Anorexia Nervosa

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Anorexia nervosa is an eating disorder characterized by excessive food restriction and irrational fear of gaining weight, and a distorted body self-perception. It typically involves excessive weight loss. Anorexia nervosa usually develops during adolescence and early adulthood.Hockenbury,Don and Sandra (2008). Psychology , p. 593. Worth Publishers, New York. ISBN 978-1-4292-0143-8. Due to the fear of gaining weight, people with this disorder restrict the amount of food they consume. This restriction of food intake causes metabolic and hormonal disorders. Outside of medical literature, the terms anorexia nervosa and anorexia are often used interchangeably; however, Anorexia (symptom)|anorexia is simply a medical term for lack of appetite. However, people with anorexia nervosa do not lose their appetites.

People suffering from anorexia have extremely high levels of ghrelin , the hunger hormone that tells the brain when it is time to eat, in their blood. The high levels of ghrelin suggests that their bodies are trying desperately to switch hunger on but that hunger’s call is being suppressed, ignored, or overridden. Nevertheless, one small single-blind study found that intravenous administration of ghrelin to anorexia nervosa patients increased food intake by 12-36% over the trial period.

Anorexia nervosa has many complicated implications and may be thought of as a lifelong illness that may never be truly cured, but only managed over time. Anorexia nervosa is characterized by low body weight, inappropriate eating habits and obsession with having a thin figure. Individuals suffering from it may also practice repeated weighing, measuring, and mirror gazing, alongside other obsessive actions, to make sure they are still thin, a common practice known as "body checking". WHO. International statistical classification of diseases and related health problems, 10th revision. Geneva: WHO, 1992

Anorexia nervosa is often coupled with a distorted Body image|self image which may be maintained by various cognitive bias es that alter how the affected individual evaluates and thinks about her or his body, food and eating. Anorexia nervosa is characterized by the fear of gaining weight. Those suffering from this disorder often view themselves as "too fat" even if they are already underweight. Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600–800 calories per day, but extreme cases of complete self-starvation are known. It is a serious mental illness with a high incidence of comorbidity and similarly high mortality rates to serious psychiatric disorders.

Anorexia nervosa most often has its onset in adolescence and is more prevalent among adolescent girls than adolescent males. However, more recent studies show the onset age has decreased from an average of 13 to 17 years of age to 9 to 12.. CNN.com (2011-08-08). Retrieved on 2012-02-04. While it can affect men and women of any age, Race (classification of human beings)|race , and Socioeconomics|socioeconomic and Culture|cultural background, anorexia nervosa occurs in 10 times more females than males.

The term anorexia nervosa was established in 1873 by Sir William Gull, 1st Baronet|Sir William Gull , one of Queen Victoria 's personal physicians. The term is of Greek origin: an- (??-, prefix denoting negation) and orexis (??e???, "appetite"), thus meaning a lack of desire to eat. However, while the term "anorexia nervosa" literally means "neurotic loss of appetite", the literal meaning of the term is somewhat misleading. Many anorexics do enjoy eating and have certainly not lost their appetites as the term "loss of appetite" is normally understood; it is better to regard anorexia nervosa as a self-punitive addiction to fasting , rather than a literal loss of appetite.

Schneer suggested anorexia nervosa patients who have "difficulties in identifying, containing and articulating emotions resort to food as a symbolic expression of the inability to establish subjective limits in their relationships with others". Rojo-Moreno, L., Plumed, J. J., Fons, M. B., Gonzalez-Piqueras, J. C., Rojo-Bofill, L. and Livianos, L. (2011), "Auditory hallucinations in anorexia nervosa". Eur. Eat. Disorders Rev. (19): 494–500. doi:10.1002/erv.1084"

Signs and symptoms

Anorexia nervosa is an eating disorder characterized by attempts to lose weight, sometimes to the point of starvation. A person with anorexia nervosa may exhibit a number of signs and symptoms, the type and severity of which may vary in each case and may be present but not readily apparent. Anorexia nervosa, and the associated malnutrition that results from self-imposed starvation , can cause severe complications in every major organ system in the body.

Hypokalaemia, a drop in the level of potassium in the blood, is a symptom of Anorexia nervosa. A significant drop in potassium can cause abnormal heart rhythms, constipation, fatigue, muscle damage and paralysis.

50-75% of individuals with an eating disorder experience depression. In addition, 1 in 4 individuals who are diagnosed with anorexia nervosa also exhibit obsessive compulsive disorder.

Symptoms for a typical patient include:

Refusal to maintain a normal body mass index for their age

Amenorrhea, the absence of three consecutive menstrual cycles

Fearful of even the slightest weight gain and takes all precautionary measures to avoid weight gain and becoming overweight

Obvious, rapid, dramatic weight loss

Lanugo : soft, fine hair growing on the face and body

fixation (psychology)|Obsession with food energy|calories and fat content of food

Preoccupation with food , recipes , or cooking ; may cook elaborate dinners for others, but not eat the food themselves

Dieting despite being thin or dangerously underweight

Rituals: cuts food into tiny pieces; refuses to eat around others; hides or discards food

Purging: uses laxatives , diet pills , ipecac syrup , or water pills ; may engage in self-induced vomiting ; may run to the bathroom after eating in order to vomit and quickly get rid of the calorie s (see also bulimia nervosa ).

