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| '''For patient information click [[Anorexia nervosa (patient information)|here]]''' | | '''For patient information click [[Anorexia nervosa (patient information)|here]]''' |
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| {{Infobox_Disease | | {{Anorexia nervosa}} |
| | Name = Anorexia Nervosa
| | '''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:charlesmichaelgibson@gmail.com]; {{AE}} {{KS}} |
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| | ==[[Anorexia nervosa overview|Overview]]== |
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| | DiseasesDB = 749
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| | ICD10 = {{ICD10|F|50|0|f|50}}-{{ICD10|F|50|1|f|50}}
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| | ICD9 = {{ICD9|307.1}}
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| | ICDO =
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| | OMIM = 606788
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| | MedlinePlus = 000362
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| | eMedicineSubj =
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| | eMedicineTopic =
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| {{SI}}
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| '''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Mark Warren, MD, MPH; Fellow, Academy of Eating Disorders [mailto:mwarren@eatingdisorderscleveland.org]
| | ==[[Anorexia nervosa historical perspective|Historical Perspective]]== |
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| ==Overview== | | ==[[Anorexia nervosa classification|Classification]]== |
| '''Anorexia nervosa''' is a [[psychiatry|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]], [[vomit]]ing, excessive [[exercise]], or other weight control measures, such as [[diet pill]]s or [[diuretic]] drugs. It primarily affects adolescent females all over the world, however approximately 10% of all afflicted are male. Anorexia nervosa is a complex condition, involving [[psychological]], [[neurobiology|neurobiological]], and [[sociological]] components.<ref name="LaskBryant-Waugh2000">Lask B, and Bryant-Waugh, R (eds) (2000) Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence. Hove: Psychology Press. ISBN 0-86377-804-6.</ref>
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| '''Anorexia Nervosa''' is a disease condition that can put a serious strain on many of the body's organs and [[physiological]] resources;<ref name="Katzman">Katzman DK. (2005) Medical complications in adolescents with anorexia nervosa: a review of the literature. ''International Journal of Eating Disorders'', 37 Suppl, S52-9. PMID 15852321.</ref><ref>[http://www.lilith-ezine.com/articles/2005/anorexia_vs_obesity.html Anorexia Vs Obesity in North America], retrieved May 25th 2007.</ref> <ref>Birmingham CL, Su J, Hlynsky JA, Goldner EM, Gao M. (2005) The mortality rate from anorexia nervosa. ''International Journal of Eating Disorders'', 38 (2), 143-6. PMID 16134111.</ref> 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 system|immune]] dysfunction, and ultimately death. Those who develop anorexia before adulthood may suffer stunted growth and subsequent low levels of essential [[hormone]]s (including sex hormones) and chronically increased [[cortisol]] levels. [[Osteoporosis]] can also develop as a result of anorexia in 38-50% of cases,<ref>Legroux-Gerot I, Vignau J, Collier F, Cortet B. (2005) Bone loss associated with anorexia nervosa. ''Joint Bone Spine'', 72 (6), 489-95. PMID 16242373.</ref> 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.<ref name="Katzman"/>
| | ==[[Anorexia nervosa pathophysiology|Pathophysiology]]== |
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| Changes in brain structure and function are early signs of the condition. Enlargement of the [[ventricular system|ventricles]] of the brain is thought to be associated with [[starvation]], and is partially reversed when normal weight is regained.<ref>Palazidou E, Robinson P, Lishman WA. (1990) Neuroradiological and neuropsychological assessment in anorexia nervosa. ''Psychol Med'', 20 (3), 521-7. PMID 2236361.</ref> Anorexia is also linked to reduced blood flow in the [[temporal lobe]]s, 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.<ref>Lask B, Gordon I, Christie D, Frampton I, Chowdhury U, Watkins B. (2005) Functional neuroimaging in early-onset anorexia nervosa. ''Int J Eat Disord'', 37 Suppl, S49-51. PMID 15852320.</ref>
| | ==[[Anorexia nervosa causes|Causes]]== |
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| ==Terminology== | | ==[[Anorexia nervosa differential diagnosis|Differentiating Anorexia Nervosa from other Diseases]]== |
| The term anorexia is of Greek origin: ''an'' (privation or lack of) and ''orexis'' (appetite) thus meaning a lack of desire to eat.<ref> Costin, Carolyn.~ (1999) The Eating Disorder Sourcebook. Linconwood: Lowell House. 6.</ref> 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.
