipation, or lack of energy. The patient may feel chilly or have developed lanugo, a growth of downy body hair. If the patient has been self-inducing vomiting, she may have eroded tooth enamel or Russell's sign (scars on the back of the hand). The second step in diagnosis is measurement of the patient's weight loss. DSM-IV specifies a weight loss leading to a body weight 15 percent below normal, with some allowance for body build and weight history.

The doctor will need to rule out other physical conditions that can cause weight loss or vomiting after eating, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome. Persons with this condition sometimes vomit after meals because the blood supply to the intestine is blocked. The doctor will usually order blood tests, an electrocardiogram, urinalysis, and bone densitometry (bone density test) in order to exclude other diseases and to assess the patient's nutritional status.

The doctor will also need to distinguish between anorexia and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that are often used are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).

Treatment

Treatment of anorexia nervosa includes both short- and long-term measures and requires assessment by dietitians and psychiatrists as well as medical specialists. Therapy is often complicated by the patient's resistance or failure to carry out a treatment plan.

Hospital Treatment

Hospitalization is recommended for anorexics with any of the following characteristics:

• weight of 40 percent or more below normal or weight loss over a three-month period of more than 30 lbs (13.6 kg)
• severely disturbed metabolism
• severe binging and purging
• signs of psychosis
• severe depression or risk of suicide
• family in crisis

Hospital treatment includes individual and group therapy as well as refeeding and monitoring of the patient's physical condition. Treatment usually requires two to four months in the hospital. In extreme cases, hospitalized patients may be force-fed through a tube inserted in the nose (nasogastric tube) or into a vein (hyperalimentation).

Outpatient Treatment

Anorexics who are not severely malnourished can be treated by outpatient psychotherapy. The types of treatment recommended are supportive rather than insight-oriented and include behavioral approaches as well as individual or group therapy. Family therapy is often recommended when the patient's eating disorder is closely tied to family dysfunction. Self-help groups are often useful in helping anorexics find social support and encouragement. Psychotherapy with anorexics is a slow and difficult process; about 50 percent of patients continue to have serious psychiatric problems after their weight has stabilized.

Medications

Anorexics have been treated with a variety of medications, including antidepressants, antianxiety drugs, selective serotonin reuptake inhibitors, and lithium carbonate. The effectiveness of medications in treatment regimens is as of 2004 debated. However, at least one study of fluoxetine (Prozac) showed it helped the patient maintain weight gained while in the hospital.

Nutritional Concerns

A key focus of treatment for anorexia nervosa is teaching the principles of healthy eating and improving disordered eating behaviors. A dietician or nutritionist plays an important role in forming a nutrition plan for the patient; such plans are individualized and ensure that the patient is consuming enough food to gain or maintain weight as needed and stabilize medically. The anorexic's weight and food intake are closely monitored to ensure that the plan is being followed.

Prognosis

Figures for long-term recovery vary from study to study, but reliable estimates are that 40 to 60 percent of anorexics make a good physical and social recovery, and 75 percent gain weight. The long-term mortality rate for anorexia is estimated at around 10 percent, although some studies give a lower figure of 3 to 4 percent. The most frequent causes of death associated with anorexia are starvation, electrolyte imbalance, heart failure, and suicide.

Prevention

Short of major long-term changes in the larger society, the best strategy for prevention of anorexia is the cultivation of healthy attitudes toward food, weight control, and beauty (or body image) within families. Early treatment such as counseling may help to prevent early signs of disordered eating from progressing into more serious behaviors.

Parental Concerns

There are many strategies that parents can undertake to help encourage healthy attitudes toward weight, food, and exercise in their children. These include the following:

• teaching children the importance of healthy eating and exercise
• avoiding using food as a punishment or reward
• instilling healthy eating and exercise habits by example
• being a good role model by promoting healthy body image and encouraging children and adolescents to find role models in the media who do the same
• encouraging children or teens who wish to diet to talk to a healthcare professional about healthy strategies to lose weight

See also Binge eating disorder; Bulimia nervosa.

Resources

Books

"Anorexia Nervosa." In The Merck Manual of Diagnosis and Therapy, 17th ed. Edited by Mark H. Beers and Robert Berkow. Whitehouse Station, NJ: Merck & Co. Inc., 2004.

Knowles, Jarol B. "Eating Disorders." In Textbook of Primary Care Medicine, 3rd ed. Edited by John Noble. St. Louis: Mosby Inc., 2001.

Litt, Iris F. "Anorexia Nervosa and Bulimia." In Nelson Textbook of Pediatrics, 17th ed. Edited by Richard E. Behrman, Robert M. Kliegman, and Hal B. Jenson. Philadelphia: Saunders, 2004.

Smith, Delia. "The Eating Disorders." In Cecil Textbook of Medicine, 21st ed. Edited by Lee Goldman and J. Claude Bennett. Philadelphia: Saunders, 2000.

Periodicals

American Academy of Pediatrics Committee on Adolescence. "Identifying and Treating Eating Disorders." Pediatrics 111, no. 1 (January 1, 2003): 204–11.

Pritts, Sarah D., and Jeffrey Susman. "Diagnosis of Eating Disorders in Primary Care." American Family Physician 67, no. 2 (January 15, 2003): 297–304.

Rome, E. S. "Eating Disorders." Obstetrics and Gynecology Clinics of North America 30, no. 2 (June 1, 2003): 353–77.

Rosen, David S. "Eating Disorders in Children and Young Adolescents: Etiology, Classification, Clinical Features, and Treatment." Adolescent Medicine 14, no. 1 (February 1, 2003): 49–59.

——. "Eating Disorders in Adolescent Males." Adolescent Medicine 14, no. 3 (October 1, 2003): 677–89.

Sigman, Gary S. "Eating Disorders in Children and Adolescents." Pediatric Clinics of North America 50, no. 5 (October 2003): 1139–77.

Organizations

American Anorexia/Bulimia Association. 418 East 76th St., New York, NY 10021. Telephone: 212/734–1114.

National Association of Anorexia Nervosa and Associated Disorders. Web site: www.anad.org.

National Institute of Mental Health Eating Disorders Program. Building 10, Room 3S231. 9000 Rockville Pike, Bethesda, MD 20892. Telephone: 301/496–1891.

[Article by: Rebecca J. Frey, PhD Stephanie Dionne Sherk]

For more information on anorexia nervosa, visit Britannica.com.

An eating disorder (usually abbreviated as anorexia and sometimes called self-starvation syndrome) characterized by loss of appetite and desire for food, a refusal to maintain body weight over minimal weight for age and height, an intense fear of becoming fat or gaining weight, a distorted body image, and (in females) amenorrhoea. A persistent anorexic may suffer serious medical complications and the condition can be fatal. Anorexia nervosa occurs in males and females, but is most frequent in adolescent girls. Gymnasts, cheerleaders, and dancers may be particularly prone to anorexia because of the pressures on them to remain slim The illness requires medical treatment and may respond to psychotherapy. See also eating disorder.

The term "anorexia nervosa" was coined by William Gull in 1873. Although the term has existed for little more than a century, the clinical description of the syndrome is much older. Among other works, we can find a description in Avicenna in the eleventh century, and we have no difficulty recognizing it in Richard Morton's 1694 account of "nervous consumption." The first complete description in terms identical to those of Gull can be found in an article written by Dr. Louis Victor Marcé in 1860.