May engage in frequent, strenuous exercise

Perception of self to be overweight despite being told by others they are too thin and, in most cases, underweight.

Becomes intolerant to cold and frequently complains of being cold from loss of insulating body fat or poor circulation resulting from extremely low blood pressure; body temperature lowers ( hypothermia ) in effort to conserve energy

Depression (mood)|Depression : may frequently be in a sad, lethargic state

Solitude : may avoid friends and family; becomes withdrawn and secretive

Cheeks may become swollen because of enlargement of the salivary gland s caused by excessive vomiting

Swollen joints

Abdominal distension

Bad breath (from vomiting or starvation-induced ketosis )

Hair loss or thinning

Fatigue

Dermatologic signs of anorexia nervosa Cite journal
xerosis
seborrheic dermatitis
Intertrigo
prurigo pigmentosa
Possible medical complications of anorexia nervosa
constipation Cite journal
cardiac arrest Cite journal
hyponatremia Cite journal

Medical complications

Anorexia nervosa can have serious implications when onset occurs before the completion of growth, pubertal maturation and prior to attaining peak bone mass.Nicholls, D. & Stanhope, R. "Medical Complications of Anorexia Nervosa in Children and Young Adolescents". European Disorders Review,2000,p.171Complications specific to adolescents and children with anorexia nervosa can include:

:*Growth retardation - height gain slows and can stop completely with severe weight loss. Growth in height can commence a few months after weight restoration.Nicholls, D. & Stanhope, R. "Medical Complications of Anorexia Nervosa in Children and Young Adolescents". European Eating Disorders Review, 2000, p.173

:*Pubertal delay or arrest - both height gain and pubertal development are dependent on the release of growth hormone and gonadotrophins (LH and FSH) from the pituitary gland. Suppression of gonadotrophins in patients with anorexia nervosa has been frequently documented.Nicholls, D. & Stanhope, R. "Medical Complications of Anorexia Nervosa in Children and Young Adolescents". European Eating Disorders Review, 2000, p.174

:*Reduction of Peak Bone Mass - bone accretion is the highest during adolescence, and if onset of anorexia nervosa occurs during this time and stalls puberty, bone mass may remain low.

:*Hepatic steatosis - fatty infiltration of the liver, is an indicator of malnutrition in children.

More information on symptoms and complications of anorexia nervosa in children and adolescents can be found at .

Causes

Studies have hypothesis|hypothesized the continuance of disordered eating patterns may be Epiphenomenon|epiphenomena of starvation. The results of the Minnesota Starvation Experiment showed normal controls exhibit many of the behavioral patterns of anorexia nervosa (AN) when subjected to starvation. This may be due to the numerous changes in the neuroendocrine system , which results in a self-perpetuating cycle. Studies have suggested the initial weight loss such as dieting may be the triggering factor in developing AN in some cases, possibly because of an already inherent predisposition toward AN. One study reported cases of AN resulting from unintended weight loss that resulted from varied causes, such as a parasitic infection, medication side effects, and surgery. The weight loss itself was the triggering factor.

Biological

Obstetric complications: various prenatal and perinatal complications may factor into the development of AN, such as maternal anemia , diabetes mellitus , preeclampsia , placental infarction , and neonatal cardiac abnormalities. Neonatal complications may also have an influence on harm avoidance , one of the personality traits associated with the development of AN.

Genetics : anorexia nervosa is believed to be highly heritable , with estimated inheritance rates ranging from 56% to 84%. Association studies have been performed, studying 128 different Polymorphism (biology)|polymorphisms related to 43 genes including genes involved in regulation of eating behavior, motivation and reward system|reward mechanics , personality traits and emotion . Consistent associations have been identified for polymorphisms associated with agouti-related peptide , BDNF|brain derived neurotrophic factor , COMT|catechol-o-methyl transferase , SK3 and OPRD1|opioid receptor delta-1 . In one study, variations in the norepinephrine transporter gene Promoter (biology)|promoter were associated with restrictive anorexia nervosa, but not binge-purge anorexia. Recent studies have advanced the theory that the sex difference in incidence and the common onset at the age of puberty may reflect an abnormal response of the brain to anorexic (feeding suppressing) effects of the female sex hormone, estrogen. This viewpoint has been recently supported by a report that abnormal forms of the estrogen receptor are more common in women with anorexia nervosa of the restricting type.