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| "Anorexia nervosa" is frequently shortened to "[[anorexia (symptom)|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 epidemiology and demographics|Epidemiology and Demographics]]== |
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| In popular culture, and especially with anorectics themselves, the term is often shortened to "ana" to avoid sounding clinical and impersonal. "[[Pro-ana]]" groups often use the terms "ana" and "mia" (referring to [[bulimia nervosa]]) to describe their conditions, as it has less negative connotations than the full medical term. Some pro-ana groups discourage or deride the use of colloquial abbreviations.
| | ==[[Anorexia nervosa risk factors|Risk Factors]]== |
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| ==Incidence, prevalence and demographics== | | ==[[Anorexia nervosa screening|Screening]]== |
| 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<ref>Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. (2005) Anorexia nervosa: definition, epidemiology, and cycle of risk. ''Int J Eat Disord'', 37 Suppl, S2-9. PMID 15852310.</ref><ref>Hoek HW. (2006) Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. ''Curr Opin Psychiatry.'', 19 (4), 389-94. PMID 16721169.</ref> 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.<ref name="LaskBryant-Waugh2000" />
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| ==Causes and contributory factors== | | ==[[Anorexia nervosa natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| It is clear that there is no single cause for anorexia and that it stems from a mixture of social, psychological and biological factors. Current research is commonly focused on explaining existing factors and uncovering new causes. However, there is considerable debate over how much each of the known causes contributes to the development of anorexia. In particular, the contribution of perceived media pressure on women to be thin has been especially contentious.<ref>Tiggemann M and Pickering AS. (1996) Role of television in adolescent women's body dissatisfaction and drive for thinness ''Int J Eat Disord'', Sep;20(2):199-203.</ref>
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| ===Physiological factors===
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| ====Genetic factors====
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| Family and [[twin study|twin studies]] have suggested that genetic factors contribute to about 50% of the [[variance]] for the development of an eating disorder<ref>Klump KL, Kaye WH, Strober M (2001) The evolving genetic foundations of eating disorders. ''Psychiatr Clin North Am'', 24 (2), 215-25. PMID 11416922.</ref> and that anorexia shares a genetic risk with [[clinical depression]].<ref>Wade TD, Bulik CM, Neale M, Kendler KS. (2000) Anorexia nervosa and major depression: shared genetic and environmental risk factors. ''Am J Psychiatry'', 157 (3), 469-71. PMID 10698830.</ref> This evidence suggests that genes influencing both eating regulation, and personality and emotion, may be important contributing factors.
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| Several rodent models of anorexia have been developed which largely involve subjecting the animals to various environmental stressors or using [[gene knockout]] mice to test hypotheses about the effects of certain genes on related behavior.<ref>Siegfried Z, Berry EM, Hao S, Avraham Y. (2003) Animal models in the investigation of anorexia. ''Physiol Behav'', 79 (1), 39-45. PMID 12818708.</ref> These models have suggested that the [[hypothalamic-pituitary-adrenal axis]] may be a contributory factor, although the models have been criticised as food is being limited by the experimenter and not the animal, and these models cannot take into account the complex cultural factors known to affect the development of anorexia nervosa.