The classic clinical picture of anorexia brings together three factors: weight loss of more than 10 percent, amenorrhea, and the absence of a manifest melancholic or delusional mental disturbance. But the emphasis has changed from these classic symptoms to more specific symptoms, such as a confused body image, denial of being thin, desperate desire to be thin, and fear of putting on weight. Also, two major types of anorexia nervosa have been distinguished: purely restrictive forms and forms associated with bulimic episodes accompanied by weight monitoring, self-induced vomiting, and excessive use of laxatives and diuretics. Anorexia nervosa frequently occurs during adolescence, especially among females (ten girls for every one boy). It affects between 1 and 2 percent of the female adolescent population.

Without ever dealing specifically with eating disorders, Freud did in fact establish all of the perspectives—hysteria, melancholia, and "actual" neurosis—around which the pathological manifestations of anorexia can be understood metapsychologically. As a hysteria, anorexia involves a double polarity: oral fixations of the libido serve as a point of regression, and sexual fantasies become oral and are then repressed. As a melancholia, anorexia involves melancholy over the issue of object loss and a loss of instinctual needs. Freud speaks of an anesthesia that leads to melancholic thinking, which opens up a research path related to the next perspective. As an "actual" neurosis, anorexia poses a threefold question about the importance of the current situation, of somatic and infrarepresentational factors, and of the inadequacy of the ego and capacities for working matters out.

Melanie Klein and her students have stressed the importance of archaic fantasies of sadistic devouring, destruction, and poisoning in anorexia. Psychoanalysts dealing specifically with eating disorders initially considered them to be primarily a symptom and took little interest in the organization of the personality. But because of the complexity of cases and the frequent severity of the evolution of the disorder, the pathology of the personality assumed a growing importance in their work. The Göttingen symposium, organized by J. E. Meyer and H. Feldmann (1965), recognized anorexia nervosa as having a specific structure and viewed it not so much as an attempt toward compromise formation but rather as an attempt to deal with psychotic failures in the organization of the ego by reestablishing the mother-child unit.

Evelyne Kestemberg et al. (1974) have provided a remarkable description of the specific modes of the regression and instinctual organization in anorexia. This organization is characterized by recourse to a primary erogenous masochism in which pleasure is linked directly to a refusal to satisfy a need. Pleasure does not accompany the feeling of having something inside oneself; rather, anorexia eroticizes not satisfying a vital need. Similarly, relationships become dominated by pleasure in their being not satisfied. The hedonization of refusal becomes the guardian of the feeling of being or existing in one's own right, corporeal activity and the body being thus liberated from all external holds. The most complete form of this hedonization of refusal is "hunger orgasm."

Different studies stress the importance of the dependence/autonomy conflict and the fundamental vulnerability of anorexics. This vulnerability is associated with powerful passive desires and, as a consequence, a constant fear of intrusion, particularly an invasion of the body by the object on which these desires depend. To pose the problem in terms that highlight the paradox of anorexia: anorexics destroy themselves to prove their own existence. The destructive effect is not sought after for its own sake, and in this respect anorexia is not a suicidal behavior, although it can be seen as the result of unleashing aggression and turning against the self an incorporation fantasy of an object experienced as destructive for the self. Anorexia is the consequence of using a physiological need indispensable for survival to preserve a feeling of autonomy. In doing so—and this is the second paradox—anorexics find themselves in fact more dependent on an environment from which they sought to free themselves. By making refusal the instrument of their liberation, they alienate themselves from the object of the refusal, which they can neither lose nor interiorize.

The anorexia-bulimia tandem leads to questions about whether a problem of dependence underlies other behaviors grouped under the label "addictive behaviors": drug addiction, alcoholism, pathological gambling, and shopping, as well as abuse of psychotropic drugs and kleptomania. The fragile narcissistic bases of such addicts makes their object relations difficult to manage, because these object relations become too exciting and too dangerous. Addiction to products or behavioral practices offers addicts a need-satisfying relational substitute that is always accessible and which they believe they can control, while in fact they fall into its grip.

The eating disorder represents a substitute for the object whose loss could plunge these patients into a collapse. This attempt to find a substitute object in addictive behavior represents a perverse organization of a relationship to the object in which the object is not recognized as having its own desires and differences, but is acknowledged only for purposes of narcissistic reassurance. An analogy exists among these patients' relationship with food, their relationship with their own bodies, and their object relations, as well as their modes of emotional investment in general.

Family-therapy approaches illustrate the sensitivity of these patients to the influences of their environment. These eating disorders can be seen as existing at an intersection between individual psychology, family interactions, the body in its most biological aspect, and society in general. An essentially mental disorder may thus have grave somatic consequences, and these consequences may in turn affect the anorexic's psychic state and thus contribute to maintaining the disorder.

Addictive behaviors raise questions about the type of society in which we live, particularly with the increase in the frequency of these disorders accompanying the increase in consumerism in our societies.

Bibliography

Agman, Gilles; Corcos, Maurice; and Jeammet, Philippe. (1994). Troubles des conduits alimentaires. In Encyclopédie medico-chirurgicale (Psychiatrie vol., fasc. 37-350-A-10). Paris: Encyclopédie medico-chirurgicale.

Brusset, Bernard. (1998). Psychopathologie de l'anorexie mentale. Paris: Dunod.

Kestemberg, Evelyne; Kestenberg, Jean; and Decobert, Simone. (1972). La faim et le corps: une étude psychanalytique de l'anorexie mentale. Paris: Presses Universitaires de France.

Venisse, Jean-Luc (Ed.). (1991). Les nouvelles addictions. Paris: Masson.

Further Reading

Aronson, Joyce K. (ed.) (1993). Insights in the dynamic psychotherapy of anorexia and bulimia: An introduction to the literature. Northvale, NJ: Jason Aronson.

Freedman, Norbert, et. al. (2002). Desymbolization: concept & observations on anorexia & bulimia. Psychoanalysis and Contemporary Thought, 25,165-200.

Sours, John. (1980). Starving to death in a sea of objects: the anorexia nervosa syndrome. New York: Jason Aronson.

Thoma, Helmut. (1967). Anorexia nervosa. New York: International Universities Press.

Wilson, Charles, Hogan, C., and Mintz, Ira. (1985). Fear of being fat: the treatment of anorexia and bulimia (2nd ed). Northvale, NJ: Aronson.

Young-Bruehl, Elisabeth. (1993). Feminism and psychoanalysis: in the case of anorexia nervosa. Psychoanalytical Psychology, 10, 317-330.

—PHILIPPE JEAMMET

A psychosomatic disorder in which the sufferer refuses to eat and undertakes activities (such as self-induced vomiting) to bring about extreme weight loss. Anorexia, which is also characterized by a distorted self-image, occurs most often in young women aged twelve to twenty-one and may result in death if medical treatment is not obtained. Treatment for anorexia often includes extensive counseling to reveal underlying emotional problems.

For other uses, see Anorexia nervosa (disambiguation) and Anorexia.

Anorexia Nervosa
Classification and external resources
ICD-10	F50.0-F50.1
ICD-9	307.1
OMIM	606788
DiseasesDB	749
eMedicine	emerg/34 med/144

Anorexia nervosa is a psychiatric illness that describes an eating disorder characterized by extremely low body weight and body image distortion with an obsessive fear of gaining weight. Individuals with anorexia nervosa are known to control body weight commonly through the means of voluntary starvation, excessive exercise, or other weight control measures such as diet pills or diuretic drugs. Although the condition primarily affects adolescent females, approximately 10% of people with the diagnosis are male.^[1] Anorexia nervosa, involving neurobiological, psychological, and sociological components^[2], is a complex condition that can lead to death in the most severe cases.