* epigenetics : Epigenetic mechanisms: are means by which genetic mutations are caused by environmental effects that alter gene expression via methods such as DNA methylation , these are independent of and do not alter the underlying DNA sequence. They are heritable, as was shown in the Överkalix study , but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission and Atrial natriuretic peptide homeostasis resulting from epigenetic mechanisms has been implicated in various eating disorders. "We conclude that epigenetic mechanisms may contribute to the known alterations of Atrial natriuretic peptide|ANP homeostasis in women with eating disorders." Epigenetic Downregulation of Atrial Natriuretic Peptide but not Vasopressin mRNA Expression in Females with Eating Disorders is Related to Impulsivity

serotonin dysregulation; particularly high levels in those areas in the brain with the 5-HT receptor|5HT_1A receptor – a system particularly linked to anxiety , Mood (psychology)|mood and impulse control . Starvation has been hypothesized to be a response to these effects, as it is known to lower tryptophan and steroid hormone metabolism, which might reduce serotonin levels at these critical sites and ward off anxiety. Other studies of the 5HT_2A serotonin receptor (linked to regulation of feeding, mood, and anxiety), suggest that serotonin activity is decreased at these sites. There is evidence that both personality characteristics associated with AN, and disturbances to the serotonin system are still apparent after patients have recovered from anorexia.

Brain-derived neurotrophic factor (BDNF) is a protein that regulates neural development|neuronal development and neuroplasticity , it also plays a role in learning , memory and in the Hypothalamic–pituitary–adrenal axis|hypothalamic pathway that controls eating behavior and energy homeostasis . BDNF amplifies neurotransmitter responses and promotes synaptic communication in the enteric nervous system . Low levels of BDNF are found in patients with AN and some comorbid disorders such as major depression. Exercise increases levels of BDNF

leptin and ghrelin ; leptin is a hormone produced primarily by the adipocytes|fat cells in white adipose tissue of the body it has an inhibitory (anorexigenic) effect on appetite, by inducing a feeling of satiety. Ghrelin is an appetite inducing ( orexigenic ) hormone produced in the stomach and the upper portion of the small intestine . Circulating levels of both hormones are an important factor in weight control. While often associated with obesity both have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.

cerebral blood flow (CBF); neuroimaging studies have shown reduced CBF in the temporal lobe s of anorectic patients, which may be a predisposing factor in the onset of AN.

autoimmune system ; Autoantibodies against neuropeptides such as melanocortin have been shown to affect personality traits associated with eating disorders such as those that influence appetite and stress responses.

Infections: Some people are hypothesized to have developed anorexia abruptly as a reaction to a streptococcus or mycoplasma infection. PANS is an acronym for Pediatric acute-onset neuropsychiatric syndrome , a hypothesis describing children who have abrupt, dramatic onset of obsessive-compulsive disorder (OCD) or anorexia nervosa coincident with the presence of two or more neuropsychiatric symptoms.

Nutritional deficiencies

* Zinc deficiency may play a role in anorexia. It is not thought responsible for causation of the initial illness but there is evidence that it may be an accelerating factor that deepens the pathology of the anorexia. A 1994 randomized, double-blind, placebo-controlled trial showed that zinc (14& nbsp;mg per day) doubled the rate of body mass increase compared to patients receiving the placebo.

Environmental

Sociocultural studies have highlighted the role of cultural factors, such as the promotion of thinness as the ideal female form in Western industrialized nations, particularly through the media.. Rcpsych.ac.uk (2010-02-23). Retrieved on 2012-02-04. A change in culture can cause anorexia nervosa in teenage girls who live in a Western culture and are from immigrant families.DiNicola, V. (1990). Anorexia Multiforme: Self-Starvation in Historical and Cultural Context.Part II: Anorexia Nervosa as a Culture-Reactive Syndrome . Transcultural Psychiatric Research Review, 27(4), 245-286. Retrieved April 9, 2012, doi: 10.1177/136346159002700401A 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. People in professions where there is a particular social pressure to be thin (such as model (person)|models and dancer s) were much more likely to develop anorexia during the course of their career, and further research has suggested that those with anorexia have much higher contact with cultural sources that promote weight-loss.

Anorexia nervosa is more likely to occur in a person’s pubertal years, especially for girls.Schmidt U, Treasure J. Anorexia nervosa: valued and visible. A cognitive-interpersonal maintenance model and its implications for research and practice. Br J Clin Psychol 2006 Female students are 10 times more likely to suffer from anorexia nervosa than male students. According to a survey of 1799 Japanese female high school students, “85% who were a normal weight wanted to be thinner and 45% who were 10–20% underweight wanted to be thinner.” Teenage girls concerned about their weight and who believe that slimness is more attractive among peers trend to weight-control behaviors. Teen girls are learning from each other to consume low-caloric, low-fat foods and diet pills. This results in lack of nutrition and a greater chance of developing anorexia nervosa.Levine et al. 1994, Shisslak et al. 1998, Stice 1998, Wertheim et al. 1997

It has also been noted that anorexia nervosa is more likely to occur in populations in which obesity is more prevalent. It has been suggested that anorexia nervosa results from a sexually selected evolutionary drive to appear youthful in populations in which size becomes the primary indicator of age.

There is also evidence to suggest that patients who have anorexia nervosa can be characterised by alexithymia and also a deficit in certain emotional functions. A research study showed that this was the case in both adult and adolescent anorexia nervosa patients.