| | ==Diagnosis== |
| | | [[Anorexia nervosa diagnostic criteria|Diagnostic Criteria]] | [[Anorexia nervosa history and symptoms|History and Symptoms]] | [[Anorexia nervosa physical examination|Physical Examination]] | [[Anorexia nervosa laboratory findings|Laboratory Findings]] | [[Anorexia nervosa electrocardiogram|Electrocardiogram]] | [[Anorexia nervosa other imaging findings|Other Imaging Findings]] | [[Anorexia nervosa other diagnostic studies|Other Diagnostic Studies]] |
| ====Neurobiological factors====
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| There are strong correlations (but not proven causation) between the neurotransmitter [[serotonin]] and various psychological symptoms such as mood, sleep, emesis (vomiting), sexuality and appetite. A recent review of the scientific literature has suggested that anorexia is linked to a disturbed serotonin system,<ref>Kaye WH, Frank GK, Bailer UF, Henry SE, Meltzer CC, Price JC, Mathis CA, Wagner A. (2005) Serotonin alterations in anorexia and bulimia nervosa: new insights from imaging studies. ''Physiol Behav'', 85 (1), 73-81. PMID 15869768.</ref> particularly to high levels at areas in the brain with the [[5-HT receptor|5HT<sub>1A</sub> receptor]] - a system particularly linked to [[anxiety]], [[mood]] and [[impulse control]]. Starvation has been hypothesised to be a response to these effects, as it is known to lower [[tryptophan]] and [[steroid hormone]] metabolism, which, in turn, might reduce serotonin levels at these critical sites and, hence, ward off anxiety. In contrast, studies of the 5HT<sub>2A</sub> serotonin receptor (linked to regulation of feeding, mood, and anxiety), suggest that serotonin activity is decreased at these sites. One difficulty with this work, however, is that it is sometimes difficult to separate cause and effect, in that these disturbances to brain neurochemistry may be as much the result of starvation, than continuously existing traits that might predispose someone to develop anorexia. There is evidence, however, that both personality characteristics (such as anxiety and perfectionism) and disturbances to the serotonin system are still apparent after patients have recovered from anorexia,<ref>Kaye WH, Bailer UF, Frank GK, Wagner A, Henry SE. (2005) Brain imaging of serotonin after recovery from anorexia and bulimia nervosa. ''Physiol Behav'', 86(1-2), 15-7. PMID 16102788.</ref> suggesting that these disturbances are likely to be causal risk factors.
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| Recent studies also suggest anorexia may be linked to an autoimmune response to [[melanocortin]] [[peptides]] which influence appetite and stress responses.<ref>Fetissov SO, Harro J, Jaanisk M, Jarv A, Podar I, Allik J, Nilsson I, Sakthivel P, Lefvert AK, Hokfelt T. (2005) Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. ''Proc Natl Acad Sci U S A'', 102 (41), 14865-70. PMID 16195379.</ref>
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| ====Nutritional factors====
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| [[Zinc]] deficiency causes a decrease in [[appetite]] that can degenerate in anorexia nervosa (AN), appetite disorders and, notably, inadequate [[zinc]] nutriture. The use of zinc in the treatment of anorexia nervosa has been advocated since 1979 by Bakan. At least five trials showed that zinc improved weight gain in anorexia. A 1994 randomized, double-blind, placebo-controlled trial showed that zinc (14 mg per day) doubled the rate of body mass increase in the treatment of AN.<ref name="Zincappetitereview"/>
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| Deficiency of other [[nutrients]] such as [[tyrosine]] and [[tryptophan]] (precursors of the [[monoamine]] [[neurotransmitter]]s [[norepinephrine]] and [[serotonin]], respectively), as well as vitamin B1 ([[thiamine]]) could contribute to this phenomenon of malnutrition-induced malnutrition.<ref name="Zincappetitereview">Neurobiology of Zinc-Influenced Eating Behavior | [http://jn.nutrition.org/cgi/content/full/130/5/1493S]</ref>
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| ===Psychological factors===
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| There has been a significant amount of work into psychological factors that suggests how biases in thinking and perception help maintain or contribute to the risk of developing anorexia.
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| Anorexic eating behavior is thought to originate from feelings of fatness and unattractiveness<ref>Rosen JC, Reiter J, Orosan P. (1995) Assessment of body image in eating disorders with the body dysmorphic disorder examination. ''Behav Res Ther'', 1, 77-84. PMID 7872941.<br></ref> and is maintained by various [[cognitive bias]]es that alter how the affected individual evaluates and thinks about their body, food and eating.