The term anorexia is of Greek origin: a (α, prefix of negation), n (ν, link between two vowels) and orexis (ορεξις, appetite), thus meaning a lack of desire to eat.^[3]

"Anorexia nervosa" is frequently shortened to "anorexia" in the popular media. This is technically incorrect, as the term "anorexia" used separately refers to the medical symptom of reduced appetite (which therefore is distinguishable from anorexia nervosa in being non-psychiatric).

Contents 1 Definition 2 Presentation 2.1 Physical 2.2 Psychological 2.3 Emotional 2.4 Behavioral 2.5 Diagnostic issues and controversies 3 Causes and contributory factors 3.1 Physiological factors 3.1.1 Genetic factors 3.1.2 Neurobiological factors 3.1.3 Nutritional factors 3.2 Psychological factors 3.2.1 Social and environmental factors 4 Relationship to autism 5 Prognosis 6 Incidence, prevalence and demographics 7 Treatment 7.1 Family-Based Treatment or Maudsley Approach 7.1.1 Methodology 8 See also 9 References 10 External links 10.1 Informational resources 10.2 Media stories and reports

Definition

A definition of anorexia nervosa was established by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD).

DSM-IV-TR criteria are:

• Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
• 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.
• In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Furthermore, the DSM-IV-TR specifies two subtypes:

• Restricting Type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas). Weight loss is accomplished primarily through dieting, fasting, or excessive exercise.
• Binge-Eating Type or Purging Type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating OR purging behavior (that is, self-induced vomiting, or the misuse of laxatives, diuretics, or enemas).

The ICD-10 criteria are similar, but in addition, specifically mention

1. The ways that individuals might induce weight-loss or maintain low body weight (avoiding fattening foods, self-induced vomiting, self-induced purging, excessive exercise, excessive use of appetite suppressants or diuretics).
2. Certain physiological features, including "widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhoea and in men as loss of sexual interest and potency. There may also be elevated levels of growth hormones, raised cortisol levels, changes in the peripheral metabolism of thyroid hormone and abnormalities of insulin secretion".
3. If onset is before puberty, that development is delayed or arrested.

Presentation

There are a number of features that, although not necessarily diagnostic of anorexia, have been found to be commonly (but not exclusively) present in those with this eating disorder.^[2][4][5]

Physical

Changes in brain structure and function are early signs often to be associated with starvation, and is partially reversed when normal weight is regained.^[6] Anorexia is also linked to reduced blood flow in the temporal lobes, although since this finding does not correlate with current weight, it is possible that it is a risk trait rather than an effect of starvation.^[7]

Other effects may include the following:

• Extreme weight loss
• Body mass index less than 17.5 in adults, or 85% of expected weight in children
• Stunted growth
• Endocrine disorder, leading to cessation of periods in females (amenorrhoea)
• Decreased libido; impotence in males
• Reduced metabolism, slow heart rate (bradycardia), hypotension, orthostatic hypotension, hypothermia, inappropriate sinus tachycardia and anemia
• Thinning of the hair
• Growth of lanugo hair over the body
• Constantly feeling cold
• Constipation
• Abnormalities of mineral and electrolyte levels
• Zinc deficiency
• Potassium deficiency
• Refeeding syndrome
• Reduction in white blood cell count
• Reduced immune system function
• Pallid complexion and sunken eyes
• Patulous eustachian tube
• Creaking joints and bones
• Osteoporosis
• Collection of fluid in ankles during the day and around eyes during the night or peripheral oedema
• Tooth decay
• Dry skin
• Dry or chapped lips
• Poor circulation (cool peripheries), resulting in common attacks of "pins and needles" (Parathesia) and purple extremities
• In cases of extreme weight loss, there can be nerve deterioration, leading to difficulty in moving the feet
• Headaches
• Brittle fingernails
• Bruising easily
• Fragile appearance
• Slowing of the growth rate of breasts
• Bed sores and wounds that don't heal in a timely manner
• Widespread body pain
• Extreme fatigue
• Vertigo, fainting; usually related to low blood pressure
• Difficulty concentrating, memory deficiencey ***
• Finally death

Psychological

• Distorted body image
• Poor insight
• Self-evaluation largely, or even exclusively, in terms of their shape and weight
• Pre-occupation or obsessive thoughts about food and weight
• Perfectionism
• Obsessive Compulsive Disorder (OCD)
• Autism Spectrum Disorder (ASD)
• Belief that control over food/body is synonymous with being in control of one's life
• Refusal to accept that one's weight is dangerously low even when it could be deadly
• Neuropsychological impairment at very low body weights

Emotional

• Low self-esteem and self-efficacy
• Phobia of becoming overweight
• Clinical depression or chronically low mood
• Mood swings

Behavioral

• Excessive exercise, food restriction
• Secretive about eating or exercise behavior
• Fainting
• Social withdraw or being asocial
• Self-harm, substance abuse or suicide attempts
• Very sensitive to references about body weight
• Aggressive when forced to eat "forbidden" foods
• Weighing themselves and constantly checking themselves in the mirror
• Taking unusual pleasure in cooking and caring for everyone else (but themselves)
• sudden changes in personality
• having difficulties adjusting to changes of plan, unusual situations or loss of "control" over them.

Diagnostic issues and controversies

The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make in practice and there is considerable overlap between patients diagnosed with these conditions. Furthermore, seemingly minor changes in a patient's overall behavior or attitude (such as reported feeling of "control" over any binging behavior) can change a diagnosis from "anorexia: binge-eating type" to bulimia nervosa. It is not unusual for a person with an eating disorder to "move through" various diagnoses as his or her behavior and beliefs change over time.^[4]

A substantial number of patients diagnosed with ED-NOS lack the three consecutive missed menstrual cycles needed for a diagnosis of anorexia nervosa, but meet all other diagnostic criteria.^[2] A person need not meet all diagnostic criteria for anorexia nervosa for their health and/or life to be in jeopardy; those with only some symptoms can still face permanent damage to their bodies, and even death.

Feminist writers such as Susie Orbach and Naomi Wolf have criticized the medicalization of extreme dieting and weight-loss as locating the problem within the affected women, rather than in a society that imposes concepts of unreasonable and unhealthy thinness as a measure of female beauty and gaining weight. Other writers have suggested that the disorder relates to issues of self-perception that are deeper than concerns with beauty and public perception.^[8]

A vigorous debate exists on the topic of whether eating disorders are a choice or a biological illness.^{[citation needed]} In 2006, Dr. Thomas Insel, director of the US National Institute of Mental Health, wrote an open letter to the National Eating Disorder Association stating "eating disorders are brain disorders."

Causes and contributory factors

It is clear that there is no single cause for anorexia and that it stems from a mixture of biological, social, and psychological factors. Current research is commonly focused on explaining existing factors and uncovering new causes. However, there is considerable debate over how much each of the known causes contributes to the development of anorexia. In particular, the contribution of perceived media pressure on women to be thin has been especially contentious.^[9]

Physiological factors

Genetic factors

Family and twin studies have suggested that genetic and environmental factors account for 74% and 26% of the variance in anorexia nervosa, respectively.^[10] This evidence suggests that genes influencing both eating regulation, and personality and emotion, may be important contributing factors. In one study, variations in the norepinephrine transporter gene promoter were associated with restrictive anorexia nervosa, but not binge-purge anorexia (though the latter may have been due to small sample size).^[11]

Several rodent models of anorexia have been developed which largely involve subjecting the animals to various environmental stressors or using gene knockout mice to test hypotheses about the effects of certain genes.^[12] These models have suggested that the hypothalamic-pituitary-adrenal axis may be a contributory factor. However, these models have been criticised as food is being limited by the experimenter and not the animal and cannot take into account the complex cultural factors known to affect the development of anorexia nervosa.

