anorexia nervosa: Definition from Answers.com

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.

Criteria
SOURCE: Diagnostic and Statistical Manual of Mental Disorders IV.
1. Refusal to maintain body weight at or above a minimally normal weight for age and height. Body weight is less than 85 percent of what is expected.
2. Intense fear of gaining weight or becoming fat, even though patient is underweight.
3. Undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current underweight condition.
4. Absence of at least three consecutive menstrual cycles in previously menstruating females.
Restricting type: No regular episodes of binge-eating or purging (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
Binge-eating/purging type: Regular episodes of binge-eating or purging (self-induced vomiting or misuse of laxatives, diuretics, or enemas).

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

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

"Anorexic" redirects here. For the use of the term as an appetite suppressant, see Anorectic.

Anorexia nervosa
Classification and external resources
"Miss A—” pictured in 1866 and in 1870 after treatment. She was one of the earliest Anorexia nervosa case studies. From the published medical papers of Sir William Gull.
ICD-10	F 50.0-F 50.1
ICD-9	307.1
OMIM	606788
DiseasesDB	749
eMedicine	emerg/34 med/144
MeSH	D000856

Anorexia nervosa is an eating disorder characterized by an obsessive fear of gaining weight. The terms anorexia nervosa and anorexia are often used interchangeably, however anorexia is simply a medical term for lack of appetite. Anorexia nervosa has many complicated implications and may be thought of as a lifelong illness that may never be truly cured, but only managed over time.

Anorexia nervosa is often coupled with a distorted self image^[1]^[2] which may be maintained by various cognitive biases^[3] that alter how the affected individual evaluates and thinks about her or his body, food and eating. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known.^[4] It is a serious mental illness with a high incidence of comorbidity and the highest mortality rate of any psychiatric disorder.^[5]

Anorexia most often has its onset in adolescence and is most prevalent among adolescent girls. ^[6] However, more recent studies show that the onset age of anorexia decreased from an average of 13 to 17 years of age to 9 to 12. ^[7] While it can affect men and women of any age, race, and socioeconomic and cultural background,^[8] Anorexia nervosa occurs in females 10 times more than in males.^[9] While anorexia nervosa is quite commonly (in lay circles) believed to be a woman 's illness, it should not be forgotten than ten per cent of people with anorexia nervosa are male.

The term anorexia nervosa was established in 1873 by Sir William Gull, one of Queen Victoria's personal physicians.^[10] The term is of Greek origin: an- (ἀν-, prefix denoting negation) and orexis (ὄρεξις, "appetite"), thus meaning a lack of desire to eat.^[11] However, while the term "anorexia nervosa" literally means "neurotic loss of appetite" the literal meaning of the term is somewhat misleading. Many anorexics do enjoy eating and have certainly not lost their appetite as the term "loss of appetite" is normally understood; it is better to regard anorexia nervosa as a self-punitive addiction to fasting, rather than a literal loss of appetite.

Signs and symptoms

A person with anorexia nervosa may exhibit a number of signs and symptoms, some of which are listed below. The type and severity vary in each case and may be present but not readily apparent. Anorexia nervosa and the associated malnutrition that results from self-imposed starvation, can cause severe complications in every major organ system in the body.^[12]^[13]^[14]

Refusal to maintain a normal BMI for their age^[15]
amenorrhea: The absence of 3 consecutive menstural cycles ^[15]
Fearful of even the slightest weight gain and takes all precautionary measures to avoid weight gain and becoming overweight ^[15]
obvious, rapid, dramatic weight loss
lanugo: soft, fine hair grows on face and body^[16]
obsession with calories and fat content
preoccupation with food, recipes, or cooking; may cook elaborate dinners for others but not eat themselves^[17]
dieting despite being thin or dangerously underweight
rituals: cuts food into tiny pieces; refuses to eat around others; hides or discards food
purging: uses laxatives, diet pills, ipecac syrup, or water pills; may engage in self-induced vomiting; may run to the bathroom after eating in order to vomit and quickly get rid of the calories^[18]^[19] (see also bulimia nervosa).
may engage in frequent, strenuous exercise^[20]
perception: perceives self to be overweight despite being told by others they are too thin
becomes intolerant to cold: frequently complains of being cold from loss of insulating body fat or poor circulation resulting from extremely low blood pressure; body temperature lowers (hypothermia) in effort to conserve energy^[21]
depression: may frequently be in a sad, lethargic state^[22]
solitude: may avoid friends and family; becomes withdrawn and secretive
cheeks may become swollen because of enlargement of the salivary glands caused by excessive vomiting^[23]
swollen joints^{[citation needed]}
abdominal distension^{[citation needed]}
bad breath^{[citation needed]}
hair loss or thinning^{[citation needed]}