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| One of the most well-known findings is that people with anorexia tend to over-estimate the size or fatness of their own bodies. A recent review of research in this area suggests that this is not a [[perception|perceptual]] problem, but one of how the perceptual information is evaluated by the affected person.<ref>Skrzypek S, Wehmeier PM, Remschmidt H. (2001) Body image assessment using body size estimation in recent studies on anorexia nervosa. A brief review. ''Eur Child Adolesc Psychiatry'', 10 (4), 215-21. PMID 11794546.</ref> Recent research suggests people with anorexia nervosa may lack a type of [[overconfidence effect|overconfidence bias]] in which the majority of people feel themselves more attractive than others would rate them. In contrast, people with anorexia nervosa seem to more accurately judge their own attractiveness compared to unaffected people, meaning that they potentially lack this self-esteem boosting bias.<ref>Jansen A, Smeets T, Martijn C, Nederkoorn C. (2006) I see what you see: the lack of a self-serving body-image bias in eating disorders. ''Br J Clin Psychol'', 45 (1), 123-35. PMID 16480571.</ref>
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| People with anorexia have been found to have certain personality traits that are thought to predispose them to develop eating disorders. High levels of obsessionality (being subject to intrusive thoughts about food and weight-related issues), restraint (being able to fight temptation), and clinical levels of [[perfectionism (psychology)|perfectionism]] (the pathological pursuit of personal high-standards and the need for control) have been cited as commonly reported factors in research studies.<ref>Wonderlich SA, Lilenfeld LR, Riso LP, Engel S, Mitchell JE. (2005) Personality and anorexia nervosa. ''Int J Eat Disord'', 37 Suppl, S68-71. PMID 15852324.</ref>
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| It is often the case that other psychological difficulties and [[mental illness]]es exist alongside anorexia nervosa in the sufferer. [[Clinical depression]], [[obsessive compulsive disorder]], [[substance abuse]] and one or more [[personality disorders]] are the most likely conditions to be [[comorbid]] with anorexia, and high-levels of anxiety and depression are likely to be present regardless of whether they fulfill diagnostic criteria for a specific syndrome.<ref>O'Brien KM, Vincent NK. (2003) Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. ''Clin Psychol Rev'', 23 (1), 57-74. PMID 12559994</ref>
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| Research into the [[neuropsychology]] of anorexia has indicated that many of the findings are inconsistent across studies and that it is hard to differentiate the effects of starvation on the brain from any long-standing characteristics. Nevertheless, one reasonably reliable finding is that those with anorexia have poor cognitive flexibility<ref>Tchanturia K, Campbell IC, Morris R, Treasure J. (2005) Neuropsychological studies in anorexia nervosa. ''Int J Eat Disord'', 37 Suppl, S72-6. PMID 15852325.</ref> (the ability to change past patterns of thinking, particularly linked to the function of the [[frontal lobe]]s and [[executive system]]).
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| Other studies have suggested that there are some [[attention]] and [[memory]] biases that may maintain anorexia.<ref>Cooper MJ (2005) Cognitive theory in anorexia nervosa and bulimia nervosa: progress, development and future directions. ''Clin Psychol Rev'', 25 (4), 511-31. PMID 15914267.</ref> Attentional biases seem to focus particularly on body and body-shape related concepts, making them more salient for those affected by the condition, and some limited studies have found that those with anorexia may be more likely to recall related material than unrelated material.
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| [[Image:Fairburn.jpg|400px|thumb|left|Fairburn and colleagues psychological model of anorexia]]
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| Although there has been quite a lot of research into psychological factors, there are relatively few theories which attempt to explain the condition as a whole.
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| Professor Chris Fairburn, of the University of Oxford and his colleges have created a 'transdiagnostic' model,<ref>Fairburn CG, Cooper Z, Shafran R. (2003) Cognitive behavior therapy for eating disorders: a "transdiagnostic" theory and treatment. ''Behav Res Ther'', 41 (5), 509-28. PMID 12711261.</ref> in which they aim to explain how anorexia, as well as related disorders such as bulimia nervosa and ED-NOS, are maintained. Their model is developed with psychological therapies, particularly [[cognitive behavioral therapy]], in mind, and so suggests areas where clinicians could provide psychological treatment.
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| Their model is based on the idea that all major eating disorders (with the exception of [[obesity]]) share some core types of [[psychopathology]] which help maintain the eating disorder behavior. This includes clinical [[perfectionism (psychology)|perfectionism]], chronic low [[self-esteem]], mood intolerance (inability to cope appropriately with certain emotional states) and interpersonal difficulties.