Neurobiological factors

There are strong correlations between the neurotransmitter serotonin and various psychological symptoms such as mood, sleep, emesis (vomiting), sexuality and appetite. A recent review of the scientific literature has suggested that anorexia is linked to a disturbed serotonin system,^[13] particularly to high levels at areas in the brain with the 5HT_1A receptor - a system particularly linked to anxiety, mood and impulse control. Starvation has been hypothesised to be a response to these effects, as it is known to lower tryptophan and steroid hormone metabolism, which, in turn, might reduce serotonin levels at these critical sites and, hence, ward off anxiety. In contrast, studies of the 5HT_2A serotonin receptor (linked to regulation of feeding, mood, and anxiety), suggest that serotonin activity is decreased at these sites. One difficulty with this work is that it is sometimes difficult to separate cause and effect, in that these disturbances to brain neurochemistry may be as much the result of starvation, than continuously existing traits that might predispose someone to develop anorexia. However, there is evidence that both personality characteristics (such as anxiety and perfectionism) and disturbances to the serotonin system are still apparent after patients have recovered from anorexia.^[14] This suggests that these disturbances are likely to be causal risk factors.

Recent studies also suggest anorexia may be linked to an autoimmune response to melanocortin peptides which influence appetite and stress responses. ^[15] Brain-derived neurotrophic factor (BDNF) is also under investigation as a possible cause.^[16]

Nutritional factors

Zinc deficiency causes a decrease in appetite that can degenerate in anorexia nervosa (AN), appetite disorders and, notably, inadequate zinc nutriture. The use of zinc in the treatment of anorexia nervosa has been advocated since 1979 by Bakan. At least five trials showed that zinc improved weight gain in anorexia. A 1994 randomized, double-blind, placebo-controlled trial showed that zinc (14 mg per day) doubled the rate of body mass increase in the treatment of AN.^[17] Deficiency of other nutrients such as tyrosine and tryptophan (precursors of the monoamine neurotransmitters norepinephrine and serotonin, respectively), as well as vitamin B1 (thiamine) could contribute to this phenomenon of malnutrition-induced malnutrition.^[17]

Psychological factors

There has been a significant amount of study on psychological factors that suggests how biases in thinking and perception help maintain or contribute to the risk of developing anorexia.

Anorexic eating behavior is thought to originate from feelings of fatness and unattractiveness^[18] and is maintained by various cognitive biases that alter how the affected individual evaluates and thinks about their body, food and eating.

One of the most well-known findings is that people with anorexia tend to over-estimate the size or fatness of their own bodies. A recent review of research in this area suggests that this is not a perceptual problem, but one of how the perceptual information is evaluated by the affected person.^[19] Recent research suggests people with anorexia nervosa may lack a type of overconfidence bias in which the majority of people feel themselves more attractive than others would rate them. In contrast, people with anorexia nervosa seem to more accurately judge their own attractiveness compared to unaffected people, meaning that they potentially lack this self-esteem boosting bias.^[20]

People with anorexia have been found to have certain personality traits that are thought to predispose them to develop eating disorders. High levels of obsession (being subject to intrusive thoughts about food and weight-related issues), restraint (being able to fight temptation), and clinical levels of perfectionism (the pathological pursuit of personal high-standards and the need for control) have been cited as commonly reported factors in research studies.^[21]

It is often the case that people with anorexia nervosa also have other psychological difficulties and mental illness. Clinical depression, obsessive compulsive disorder, substance abuse and one or more personality disorders are the most likely conditions to be comorbid with anorexia, and high-levels of anxiety and depression are likely to be present regardless of whether they fulfill diagnostic criteria for a specific syndrome.^[22]

Research into the neuropsychology of anorexia has indicated that many of the findings are inconsistent across studies and that it is hard to differentiate the effects of starvation on the brain from any long-standing characteristics. Nevertheless, one reasonably reliable finding is that those with anorexia have poor cognitive flexibility^[23] (the ability to change past patterns of thinking, particularly linked to the function of the frontal lobes and executive system).

Other studies have suggested that there are some attention and memory biases that may maintain anorexia.^[24] Attentional biases seem to focus particularly on body and body-shape related concepts, making them more salient for those affected by the condition, and some limited studies have found that those with anorexia may be more likely to recall related material than unrelated material.

Fairburn and colleagues psychological model of anorexia

Although there has been quite a lot of research into psychological factors, there are relatively few hypotheses which attempt to explain the condition as a whole.

Professor Chris Fairburn, of the University of Oxford and his colleagues have created a "transdiagnostic" model,^[25] in which they aim to explain how anorexia, as well as related disorders such as bulimia nervosa and ED-NOS, are maintained. Their model is developed with psychological therapies, particularly cognitive behavioral therapy, in mind, and so suggests areas where clinicians could provide psychological treatment.

Their model is based on the idea that all major eating disorders (with the exception of obesity) share some core types of psychopathology which help maintain the eating disorder behavior. This includes clinical perfectionism, chronic low self-esteem, mood intolerance (inability to cope appropriately with certain emotional states) and interpersonal difficulties.

Social and environmental factors

Sociocultural studies have highlighted the role of cultural factors, such as the promotion of thinness as the ideal female form in Western industrialised nations, particularly through the media. A recent epidemiological study of 989,871 Swedish residents indicated that gender, ethnicity and socio-economic status were large influences on the chance of developing anorexia, with those with non-European parents among the least likely to be diagnosed with the condition, and those in wealthy, white families being most at risk.^[26] A study by Garner and Garfinkel demonstrated that those in professions where there is a particular social pressure to be thin (such as models and dancers) were much more likely to develop anorexia during the course of their career,^[27] and further research has suggested that those with anorexia have much higher contact with cultural sources that promote weight-loss.^[28]

Although anorexia nervosa is usually associated with Western cultures, exposure to Western media is thought to have led to an increase in cases in non-Western countries. However, it is notable that other cultures may not display the same "fat phobic" worries about becoming fat as those with the condition in the West, and instead may present with low appetite with the other common features.^[29]

There is a high rate of reported child sexual abuse experiences in clinical groups of who have been diagnosed with anorexia (up to 50% in those admitted to inpatient wards, with a lesser prevalence among people treated in the community). Although prior sexual abuse is not thought to be a specific risk factor for anorexia, those who have experienced such abuse are more likely to have more serious and chronic symptoms.^[30]

The Internet has enabled anorexics and bulimics to contact and communicate with each other outside of a treatment environment, with much lower risks of rejection by mainstream society. A variety of websites exist, some run by people with anorexia, some by people in recovery, and some by professionals. The majority of such sites support a medical view of anorexia as a disorder to be cured, although some people affected by anorexia have formed online pro-ana communities that reject the medical view and argue that anorexia is a "lifestyle choice", using the internet for mutual support, and to swap weight-loss tips.^[31] Such websites were the subject of significant media interest, largely focusing on concerns that these communities could encourage young women to develop or maintain eating disorders, and many were taken offline as a result.^[32]

Relationship to autism

A summary of the strategy Zucker et al. (2007) used to assess the relationship between anorexia nervosa and the autism spectrum.^[5]

Since Gillberg's (1985) and others initial suggestion of relationship between anorexia nervosa and autism,^[33][34][35] a large scale longitudinal study into teenage onset anorexia nervosa conducted in Sweden found that 23% of people with a long-standing eating disorder were on the autism spectrum.^{[36][37][38][39][40][41][42]} Those on autism spectrum tend to have a worse outcome,^[43] but may benefit from the combined use of behavioural and pharmacological therapies tailored to ameliorate autism rather than anorexia nervosa per se.^[44][45] Other studies, most notably research conducted at the Maudsley Hospital UK, furthermore suggest that autistic traits are common in people with anorexia nervosa, shared traits include e.g. executive function, autism quotient score, central coherence, theory of mind, cognitive-behavioural flexibility, emotion regulation and understanding facial expressions.^{[46][47][48][49][50][51]} Studies of identical twins indicate that genetics accounts for about three-quarters of the variance in anorexia nervosa;^[10] the high degree of heritability, similar to that for autism, attests to a strong neurobiological component i.e. an atypical development of the brain.

