Anorexia Nervosa

Characteristic Symptoms of Anorexia Nervosa

File photo | Credit: South CoastOpens in new window Anorexia Nervosa is characterized by Persistent refusal to maintain body weight; Fears of gaining weight or becoming fat, or behavior that interferes with weight gain; and A disturbance in self-perceived weight or shape.

Its main characteristic features are a refusal to maintain body weight at or above a minimally normal weight for age and height, intense fear of gaining weight or becoming fat, disturbance in the way in which the patient’s body weight or shape is experienced, and in females, amenorrheaOpens in new window or absence of at least three consecutive menstrual cycles.

The disorder often begins after pubertyOpens in new window and is much more common in females than in males, by a proportion of nine females to one male, the disorder is often accompanied by surreptitious attempts to lose weight (by vomiting, purging, abusing laxatives or diet pills, etc.). The patient is obsessed with food, and often has a distorted sense of body image. Even if she is emaciated, she may see herself as being overweight. Specific parts of the body, such as the thighs and abdomen, are perceived as being fat and unsightly. It is an extremely serious condition and can be life threatening, because malnutrition impacts many of the body’s major organ systems often resulting in several physical complications.

The disorder is far more prevalent in industrialized countries, such as the US and the countries of western Europe, than in third world countries of Asia and Africa. This difference has been attributed to the cultural factors which promote a thin female figure as the ideal in the western world.

A person with Anorexia Nervosa maintains a weight that is significantly below normal for the person’s age, sex, developmental stage, and physical health.

The individual has either lost a significant amount of weight or failed to make expected weight gains (in the case of a child or adolescent), either through dieting, fasting, and excessive exercise (noted with the subtype Restricting Type) or, if also engaging in eating binges, through self-induced vomiting or misuse of laxatives, diuretics, or enemas (noted with the subtype Binge-Eating/Purging Type). The fear of gaining weight or becoming fat often persists, or even increases, as weight is lost.

Some individuals with Anorexia Nervosa deny a fear of becoming fat but do things to interfere with maintaining their weight, such as engaging in self-starvation.

Some people with Anorexia Nervosa feel fat all over, whereas others focus on specific parts of their bodies—commonly their abdomens, buttocks, or thighs—which they insist are “fat,” and they are constantly weighing and measuring themselves and checking their appearance in a mirror. Weight loss is perceived as a sign of self-control; weight gain is a failure. Those who acknowledge that they are thin often deny the medical seriousness of their condition.

Subtypes

There are two subtypes of anorexia nervosa: restricting type and binge eating/purging type. An individual with the restricting type will not engage in binge eating or purging behaviors such as self-induced vomiting (APA, 2013). Instead, these individuals will decrease their food intake dramatically and continuously, leading to a striking weight loss. Individuals with the binge/purging type of anorexia regularly engage in binge eating and/or purging behavior (APA, 2013).

DSM-5 Criteria

Because Anorexia Nervosa develops most often during adolescence. It is sometimes difficult to differentiate between normal growth and developmental changes and the development of the eating disorder.

Weight loss is often noted at the time of pubertal menarche, and growing concerns about appearance and body image are common. Therefore, specific diagnostic criteria have been developed by the APA and recently reviewed in the DSM-5 (APA, 2013).

The intense fear of being fat and a distorted body image are specific traits of the disorder. In fact, individuals with anorexia nervosa are often thin to the point of emaciation, but they do not recognize this. Therefore, they become or remain obsessed with food and weight. They count calories, engage in vigorous exercise, and tend to isolate themselves in order to continue these self-reinforcing behavior.

Associated Psychological and Physical Conditions

Several psychological and physical comorbidities are observed in individuals with anorexia (APA, 2013). The most frequently psychological factors are depression, anxiety, obsessive-compulsive disorders, personality disorders, and mood disorders (APA, 2013).

A diagnosis of obsessive-Compulsive disorderOpens in new window is made if the obsessions and compulsions are not related to food, body shape, or weight. Cultural values of “thinness,” and occupations and avocations that encourage thinness, such as modeling and some athletics, may contribute to the risk for Anorexia Nervosa.

There is an increased risk of the disorder in the first-degree relatives to patients with anorexia nervosa and also of mood disorders such as depression. The malnourishment and food restriction observed in anorexia are believed to lead to many physical problems, including the following (APA, 2013):

Most physical problems abate when the individual resumes healthy eating habits, but osteoporosis is irreversible. Finally, deaths from anorexia are most often caused by cardiac arrest secondary to severe food restriction or suicide (APA, 2013; Arcedus et al., 2011). Recent evidence indicates that the mortality rate for people with anorexia is 5.86 times higher for people with the disorder (Arcedus et al., 2011).

Discussion of “Sixty-Seven Pound Weakling”

As is usually the case with Anorexia Nervosa (DSM-5, p. 338), the characteristic signs and symptoms leave little doubt as to the correct diagnosis. Peggy has all of the salient features, including refusal to maintain body weight at or above a minimally normal weight for age and height; intense fear of gaining weight or of becoming fat, even though underweight; and disturbance in the way in which her body weight or shape is experienced (anxiety when viewing her body).

She also has the common but not universal sign (in postmenarchal females) of amenorrhea. Amenorrhea in Anorexia Nervosa is believed to be caused by underactivity of hypothalamic and pituitary gland hormones due to stress or nutritional factors, which in turn lead to underactivity of ovariaon hormones responsible for the menstrual cycle.

Because Peggy’s method of losing weight has never involved purging (self-induced vomiting or use of laxatives or diuretics) and she has never engaged in binge eating (consumption of large amounts of food with a sense of loss of control), the subtype is the Restricting Type.

Peggy exhibited compulsive ritualistic behavior surrounding food (e.g., cutting her food into very small pieces and moving it around on her plate before eating it), a feature commonly seen in patients with Anorexia Nervosa. Although her compulsive eating behavior might suggest the possible additional diagnosis of Obsessive-Compulsive Disorder, a separate diagnosis is not given because her compulsive behavior only involves food and is thus explained by the diagnosis of Anorexia Nervosa.

Anorexia Nervosa is a serious and often life-threatening disorder. This case illustrates that with expert treatment, a good outcome is possible.