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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 are known to control body weight commonly through the means of voluntary starvation, purging, excessive exercise or other weight control measures, such as diet pills or diuretic drugs. While the condition primarily affects adolescent females, approximately 10% of people with the diagnosis are male. Anorexia nervosa, involving neurobiological, psychological, and sociological components, is a complex condition that can lead to death in severe cases.
The term anorexia is of Greek origin: a (α, prefix of negation), n (ν, link between two vowels) and orexis (ορεξις, appetite), thus meaning a lack of desire to eat.
"Anorexia nervosa" is frequently shortened to "anorexia" in the popular media. This is technically incorrect, as the term "anorexia" used separately refers to the medical symptom of reduced appetite (which therefore is distinguishable from anorexia nervosa in being non-psychiatric).
Diagnosis and clinical features
Established by the 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.
- The absence of at least three consecutive menstrual cycles (amenorrhea) in women who have had their first menstrual period but have not yet gone through menopause (postmenarcheal, premenopausal females).
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
- The 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).
- Certain 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" .
- If onset is before puberty, that 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.
Physical
Changes in brain structure and function are early signs often 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
- Fragile appearance; frail body image
- Slowing of the rate of growth of breasts
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
- Refusal to accept that one's weight is dangerously low even when it could be deadly
- Refusal to accept that one's weight is normal, or healthy
Emotional
- Low self-esteem and self-efficacy
- Intense fear about becoming overweight
- Clinical depression or chronically low mood
- Mood swings
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
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 binging 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., sub-clinical 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 criticized the medicalization 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 and gaining weight.
A vigorous debate exists on the topic of whether eating disorders are a choice or a biological illness. In 2006, Dr. Thomas Insel, director of the US National Institute of Mental Health, wrote an open letter to the National Eating Disorder Association stating "eating disorders are brain disorders."
Causes and contributory factors
It is clear that there is no single cause for anorexia and that it stems from a mixture of biological, social, and psychological 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.