Anorexia nervosa

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"Anorexic" redirects here. For the use of the term as an appetite suppressant, see Anorectic.
Anorexia nervosa
Gull - Anorexia Miss A.jpg
"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
Classification and external resources
ICD-10 F50.0-F50.1
ICD-9 307.1
OMIM 606788
DiseasesDB 749
MedlinePlus 000362
eMedicine emerg/34 med/144
Patient UK Anorexia nervosa
MeSH D000856

Anorexia nervosa is an eating disorder characterized by food restriction, odd eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain. It is accompanied by a distorted body self-perception, and typically involves excessive weight loss.

Due to their fear of gaining weight, individuals with this disorder restrict the amount of food they consume. Outside of medical literature, the terms anorexia nervosa and anorexia are often used interchangeably; however, anorexia is simply a medical term for lack of appetite and the majority of individuals afflicted with anorexia nervosa do not lose their appetites.[1]

Anorexia nervosa is often coupled with a distorted self image[2] which may be maintained by various cognitive biases[3] that alter how individuals evaluate and think about their body, food, and eating.[4] People with anorexia nervosa often view themselves as overweight or not thin enough even when they are underweight.[5] While the majority of people with anorexia nervosa continue to feel hunger, they deny themselves all but very small quantities of food.[4][page needed]

Anorexia nervosa is diagnosed approximately nine times more often in females than in males.[6] In 2013 it resulted in about 600 deaths globally up from 400 deaths in 1990.[7] It is a serious health condition with a high incidence of comorbidity and similarly high mortality rate to serious psychiatric disorders.[5]

Signs and symptoms[edit]

Anorexia nervosa is an eating disorder that is characterized by attempts to lose weight, to the point of self-starvation. A person with anorexia nervosa may exhibit a number of signs and symptoms, the type and severity of which may vary in each case and may be present but not readily apparent.[8]

Anorexia nervosa, and the associated malnutrition that results from self-imposed starvation, can cause severe complications in every major organ system in the body.[medical citation needed] Hypokalaemia, a drop in the level of potassium in the blood, is a sign of anorexia nervosa.[medical citation needed] A significant drop in potassium can cause abnormal heart rhythms, constipation, fatigue, muscle damage and paralysis.[medical citation needed]

Symptoms of AN may include:

  • Refusal to maintain a normal body mass index for one's age
  • Amenorrhea, a symptom that occurs after prolonged weight loss; causes menses to stop, hair becomes brittle, and skin becomes yellow and unhealthy
  • Fearful of even the slightest weight gain and takes all precautionary measures to avoid weight gain and becoming overweight
  • Obvious, rapid, dramatic weight loss to at least 15% under normal body weight[9]
  • Lanugo: soft, fine hair growing on the face and body[10]
  • Obsession with calories and fat content of food
  • Preoccupation with food, recipes, or cooking; may cook elaborate dinners for others, but not eat the food themselves
  • Food restriction despite being underweight
  • Food rituals, such as cutting food into tiny pieces, refusing to eat around others, hiding or discarding food
  • Purging: May use 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 ingested calories
  • Excessive exercise[11]
  • Perception of self as overweight despite being told by others they are too thin
  • Intolerance to cold and frequent complaints of being cold; body temperature may lower (hypothermia) in an effort to conserve energy[12]
  • Hypotension and/or orthostatic hypotension
  • Bradycardia or tachycardia
  • Depression
  • Solitude: may avoid friends and family; becomes withdrawn and secretive
  • Abdominal distension
  • Halitosis (from vomiting or starvation-induced ketosis)
  • Dry hair and skin, as well as hair thinning
  • Fatigue
  • Rapid mood swings

Comorbidity[edit]

Between 50% and 75% of individuals with an eating disorder experience depression. In addition, one in every four individuals who are diagnosed with anorexia nervosa also exhibit obsessive-compulsive disorder.[13]