Zucker et al. (2007) proposed that conditions on the autism spectrum make up the cognitive endophenotype underlying anorexia nervosa and appealed for increased interdisciplinary collaboration (see figure to right).^[5] These research findings have been reported in the media and have included the claim that women not identified as being on the autism spectrum (e.g. those with undiagnosed Asperger syndrome), maybe identified via a co-morbid eating disorder.^[52][53][54] A pilot study into the effectiveness Cognitive Behaviour Therapy, which based its treatment protocol on the hypothesised relationship between anorexia nervosa and an underlying autistic like condition, reduced perfectionism and rigidity in 17 out of 19 participants.^[55]

Prognosis

Anorexia is thought to have the highest mortality rate of any psychiatric disorder, with anywhere from 6-20% of those who are diagnosed with the disorder eventually dying due to related causes.^[56] The suicide rate of people with anorexia is also higher than that of the general population and is thought to be the major cause of death for those with the condition.^[57]

Incidence, prevalence and demographics

The majority of research into the incidence and prevalence of anorexia has been done in Western industrialized countries, so results are generally not applicable outside these areas. However, recent reviews^[58][59] of studies on the epidemiology of anorexia have suggested an incidence of between 8 and 13 cases per 100,000 persons per year and an average prevalence of 0.3% using strict criteria for diagnosis. These studies also confirm the view that the condition largely affects young adolescent females, with females between 15 and 19 years old making up 40% of all cases. Furthermore, the majority of cases are unlikely to be in contact with mental health services. As a whole, about 10% of people with anorexia are male and about 90% of people with anorexia are female.^[2] Anorexia, however, is not exclusively limited to any age or demographic. In March 2008, a British senior university lecturer with PhD in psychology and a professional background in health, Rosemary Pope, died from anorexia.^[60] Anorexia has been reported occurring throughout a patient's life extending into the seventies and eighties.^[61] In addition, onset can occur in one's sixties or later.^[62] The Italian character actor, Giovanni Rovini, died of onset of symptoms commencing in his early nineties. ^[63]

Treatment

The first line treatment for anorexia is usually focused on immediate weight gain, especially with those who have particularly serious conditions that require hospitalization. In particularly serious cases, this may be done as an involuntary hospital treatment under mental health law, where such legislation exists. In the majority of cases, however, people with anorexia are treated as outpatients, with input from physicians, psychiatrists, clinical psychologists and other mental health professionals.

Medication treatments play a much less prominent role in anorexia than for many other psychiatric disorders. There is some evidence for the benefit from pharmacologic treatments but the use of medication in anorexia is not all that well established. Many medications have been tried with mixed but mostly discouraging results. There are divergent reports on the use and efficacy of fluoxetine for anorexia relapse prevention. There has been some encouraging research on the use of antipsychotics in the treatment of anorexia, most namely olanzapine, risperidone and quetiapine.^{[citation needed]} But on the whole there is no convincing evidence of the efficacy for any drug treatment for anorexia in either the acute or chronic phrase of the disorder. Anorexia is one of the few mental disorders of which this may be said. To date, no specific type of psychotherapy seems to show any overall advantage when compared to other types.

Family therapy has also been found to be an effective treatment for adolescents with anorexia^[64] and in particular, a method developed at the Maudsley Hospital called the Maudsley Approach or Family-Based Treatment (FBT) is widely used and found to maintain improvement over time.^[65]

An alternative approach to treatment has been proposed by Per Södersten in Sweden, who has found that the main features of anorexia (slow, deliberate eating patterns, hyperactivity, and hypothermia) seem to reinforce the disorder. Sodersten's group suggests that keeping patients warm and normally active, and encouraging more normal meal-taking patterns, may be of aid (Sodersten P (2003) Anorexia nervosa: towards a neurbiologically based therapy. European J. Pharmacology, 480, 67-74.)

Drug treatments, such as SSRI or other antidepressant medication, have not been found to be generally effective for either treating anorexia,^[66] or preventing relapse^[67] although it has also been noted that there is a lack of adequate research in this area. It is common, however, for antidepressants to be prescribed, often with the intent of trying to treat the associated anxiety and depression.

Supplementation with 14 mg/day of zinc is recommended as routine treatment for anorexia nervosa due to a study showing a doubling of weight regain after treatment with zinc was begun. The mechanism of action is hypothesized to be an increased effectiveness of neurotransmission in various parts of the brain, including the amygdala, after adequate zinc intake begins resulting in increased appetite.^[68]

There are various non-profit and community groups that offer support and advice to people who have anorexia or who care for someone who does.

Family-Based Treatment or Maudsley Approach

The neutrality of this section is disputed. Please see the discussion on the talk page. Please do not remove this message until the dispute is resolved. (June 2009)

Family-Based Treatment (FBT) has been shown to be an effective treatment for adolescents and young adults (younger than 19 years old) who have anorexia nervosa with a short history (less than 3 years).^[69] Developed in the 1980s at the Maudsley Hospital in London, FBT is also known as the Maudsley Approach, Maudsley Treatment or Maudsley Method. A somewhat similar treatment method based on Maudsley called Behavioral Systems Family Therapy (BSFT) is also promising, according to studies. Another Maudsley offshoot, called Multiple-Family Day Treatment (MFDT), is currently being evaluated.^[70]

"At this time, the evidence base is strongest for the Maudsley model of family therapy for anorexia nervosa," according to a 2008 paper published in the Journal of Clinical Child & Adolescent Psychology^[71]. In 2008 published research on family-based interventions involving adolescents shows that "At 4-5 year follow-up, the majority (60-90%) will have fully recovered while only 10-15% will still be seriously ill. Outpatient family therapy compares quite favorably to other treatment modalities such as inpatient care where full recovery rates vary between 33% - 55%."^[72]

FBT sees the parents of the ill person as the best ally for recovery. The effects of dieting (or insufficient food for a person's activity level) create for many people a self-perpetuating cycle that requires intervention. In this approach, parents are seen as the most committed and competent people in the patient's life and therefore best qualified to find ways to fight the illness, to regain healthy weight, to end unhealthy behaviors and to return their child to normal adolescent development unencumbered by the eating disorder.^{[citation needed]}

FBT, with its emphasis on full weight restoration as the basis of recovery, differs from other approaches which rely on the patient's insight and motivation as necessary to recovery. FBT also challenges the traditional psychiatric view^[vague] which holds that family and parental dysfunction are at the root of eating disorders and which questions the role of parents in the treatment. The approach is also appropriate for bulimia and for older patients whose families are able to take on this role.^{[citation needed]}

Since its successful use in the UK, the treatment has spread to the United States, Australia, and Canada and is seen as a alternative model to costly inpatient or day hospital programs. Research has validated FBT for use with children and adolescents living at home. Modified versions of the approach have been used successfully with older patients, multi-family group trainings, Binge Eating Disorder patients, and for couples. Success rates for treatment are promising: small trials indicate 75-90% of patients are still well five years after treatment for anorexia, while most other treatments show only one third of patients in long-term recovery.^{[citation needed]}

Methodology

In most cases, the treatment has three phases over a period of 6–12 months, led by an FBT therapist, and involve the entire family in hour-long weekly sessions. The parents are coached in how to help the patient eat (and/or stop purging and over-exercising) and siblings are encouraged to ally with the ill sibling. Patients are neither expected to nor asked to cooperate; in the first session of FBT/Maudsley therapy a meal is eaten in the therapist's office and the ill person is asked to resist eating to demonstrate the dynamics of the family around the meal.

