Eating Disorder - Anorexia Nervosa
Anorexia nervosa is a psychiatric diagnosis that describes an eating disorder characterized by low body weight and body image distortion with an obsessive fear of gaining weight. Individuals with anorexia often control body weight by voluntary starvation, purging, vomiting, excessive exercise, or other weight control measures, such as diet pills or diuretic drugs. It primarily affects adolescent females, however approximately 10% of people with the diagnosis are male. Anorexia nervosa is a complex condition, involving psychological, neurobiological, and sociological components.
Anorexia Nervosa - Terminology
The term anorexia is of Greek origin: an (privation or lack of) and orexis (appetite) thus meaning a lack of desire to eat. A person who is diagnosed with anorexia nervosa is most commonly referred to with the adjectival form anorexic. The noun form, as in 'he is an anorectic', is used less commonly. The term "anorectic" can also refer to any drug that suppresses appetite.
"Anorexia nervosa" is frequently shortened to "anorexia" in both the popular media and scientific literature. This is technically incorrect, as strictly speaking "anorexia" refers to the medical symptom of reduced appetite.
Anorexia Nervosa - 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 obese.
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.
Anorexia Nervosa - Physical
Anorexia nervosa can put a serious strain on many of the body's organs and physiological resources; Anorexia puts a particular strain on the structure and function of the heart and cardiovascular system, with slow heart rate (bradycardia) and elongation of the QT interval seen early on. People with anorexia typically have a disturbed electrolyte balance, particularly low levels of phosphate, which has been linked to heart failure, muscle weakness, immune dysfunction, and ultimately death. Those who develop anorexia before adulthood may suffer stunted growth and subsequent low levels of essential hormones (including sex hormones) and chronically increased cortisol levels. Osteoporosis can also develop as a result of anorexia in 38-50% of cases, as poor nutrition leads to the retarded growth of essential bone structure and low bone mineral density. Anorexia does not harm everyone in the same way. For example, evidence suggests that the results of the disease in adolescents may differ from those in adults.
Changes in brain structure and function are early signs of the condition. Enlargement of the ventricles of the brain is thought to be associated with starvation, and is partially reversed when normal weight is regained. Anorexia is also linked to reduced blood flow in the temporal lobes, although since this finding does not correlate with current weight, it is possible that it is a risk trait rather than an effect of starvation.
Other effects may include the following:
Extreme weight loss
Body mass index less than 17.5 in adults, or 85% of expected weight in children
Stunted growth
Endocrine disorder, leading to cessation of periods in girls (amenorrhoea)
Decreased libido; impotence in males
Starvation symptoms, such as reduced metabolism, slow heart rate (bradycardia), hypotension, hypothermia and anemia
Abnormalities of mineral and electrolyte levels in the body
Thinning of the hair
Growth of lanugo hair over the body
Constantly feeling "cold"
Zinc deficiency
Reduction in white blood cell count
Reduced immune system function
Pallid complexion and sunken eyes
Creaking joints and bones
Collection of fluid in ankles during the day and around eyes during the night
Tooth decay
Constipation
Dry skin
Dry or chapped lips
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
Brittle fingernails
Bruising easily
Anorexia Nervosa - Psychological
Distorted body image
Poor insight
Self-evaluation largely, or even exclusively, in terms of their shape and weight
Pre-occupation or obsessive thoughts about food and weight
Perfectionism
obsessive compulsive disorder (OCD)
Belief that control over food/body is synonymous with being in control of one's life
Anorexia Nervosa - Emotional
Low self-esteem and self-efficacy
Intense fear about becoming overweight
Clinical depression or chronically low mood
Mood swings
Anorexia Nervosa - Interpersonal and social
Withdrawal from previous friendships and other peer-relationships
Deterioration in relationships with the family
Denial of Basic needs, such as food
Anorexia Nervosa - Behavioral
Excessive exercise, food restriction
Secretive about eating or exercise behavior
Fainting
Self-harm, substance abuse or suicide attempts
Very sensitive to references about body weight
Aggressive when forced to eat "forbidden" foods
Anorexia Nervosa - 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.
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.
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.
Anorexia Nervosa - Prognosis
Anorexia is thought to have the highest mortality rate of any psychiatric disorder, with approximately 10% of those who are diagnosed with the disorder eventually dying due to related causes. 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. A recent review suggested that less than one-half recover fully, one-third improve, and 20% remain chronically ill.
Anorexia Nervosa - Incidence, Prevalence and Demographics
The majority of research into the incidence and prevalence of anorexia has been done in Western industrialized countries, so results are generally not applicable outside these areas. However, recent reviews of studies on the epidemiology of anorexia have suggested an incidence of between 8 and 13 cases per 100,000 persons per year and an average prevalence of 0.3% using strict criteria for diagnosis. These studies also confirm the view that the condition largely affects young adolescent females, with females between 15 and 19 years old making up 40% of all cases. Furthermore, the majority of cases are unlikely to be in contact with mental health services. As a whole, about 90% of people with anorexia are female.
Eating Disorder Treatment - Anorexia Nervosa
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