There is a high rate of reported child sexual abuse experiences in clinical groups of who have been diagnosed with anorexia. The connection between eating disorders and abuse has been convincingly evidenced by a number of studies, including one published in Epidemiology (and strengthened by blind hypothesis survey), which showed in a comparison of women with no history of eating disorders, women with a history of eating disorders were twice as likely to have reported childhood sexual abuse. While the joint effect of both physical and sexual abuse resulted in a nearly 4-fold risk of eating disorders that met DSM-IV criteria. It is thought that links between childhood abuse and sexual abuse are complex, such as by influencing psychologic processes that increase a woman's susceptibility to the development of an eating disorder, or perhaps by producing changes in psychobiologic process and neurotransmitting function, associated with eating behaviour.

Recent efforts have been made to dispel some of the myths around anorexia nervosa and eating disorders, such as the misconception that families, in particular mothers, are responsible for their daughter developing an eating disorder."Lessons for Parents of Anorexics" (2005) in BBC Health News, 22 October 2005 viewable at http://news.bbc.co.uk/1/hi/health/4363304.stm (Accessed 22 Aug, 2011)

Relationship to autism

Since Christopher Gillberg|Gillberg's (1983 & 1985) and others' initial suggestion of relationship between anorexia nervosa and autism , a large-scale longitudinal study into teenage-onset anorexia nervosa conducted in Sweden confirmed that 23% of people with a long-standing eating disorder are on the autism spectrum . Those on autism spectrum tend to have a worse outcome, but may benefit from the combined use of behavioural and pharmacological therapies tailored to ameliorate autism rather than anorexia nervosa :wikt:per se|per se . Other studies, most notably research conducted at the Maudsley Hospital , UK , furthermore suggest that autistic traits are common in people with anorexia nervosa; shared traits include, e.g. , poor executive function , autism quotient|autism quotient score , weak central coherence theory|central coherence , Theory of mind impairment in autism|theory of mind , cognitive-behavioural flexibility, emotion regulation and understanding facial expressions.

Zucker et al. (2007) proposed that conditions on the autism spectrum make up the endophenotype|cognitive endophenotype underlying anorexia nervosa and appealed for increased interdisciplinary collaboration (see figure to right). A pilot study into the effectiveness Cognitive Behaviour Therapy , which based its treatment protocol on the hypothesised relationship between anorexia nervosa and an underlying autistic like condition, reduced perfectionism and rigidity in 17 out of 19 participants.

Diagnosis

Medical

The initial diagnosis should be made by a Competence (human resources)|competent Medical doctor|medical professional . There are multiple medical conditions, such as viral or bacterial infection s, Hormone imbalance|hormonal imbalances , Neurodegeneration|neurodegenerative diseases and brain tumor s which may mimic psychiatric disorders including anorexia nervosa.
According to an in depth study conducted by psychiatrist Richard Hall as published in the Archives of General Psychiatry :

Medical illness often presents with psychiatric symptoms.

It is difficult to distinguish physical disorders from functional psychiatric disorders on the basis of psychiatric symptoms alone.

Detailed physical examination and laboratory screening are indicated as a Medical guideline|routine procedure in the initial evaluation of psychiatric patients.

Most patients are unaware of the medical illness that is causative of their psychiatric symptoms.

The conditions of patients with medically induced symptoms are often initially misdiagnosed as a functional psychosis.

Complete Blood Count (CBC): a test of the white blood cells . red blood cells and platelets used to assess the presence of various disorders such as leukocytosis , leukopenia , thrombocytosis and anemia which may result from malnutrition .. Nlm.nih.gov. Retrieved on 2012-02-04.

urinalysis : a variety of tests performed on the urine used in the diagnosis of medical disorders, to test for substance abuse, and as an indicator of overall health. Nlm.nih.gov (2012-01-26). Retrieved on 2012-02-04.

ELISA : Various subtypes of ELISA used to test for antibodies to various viruses and bacteria such as Borrelia burgdoferi (Lyme Disease)

Western Blot|Western Blot Analysis : Used to confirm the preliminary results of the ELISA

SMA 20|Chem-20 : Chem-20 also known as SMA-20 a group of twenty separate chemical tests performed on blood serum . Tests include cholesterol , protein and electrolytes such as potassium , chlorine and sodium and tests specific to liver and kidney function.. Nlm.nih.gov. Retrieved on 2012-02-04.

glucose tolerance test : Oral glucose tolerance test (OGTT) used to assess the body's ability to metabolize glucose. Can be useful in detecting various disorders such as diabetes , an insulinoma , Cushing's Syndrome , hypoglycemia and polycystic ovary syndrome

Secretin-cholecystokinin test|Secritin-CCK Test : Used to assess function of pancreas and gall bladder

Serum (blood)|Serum cholinesterase test: a test of liver enzymes ( acetylcholinesterase and Butyrylcholinesterase|pseudocholinesterase ) useful as a test of liver function and to assess the effects of malnutrition

Liver function tests|Liver Function Test : A series of tests used to assess liver function some of the tests are also used in the assessment of malnutrition, protein deficiency , kidney function, bleeding disorders, Crohn's Disease

Lh response to GnRH: Luteinizing hormone (Lh) response to gonadotropin-releasing hormone (GnRH): Tests the pituitary glands' response to GnRh a hormone produced in the hypothalumus. Central hypogonadism is often seen in anorexia nervosa cases.

creatine kinase|Creatine Kinase Test (CK-Test): measures the circulating blood levels of creatine kinase an enzyme found in the heart (CK-MB), brain (CK-BB) and skeletal muscle (CK-MM).