The treatment for bulimia is slightly different: the patients, usually older and more ready to engage in therapy, are more involved with the problem-solving phase of recovery.

No one is blamed in FBT therapy; the illness is not seen as anyone's fault, and finding cause for the eating disorder is not part of the treatment at all. For many, the symptoms, behaviors and rituals seen in anorexia lighten in intensity or disappear completely as a result of refeeding and full weight restoration. Many patients make use of psychotherapy after weight restoration, but such therapy is not integral to FBT.

The three phases of treatment are:

• Parents take control of decisions of what, when, and how much the ill patient eats. The goal is to refeed the patient, usually within 1–3 months.
• After weight restoration is nearly achieved, control is carefully given back to the patient.
• In the last phase, the therapist and family work to restore normal and age-appropriate lifestyle and relations between family members.

See also

• History of anorexia nervosa
• Adi Barkan (photographer who has campaigned against the use of anorexic models)
• Anorexia (symptom)
• Anorexia mirabilis
• Body dysmorphic disorder
• Body image
• Bulimia nervosa
• Binge eating disorder
• Cachexia
• Calorie restriction
• Defensive vomiting
• Eating disorder
• Eating disorder not otherwise specified
• Empress Elisabeth of Austria
• Fasting girls for a historical perspective on anorexia nervosa
• F.E.A.S.T.
• Female athlete triad
• Female body shape
• Hungry: A Mother and Daughter Fight Anorexia (book)
• Karen Carpenter
• Malnutrition
• Mary-Kate Olsen
• Muscle dysmorphia (a reversed mental disorder of anorexia)
• National Association of Anorexia Nervosa and Associated Disorders
• Orthorexia nervosa
• Pro-ana
• Purging disorder
• Refeeding syndrome
• Wannarexia — a term for people who wish to be anorexic

References

1. ^ "The Numbers Count: Mental Disorders in America". The National Institute of Mental Health. http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml#Eating. Retrieved 2008-10-09. 
2. ^ ^{a b c d} Lask B, and Bryant-Waugh, R (eds) (2000) Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. Hove: Psychology Press. ISBN 0-86377-804-6.
3. ^ Costin, Carolyn.~ (1999) The Eating Disorder Sourcebook. Linconwood: Lowell House. 6.
4. ^ ^{a b} Gowers S, Bryant-Waugh R. (2004) Management of child and adolescent eating disorders: the current evidence base and future directions. J Child Psychol Psychiatry, 45 (1), 63-83. PMID 14959803
5. ^ ^{a b c} Zucker, N. L; M. Losh, C. M Bulik, K. S LaBar, J. Piven, K. A Pelphrey (2007). "Anorexia nervosa and autism spectrum disorders: Guided investigation of social cognitive endophenotypes". Psychological Bulletin 133 (6): 976-1006. http://www.duke.edu/web/mind/level2/faculty/labar/pdfs/Zucker_et_al_2007.pdf. 
6. ^ Palazidou E, Robinson P, Lishman WA. (1990) Neuroradiological and neuropsychological assessment in anorexia nervosa. Psychol Med, 20 (3), 521-7. PMID 2236361.
7. ^ Lask B, Gordon I, Christie D, Frampton I, Chowdhury U, Watkins B. (2005) Functional neuroimaging in early-onset anorexia nervosa. Int J Eat Disord, 37 Suppl, S49-51. PMID 15852320.
8. ^ Jacobson, K. (2006) The Interpersonal Experience of Human Spatiality: A Phenomenological Interpretation of Anorexia Nervosa. Chiasmi International 8, 157-74
9. ^ Tiggemann M and Pickering AS. (1996) Role of television in adolescent women's body dissatisfaction and drive for thinness Int J Eat Disord, Sep;20(2):199-203.
10. ^ ^{a b} Klump, K. L.; K. B. Miller, P. K. Keel, M. McGue, W. G. Iacono (2001). "Genetic and Environmental Influences on Anorexia Nervosa Syndromes in a Population–based Twin Sample". Psychological Medicine 31 (04): 737-740. doi:10.1017/S0033291701003725. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=75247. Retrieved 2009-09-29. 
11. ^ Urwin, R.E., Bennetts, B., Wilcken, B. et al. (2002). "Anorexia nervosa (restrictive subtype) is associated with a polymorphism in the novel norepinephrine transporter gene promoter polymorphic region," Molecular Psychiatry, 7(6), 652–657.
12. ^ Siegfried Z, Berry EM, Hao S, Avraham Y. (2003) Animal models in the investigation of anorexia. Physiol Behav, 79 (1), 39-45. PMID 12818708.
13. ^ Kaye WH, Frank GK, Bailer UF, Henry SE, Meltzer CC, Price JC, Mathis CA, Wagner A. (2005) Serotonin alterations in anorexia and bulimia nervosa: new insights from imaging studies. Physiol Behav, 85 (1), 73-81. PMID 15869768.
14. ^ Kaye WH, Bailer UF, Frank GK, Wagner A, Henry SE. (2005) Brain imaging of serotonin after recovery from anorexia and bulimia nervosa. Physiol Behav, 86(1-2), 15-7. PMID 16102788.
15. ^ Fetissov SO, Harro J, Jaanisk M, Jarv A, Podar I, Allik J, Nilsson I, Sakthivel P, Lefvert AK, Hokfelt T. (2005) Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. Proc Natl Acad Sci U S A, 102 (41), 14865-70. PMID 16195379.
16. ^ Ribasés, M.; Gratacòs, M.; Fernández-Aranda, F.; Bellodi, L.; Boni, C.; Anderluh, M.; Cavallini, C.; Cellini, E. et al. (Jun 2004). "Association of BDNF with anorexia, bulimia and age of onset of weight loss in six European populations" (Free full text). Human Molecular Genetics 13 (12): 1205. doi:10.1093/hmg/ddh137. ISSN 0964-6906. PMID 15115760. http://hmg.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15115760.  edit
17. ^ ^{a b} Shay NF, Mangian HF (May 2000). "Neurobiology of zinc-influenced eating behavior". The Journal of nutrition 130 (5S Suppl): 1493S–9S. PMID 10801965. http://jn.nutrition.org/cgi/pmidlookup?view=long&pmid=10801965. 
18. ^ Rosen JC, Reiter J, Orosan P. (1995) Assessment of body image in eating disorders with the body dysmorphic disorder examination. Behav Res Ther, 1, 77-84. PMID 7872941.
    