Dermatologic signs of anorexia nervosa^[24]
xerosis	telogen effluvium	carotenoderma	acne	hyperpigmentation
seborrheic dermatitis	acrocyanosis	perniosis	petechiae	livedo reticularis
interdigital intertrigo	paronychia	generalized pruritus	acquired striae distensae	angular stomatitis
prurigo pigmentosa	edema	linear erythema craquele	acrodermatitis enteropathica	pellagra
Possible medical complications of anorexia nervosa
constipation^[25]	diarrhea^[26]	electrolyte imbalance^[27]	cavities^[28]	tooth loss^[29]
cardiac arrest^[30]	amenorrhoea^[31]	edema^[32]	osteoporosis^[33]	osteopenia^[34]
hyponatremia^[35]	hypokalemia^[36]	optic neuropathy^[37]	brain atrophy^[38]^[39]	leukopenia^[40]^[41]

Causes

Studies have hypothesized that the continuance of disordered eating patterns may be epiphenomena of starvation. The results of the Minnesota Starvation Experiment showed that normal controls exhibit many of the behavioral patterns of anorexia nervosa when subjected to starvation. This may be due to the numerous changes in the neuroendocrine system, which results in a self perpetuating cycle.^[42]^[43]^[44]^[45] Studies have suggested that the initial weight loss such as dieting may be the triggering factor in developing AN in some cases, possibly because of an already inherent predisposition toward AN. One study reports cases of AN resulting from unintended weight loss that resulted from varied causes such as a parasitic infection, medication side effects, and surgery. The weight loss itself was the triggering factor.^[46]^[47]

Biological

Obstetric complications: various prenatal and perinatal complications may factor into the development of AN such as maternal anemia, diabetes mellitus, preeclampsia, placental infarction, and neonatal cardiac abnormalities. Neonatal complications may also have an influence on harm avoidance, one of the personality traits associated with the development of AN.^[48]^[49]
Genetics: anorexia nervosa is believed to be highly heritable, with estimated inheritance rates ranging from 56% to 84%.^[50]^[51]^[52] Association studies have been performed, studying 128 different polymorphisms related to 43 genes including genes involved in regulation of eating behavior, motivation and reward mechanics, personality traits and emotion. Consistent associations have been identified for polymorphisms associated with agouti-related peptide, brain derived neurotrophic factor, catechol-o-methyl transferase, SK3 and opioid receptor delta-1.^[53] In one study, variations in the norepinephrine transporter gene promoter were associated with restrictive anorexia nervosa, but not binge-purge anorexia.^[54] Recent studies have advanced the theory that the sex difference in incidence and the common onset at the age of puberty may reflect an abnormal response of the brain to anorexic (feeding suppressing) effects of the female sex hormone, estrogen.^[55] This viewpoint has been recently supported by a report that abnormal forms of the estrogen receptor are more common in women with anorexia nervosa of the restricting type.^[56]
- epigenetics: Epigenetic mechanisms: are means by which genetic mutations are caused by environmental effects that alter gene expression via methods such as DNA methylation, these are independent of and do not alter the underlying DNA sequence. They are heritable, as was shown in the Överkalix study, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission and Atrial natriuretic peptide homeostasis resulting from epigenetic mechanisms has been implicated in various eating disorders.^[57] "We conclude that epigenetic mechanisms may contribute to the known alterations of ANP homeostasis in women with eating disorders."^[57]^[58]

