Anorexia nervosa
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Anorexia Nervosa | |
ICD-10 | F50.0-F50.1 |
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ICD-9 | 307.1 |
OMIM | 606788 |
DiseasesDB | 749 |
MedlinePlus | 000362 |
Anorexia nervosa Microchapters |
Diagnosis |
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Treatment |
Case Studies |
Anorexia nervosa On the Web |
American Roentgen Ray Society Images of Anorexia nervosa |
Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Mark Warren, MD, MPH; Fellow, Academy of Eating Disorders [2]
Diagnosis and clinical features
The most commonly used criteria for diagnosing anorexia are from the American Psychiatric Association's 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).
Although biological tests can aid the diagnosis of anorexia, the diagnosis is based on a combination of behavior, reported beliefs and experiences, and physical characteristics of the patient. Anorexia is typically diagnosed by a clinical psychologist, psychiatrist or other suitably qualified clinician.
Notably, diagnostic criteria are intended to assist clinicians, and are not intended to be representative of what an individual sufferer feels or experiences in living with the illness.
The full ICD-10 diagnostic criteria for anorexia nervosa can be found here, and the DSM-IV-TR criteria can be found here.
To be diagnosed as having anorexia nervosa, according to the DSM-IV-TR, a person must display:
- 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.
- 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, premenopausal females (women who have had their first menstrual period but have not yet gone through menopause), amenorrhea (the absence of at least three consecutive menstrual cycles).
- Or other eating related disorders.
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, over-exercise or the misuse of laxatives, diuretics, or enemas)
- 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, over-exercise or the misuse of laxatives, diuretics, or enemas).
The ICD-10 criteria are similar, but in addition, specifically mention
- 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);
- 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"; and
- if the onset is before puberty, 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.[1][2]
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
- OCD (obsessive compulsive disorder)
- belief that control over food is synonymous with being in control of one's life
Emotional
- Low self-esteem and self-efficacy
- Clinical depression or chronically low mood
- Intense fear about becoming overweight
- Moodiness or 'mood swings'
Interpersonal and social
- Withdrawal from previous friendships and other peer-relationships
- Deterioration in relationships with the family
- Denial of Basic needs, such as food
Physical
- Extreme weight loss
- Stunted growth
- Endocrine disorder, leading to cessation of periods in girls (amenorrhea)
- Decreased libido; impotence in males
- Starvation symptoms, such as reduced metabolism, slow heart rate (bradycardia), hypotension, hypothermia and anemia
- Growth of lanugo hair over the body
- Abnormalities of mineral and electrolyte levels in the body
- Zinc deficiency
- Often a reduction in white blood cell count
- Reduced immune system function
- Body mass index less than 17.5 in adults, or 85% of expected weight in children
- Possibly with pallid complexion and sunken eyes
- Creaking joints and bones
- Tooth decay
- Collection of fluid in ankles during the day and around eyes during the night
- Constipation
- Very dry/chapped lips due to malnutrition
- Poor circulation, resulting in common attacks of 'pins and needles' and purple extremities
- In cases of extreme weight loss, there can be nerve deterioration, leading to difficulty in moving the feet
- Headaches, due to malnutrition
- Thinning of the hair
- Nails become more brittle
- Constantly feeling "cold"
- Bruise easily
- Dry skin
Behavioral
- Excessive exercise, food restriction
- Fainting
- Secretive about eating or exercise behavior
- Possible self-harm, substance abuse or suicide attempts
- Very sensitive to references about body weight
- Become very aggressive when forced to eat "forbidden" foods
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 bingeing 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.[1]
Additionally, it is important to note that an individual may still suffer from a health- or life-threatening eating disorder (e.g., subclinical anorexia nervosa or EDNOS) even if one diagnostic sign or symptom is still present. For example, a substantial number of patients diagnosed with EDNOS meet all criteria for diagnosis of anorexia nervosa, but lack the three consecutive missed menstrual cycles needed for a diagnosis of anorexia.[2]
Feminist writers such as Susie Orbach and Naomi Wolf have criticised the medicalisation 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.
Prognosis
Anorexia is thought to have the highest mortality rate of any psychiatric disorder, with approximately 6% of those who are diagnosed with the disorder eventually dying due to related causes.[3] 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.[4] A recent review suggested that less than one-half recover fully, one-third improve, and 20% remain chronically ill.[5]
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.
A recent clinical review has suggested that psychotherapy is an effective form of treatment and can lead to restoration of weight, return of menses among female patients, and improved psychological and social functioning when compared to simple support or education programmes.[6] However, this review also noted that there are only a small number of randomised controlled trials on which to base this recommendation, and 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[7] and in particular, a method developed at the Maudsley Hospital is widely used and found to maintain improvement over time.[8]
It is important to note that many recovering underweight people often harbour a hateful dislike for those who they feel to be robbing them of their treasured emaciation. Often when well-meaning friends or relatives compliment the recoveree on how much healthier they look, the recoveree's mind replaces "healthy" with "fat".
Drug treatments, such as SSRI or other antidepressant medication, have not been found to be generally effective for either treating anorexia,[9] or preventing relapse[10] 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 14mg/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.[11]
There are various non-profit and community groups that offer support and advice to people who have anorexia, or are the carer of someone who does. Several are listed in the links below and may provide useful information for those wanting more information or help on treatment and medical care.
See also
- History of anorexia nervosa
- Adi Barkan (photographer who has campaigned against use of anorexic models)
- Anorexia (symptom)
- Body dysmorphic disorder
- Body image
- Bulimia nervosa
- Binge eating disorder
- Cachexia
- Calorie restriction
- Defensive vomiting
- Eating disorder
- Eating disorder not otherwise specified
- Female body shape
- Malnutrition
- Muscle dysmorphia ('reverse' anorexia nervosa)
- Orthorexia nervosa
- Pro-ana
- Purging disorder
- Refeeding syndrome
- Wannarexia — a term for people who want to be anorexic
References
- ↑ 1.0 1.1 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
- ↑ 2.0 2.1
- ↑ 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
- ↑ Pompili M, Mancinelli I, Girardi P, Ruberto A, Tatarelli R. (2004) Suicide in anorexia nervosa: a meta-analysis. Int J Eat Disord, 36 (1), 99-103. PMID 15185278
- ↑ Steinhausen HC. (2002) The outcome of anorexia nervosa in the 20th century. Am J Psychiatry, 159 (8), 1284-93. PMID 12153817.
- ↑ Hay P, Bacaltchuk J, Claudino A, Ben-Tovim D, Yong PY. (2003) Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database Syst Rev, 4, CD003909. PMID 14583998.
- ↑ Lock J, Le Grange D. (2005) Family-based treatment of eating disorders. Int J Eat Disord, 37 Suppl, S64-7. PMID 15852323.
- ↑ Le Grange D. (2005) The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry, 4 (3), 142-6. PMID 16633532.
- ↑ 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.
- ↑ 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.
- ↑ Birmingham CL, Gritzner S (2006) How does zinc supplementation benefit anorexia nervosa? Eating and Weight Disorders, 11 (4), e109-111. PMID 17272939
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