Other psychological issues 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. The causality between personality disorders and eating disorders has yet to be fully established.[medical citation needed] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder and some develop them afterwards.[medical citation needed] The presence of Axis I and/or Axis II psychiatric comorbidity has been shown to affect the severity and type of anorexia nervosa symptoms in both adolescents and adults.[medical citation needed] Obsessive-compulsive personality disorder is linked with more severe symptomatology and worse prognosis.[14] Comorbid conditions include depression,[15] obsessive compulsive personality disorder,[16] substance abuse,[medical citation needed] alcoholism,[medical citation needed] borderline personality disorder,[medical citation needed] anxiety disorders,[17] obsessive compulsive disorder,[medical citation needed] attention deficit hyperactivity disorder,[18] and body dysmorphic disorder (BDD).[medical citation needed]

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).[19]

Diagnosis[edit]

A diagnostic assessment may be conducted by a suitably trained general practitioner, or by a psychiatrist or psychologist, who records the person's current circumstances, biographical history, current symptoms, and family history. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, focussing on views on weight and patterns of eating. 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.

DSM-5 and ICD-10 criteria[edit]

Anorexia nervosa is classified as an Axis I disorder in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM 5), published by the American Psychiatric Association. The DSM 5 has replaced the previously used volume DSM-IV-TR, and there have been several changes made to the criteria in the new DSM 5 for anorexia nervosa, most notably that of the amenorrhea criterion being removed. However, significant changes in wording have also been made to each remaining criterion.

  • Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health).
  • Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low in weight).
  • Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.[20]

Subtypes[edit]

  • Restricting type: Individual does not utilize binge eating nor displays purging behavior as their main strategy for weight loss. Instead, the individual uses restricting food intake, fasting, diet pills, and/or exercise as a means for losing weight.[21]
  • Binge-eating/purging type: Individual utilizes binge eating or displays purging behavior as a means for losing weight.[21]

Levels of severity[edit]

Body mass index (BMI) is used by the DSM-V as an indicator of the level of severity of anorexia nervosa. The DSM-V states these as follows:

  • Mild: BMI of 17-17.99
  • Moderate: BMI of 16-16.99
  • Severe: BMI of 15-15.99
  • Extreme: BMI of less than 15

F 50.0[edit]

A disorder characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected, as may children approaching puberty and older women up to the menopause. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves. There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function. The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics.[22]

Investigations[edit]

Medical tests to check for signs of physical deterioration in anorexia nervosa may be performed by a general physician or psychiatrist, including:

Differential diagnoses[edit]

A variety of medical and psychological conditions have been misdiagnosed as anorexia nervosa; in some cases the correct diagnosis was not made for more than ten years.

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. A main factor differentiating binge-purge anorexia from bulimia is the gap in physical weight. Someone with bulimia nervosa is ordinarily at a healthy weight, or slightly overweight. Someone with binge-purge anorexia is commonly underweight.[42] It is not unusual for a person with an eating disorder to "move through" various diagnoses as their behavior and beliefs change over time.[19]

Causes[edit]

There is evidence for biological, psychological, developmental, and sociocultural risk factors, but the exact cause of eating disorders is unknown.[43]

Biological[edit]

Dysregulation of the serotonin pathways has been implicated in the etiology, pathogenesis and pathophysiology of anorexia nervosa.[43]
  • Serotonin dysregulation; brain imaging studies implicate alterations of 5-HT1A and 5-HT2A receptors and the 5-HT transporter.[43] Alterations of these circuits may affect mood and impulse control as well as the motivating and hedonic aspects of feeding behavior.[44] 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.[44]
  • Genetics: anorexia nervosa is highly heritable.[43] Twin studies have shown a heritability rate of 56%.[45][46] 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.[47]
  • Addiction to the chemicals released in the brain during starving and physical activity;[48][49] people affected with anorexia often report getting some sort of high from not eating. The effect of food restriction and intense activity causes symptoms similar to anorexia in female rats,[48] though it is not explained why this addiction affects only females.
  • Obstetric complications: prenatal and perinatal complications may factor into the development of anorexia nervosa, 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.[medical citation needed]
  • Orexin; orexin is a neurotransmitter that regulates appetite and is responsible for increasing the craving for food.[50]
  • Infections: Some people are hypothesized to have developed anorexia abruptly as a reaction to a streptococcus or mycoplasma infection. Pediatric acute-onset neuropsychiatric syndrome (PANS) is a hypothesis describing children who have abrupt, dramatic onset of obsessive-compulsive disorder (OCD) or anorexia nervosa coincident with the presence of two or more neuropsychiatric symptoms.[51]
  • 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.[52]