Dysregulation of the dopamine and serotonin pathways has been implicated in the etiology, pathogenesis and pathophysiology of anorexia nervosa.^[59]^[60]^[61]^[62]

serotonin dysregulation;^[63] particularly high levels in those areas in the brain with the 5HT_1A receptor – a system particularly linked to anxiety, mood and impulse control. Starvation has been hypothesized to be a response to these effects, as it is known to lower tryptophan and steroid hormone metabolism, which might reduce serotonin levels at these critical sites and ward off anxiety. Other studies of the 5HT_2A serotonin receptor (linked to regulation of feeding, mood, and anxiety), suggest that serotonin activity is decreased at these sites. There is evidence that both personality characteristics associated with AN, and disturbances to the serotonin system are still apparent after patients have recovered from anorexia.^[64]
Brain-derived neurotrophic factor (BDNF) is a protein that regulates neuronal development and neuroplasticity, it also plays a role in learning, memory and in the hypothalamic pathway that controls eating behavior and energy homeostasis. BDNF amplifies neurotransmitter responses and promotes synaptic communication in the enteric nervous system. Low levels of BDNF are found in patients with AN and some comorbid disorders such as major depression.^[65]^[66] Exercise increases levels of BDNF^[67]
leptin and ghrelin; leptin is a hormone produced primarily by the fat cells in white adipose tissue of the body it has an inhibitory (anorexigenic) effect on appetite, by inducing a feeling of satiety. Ghrelin is an appetite inducing (orexigenic) hormone produced in the stomach and the upper portion of the small intestine. Circulating levels of both hormones are an important factor in weight control. While often associated with obesity both have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.^[68]
cerebral blood flow (CBF); neuroimaging studies have shown reduced CBF in the temporal lobes of anorectic patients, which may be a predisposing factor in the onset of AN.^[69]
autoimmune system; Autoantibodies against neuropeptides such as melanocortin have been shown to affect personality traits associated with eating disorders such as those that influence appetite and stress responses.^[70]

Nutritional deficiencies
- Zinc deficiency may play a role in anorexia. It is not thought responsible for causation of the initial illness but there is evidence that it may be an accelerating factor that deepens the pathology of the anorexia. A 1994 randomized, double-blind, placebo-controlled trial showed that zinc (14 mg per day) doubled the rate of body mass increase compared to patients receiving the placebo.^[71]

Environmental

Sociocultural studies have highlighted the role of cultural factors, such as the promotion of thinness as the ideal female form in Western industrialized nations, particularly through the media.^[72] 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.^[73] People 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,^[74] and further research has suggested that those with anorexia have much higher contact with cultural sources that promote weight-loss.^[75]

Anorexia nervosa is more likely to occur in a person’s pubertal years, especially for girls.^[76] Female students are 10 times more likely to suffer from anorexia nervosa than male students. According to a survey of 1799 Japanese female high school students, “85% who were a normal weight wanted to be thinner and 45% who were 10–20% underweight wanted to be thinner.”^[77] Teenage girls concerned about their weight and who believe that slimness is more attractive among peers trend to weight-control behaviors. Teen girls are learning from each other to consume low-caloric, low-fat foods and diet pills. This results in lack of nutrition and a greater chance of developing anorexia nervosa.^[78]

It has also been noted that anorexia nervosa is more likely to occur in populations in which obesity is more prevalent. It has been suggested that anorexia nervosa results from a sexually selected evolutionary drive to appear youthful in populations in which size becomes the primary indicator of age.^[79]

There is also evidence to suggest that patients who have anorexia nervosa can be characterised by alexithymia^[80] and also a deficit in certain emotional functions. A research study showed that this was the case in both adult and adolescent anorexia nervosa patients.^[81]

There is a high rate of reported child sexual abuse experiences in clinical groups of who have been diagnosed with anorexia. The connection between eating disorders and abuse has been convincingly evidenced by a number of studies, including one published in Epidemiology (and strengthened by blind hypothesis survey), which showed in a comparison of women with no history of eating disorders, women with a history of eating disorders were twice as likely to have reported childhood sexual abuse.^[82] While the joint effect of both physical and sexual abuse resulted in a nearly 4-fold risk of eating disorders that met DSM-IV criteria.^[82] It is thought that links between childhood abuse and sexual abuse are complex, such as by influencing psychologic processes that increase a woman's susceptibility to the development of an eating disorder, or perhaps by producing changes in psychobiologic process and neurotransmitting function, associated with eating behaviour.^[82]

