Anorexia nervosa history and symptoms
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Joseph Nasr, M.D.[2]
Overview and Diagnostic Framework
Anorexia nervosa is diagnosed clinically using standardized criteria defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11).[1][2]
Although laboratory testing and imaging may help assess medical complications or exclude alternative diagnoses, the diagnosis is based primarily on clinical history, reported beliefs and behaviors, and physical examination findings. Diagnosis is typically made by a psychiatrist, psychologist, or other appropriately trained clinician.[1][3]
Diagnostic criteria are intended to guide clinicians and may not fully capture the subjective experience of individuals living with anorexia nervosa.
Core Diagnostic Features (DSM-5-TR)
To meet diagnostic criteria for anorexia nervosa, individuals must demonstrate all of the following:[1]
- Restriction of energy intake relative to requirements, leading to significantly low body weight for age, sex, developmental trajectory, and physical health
- Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain
- Disturbance in self-perceived weight or shape, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
Amenorrhea is no longer required for diagnosis in DSM-5-TR, reflecting broader applicability across sexes and age groups.[1]
Subtypes of Anorexia Nervosa
Two clinical subtypes are recognized:[1]
- Restricting type
- Weight loss achieved primarily through dieting, fasting, and/or excessive exercise
- No recurrent binge-eating or purging behaviors during the current episode
- Binge-eating/purging type
- Recurrent episodes of binge eating and/or purging behaviors, including:
- Self-induced vomiting
- Misuse of laxatives, diuretics, or enemas
- Recurrent episodes of binge eating and/or purging behaviors, including:
ICD-Based Clinical Features
ICD diagnostic descriptions additionally emphasize:[2]
- Methods used to induce or maintain weight loss, including food avoidance, excessive exercise, vomiting, or misuse of appetite suppressants
- Physiologic consequences of starvation, including hypothalamic-pituitary-gonadal axis suppression
- Delayed or arrested pubertal development when onset occurs before puberty
Clinical Presentation
Psychological and Cognitive Symptoms
Common psychological features include:[4][5]
- Distorted body image
- Poor insight into illness severity
- Overvaluation of weight and shape in self-assessment
- Preoccupation with food, calories, weight, or eating rituals
- Perfectionism and cognitive rigidity
- Obsessive or compulsive traits
- Belief that control over food equates to control over life
Emotional and Psychiatric Symptoms
Frequently observed emotional features include:[4]
- Low self-esteem and diminished self-efficacy
- Persistent low mood or major depressive disorder
- Intense fear of weight gain
- Emotional lability or mood swings
- High rates of anxiety disorders, including obsessive-compulsive disorder
Behavioral Symptoms
Characteristic behaviors include:[1][6]
- Severe dietary restriction or fasting
- Avoidance of eating in social settings
- Rigid food rules and rituals
- Excessive or compulsive exercise, often despite injury or illness
- Concealment of weight loss or eating behaviors
Interpersonal and Social Features
Social and relational changes are common:[7]
- Withdrawal from peers and social activities
- Deterioration of family relationships
- Social isolation related to eating avoidance
- Denial of basic needs, including food and rest
Physical and Somatic Symptoms
Physical manifestations result from prolonged undernutrition and include:[6][8]
- Significant weight loss or failure to gain expected weight
- Bradycardia, hypotension, and hypothermia
- Amenorrhea or oligomenorrhea in females
- Decreased libido or sexual dysfunction in males
- Fatigue, dizziness, and cold intolerance
- Lanugo hair and hair thinning
- Gastrointestinal symptoms such as constipation and delayed gastric emptying
Summary
Anorexia nervosa is characterized by restrictive eating, intense fear of weight gain, and disturbed body image, with wide-ranging psychological, behavioral, and physical manifestations. Symptoms often evolve insidiously and may be denied or minimized, contributing to delayed diagnosis and increased medical risk.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association Publishing; 2022.
- ↑ 2.0 2.1 World Health Organization. ICD-11: International Classification of Diseases, 11th Revision. Accessed May 22, 2024. https://icd.who.int/en
- ↑ American Psychiatric Association. Practice Guideline for the Treatment of Patients With Eating Disorders. 4th ed. American Psychiatric Association Publishing; 2023.
- ↑ 4.0 4.1 Udo T, Grilo CM. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int J Eat Disord. 2019;52(1):42-50. doi:10. 1002/eat.23004
- ↑ Wagner AF, Vitousek KM. Personality variables and eating pathology. Psychiatr Clin North Am. 2019;42(1):105-119. doi:10.1016/j.psc.2018.10.012
- ↑ 6.0 6.1 Nitsch A, Dlugosz H, Gibson D, Mehler PS. Medical complications of bulimia nervosa. Cleve Clin J Med. 2021;88(6):333-343. doi:10.3949/ccjm.88a. 20168
- ↑ Mills R, Hyam L, Schmidt U. A narrative review of early intervention for eating disorders: barriers and facilitators. Adolesc Health Med Ther. 2023;14: 217-235. doi:10.2147/AHMT.S415698
- ↑ SøebyM, Gribsholt SB, Clausen L, Richelsen B. Fracture risk in patients with anorexia nervosa over a 40-year period. J Bone Miner Res. 2023;38(11): 1586-1593. doi:10.1002/jbmr.4901