Studies have hypothesized the continuance of disordered eating patterns may be epiphenomena of starvation. The results of the Minnesota Starvation Experiment showed normal controls exhibit many of the behavioral patterns of anorexia nervosa (AN) when subjected to starvation. This may be due to the numerous changes in the neuroendocrine system, which results in a self-perpetuating cycle.[53][54][55]

Males with a female twin have a higher chance of getting anorexia; anorexia may be linked to intrauterine exposure to female hormones.[56]

Another hypothesis is that anorexia nervosa is more likely to occur in populations in which obesity is more prevalent, and results from a sexually selected evolutionary drive to appear youthful in populations in which size becomes the primary indicator of age.[57]

Anorexia nervosa is more likely to occur in a person's pubertal years. Some explanatory hypotheses for the rising prevalence of eating disorders in adolescence are "increase of adipose tissue in girls, hormonal changes of puberty, societal expectations of increased independence and autonomy that are particularly difficult for anorexic adolescents to meet; [and] increased influence of the peer group and its values." [58]

Psychological[edit]

Early theories of the cause of anorexia linked it to childhood sexual abuse or dysfunctional families;[59][60] evidence is conflicting, and well-designed research is needed.[43]

Sociological[edit]

Anorexia nervosa has been increasingly diagnosed since 1950;[61] the increase has been linked to vulnerability and internalization of body ideals.[58] People in professions where there is a particular social pressure to be thin (such as models and dancers) were more likely to develop anorexia,[medical citation needed] and those with anorexia have much higher contact with cultural sources that promote weight loss.[medical citation needed] This trend can also be observed for people who partake in certain sports, such as jockeys and wrestlers.[62] There is a higher incidence and prevalence of anorexia nervosa in sports with an emphasis on aesthetics, where low body fat is advantageous, and sports in which one has to make weight for competition.[63]

Media effects

Constant exposure to media that presents body ideals may constitute a risk factor for body dissatisfaction and anorexia nervosa. The cultural ideal for body shape for men versus women continues to favor slender women and athletic, V-shaped muscular men. A 2002 review found that the magazines most popular among people aged 18 to 24 years, those read by men, unlike those read by women, were more likely to feature ads and articles on shape than on diet.[unreliable medical source?][64] Body dissatisfaction and internalization of body ideals are risk factors for anorexia nervosa that threaten the health of both male and female populations.[medical citation needed]

Websites that stress the importance of attainment of body ideals extol and promote anorexia nervosa through the use of religious metaphors, lifestyle descriptions, "thinspiration" or "fitspiration" (inspirational photo galleries and quotes that aim to serve as motivators for attainment of body ideals).[65] Pro-anorexia websites reinforce internalization of body ideals and the importance of their attainment.[65]

Treatment[edit]

There is no conclusive evidence that any particular treatment for anorexia nervosa works better than others; however, there is enough evidence to suggest that early intervention and treatment are more effective.[66] Treatment for anorexia nervosa tries to address three main areas.

  • Restoring the person to a healthy weight;
  • Treating the psychological disorders related to the illness;
  • Reducing or eliminating behaviours or thoughts that originally led to the disordered eating.[67]

Although restoring the person's weight is the primary task at hand, optimal treatment also includes and monitors behavioral change in the individual as well.[medical citation needed] Not all anorexia nervosa patients recover completely: about 20% develop anorexia nervosa as a chronic disorder.[68] If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can arise and eventually lead to death.[69]

Dietary[edit]

P. Sodersten and colleagues suggest that effective treatment of this disorder depends on re-establishing reinforcement for normal eating behaviours instead of unhealthy weight loss.[1] Diet is the most essential factor to work on in patients with anorexia nervosa, and must be tailored to each patient's needs. Food variety is important when establishing meal plans as well as foods that are higher in energy density.[70] Patients must consume adequate calories, starting slowly, and increasing at a measured pace.[11]

Medication[edit]

