Anorexia Nervosa

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I. DSM IV Diagnostic Criteria for Anorexia Nervosa

A. The patient refuses to maintain weight above 85% of expected weight for age and height.

B. Intense fear of weight gain or of being fat, even though underweight.

C. Disturbance in the perception of ones weight and shape, or denial of seriousness of current low weight.

D. Amenorrhea for three cycles in post-menarchal females.

II. Classification of Anorexia Nervosa

A. Restricting Type or Excessive Dieting Type. Binging or purging are not present.

B. Binge-Eating Type or Purging Type. Regular binging and purging behavior occurs during current episode (purging may be in the form of vomiting, laxative abuse, enema abuse, or diuretic abuse).

III. Clinical Features of Anorexia Nervosa

A. Anorexia nervosa is characterized by obsessive-compulsive features (counting calories, hoarding food), diminished sexual activity, rigid personality, strong need to control ones environment, social phobia (fear of eating in public). Anorexia nervosa commonly coexists with major depressive disorder.

B. Complications of Anorexia Nervosa. All body systems may be affected, depending on the degree of starvation and the type of purging. Leukopenia and anemia, dehydration, metabolic acidosis (due to vomiting), or alkalosis (due to laxatives), diminished thyroid function, low sex hormone levels, osteoporosis, bradycardia, and encephalopathy are commonly seen.

C. Physical signs and symptoms may include gastrointestinal complaints, cold intolerance, emaciation, parotid gland enlargement, lanugo hair development, hypotension, peripheral edema, poor dentition, and lethargy.

IV. Epidemiology of Anorexia Nervosa

A. Ninety percent of cases occur in females. The prevalence in females is 0.5-1.0%. The disorder begins in early adolescence and is rare after the age of forty. Peak incidences occur at age 14 and at age 18 years.

B. There is an increased risk in first-degree relatives, and there is a higher concordance rate in monozygotic twins. Patients with a history of hospitalization secondary to anorexia have a 10% mortality rate.

V. Differential Diagnosis of Anorexia Nervosa

A. Major Depression. Not associated with intense desire to lose weight or fear of weight gain.

B. Medical Conditions. Malignancies, AIDS, superior mesenteric artery syndrome (postprandial vomiting due to gastric outlet obstruction) are not associated with a distorted body image nor the desire to lose weight.

C. Social Phobia. Social phobia may manifest as fear of eating in public, but it is distinguished from anorexia by the presence of additional fears (eg, speaking in public).

D. Obsessive-Compulsive Disorder. Additional obsessions and compulsions unrelated to weight and food must be present to diagnose this disorder.

E. Body Dysmorphic Disorder. Additional distortions of body image must be present to diagnosis this disorder.

F. Bulimia Nervosa. These patients are able to maintain weight at or above expected minimum.

VI. Laboratory Evaluation of Anorexia Nervosa. Decreased serum albumin, globulin, calcium, hypokalemia, hyponatremia, anemia, and leukopenia may be present.

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