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| ====Social and environmental factors====
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| Sociocultural studies have highlighted the role of cultural factors, such as the promotion of thinness as the ideal female form in Western industrialised nations, particularly through the media. A recent epidemiological study of 989,871 Swedish residents indicated that [[gender]], ethnicity and [[socio-economic status]] were large influences on the chance of developing anorexia, with those with non-European parents among the least likely to be diagnosed with the condition, and those in wealthy, white families being most at risk.<ref>Lindberg L, Hjern A. (2003) Risk factors for anorexia nervosa: a national cohort study. ''International Journal of Eating Disorders'', 34 (4), 397-408. PMID 14566927</ref> A classic study by Garner and Garfinkel demonstrated that those in professions where there is a particular social pressure to be thin (such as models and dancers) were much more likely to develop anorexia during the course of their career,<ref>Garner DM, Garfinkel PE. (1980) Socio-cultural factors in the development of anorexia nervosa. ''Psychol Med'', 10 (4), 647-56. PMID 7208724.</ref> and further research has suggested that those with anorexia have much higher contact with cultural sources that promote weight-loss.<ref>Toro J, Salamero M, Martinez E. (1994) Assessment of sociocultural influences on the aesthetic body shape model in anorexia nervosa. ''Acta Psychiatr Scand'', 89 (3), 147-51. PMID 8178671.</ref>
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| Although anorexia nervosa is usually associated with Western cultures, exposure to Western media is thought to have led to an increase in cases in non-Western countries. However, it is notable that other cultures may not display the same 'fat phobic' worries about becoming fat as those with the condition in the West, and instead may present with low appetite with the other common features.<ref>Simpson KJ. (2002) Anorexia Nervosa and culture. ''J Psychiatr Ment Health Nurs'', 9 (1), 65-71. PMID 11896858.</ref>
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| There is a high rate of child sexual abuse experiences in those who have been diagnosed with anorexia (up to 50% in those admitted to inpatient wards, with a lesser prevalence among people treated in the community). Although prior sexual abuse is not thought to be a specific risk factor for anorexia (although it is a risk factor of mental illness in general), those who have experienced such abuse are more likely to have more serious and chronic symptoms.<ref>Carter JC, Bewell C, Blackmore E, Woodside DB. (2006) The impact of childhood sexual abuse in anorexia nervosa. ''Child Abuse Negl'', 30 (3), 257-69. PMID 16524628.</ref>
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| The Internet has enabled anorexics and bulimics to contact and communicate with each other outside of a treatment environment, with much lower risks of rejection by mainstream society. A variety of websites exist, some run by sufferers, some by former sufferers, and some by professionals. The majority of such sites support a medical view of anorexia as a disorder to be cured, although some people affected by anorexia have formed online [[pro-ana]] communities that reject the medical view and argue that anorexia is a 'lifestyle choice', using the internet for mutual support, and to swap weight-loss tips.<ref>Norris ML, Boydell KM, Pinhas L, Katzman DK. (2006) Ana and the internet: A review of pro-anorexia websites. ''International Journal of Eating Disorders'', 39(6):443-7. PMID 16721839.</ref> Such websites were the subject of significant media interest, largely focusing on concerns that these communities could encourage young women to develop or maintain eating disorders, and many were taken offline as a result.<ref>Reaves, J. (2001). [http://www.time.com/time/health/article/0,8599,169660,00.html Anorexia goes high tech]. ''Time'' (July). Retrieved on April 16, 2007.</ref>
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| ==Diagnosis and clinical features==
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| The most commonly used criteria for diagnosing anorexia are from the [[American Psychiatric Association|American Psychiatric Association's]] [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM-IV-TR) and the [[World Health Organization|World Health Organization's]] [[ICD|International Statistical Classification of Diseases and Related Health Problems]] (ICD).
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| 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.
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| 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.
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| The full [[ICD-10]] diagnostic criteria for anorexia nervosa can be found [http://www3.who.int/icd/currentversion/fr-icd.htm?gf50.htm+ here], and the [[DSM-IV-TR]] criteria can be found [http://www.behavenet.com/capsules/disorders/anorexia.htm here].
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| To be diagnosed as having anorexia nervosa, according to the DSM-IV-TR, a person must display:
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| # Refusal to maintain [[human weight|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).
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| # Intense fear of gaining weight or becoming [[overweight|fat]].
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| # 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.
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| # 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).
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| # Or other eating related disorders.
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| Furthermore, the DSM-IV-TR specifies two subtypes:
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| * ''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 [[laxative]]s, [[diuretic]]s, or [[enema]]s)
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| * ''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).
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| The [[ICD|ICD-10]] criteria are similar, but in addition, specifically mention
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| # 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);
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| # physiological features, including "widespread [[endocrine]] disorder involving [[hypothalamus|hypothalamic]]-[[pituitary]]-[[gonad]]al 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 hormone]]s, raised [[cortisol]] levels, changes in the peripheral [[metabolism]] of [[thyroid]] hormone and abnormalities of insulin secretion"; and
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| # if the onset is before puberty, development is delayed or arrested.