BUN|Blood urea nitrogen (BUN) test : urea nitrogen is the byproduct of protein metabolism first formed in the liver then removed from the body by the kidneys. The BUN test is used primarily to test kidney function. A low BUN level may indicate the effects of malnutrition.. Nlm.nih.gov (2012-01-26). Retrieved on 2012-02-04.

BUN-to-creatinine ratio : A BUN to creatinine ratio is used to predict various conditions. High BUN/creatinine ratio can occur in severe hydration, acute kidney failure, congestive heart failure, intestinal bleeding. A low BUN/creatinine can indicate a low protein diet, celiac disease rhabdomyolysis , cirrhosis of the liver.

echocardiogram : utilizes ultrasound to create a moving picture of the human heart|heart to assess function

electrocardiogram (EKG or ECG): measures electrical activity of heart can be used to detect various disorders such as hyperkalemia

electroencephalogram (EEG): measures the electrical activity of the brain. Can be used to detect abnormalities such as those associated with pituitary tumors. Nlm.nih.gov (2012-01-26). Retrieved on 2012-02-04.

upper GI series|Upper GI Series : test used to assess gastrointestinal problems of the middle and upper intestinal tract

Thyroid stimulating hormone|Thyroid Screen TSH, t4, t3 :test used to assess thyroid functioning by checking levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3)

Parathyroid hormone (PTH) test: tests the functioning of the parathyroid by measuring the amount of (PTH) in the blood. Test is used to diagnose parahypothyroidism. PTH also controls the levels of calcium and phosphorus in the blood ( homeostasis ).

barium enema : an x-ray examination of the lower gastrointestinal tract. Nlm.nih.gov (2012-01-26). Retrieved on 2012-02-04.

neuroimaging ; via the use of various techniques such as PET scan , fMRI , MRI and SPECT|SPECT imaging should be included in the diagnostic procedure for any eating disorder to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder.

Psychological

Not only does starvation result in physical complications, but mental complications as well . It has been shown that eating disorders such as anorexia nervosa are reinforced by reward and attention. P.Sodersten and colleagues suggests that effective treatment of this disorder depends on re-establishing reinforcement for normal eating behaviours instead of unhealthy weight loss.

Anorexia nervosa is classified as an Axis I disorder in the Diagnostic and Statistical Manual of Mental Health Disorders ( DSM-IV ), published by the American Psychiatric Association . The DSM-IV should not be used by laypersons to diagnose themselves.

DSM-IV-TR : diagnostic criteria for AN includes intense fear of gaining weight, a refusal to maintain body weight above 85% of the expected weight for a given age and height, and three consecutive missed menstrual cycle|periods and either refusal to admit the seriousness of the weight loss, or undue influence of shape or weight on one's self image, or a disturbed experience in one's shape or weight. There are two types: the binge-eating/purging type is characterized by overeating or purging, and the restricting type is not.

* Criticism of DSM-IV There has been criticisms over various aspects of the diagnostic criteria utilized for anorexia nervosa in the DSM-IV. Including the requirement of maintaining a body weight below 85% of the expected weight and the requirement of amenorrhea for diagnosis; some women have all the symptoms of AN and continue to menstruate. Those who do not meet these criteria are usually classified as eating disorder not otherwise specified this may affect treatment options and insurance reimbursments. The validity of the AN subtype classification has also been questioned because of the considerable diagnostic overlap between the binge eating/ purging type and the restricting type and the propensity of the patient to switch between the two.Marlene Busko . Medscape.com (2007-05-30). Retrieved on 2012-02-04.

Criticisms of DSM-IV and Diagnosing Adolescents with Anorexia Nervosa - There have been criticisms over the diagnostic criteria utilized for anorexia nervosa in the DSM- IV and it’s applicability in diagnosing adolescents with anorexia nervosa. Several criticisms of the DSM-IV in diagnosing adolescents with anorexia nervosa are:

:*Fulfillment of DSM- IV criteria B and C for anorexia nervosa are dependent on complex abstract reasoning, the capacity to describe internal experiences, and the ability to perceive riskWorkgroup for Classification of Eating Disorders in Children and Adolescents. "Classifications of Eating Disturbance in Children and Adolescents: Proposed Changes for the DSM-V". European Eating Disorders Review, 2010,p.81. While formal thought emerges between ages 11–13, complex abstract reasoning continues to develop late into adolescence. The ability to perceive risk also continues to develop through adolescence, as some preadolescents have difficult perceiving the relative risk of alternative outcomes. Adolescents and children must first develop these internal thought processes in order to then endorse fear of weight gain or distortion of body image, and deny the seriousness of low body weight despite their behaviors that contribute to harmful weight loss, which are necessary to fulfill criterion B and CKnoll, S., Bulik, C., & Hebebrand, J. "Do the currently proposed DSM-5 criteria for anorexia nervosa adequately consider developmental aspects in children and adolescents? ". Early Adolescent Psychiatry, 2011,p.96. These developmental factors may impede an adolescent or child from receiving a diagnosis of anorexia nervosa. It is the hope of certain professionals that the DSM- V will take the unique developmental stages of children and adolescents into account when revising the current criteria. One proposed amendment would be to allow behavioral indicators as a means of substituting internally referenced cognitive criteria.

