Psychological Disorders: Anorexia Nervosa
American
Description
A. 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).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. 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.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at
least three consecutive menstrual cycles. (A woman is considered to
have amenorrhea if her periods occur only following hormone, e.g.,
estrogen, administration.)
Specify
type:
Restricting Type: during the current episode of Anorexia Nervosa,
the person has not regularly engaged in binge-eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics,
or enemas)
Binge-Eating/Purging
Type: during the current episode of Anorexia Nervosa, the person has
regularly engaged in binge-eating or purging behavior (i.e., self-induced
vomiting or the misuse of laxatives, diuretics, or enemas)
European
Description
Anorexia nervosa is a disorder characterized by deliberate weight
loss, induced and/or sustained by the patient. The disorder occurs
most commonly in adolescent girls and young women, but adolescent
boys and young men may be affected more rarely, as may children approaching
puberty and older women up to the menopause. Anorexia nervosa constitutes
an independent syndrome in the following sense:
(a)
the clinical features of the syndrome are easily recognized, so that
diagnosis is reliable with a high level of agreement between clinicians;
(b) follow-up studies have shown that, among patients who do not recover,
a considerable number continue to show the same main features of anorexia
nervosa, in a chronic form.
Although
the fundamental causes of anorexia nervosa remain elusive, there is
growing evidence that interacting sociocultural and biological factors
contribute to its causation, as do less specific psychological mechanism
and a vulnerability of personality. The disorder is associated with
undernutrition of varying severity, with resulting secondary endocrine
and metabolic changes and disturbances of bodily function. There remains
some doubt as to whether the characteristic endocrine disorder is
entirely due to the undernutrition and the direct effect of various
behaviours that have brought it about (e.g. restricted dietary choice,
excessive exercise and alterations in body composition, induced vomiting
and purgation and the consequent electrolyte disturbances), or whether
uncertain factors are also involved.
Diagnostic
Guidelines
For a definite diagnosis, all the following are required:
(a)
Body weight is maintained at least 15% below that expected (either
lost or never achieved), or Quetelet's body-mass index is 17.5 or
less. Prepubertal patients may show failure to make the expected weight
gain during the period of growth.
(b) The weight loss is self-induced by avoidance of "fattening
foods" and one or more of the following: self-induced vomiting;
self-induced purging; excessive exercise; use of appetite suppressants
and/or diuretics.
(c) There is body-image distortion in the form of a specific psychopathology
whereby a dread of fatness persists as an intrusive, overvalued idea
and the patient imposes a low weight threshold on himself or herself.
(d) A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal
axis is manifest in women as amenorrhoea and in men as a loss of sexual
interest and potency. (An apparent exception is the persistence of
vaginal bleeds in anorexic women who are receiving replacement hormonal
therapy, most commonly taken as a contraceptive pill.) There may also
be elevated levels of growth hormone, raised levels of cortisol, changes
in the peripheral metabolism of the thyroid hormone, and abnormalities
of insulin secretion.
(e) If onset is prepubertal, the sequence of pubertal events is delayed
or even arrested (growth ceases; in girls the breasts do not develop
and there is a primary amenorrhoea; in boys the genitals remain juvenile).
With recovery, puberty is often completed normally, but the menarche
is late.
Differential
Diagnosis
There may be associated depressive or obsessional symptoms, as well
as features of a personality disorder, which may make differentiation
difficult and/or require the use of more than one diagnostic code.
Somatic causes of weight loss in young patients that must be distinguished
include chronic debilitating diseases, brain tumors, and intestinal
disorders such as Crohn's disease or a malabsorption syndrome.