Recent efforts have been made to dispel some of the myths around anorexia nervosa and eating disorders, such as the misconception that families, in particular mothers, are responsible for their daughter developing an eating disorder.^[83]

Relationship to autism

A summary of the strategy Zucker et al. (2007) used to assess the relationship between anorexia nervosa and the autism spectrum.^[84]

Since Gillberg's (1983 & 1985)^[85]^[86] and others' initial suggestion of relationship between anorexia nervosa and autism,^[87]^[88] a large-scale longitudinal study into teenage-onset anorexia nervosa conducted in Sweden confirmed that 23% of people with a long-standing eating disorder are on the autism spectrum.^[89]^[90]^[91]^[92]^[93]^[94]^[95] Those on autism spectrum tend to have a worse outcome,^[96] but may benefit from the combined use of behavioural and pharmacological therapies tailored to ameliorate autism rather than anorexia nervosa per se.^[97]^[98] 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., poor executive function, autism quotient score, central coherence, theory of mind, cognitive-behavioural flexibility, emotion regulation and understanding facial expressions.^[99]^[100]^[101]^[102]^[103]^[104]

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).^[84] 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.^[105]

Diagnosis

Medical

The initial diagnosis should be made by a competent medical professional. There are multiple medical conditions, such as viral or bacterial infections, hormonal imbalances, neurodegenerative diseases and brain tumors which may mimic psychiatric disorders including anorexia nervosa. According to an in depth study conducted by psychiatrist Richard Hall as published in the Archives of General Psychiatry:

Medical illness often presents with psychiatric symptoms.
It is difficult to distinguish physical disorders from functional psychiatric disorders on the basis of psychiatric symptoms alone.
Detailed physical examination and laboratory screening are indicated as a routine procedure in the initial evaluation of psychiatric patients.
Most patients are unaware of the medical illness that is causative of their psychiatric symptoms.
The conditions of patients with medically induced symptoms are often initially misdiagnosed as a functional psychosis.^[106]^[107]

Complete Blood Count (CBC): a test of the white blood cells. red blood cells and platelets used to assess the presence of various disorders such as leukocytosis, leukopenia, thrombocytosis and anemia which may result from malnutrition.^[108]
urinalysis: a variety of tests performed on the urine used in the diagnosis of medical disorders, to test for substance abuse, and as an indicator of overall health^[109]
ELISA: Various subtypes of ELISA used to test for antibodies to various viruses and bacteria such as Borrelia burgdoferi (Lyme Disease)^[110]
Western Blot Analysis: Used to confirm the preliminary results of the ELISA^[111]
Chem-20: Chem-20 also known as SMA-20 a group of twenty separate chemical tests performed on blood serum. Tests include cholesterol, protein and electrolytes such as potassium, chlorine and sodium and tests specific to liver and kidney function.^[112]
glucose tolerance test: Oral glucose tolerance test (OGTT) used to assess the body's ability to metabolize glucose. Can be useful in detecting various disorders such as diabetes, an insulinoma, Cushing's Syndrome, hypoglycemia and polycystic ovary syndrome^[113]^[114]
Secritin-CCK Test: Used to assess function of pancreas and gall bladder^[115]^[116]
Serum cholinesterase test: a test of liver enzymes (acetylcholinesterase and pseudocholinesterase) useful as a test of liver function and to assess the effects of malnutrition^[117]
Liver Function Test: A series of tests used to assess liver function some of the tests are also used in the assessment of malnutrition, protein deficiency, kidney function, bleeding disorders, Crohn's Disease^[118]
Lh response to GnRH: Luteinizing hormone (Lh) response to gonadotropin-releasing hormone (GnRH): Tests the pituitary glands' response to GnRh a hormone produced in the hypothalumus. Central hypogonadism is often seen in anorexia nervosa cases.^[119]
Creatine Kinase Test (CK-Test): measures the circulating blood levels of creatine kinase an enzyme found in the heart (CK-MB), brain (CK-BB) and skeletal muscle (CK-MM).^[120]^[121]
Blood urea nitrogen (BUN) test: urea nitrogen is the byproduct of protein metabolism first formed in the liver then removed from the body by the kidneys. The BUN test is used primarily to test kidney function. A low BUN level may indicate the effects of malnutrition.^[122]
BUN-to-creatinine ratio: A BUN to creatinine ratio is used to predict various conditions. High BUN/creatinine ratio can occur in severe hydration, acute kidney failure, congestive heart failure, intestinal bleeding. A low BUN/creatinine can indicate a low protein diet, celiac disease rhabdomyolysis, cirrhosis of the liver.^[123]^[124]^[125]
echocardiogram: utilizes ultrasound to create a moving picture of the heart to assess function^[126]
electrocardiogram (EKG or ECG): measures electrical activity of heart can be used to detect various disorders such as hyperkalemia^[127]
electroencephalogram (EEG): measures the electrical activity of the brain. Can be used to detect abnormalities such as those associated with pituitary tumors^[128]^[129]
Upper GI Series: test used to assess gastrointestinal problems of the middle and upper intestinal tract^[130]
Thyroid Screen TSH, t4, t3 :test used to assess thyroid functioning by checking levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3)^[131]
Parathyroid hormone (PTH) test: tests the functioning of the parathyroid by measuring the amount of (PTH) in the blood. Test is used to diagnose parahypothyroidism. PTH also controls the levels of calcium and phosphorus in the blood (homeostasis).^[132]
barium enema: an x-ray examination of the lower gastrointestinal tract^[133]
neuroimaging; via the use of various techniques such as PET scan, fMRI, MRI and SPECT imaging should be included in the diagnostic procedure for any eating disorder to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder.^{[citation needed]}