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| ===Presentation===
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| 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.<ref name="GowersBryant-Waugh2004">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</ref><ref name="LaskBryant-Waugh2000" />
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| ====Psychological====
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| * Distorted [[body image]]
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| * Poor insight
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| * Self-evaluation largely, or even exclusively, in terms of their shape and weight
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| * Pre-occupation or [[obsessive-compulsive disorder|obsessive]] thoughts about food and weight
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| * [[Perfectionism (psychology)|Perfectionism]]
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| * [[OCD]] (obsessive compulsive disorder)
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| * belief that control over food is synonymous with being in control of one's life
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| ====Emotional====
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| * Low [[self-esteem]] and [[self-efficacy]]
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| * [[Clinical depression]] or chronically low mood
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| * Intense fear about becoming overweight
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| * Moodiness or 'mood swings'
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| ====Interpersonal and social====
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| * Withdrawal from previous friendships and other peer-relationships
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| * Deterioration in relationships with the family
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| * Denial of Basic needs, such as food
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| ====Physical====
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| * Extreme weight loss
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| * Stunted [[puberty|growth]]
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| * [[Endocrine]] disorder, leading to cessation of periods in girls ([[amenorrhea]])
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| * Decreased [[libido]]; [[impotence]] in males
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| * Starvation symptoms, such as reduced [[metabolism]], slow heart rate ([[bradycardia]]), [[hypotension]], [[hypothermia]] and [[anemia]]
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| * Growth of [[lanugo]] hair over the body
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| * Abnormalities of mineral and [[electrolyte]] levels in the body
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| * [[Zinc]] deficiency
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| * Often a reduction in [[white blood cell]] count
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| * Reduced [[immune system]] function
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| * [[Body mass index]] less than 17.5 in adults, or 85% of expected weight in children
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| * Possibly with pallid [[complexion]] and sunken eyes
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| * Creaking joints and bones
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| * [[Tooth decay]]
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| * Collection of fluid in ankles during the day and around eyes during the night
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| * [[Constipation]]
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| * Very dry/chapped lips due to malnutrition
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| * Poor circulation, resulting in common attacks of 'pins and needles' and purple extremities
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| * In cases of extreme weight loss, there can be nerve deterioration, leading to difficulty in moving the feet
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| * Headaches, due to malnutrition
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| * Thinning of the hair
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| * Nails become more brittle
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| * Constantly feeling "cold"
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| * Bruise easily
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| * Dry skin
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| ====Behavioral====
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| * Excessive exercise, food restriction
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| * [[Fainting]]
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| * Secretive about eating or exercise behavior
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| * Possible [[self-harm]], [[substance abuse]] or [[suicide]] attempts
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| * Very sensitive to references about body weight
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| * Become very aggressive when forced to eat "forbidden" foods
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| ===Diagnostic issues and controversies===
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| 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.<ref name="GowersBryant-Waugh2004"/>
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| 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 [[eating disorder not otherwise specified|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.<ref name="LaskBryant-Waugh2000"/>
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| 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.
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| ==Prognosis==
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| 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.<ref>{{citation|first1 = David B|last1 = Herzog|first2 = Dara N|last2 = Greenwood|first3 = David J|last3 = Dorer|first4 = Andrea T|last4 = Flores|first5 = Elizabeth R|last5 = Ekeblad|first6 = Ana|last6 = Richards|first7 = Mark A|last7 = Blais|first8 = Martin B|last8 = Keller|title = Mortality in eating disorders: A descriptive study|journal = International Journal of Eating Disorders|volume = 28|number = 1|pages = 20-26|year = 2000}}</ref> 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.<ref>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</ref> A recent review suggested that less than one-half recover fully, one-third improve, and 20% remain chronically ill.<ref>Steinhausen HC. (2002) The outcome of anorexia nervosa in the 20th century. ''Am J Psychiatry'', 159 (8), 1284-93. PMID 12153817.</ref>
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| ==Treatment== | | ==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 commitment|involuntary hospital treatment]] under [[mental health law]], where such legislation exists. In the majority of cases, however, people with anorexia are treated as [[outpatient]]s, with input from [[physician]]s, [[psychiatrist]]s, [[clinical psychologist]]s and other mental health professionals.