19. ^ Skrzypek S, Wehmeier PM, Remschmidt H. (2001) Body image assessment using body size estimation in recent studies on anorexia nervosa. A brief review. Eur Child Adolesc Psychiatry, 10 (4), 215-21. PMID 11794546.
20. ^ Jansen A, Smeets T, Martijn C, Nederkoorn C. (2006) I see what you see: the lack of a self-serving body-image bias in eating disorders. Br J Clin Psychol, 45 (1), 123-35. PMID 16480571.
21. ^ Wonderlich SA, Lilenfeld LR, Riso LP, Engel S, Mitchell JE. (2005) Personality and anorexia nervosa. Int J Eat Disord, 37 Suppl, S68-71. PMID 15852324.
22. ^ O'Brien KM, Vincent NK. (2003) Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clin Psychol Rev, 23 (1), 57-74. PMID 12559994
23. ^ Tchanturia K, Campbell IC, Morris R, Treasure J. (2005) Neuropsychological studies in anorexia nervosa. Int J Eat Disord, 37 Suppl, S72-6. PMID 15852325.
24. ^ Cooper MJ (2005) Cognitive theory in anorexia nervosa and bulimia nervosa: progress, development and future directions. Clin Psychol Rev, 25 (4), 511-31. PMID 15914267.
25. ^ Fairburn CG, Cooper Z, Shafran R. (2003) Cognitive behavior therapy for eating disorders: a "transdiagnostic" theory and treatment. Behav Res Ther, 41 (5), 509-28. PMID 12711261.
26. ^ Lindberg L, Hjern A. (2003) Risk factors for anorexia nervosa: a national cohort study. International Journal of Eating Disorders, 34 (4), 397-408. PMID 14566927
27. ^ Garner DM, Garfinkel PE. (1980) Socio-cultural factors in the development of anorexia nervosa. Psychol Med, 10 (4), 647-56. PMID 7208724.
28. ^ Toro J, Salamero M, Martinez E. (1994) Assessment of sociocultural influences on the aesthetic body shape model in anorexia nervosa. Acta Psychiatrica Scandinavica, 89 (3), 147-51. PMID 8178671.
29. ^ Simpson KJ. (2002) Anorexia Nervosa and culture. J Psychiatr Ment Health Nurs, 9 (1), 65-71. PMID 11896858.
30. ^ Carter JC, Bewell C, Blackmore E, Woodside DB. (2006) The impact of childhood sexual abuse in anorexia nervosa. Child Abuse Negl, 30 (3), 257-69. PMID 16524628.
31. ^ Norris ML, Boydell KM, Pinhas L, Katzman DK. (2006) Ana and the internet: A review of pro-anorexia websites. International Journal of Eating Disorders, 39(6):443-7. PMID 16721839.
32. ^ Reaves, J. (2001). Anorexia goes high tech. Time (July). Retrieved on April 16, 2007.
33. ^ Gillberg, C. (1985). "Autism and anorexia nervosa: Related conditions". Nordisk Psykiatrisk Tidskrift 39 (4): 307–312. http://www.nifustep.no/norsk/publikasjoner/nordisk_psykiatrisk_tidsskrift_et_forlagssynspunkt. 
34. ^ Rothery, D.J.; D.M.F. Garden (1988-01-11). Anorexia nervosa and infantile autism. http://bjp.rcpsych.org/cgi/pdf_extract/153/5/714. Retrieved 2009-09-28. 
35. ^ Gillberg, C.; M. Rastam (1992). "Do some cases of anorexia nervosa reflect underlying autistic-like conditions?". Behavioural neurology 5 (1): 27–32. http://psycnet.apa.org/?fa=main.doiLanding&uid=1993-02071-001. 
36. ^ Gillberg, I. Carina; Maria Råstam, Christopher Gillberg (1995-02). "Anorexia nervosa 6 years after onset: Part I. Personality disorders". Comprehensive Psychiatry 36 (1): 61-69. doi:10.1016/0010-440X(95)90100-A. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WCV-4CR8YJ7-P&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1021004833&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=b9e3a928152cb3effe5dfb46d0660fa1. Retrieved 2009-09-23. 
37. ^ Gillberg, I. Carina; Christopher Gillberg, Maria Råstam, Maria Johansson (1996-02). "The cognitive profile of anorexia nervosa: A comparative study including a community-based sample". Comprehensive Psychiatry 37 (1): 23-30. doi:10.1016/S0010-440X(96)90046-2. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WCV-4CR8YSX-35&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1020903699&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=06c79ff8dab55bab1fc6ce37e879e2a6. Retrieved 2009-09-23. 
38. ^ Råstam, M.; C. Gillberg, I. C. Gillberg (1996). "A six-year follow-up study of anorexia nervosa subjects with teenage onset". Journal of Youth and Adolescence 25 (4): 439-453. doi:10.1007/BF01537541. http://dx.doi.org/10.1007/BF01537541. Retrieved 2009-09-23. 
39. ^ Nilsson, E. W; C. Gillberg, I. C Gillberg (1999-11). "Ten-year follow-up of adolescent-onset anorexia nervosa: personality disorders". Journal of the American Academy of Child and Adolescent Psychiatry 38 (11): 1389-95. http://www.ncbi.nlm.nih.gov/pubmed/10560225. Retrieved 2009-09-23. 
40. ^ Wentz, Elisabet; Christopher Gillberg, I. Carina Gillberg, Maria Råstam (2001). "Ten-Year Follow-up of Adolescent-Onset Anorexia Nervosa: Psychiatric Disorders and Overall Functioning Scales". The Journal of Child Psychology and Psychiatry and Allied Disciplines 42 (05): 613-622. doi:10.1017/S0021963001007284. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=80528. Retrieved 2009-09-23. 
41. ^ Råstam, Maria; Christopher Gillberg, Elisabet Wentz (2003-01-01). "Outcome of teenage-onset anorexia nervosa in a Swedish community-based sample". European Child & Adolescent Psychiatry 12 (1). doi:10.1007/s00787-003-1111-y. http://dx.doi.org/10.1007/s00787-003-1111-y. Retrieved 2009-09-23. 
42. ^ Wentz, Elisabet; J. Lacey, Glenn Waller, Maria Råstam, Jeremy Turk, Christopher Gillberg (2005-12-01). "Childhood onset neuropsychiatric disorders in adult eating disorder patients". European Child & Adolescent Psychiatry 14 (8): 431-437. doi:10.1007/s00787-005-0494-3. http://dx.doi.org/10.1007/s00787-005-0494-3. Retrieved 2009-09-23. 
43. ^ Wentz, Elisabet; I. Carina Gillberg, Henrik Anckarsater, Christopher Gillberg, Maria Rastam (2009-02-01). "Adolescent-onset anorexia nervosa: 18-year outcome". The British Journal of Psychiatry 194 (2): 168-174. doi:10.1192/bjp.bp.107.048686. http://bjp.rcpsych.org/cgi/content/abstract/194/2/168. Retrieved 2009-09-25. 
44. ^ Fisman, S; M Steele, J Short, T Byrne, C Lavallee (1996-07). "Case study: anorexia nervosa and autistic disorder in an adolescent girl". Journal of the American Academy of Child and Adolescent Psychiatry 35 (7): 937-940. ISSN 0890-8567. http://journals.lww.com/jaacap/Abstract/1996/07000/Case_Study__Anorexia_Nervosa_and_Autistic_Disorder.21.aspx. Retrieved 2009-09-26. 
45. ^ Kerbeshian, Jacob; Larry Burd (2008). "Is anorexia nervosa a neuropsychiatric developmental disorder? An illustrative case report". World Journal of Biological Psychiatry. doi:10.1080/15622970802043117. ISSN 1562-2975. http://www.informaworld.com/10.1080/15622970802043117. Retrieved 2009-09-27. 
46. ^ Gillberg, I. C; M. Raastam, E. Wentz, C. Gillberg (2007). "Cognitive and executive functions in anorexia nervosa ten years after onset of eating disorder". Journal of Clinical and Experimental Neuropsychology 29 (2): 170–178. http://www.informaworld.com/smpp/content~db=all?content=10.1080/13803390600584632. 