Psychological

Anorexia nervosa is classified as an Axis I^[134] disorder in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV), published by the American Psychiatric Association. The DSM-IV should not be used by laypersons to diagnose themselves.

DSM-IV-TR: diagnostic criteria for AN includes intense fear of gaining weight, a refusal to maintain body weight above 85% of the expected weight for a given age and height, and three consecutive missed periods and either refusal to admit the seriousness of the weight loss, or undue influence of shape or weight on one's self image, or a disturbed experience in one's shape or weight. There are two types: the binge-eating/purging type is characterized by overeating or purging, and the restricting type is not.^[135]
- Criticism of DSM-IV There has been criticisms over various aspects of the diagnostic criteria utilized for anorexia nervosa in the DSM-IV. Including the requirement of maintaining a body weight below 85% of the expected weight and the requirement of amenorrhea for diagnosis; some women have all the symptoms of AN and continue to menstruate.^[136] Those who do not meet these criteria are usually classified as eating disorder not otherwise specified this may affect treatment options and insurance reimbursments.^[137] The validity of the AN subtype classification has also been questioned because of the considerable diagnostic overlap between the binge eating/ purging type and the restricting type and the propensity of the patient to switch between the two.^[138]^[139]

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

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).
If onset is before puberty, that development is delayed or arrested.
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".

Differential diagnoses

Main article: Anorexia nervosa (differential diagnoses)

There are various medical and psychological conditions that have been misdiagnosed as anorexia nervosa, in some cases the correct diagnosis was not made for more than ten years. In a reported case of achalasia misdiagnosed as AN, the patient spent two months confined to a psychiatric hospital.^[140]

There are various other psychological issues that may factor into anorexia nervosa, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters", A, B and C.The causality between personality disorders and eating disorders has yet to be fully established.^[141] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder.^[142]^[143]^[144] Some develop them afterwards.^[145] The severity and type of eating disorder symptoms have been shown to affect comorbidity.^[146]

Comorbid Disorders
Axis I	Axis II
depression^[147]	obsessive compulsive personality disorder^[148]
substance abuse, alcoholism^[149]	borderline personality disorder^[150]
anxiety disorders^[151]	narcissistic personality disorder^[152]
obsessive compulsive disorder^[153]^[154]	histrionic personality disorder^[155]
Attention-Deficit-Hyperactivity-Disorder^[156]^[157]^[158]^[159]	avoidant personality disorder^[160]

Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterized by excessive rumination over an actual or perceived physical flaw. BDD has been diagnosed equally among men and women. While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 25% to 39% of AN cases.^[161]

BDD is a chronic and debilitating condition which may lead to social isolation, major depression, suicidal ideation and attempts. Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex, lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing. There is a reported case of the development of BDD in a 21 year old male following an inflammatory brain process. Neuroimaging showed the presence of new atrophy in the frontotemporal region.^[162]^[163]^[164]^[164]^[165]

The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make as there is considerable overlap between patients diagnosed with these conditions. Seemingly minor changes in a patient's overall behavior or attitude 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.^[84]

Treatment

Treatment for anorexia nervosa tries to address three main areas. 1) Restoring the person to a healthy weight; 2) Treating the psychological disorders related to the illness; 3) Reducing or eliminating behaviours or thoughts that originally led to the disordered eating.^[166] If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can initiate and eventually lead to death.

Dietary

Zinc supplementation has been shown in various studies to be beneficial in the treatment of AN even in patients not suffering from zinc deficiency, by helping to increase weight gain.^[167]^[168]^[169]
Essential fatty acids:The omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have been shown to benefit various neuropsychiatric disorders. There was reported rapid improvement in a case of severe AN treated with ethyl-eicosapentaenoic acid (E-EPA) and micronutrients.^[170] DHA and EPA supplementation has been shown to be a benefit in many of the comorbid disorders of AN including: attention deficit/hyperactivity disorder (ADHD), autism, major depressive disorder (MDD),^[171] bipolar disorder, and borderline personality disorder. Accelerated cognitive decline and mild cognitive impairment (MCI) correlate with lowered tissue levels of DHA/EPA, and supplementation has improved cognitive function.^[172]^[173]
Nutrition counseling^[174]^[175]
Medical Nutrition Therapy;(MNT) also referred to as Nutrition Therapy is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person's medical history, psychosocial history, physical examination, and dietary history.^[176]^[177]^[178]

Medication

Olanzapine: has been shown to be effective in treating certain aspects of AN including to help raise the body mass index and reduce obsessionality, including obsessional thoughts about food.^[179]^[180]

Therapy

Cognitive behavioral therapy (CBT) CBT is an evidence based approach which in studies to date has shown to be useful in adolescents and adults with anorexia nervosa.^[181]^[182]^[183]
Acceptance and commitment therapy: A type of CBT, has shown promise in the treatment of AN" participants experienced clinically significant improvement on at least some measures; no participants worsened or lost weight even at 1-year follow-up."^[184]
Cognitive Remediation Therapy (CRT): is a cognitive rehabilitation therapy developed at King's College in London designed to improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved social functioning. Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility. In studies conducted at Kings College^[185] and in Poland with adolescents CRT was proven to be beneficial in treating anorexia nervosa,^[185] in the United States clinical trials are still being conducted by the National Institute of Mental Health^[186] on adolescents age 10–17 and Stanford University in subjects over 16 as a conjunctive therapy with Cognitive behavioral therapy.^[187]

Family therapy: The most effective form of therapy for adolescents with anorexia is family therapy.^[188] There are various forms of family therapy that have been proven to work in the treatment of adolescent AN including "conjoint family therapy" (CFT), in which the parents and child are seen together by the same therapist, "separated family therapy" (SFT) in which parents and child attend therapy separately with different therapists. "Eisler's cohort show that, irrespective of the type of FBT, 75% of patients have a good outcome, 15% an intermediate outcome... ".^[189]^[190]
Maudsley Family Therapy: A 4 to 5 year follow up study of the Maudsley approach, a manualized model, that shows full recovery at rates up to 90%.^[191]

Alternative medicine

Yoga: In preliminary studies indivualized yoga treatment has shown positive results for use as an adjunctive therapy to standard care. The treatment was shown to reduce eating disorder symptoms, including food preoccupation, which decreased immediately after each session. Scores on the Eating Disorder Examination decreased consistently over the course of treatment.^[192]