| | [[Anorexia nervosa medical therapy|Medical Therapy]] | [[Anorexia nervosa primary prevention|Primary Prevention]] | [[Anorexia nervosa secondary prevention|Secondary Prevention]] | [[Anorexia nervosa cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Anorexia nervosa future or investigational therapies|Future or Investigational Therapies]] |
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| 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.<ref>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.</ref> However, this review also noted that there are only a small number of [[randomised controlled trial]]s 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<ref>Lock J, Le Grange D. (2005) Family-based treatment of eating disorders. ''Int J Eat Disord'', 37 Suppl, S64-7. PMID 15852323.</ref> and in particular, a method developed at the [[Maudsley Hospital]] is widely used and found to maintain improvement over time.<ref>Le Grange D. (2005) The Maudsley family-based treatment for adolescent anorexia nervosa. ''World Psychiatry'', 4 (3), 142-6. PMID 16633532.</ref>
| | ==Case Studies== |
| | | [[Anorexia nervosa case study one|Case #1]] |
| 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".
| | {{WH}} |
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| Drug treatments, such as [[SSRI]] or other [[antidepressant]] medication, have not been found to be generally effective for either treating anorexia,<ref>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.</ref> or preventing relapse<ref>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.</ref> 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.
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| 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.<ref>Birmingham CL, Gritzner S (2006) How does [[zinc]] supplementation benefit anorexia nervosa? ''Eating and Weight Disorders'', 11 (4), e109-111. PMID 17272939</ref>
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| 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.
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| ==See also== | |
| * [[History of anorexia nervosa]]
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| * Adi Barkan (photographer who has campaigned against use of anorexic models)
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| * [[Anorexia (symptom)]]
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| * [[Body dysmorphic disorder]]
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| * [[Body image]]
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| * [[Bulimia nervosa]]
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| * [[Binge eating disorder]]
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| * [[Cachexia]]
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| * [[Calorie restriction]]
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| * [[Defensive vomiting]]
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| * [[Eating disorder]]
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| * [[Eating disorder not otherwise specified]]
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| * Female body shape
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| * [[Malnutrition]]
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| * [[Muscle dysmorphia]] ('reverse' anorexia nervosa)
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| * [[Orthorexia nervosa]]
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| * [[Pro-ana]]
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| * [[Purging disorder]]
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| * [[Refeeding syndrome]]
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| * [[Wannarexia]] — a term for people who want to be anorexic
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| ==References==
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| {{Reflist|2}} | |
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| {{SIB}} | |
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| [[Category:Psychiatry]] | | [[Category:Psychiatry]] |
| [[Category:Eating disorders]] | | [[Category:Eating disorders]] |
| [[Category:Overview complete]]
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| [[Category:Endocrinology]] | | [[Category:Endocrinology]] |
| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
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| [[ar:خلفة ذهنية]]
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| [[bg:Анорексия нервоза]]
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| [[ca:Anorèxia nerviosa]]
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| [[cs:Anorexie]]
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| [[da:Anoreksi]]
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| [[de:Anorexia nervosa]]
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| [[et:Anoreksia]]
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| [[es:Anorexia]]
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| [[eo:Anoreksio]]
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| [[fr:Anorexie mentale]]
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| [[gd:Fuath-bìdh]]
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| [[gl:Anorexia nerviosa]]
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| [[hr:Anoreksija]]
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| [[id:Anorexia nervosa]]
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| [[is:Lystarstol]]
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| [[it:Anoressia]]
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| [[he:אנורקסיה נרבוזה]]
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| [[ku:Anoreksiya nervoza]]
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| [[hu:Anorexia nervosa]]
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| [[nl:Anorexia nervosa]]
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| [[ja:神経性無食欲症]]
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| [[no:Anorexia nervosa]]
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| [[pl:Jadłowstręt psychiczny]]
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| [[pt:Anorexia nervosa]]
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| [[ru:Нервная анорексия]]
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| [[simple:Anorexia nervosa]]
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| [[sl:Nervozna anoreksija]]
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| [[sr:Анорексија нервоза]]
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| [[fi:Anoreksia]]
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| [[sv:Anorexia nervosa]]
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| [[tr:Anoreksiya nervoza]]
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| [[uk:Анорексія]]
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| [[zh:神经性厌食症]]
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| {{WH}}
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| {{WS}}
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