Pharmaceuticals have limited benefit for anorexia itself.[71] Many people with anorexics have generalized anxiety disorder, major depressive disorder, and obsessive compulsive disorder which may be treated with psychotherapy and or medications.[72]

Therapy[edit]

Family-based treatment (FBT) has been shown to be more successful than individual therapy.[73] Various forms of family-based treatment 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, and separated family therapy (SFT) in which the parents and child attend therapy separately with different therapists.[73] Proponents of Family therapy for adolescents with AN assert that it is important to include parents in the adolescent's treatment.[73]

A four- to five-year follow up study of the Maudsley family therapy, an evidence-based manualized model, showed full recovery at rates up to 90%.[74] Although this model is recommended by the NIMH,[75] critics claim that it has the potential to create power struggles in an intimate relationship and may disrupt equal partnerships.[76]

Cognitive behavioral therapy (CBT) is useful in adolescents and adults with anorexia nervosa.[medical citation needed] Acceptance and commitment therapy is a type of CBT, which has shown promise in the treatment of AN.[medical citation needed]

Cognitive remediation therapy (CRT) is used in treating anorexia nervosa.[medical citation needed]

Prognosis[edit]

AN has the highest mortality rate of any psychological disorder.[73] Due to the direct health effects of the eating disorder on the body, 5–20% of people diagnosed with anorexia nervosa die from it.[77]

Some remedies are proven to not have any value in resolving anorexia. "Incarceration in hospital" prohibits patients from many basic rights, such as using the bathroom independently. Therefore, it has been seen as catalytic in increasing weight and pushing patients away from the path to recovery.[78]

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.[medical citation needed] Recovery can be lifelong for some; energy intake and eating habits may never return to normal.[70][page needed]

Alexithymia has an impact on treatment outcome.[71] Recovery is also viewed on a spectrum rather than black and white. According to the Morgan-Russell criteria patients can have a good, intermediate, or poor outcome. Even when a patient is classified as having a "good" outcome, weight only has to be within 15% of average and normal menstruation must be present in females. The good outcome also excludes psychological health. Recovery for patients with anorexia nervosa is undeniably positive, but recovery does not mean normal.[medical citation needed]

Complications[edit]

Anorexia nervosa can have serious implications if its duration and severity are significant and if onset occurs before the completion of growth, pubertal maturation, or the attainment of peak bone mass.[medical citation needed] Complications specific to adolescents and children with anorexia nervosa can include the following:

  • Growth retardation – height gain may slow and can stop completely with severe weight loss or chronic malnutrition. In such cases, provided that growth potential is preserved, height increase can resume and reach full potential after normal intake is resumed.[medical citation needed] Height potential is normally preserved if the duration and severity of illness are not significant and/or if the illness is accompanied with delayed bone age (especially prior to a bone age of approximately 15 years), as hypogonadism may negate the deleterious effects of undernutrition on stature by allowing for a longer duration of growth compared to controls.[medical citation needed] In such cases, appropriate early treatment can preserve height potential and may even help to increase it in some post-anorexic subjects due to the aforementioned reasons in addition to factors such as long-term reduced estrogen-producing adipose tissue levels compared to premorbid levels.[medical citation needed]
  • Pubertal delay or arrest – both height gain and pubertal development are dependent on the release of growth hormone and gonadotrophins (LH and FSH) from the pituitary gland. Suppression of gonadotrophins in patients with anorexia nervosa has frequently been documented.[medical citation needed] In some cases, especially where onset is pre-pubertal, physical consequences such as stunted growth and pubertal delay are usually fully reversible.[79]
  • Reduction of Peak Bone Mass – bone accretion is the highest during adolescence, and if onset of anorexia nervosa occurs during this time and stalls puberty, bone mass may remain low.[medical citation needed]
  • Hepatic steatosis – fatty infiltration of the liver is an indicator of malnutrition in children.[medical citation needed]
  • Heart disease and arrythmias
  • Neurological disorders- seizures, tremors
  • Acute gastric dilation, infarction and perforation,[80]

Relapse[edit]

Relapse is greatest in the first year after normal body weight is obtained. This includes right after release from inpatient institutions. Relapse includes a return to food restriction as well as a shift to binge eating habits.[medical citation needed] Prevention of relapse can be helped by cognitive-behavioral therapy and pharmacological therapies.[medical citation needed]