Prognosis

The long term prognosis of anorexia is more on the favorable side. The National Comorbidity Replication Survey was conducted among more than 9,282 participants throughout the United States, the results found that the average duration of anorexia nervosa is 1.7 years. "Contrary to what people may believe, anorexia is not necessarily a chronic illness; in many cases, it runs its course and people get better..."^[193]

In cases of adolescent anorexia nervosa that utilize Family treatment 75% of patients have a good outcome and an additional 15% show an intermediate yet more positive outcome.^[189] In a five year post treatment follow-up of Maudsley Family Therapy the full recovery rate was between 75% and 90%.^[194] Even in severe cases of AN, despite a noted 30% relapse rate after hospitalization, and a lengthy time to recovery ranging from 57 to 79 months, the full recovery rate was still 76%. There were minimal cases of relapse even at the long term follow-up conducted between 10–15 years.^[195] The long-term prognosis of anorexia nervosa is changeable: a fifth of patients stay severely ill, another fifth of patients recover fully and three fifths of patients have a fluctuating and chronic course (Gelder, Mayou and Geddes 2005).

Epidemiology

Anorexia has an average prevalence of 0.3–1% in women and 0.1% in men for the diagnosis in developed countries.^[196] The condition largely affects young adolescent women, with between 15 and 19 years old making up 40% of all cases. Approximately 75% of people with anorexia are female.^[197] Anorexia nervosa is more prevalent in the upper social classes and it is declared to be rare in less developed countries (Gelder, Mayou and Geddes 2005).

History

Main article: History of anorexia nervosa

Two images of an anorexic female patient published in 1900 in "Nouvelle Iconographie de la Salpêtrière". The case was entitiled "Un cas de anorexia hysterique" (A case of hysteria anorexia).

The history of anorexia nervosa begins with descriptions of religious fasting dating from the Hellenistic era ^[198] and continuing into the medieval period. A number of well known historical figures, including Catherine of Siena and Mary, Queen of Scots are believed to have suffered from the condition.^[199]^[200]

Of interest in terms of anorexia nervosa is the medieval practice of self-starvation by women, including some young women, in the name of religious piety and purity. This is sometimes referred to as anorexia mirabilis. By the thirteenth century, it was increasingly common for women to participate in religious life . Many women who ultimately became saints engaged in self-starvation, including Saint Hedwig of Andechs in the thirteenth century and Catherine of Siena in the fourteenth century. By the time of Catherine of Siena, however, the Church became concerned about extreme fasting as an indicator of spirituality and as a criterion for sainthood. Indeed, Catherine of Siena was told by Church authorities to pray that she would be able to eat again, but was unable to give up fasting.^[199]

The earliest medical descriptions of anorexic illnesses are generally credited to English physician Richard Morton, in 1689.^[198]

However it was not until the late 19th century that anorexia nervosa was to be widely accepted by the medical profession as a recognised condition. In 1873, Sir William Gull, one of Queen Victoria’s personal physicians, published a seminal paper which established the term anorexia nervosa and provided a number of detailed case descriptions and treatments. In the same year, French physician Ernest-Charles Lasègue similarly published details of a number of cases in a paper entitled De l’Anorexie Histerique.

Awareness of the condition was largely limited to the medical profession until the latter part of the 20th century, when German-American psychoanalyst Hilde Bruch published her popular work The Golden Cage: the Enigma of Anorexia Nervosa in 1978. This book created a wider awareness of anorexia nervosa among lay readers. A further important event was the death of the popular singer Karen Carpenter in 1983, which prompted widespread ongoing media coverage of eating disorders.

Research

Marinol (dronabinol): a synthetic form of delta-9-THC a psychoactive compound extracted from the resin of the cannabis sativa plant is currently the subject of a clinical trial for use in the treatment of AN, the study is slated to end in 2011.^[201]
Ghrelin treatment: pilot studies have been concluded in the use of ghrelin infusion for the inhospital treatment of patients with AN. The results showed positive effect in the reduction of the associated gastrointestinal symptoms, an increase in appetite and energy intake without adverse effects.^[202]

Notable cases

Main article: List of people with anorexia nervosa

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