:*Another criticism focuses on the current weight criteria specified to receive a diagnosis of anorexia nervosa. Critics state that there is wide variability in the rate, timing and magnitude of both height and weight gain during normal puberty.Journal of Adolescent Health. "Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine". 2003,33,p.496 Physical development varies greatly during puberty, making it a challenge to define an optimal weight range for a growing child or adolescents.

ICD|ICD-10 : The 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).
# If onset is before puberty, that development is delayed or arrested.
# Certain 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" .

Dr. Hilde Burch, in her 1973 book, Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within , explains that Anorexia Nervosa is "not a static condition," but one that continually provokes new problems with its various stages. She writes, "The state of starvation is associated by marked psychological changes... camouflaged by rationalizations." She identifies the family interaction becomes difficult, marked by rising anxiety, annoyance and resentment. It also brings about social isolation. (Burch 215).

Dr. Burch believed that anorexia, which is simply not eating enough, as a result from schizophrenia, depression, or esophageal problems often were misdiagnosed as anorexia nervosa . In her assessment, this blurred the definition of anorexia nervosa. For this reason, she distinguished between, what she calls "atypical" and "primary" cases of anorexia nervosa. The atypical cases of anorexia were brought about by a range of stimuli (from schizophrenia to depression, as noted above). (Burch 227).

In contrast to the atypical group, Burch observed primary , or genuine anorexia nervosa , "amazingly uniform". The first outstanding symptom is "disturbance of delusional proportions in the body image". The second outstanding characteristic is "disturbance in the accuracy of their perception or cognitive interpretation of stimuli arising from the body... failure to recognize hunger and denial of fatigue". The third outstanding characteristic is a "paralyzing sense of ineffectiveness". "Anorexics struggle against a feeling of enslaved, exploited, and not being permitted to lead a life of their own. They would rather starve than continue a life of accommodation. In this blind search for a sense of identity and selfhood they will not accept anything that their parents, or the world around them, has to offer." It is a "desperate struggle for a self respecting identity". She understood that the personality disorder (struggle for control, for a sense of identity, competence, and effectiveness) precedes the somatic disorders (such as emaciation, amenorrhea, constipation, etc.) (Burch 250–255).

Differential diagnoses

There are various medical and psychological conditions that have been misdiagnosed as anorexia nervosa, in some cases the correct diagnosis was not made for more than ten years. In a reported case of achalasia misdiagnosed as AN, the patient spent two months confined to a psychiatric hospital.
There are various other psychological issues that may factor into anorexia nervosa, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters", A, B and C.The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity.

Comorbid Disorders
Axis I
depression Cite journal
	borderline personality disorder Cite journal
	narcissistic personality disorder Cite journal

Attention-Deficit-Hyperactivity-Disorder Cite journal	avoidant personality disorder Cite journal

Body dysmorphic disorder (BDD) is listed as a somatoform disorder that affects up to 2% of the population. BDD is characterized by excessive Rumination (psychology)|rumination over an actual or perceived physical flaw. BDD has been diagnosed equally among men and women. While BDD has been misdiagnosed as anorexia nervosa, it also occurs comorbidly in 25% to 39% of AN cases.

BDD is a chronic and debilitating condition which may lead to social isolation, major depression, suicidal ideation and attempts. Neuroimaging studies to measure response to facial recognition have shown activity predominately in the left hemisphere in the left lateral prefrontal cortex , lateral temporal lobe and left parietal lobe showing hemispheric imbalance in information processing. There is a reported case of the development of BDD in a 21 year old male following an inflammatory brain process. Neuroimaging showed the presence of new atrophy in the frontotemporal region.

The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make as there is considerable overlap between patients diagnosed with these conditions. Seemingly minor changes in a patient's overall behavior or attitude 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.

Treatment

Treatment for anorexia nervosa tries to address three main areas. 1) Restoring the person to a healthy weight; 2) Treating the psychological disorders related to the illness; 3) Reducing or eliminating behaviours or thoughts that originally led to the disordered eating. Although restoring the person's weight is the primary task at hand, optimal treatment also includes and monitors behavioral change in the individual as well. As treatment can prove to be difficult, "as many as 6 percent of people with the disorder die from causes related to it. Carlson N. & Heth C., "Psychology: The Science of Behaviour" p.297, Retrieved April 8, 2012.If anorexia nervosa is not treated, serious complications such as heart conditions and kidney failure can initiate and eventually lead to death.