47. ^ Hambrook, D.; K. Tchanturia, U. Schmidt, T. Russell, J. Treasure (2008). "Empathy, systemizing, and autistic traits in anorexia nervosa: a pilot study". The British journal of clinical psychology/the British Psychological Society 47 (Pt 3): 335. doi:http://dx.doi.org/10.1348/014466507X272475. http://openurl.ingenta.com/content?genre=article&issn=0144-6657&volume=47&issue=3&spage=335&epage=339. 
48. ^ Lopez, C.; K. Tchanturia, D. Stahl, R. Booth, J. Holliday, J. Treasure (2008). "An examination of the concept of central coherence in women with anorexia nervosa". International Journal of Eating Disorders 41 (2): 143–152. doi:10.1002/eat.20478. http://www3.interscience.wiley.com/journal/116330978/abstract?CRETRY=1&SRETRY=0. 
49. ^ Russell, Tamara Anne; Ulrike Schmidt, Liz Doherty, Vicky Young, Kate Tchanturia (2009). "Aspects of social cognition in anorexia nervosa: Affective and cognitive theory of mind". Psychiatry Research 168 (3): 181-185. doi:10.1016/j.psychres.2008.10.028. ISSN 01651781. http://www.psy-journal.com/article/S0165-1781(08)00398-3/abstract. Retrieved 2009-09-26. 
50. ^ Zastrow, Arne; Kaiser, Christoph Stippich, Stephan Walther, Wolfgang Herzog, Kate Tchanturia, Aysenil Belger, Matthias Weisbrod, Janet Treasure, Hans-Christoph Friederich (2009-05-01). "Neural Correlates of Impaired Cognitive-Behavioral Flexibility in Anorexia Nervosa". Am J Psychiatry 166 (5): 608-616. doi:10.1176/appi.ajp.2008.08050775. http://ajp.psychiatryonline.org/cgi/content/abstract/166/5/608. Retrieved 2009-09-28. 
51. ^ Harrison, Amy; Sarah Sullivan, Kate Tchanturia, Janet Treasure (2009). "Emotion recognition and regulation in anorexia nervosa". Clinical Psychology & Psychotherapy 16 (4): 348-356. doi:10.1002/cpp.628. http://dx.doi.org/10.1002/cpp.628. Retrieved 2009-09-27. 
52. ^ Campbell, Katy (2007-08-17). "Is anorexia the female Asperger’s?". The Times (London). ISSN 0951-9467. http://www.timesonline.co.uk/tol/life_and_style/health/features/article2272080.ece. Retrieved 2009-09-28. 
53. ^ Szalavitz, Maia (2009-06-19). "A Genetic Link Between Anorexia and Autism?". Time. ISSN 0040-718X. http://www.time.com/time/health/article/0,8599,1904999,00.html. Retrieved 2009-09-23. 
54. ^ "Girls' autism 'under-diagnosed'". BBC. 2005-06-28. http://news.bbc.co.uk/2/hi/health/4630705.stm. Retrieved 2009-09-25. 
55. ^ Whitney, Jenna; Abigail Easter, Kate Tchanturia (2008). "Service users' feedback on cognitive training in the treatment of anorexia nervosa: A qualitative study". International Journal of Eating Disorders 41 (6): 542-550. doi:10.1002/eat.20536. http://dx.doi.org/10.1002/eat.20536. Retrieved 2009-09-29. 
56. ^ Herzog, David B; Greenwood, Dara N; Dorer, David J; Flores, Andrea T; Ekeblad, Elizabeth R; Richards, Ana; Blais, Mark A; Keller, Martin B (2000), "Mortality in eating disorders: A descriptive study", International Journal of Eating Disorders 28 (1): 20–26, doi:10.1002/(SICI)1098-108X(200007)28:1<20::AID-EAT3>3.0.CO;2-X 
57. ^ Pompili, M; Mancinelli, I; Girardi, P; Ruberto, A; Tatarelli, R (2004), "Suicide in anorexia nervosa: A meta-analysis", International Journal of Eating Disorders (John Wiley) 36 (1): 99–103, doi:10.1002/eat.20011 
58. ^ Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. (2005) Anorexia nervosa: definition, epidemiology, and cycle of risk. Int J Eat Disord, 37 Suppl, S2-9. PMID 15852310.
59. ^ Hoek HW. (2006) Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry., 19 (4), 389-94. PMID 16721169.
60. ^ "Professor, 49, died from anorexia". BBC. 2008-04-22. http://news.bbc.co.uk/2/hi/uk_news/england/dorset/7360470.stm. Retrieved 2008-04-23. 
61. ^ AJ Giannini, N Telew. Anorexia nervosa in geriatric patienys. Geriatric Medicine Today. 6:75-78, 1987.
62. ^ AJ Giannini. Drug abuse and depression:possible models for geriatric anorexia. Neurobiology of Aging. 9:26-27, 1988.
63. ^ AJ Giannini, AE Slaby. The Eating Disorders. NY, Springer-Verlag,1993. ISBN 3-540-94002-2
64. ^ Lock J, Le Grange D. (2005) Family-based treatment of eating disorders. Int J Eat Disord, 37 Suppl, S64-7. PMID 15852323.
65. ^ Le Grange D. (2005) The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry, 4 (3), 142-6. PMID 16633532.
66. ^ Claudino AM, Hay P, Lima MS, Bacaltchuk J, Schmidt U, Treasure J. (2006) Antidepressants for anorexia nervosa. Cochrane Database Syst Rev, 1, CD004365. PMID 16437485.
67. ^ Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, Pike KM, Devlin MJ, Woodside B, Roberto CA, Rockert W. (2006) Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA, 295(22), 2605-12. PMID 16772623.
68. ^ Birmingham CL, Gritzner S (2006) How does zinc supplementation benefit anorexia nervosa? Eating and Weight Disorders, 11 (4), e109-111. PMID 17272939
69. ^ Christopher Dare; Ivan Eisler, "Family Therapy and Eating Disorders", Eating Disorders and Obesity (Ed. Christopher Fairburn & Kelly Brownell): pp 314-319 
70. ^ Le Grange. The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry. 2005 October; 4(3): 142–146
71. ^ Keel, Pamela K. and Haedt, Alissa. Journal of Clinical Child & Adolescent Psychology, Volume 37, Issue 1 January 2008 , pages 39 - 61
72. ^ Le Grange, Daniel and Eisler, Ivan. Family Interventions in Adolescent Anorexia Nervosa. "Child Adolesc Psychiatric Clin N Am". 18 (2008): 159-173

External links

Informational resources

• F.E.A.S.T.'s Eating Disorders Glossary, a comprehensive eating disorders dictionary with authoritative explanations for more than 400 terms and concepts used in the diagnosis, treatment and medical management of anorexia and all other eating disorders.
• Understanding eating distress from UK mental health charity Mind
• MayoClinic eating disorders information
• BBC Mental Health on eating disorders
• Anorexia nervosa NHS Direct
• Anorexia Nervosa: Signs, Symptoms, Causes, Effects, and Treatments Useful information about anorexia
• Anorexia nervosa: self sabotage in adolescence Adolescent division, Ste-Justine Hospital, ACSA-CAAH

Media stories and reports

• Anorexia goes high-tech - Time magazine on pro-ana websites.
• Fighting Anorexia: No One to Blame - Newsweek on the increasing prevalence of anorexia in young people.
• More 4 News report on how eating disorders are increasingly affecting men as well as women.
• "This is the story of Karen Carpenter's Anorexia from her success in the Carpenters to her eventual death in 1983.
• Resources on Anorexia Nervosa and other Eating Disorders including an hour long program on the subject.

This entry is from Wikipedia, the leading user-contributed encyclopedia. It may not have been reviewed by professional editors (see full disclaimer)