Epidemiology[edit]

Though anorexia is common among many groups in the United States, the disorder is more limited to the Western world.[medical citation needed]

Anorexia has an average prevalence of 0.9% in women and 0.3% in men for the diagnosis in developed countries.[81] The condition largely affects young adolescent women, with those between 15 and 19 years old making up 40% of all cases.[medical citation needed] Anorexia nervosa is more prevalent in the upper social classes and it is thought to be rare in less-developed countries.[medical citation needed] Anorexia is more prevalent in females and males born after 1945.[medical citation needed] The lifetime incidence of atypical anorexia nervosa, a form of ED-NOS in which not all of the diagnostic criteria for AN are met, is much higher, at 5–12%.[82]

The question of whether the incidence of AN is on the rise has been under debate. Most studies show that since at least 1970 the incidence of AN in adult women is fairly constant, while there is some indication that the incidence may have been increasing for girls aged between 14 and 20.[83] It is difficult to compare incidence rates at different times and possibly different locations due to changes in methods of diagnosing, reporting and changes in the population numbers, as evidenced on data from after 1970.[84][85]

Extensive research on ethnic minorities and anorexia can be attributed to the assumption that anorexia is only a disorder for the white and wealthy. [86]

Underrepresentation[edit]

Eating disorders are less reported in preindustrial, non-westernized countries than in Western countries. In Africa, not including South Africa, the only data presenting information about eating disorders occurs in case reports and isolated studies, not studies investigating prevalence. Data shows in research that in westernized civilizations, ethnic minorities have very similar rates of eating disorders, contrary to the belief that eating disorders predominantly occur in Caucasian people.[medical citation needed]

Due to different standards of beauty for men and women, men are often not diagnosed as anorexic. Many men do not conform to the ideals of women to be thin and men that do try to alter their bodies often try to be lean and muscular. In addition they may not meet the DSM IV criteria for BMI since they have muscle weight, but have very little fat.[87] Men and women athletes often are often overlooked as anorexic.[87] Research emphasizes the importance for strict watch over athletes diet, weight, and symptoms, which adhere to all of the defining characteristics of anorexia on the DSM, rather than just looking at weight and BMI. For athletes, ritualized activities such as weigh-ins place emphasis on weight, promoting the development of eating disorders among athletes.[citation needed] While women use diet pills, which is an indicator of unhealthy behavior and an eating disorder, men use steroids, which contextualizes the beauty ideals for genders. This also shows men having a preoccupation with their body, which is an indicator of an eating disorder.[43] In a Canadian study, 4% of boys in grade nine used anabolic steroids.[43] Anorexic men are sometimes referred to as manorexic.[citation needed]

History[edit]

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 term anorexia nervosa was coined in 1873 by Sir William Gull, one of Queen Victoria's personal physicians.[88] The term is of Greek origin: an- (ἀν-, prefix denoting negation) and orexis (ὄρεξις, "appetite"), thus meaning a lack of desire to eat.[89]

The history of anorexia nervosa begins with descriptions of religious fasting dating from the Hellenistic era[90] and continuing into the medieval period. The medieval practice of self-starvation by women, including some young women, in the name of religious piety and purity also concerns anorexia nervosa; it is sometimes referred to as anorexia mirabilis.[91][page needed]

The earliest medical descriptions of anorexic illnesses are generally credited to English physician Richard Morton in 1689.[90] Case descriptions fitting anorexic illnesses continued throughout the 17th, 18th and 19th centuries.[92]

In the late 19th century anorexia nervosa became widely accepted by the medical profession as a recognized condition. In 1873, Sir William Gull, one of Queen Victoria's personal physicians, published a seminal paper which coined the term anorexia nervosa and provided a number of detailed case descriptions and treatments.[92] 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.[citation needed]

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 The Golden Cage: the Enigma of Anorexia Nervosa in 1978. Despite major advances in neuroscience,[93] Bruch's theories tend to dominate popular thinking. A further important event was the death of the popular singer and drummer Karen Carpenter in 1983, which prompted widespread ongoing media coverage of eating disorders.[citation needed]

See also[edit]

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