Dietary

:* Zinc supplementation has been shown in various studies to be beneficial in the treatment of AN even in patients not suffering from zinc deficiency, by helping to increase weight gain.
:* Essential fatty acids :The omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have been shown to benefit various neuropsychiatric disorders. There was reported rapid improvement in a case of severe AN treated with Ethyl group|ethyl -eicosapentaenoic acid (E-EPA) and micronutrient s. DHA and EPA supplementation has been shown to be a benefit in many of the comorbid disorders of AN including: attention deficit/hyperactivity disorder (ADHD), autism, major depressive disorder (MDD), bipolar disorder, and borderline personality disorder. Accelerated cognitive decline and mild cognitive impairment (MCI) correlate with lowered tissue levels of DHA/EPA, and supplementation has improved cognitive function.
:* Nutrition counseling
:* Medical Nutrition Therapy ;(MNT) also referred to as Nutrition Therapy is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person's medical history, psychosocial history, physical examination, and dietary history.

Medication

:* Olanzapine : has been shown to be effective in treating certain aspects of AN including to help raise the body mass index and reduce obsessionality, including obsessional thoughts about food. However, its primary usefulness is that it is one of the most potent appetite stimulants known, and causes the body to preferentially store fat.

Therapy

:* Cognitive behavioral therapy (CBT) CBT is an evidence based approach which in studies to date has shown to be useful in adolescents and adults with anorexia nervosa.Components of using CBT with adults and adolescents with anorexia nervosa have been outlined by several professionals as:

::*the therapist focuses on using cognitive restructuring to modify distorted beliefs and attitudes about the meaning of weight, shape and appearanceRobin, M., Gilroy, M., & Dennis, A. "Treatment of Eating Disorders in Children and Adolescents" Clinical Psychology Review, 1998, p.430

::*specific behavioral techniques addressing the normalization of eating patterns and weight restorations, examples of this include the use of a food diary, meal plans, and incremental weight gain

::*cognitive techniques such as restructuring, problem solving, and identification and expression of affect

:::*When using CBT with adolescents and children with AN, several professionals have expressed concerns about the minimum age and level of cognition necessary for implementing cognitive behavioral techniques. Modified versions and elements of CBT can be implemented with children and adolescents with AN. Such modifications may include the use of behavioral experiments to disconfirm distorted beliefs and absolutistic thinking in children and adolescents.
:* Acceptance and commitment therapy : A type of CBT, has shown promise in the treatment of AN " participants experienced clinically significant improvement on at least some measures; no participants worsened or lost weight even at 1-year follow-up."
:* Cognitive Remediation Therapy (CRT): is a cognitive rehabilitation therapy developed at King's College in London designed to improve neurocognitive abilities such as attention, working memory , cognitive flexibility and planning (cognitive)|planning , and executive functioning which leads to improved social functioning. Neuropsychological studies have shown that patients with AN have difficulties in cognitive flexibility. In studies conducted at Kings College and in Poland with adolescents CRT was proven to be beneficial in treating anorexia nervosa, in the United States clinical trials are still being conducted by the National Institute of Mental Health . Nimh.nih.gov (2011-08-23). Retrieved on 2012-02-04. on adolescents age 10–17 and Stanford University in subjects over 16 as a conjunctive therapy with Cognitive behavioral therapy.. Edresearch.stanford.edu (2008-06-20). Retrieved on 2012-02-04.

:* Family therapy : The most effective form of therapy for adolescents with anorexia is family therapy. There are various forms of Maudsley Family Therapy|family-based therapy that have been proven to work in the treatment of adolescent AN including "conjoint family therapy" (CFT), in which the parents and child are seen together by the same therapist, "separated family therapy" (SFT) in which parents and child attend therapy separately with different therapists. "''Eisler's cohort show that, irrespective of the type of FBT, 75% of patients have a good outcome, 15% an intermediate outcome... "''.Dare C, Hodes M, Russell G, Dodge E, Le Grange D 2000 727–36"> Proponents of Family Therapy for adolescents with AN assert that it is important to include parents in the adolescent's treatment.Gore, S., Vander Wal, J., & Thelen, M. "Treatment of Eating Disorders in Children and Adolescents" p.297 Several components of using Family Therapy with Children and Adolescents are:

::*the family is seen as a resource for the adolescentRobin, M., Gilroy, M., & Dennis, A. "Treatment of Eating Disorders in Children and Adolescents" Clinical Psychology Review, 1998, p.434

::*anorexia nervosa is reframed in benign, non blaming terms

::*directives are provided to parents so that they may take charge of their child or adolescent's eating routine

::*a structured behavioral weight gain program is implemented

::*after weight gain, control over eating is gradually returned to the child or adolescent

::*as the child or adolescent begins to eat and gain weight, the theraputic focus broadens to include family interaction problems, growth and autonomy issues and parent child conflicts
:* Maudsley Family Therapy : A 4 to 5 year follow up study of the Maudsley approach, a manualized model, that shows full recovery at rates up to 90%.

Alternative medicine

:* Yoga : In preliminary studies indivualized yoga treatment has shown positive results for use as an adjunctive therapy to standard care. The treatment was shown to reduce eating disorder symptoms, including food preoccupation, which decreased immediately after each session. Scores on the Eating Disorder Examination Interview|Eating Disorder Examination decreased consistently over the course of treatment.

Prognosis

The long term prognosis of anorexia is more on the favorable side. The National Comorbidity Survey|National Comorbidity Replication Survey was conducted among more than 9,282 participants throughout the United States, the results found that the average duration of anorexia nervosa is 1.7 years. "Contrary to what people may believe, anorexia is not necessarily a chronic illness; in many cases, it runs its course and people get better..."

In cases of adolescent anorexia nervosa that utilize Maudsley Family Therapy|family-based treatment 75% of patients have a good outcome and an additional 15% show an intermediate yet more positive outcome.Dare C, Hodes M, Russell G, Dodge E, Le Grange D 2000 727–36"/> In a five year post treatment follow-up of Maudsley Family Therapy the full recovery rate was between 75% and 90%.
Even in severe cases of AN, despite a noted 30% relapse rate after hospitalization, and a lengthy time to recovery ranging from 57 to 79 months, the full recovery rate was still 76%. There were minimal cases of relapse even at the long term follow-up conducted between 10–15 years. The long-term prognosis of anorexia nervosa is changeable: a fifth of patients stay severely ill, another fifth of patients recover fully and three fifths of patients have a fluctuating and chronic course (Gelder, Mayou and Geddes 2005).

Epidemiology

Anorexia has an average prevalence of 0.3–1% in women and 0.1% in men for the diagnosis in developed countries. The condition largely affects young adolescent women, with between 15 and 19 years old making up 40% of all cases. Approximately 75% of people with anorexia are female. Anorexia nervosa is more prevalent in the upper social classes and it is declared to be rare in less developed countries (Gelder, Mayou and Geddes 2005). Anorexia is more prevalent in females and males born after 1945 ( Attia and Walsh 2007).
Attia, Evelyn , and Timothy Walsh. "Anorexia Nervosa Evelyn Attia; B. Timothy Walsh." The American Journal of Psychiatry 164 (2007): 1805-1810.Print.

History

The history of anorexia nervosa begins with descriptions of religious fasting dating from the Hellenistic civilization|Hellenistic era . Content.karger.com. Retrieved on 2012-02-04. and continuing into the medieval period. A number of well known historical figures, including Catherine of Siena and Mary, Queen of Scots are believed to have suffered from the condition.Hepworth, Julie. 1999. The Social Construction of Anorexia Nervosa. Thousand Oaks, CA: Sage Publications ISBN 0-7619-5309-4

Of interest in terms of anorexia nervosa is the medieval practice of self-starvation by women, including some young women, in the name of religious piety and purity. This is sometimes referred to as anorexia mirabilis . By the thirteenth century, it was increasingly common for women to participate in religious life . Many women who ultimately became saints engaged in self-starvation, including Saint Hedwig of Andechs in the thirteenth century and Catherine of Siena in the fourteenth century. By the time of Catherine of Siena, however, the Church became concerned about extreme fasting as an indicator of spirituality and as a criterion for sainthood. Indeed, Catherine of Siena was told by Church authorities to pray that she would be able to eat again, but was unable to give up fasting.

The earliest medical descriptions of anorexic illnesses are generally credited to English physician Richard Morton (physician)|Richard Morton , in 1689.

However it was not until the late 19th century that anorexia nervosa was to be widely accepted by the medical profession as a recognised condition. In 1873, Sir William Gull, 1st Baronet|Sir William Gull , one of Queen Victoria’s personal physicians, published a seminal paper which established the term anorexia nervosa and provided a number of detailed case descriptions and treatments. In the same year, French physician Charles Lasègue|Ernest-Charles Lasègue similarly published details of a number of cases in a paper entitled De l’Anorexie Histerique .

Awareness of the condition was largely limited to the medical profession until the latter part of the 20th century, when German-American psychoanalyst Hilde Bruch published her popular work The Golden Cage: the Enigma of Anorexia Nervosa in 1978. This book created a wider awareness of anorexia nervosa among lay readers. A further important event was the death of the popular singer drummer Karen Carpenter in 1983, which prompted widespread ongoing media coverage of eating disorders.

Research

Marinol (dronabinol): a synthetic form of delta-9-THC a psychoactive compound extracted from the resin of the cannabis sativa plant is currently the subject of a clinical trial for use in the treatment of AN, the study is slated to end in 2011.. clinicaltrials.gov. September 25, 2008

Ghrelin|Ghrelin treatment : Pilot experiment|pilot studies have been concluded in the use of ghrelin Intravenous therapy|infusion for the inhospital treatment of patients with AN. The results showed positive effect in the reduction of the associated gastrointestinal symptoms, an increase in appetite and energy intake without adverse effect s.

Notable cases

Copyright Citations

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