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Factual Information about Anorexia Nervosa
What is anorexia nervosa?
Anorexia nervosa is a severe, life-threatening mental illness characterized by significant weight loss through self-starvation with caloric restriction or fasting and affects approximately 0.5 - 1.0% of the population in the United States . Anorexia nervosa, often shortened to “anorexia,” is most common in young female adolescents; however, diagnoses of anorexia is increasingly found in other populations, including males, who make up approximately 10 - 15% of individuals affected by anorexia with especially high rates among homosexual men [2,3].
How is anorexia diagnosed?
Diagnosticians include psychiatrists, medical doctors, and licensed psychologists can accurately assess patients presenting with eating disorder symptoms using the Diagnostic and Statistical Manual (DSM), written by the American Psychiatric Association. The DSM is a reference guide for diagnosticians to utilize in order to accurately diagnose patients with mental illnesses and create the most beneficial treatment plans .
Clinicians will assess a patient according to medical protocol, which most commonly includes a physical exam, lab work including blood panels and an electrocardiogram (EKG), and a psychiatric evaluation, if the clinician is knowledgeable enough to do so . Clinicians who do not specialize in the treatment of eating disorders may refer a patient to a medical specialist, a therapist who treats eating disorder patients, or an eating disorder treatment facility.
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What are the diagnostic criteria for anorexia?
The diagnostic criteria for anorexia nervosa as outlined in the DSM was updated in early 2013 when the APA released the DSM-5. The changes to criteria for anorexia included the removal of “refusal to maintain a healthy weight,” in order to eliminate the misconception that a patient has a choice to continue weight loss and self-starvation, which is simply untrue for a mental illness that causes an intense fear of weight gain or becoming overweight .
More importantly, the DSM-5 removed amenorrhea, or absence of menstruation, as a criterion so that males, post-menopausal women, and women on contraceptives can be diagnosed with anorexia . As previously mentioned, while these populations constitute a minority of the population of anorexia sufferers, diagnoses of these individuals are increasing yearly .
Additionally, the weight threshold criterion of having a BMI of less than 17.5 or being below 85% of expected weight was removed and replaced with a criterion that states a patient must prevent at a “significantly low weight,” which is most usually interpreted as having a BMI below 19 for adults [1,4]. A common misconception is that overweight or individuals at healthy BMI’s can now be diagnosed with anorexia. However, the weight criterion still remains, limiting the anorexia diagnosis to underweight individuals. More information about this misconception can be found under “Common Misconceptions.”
DSM-V Criteria for AN:
- Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
- Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain, even though at a significantly low weight.
- 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 persistent lack of recognition of the seriousness of the current low body weight.
Severity Scale for AN:
The severity scale is defined as follows:
- Mild: BMI greater than to 17.
- Moderate: BMI of 16 - 16.99
- Severe: BMI of 15 - 15.99
- Extreme: BMI less than 15.
The DSM additionally outlines two sub-types of anorexia nervosa: restricting sub-type and binge-eating/purging sub-type. Restricting sub-type is defined as an individual has not engaged in recurrent episodes of binge eating or purging behavior. This sub-type describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. On the other hand, binge-eating/purging sub-type is defined as an individual who has engaged in recurrent episodes of binge-eating or purging behaviors. 
Further categories exist for patients who are either in partial or full remission. Partial remission is defined as having had a previous diagnosis of anorexia nervosa and no longer presents at a significantly low weight while phobic responses to weight gain, behaviors interfering with weight gain, or distortions regarding body weight or shape are still present ,
In other words, a patient who has become weight-restored yet continues to restrict his or her caloric intake, still fears further weight gain, or continues to present with body dysmorphia would be said to be in partial remission. Full remission is defined as an individual who has previously been diagnosed with anorexia yet no longer presents with any of the criteria for the disorder .
The most current DSM also includes a scale for severity, based on present BMI of a patient; however, severity may be increased in situations in which a patient presents with a higher degree of symptomology or has experienced a significant decrease in functionality and a significant increase in the need for supervision .
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What are the medical complications of anorexia?
Eating disorders carry the highest mortality rate of any mental illness, resulting in premature deaths of thousands of sufferers each year . The mortality rate for each eating disorder differs only slightly, with anorexia resulting in a mortality rate of 4%, bulimia nervosa resulting in a mortality rate of 3.9%, and eating disorder (not otherwise specified) resulting in the highest mortality rate of all eating disorders at 5.2% . The statistics for mortality rates differ greatly; however, the deaths of many sufferers of anorexia are often attributed to suicide as a result of the emotional pain of anorexia . Acknowledging the statistics regarding death among sufferers is a sobering reminder of the seriousness of all eating disorders.
Although most sufferers of anorexia do not succumb to the illness, most individuals suffer physical symptoms ranging to temporary to life-long. The most common and life-threatening physical complications are alterations in cardiovascular function, including low heart rate, low blood pressure, heart arrhythmia, and congestive or acute heart failure . These symptoms can occur very early in the progression of anorexia and should always be taken seriously.
Other physical repercussions of starvation include renal or kidney abnormalities, including renal failure or decreased renal function; electrolyte imbalances that can lead to cardiac arrest or seizures; esophageal tears or the development of Barrett’s esophagus in purging anorexics; delayed gastric emptying that continues well after re-feeding; alternating constipation and diarrhea that can damage the intestinal lining, especially in cases of laxative abuse; amenorrhea leading to permanent infertility and osteoporosis; decreased liver function resulting in high cholesterol; tooth loss or fractures as a result of decreased bone density; and dermatological changes including painfully dry skin and lanugo, or abnormal hair growth [5,8].
Many sufferers of anorexia justify remaining in relapse by referencing normal lab results; however, these symptoms can occur suddenly, even when previous blood chemistry and EKG results are normal. Most individuals who suffer these consequences often do so very rapidly, which can be dangerous and even fatal. Remember that an important cognitive distortion within anorexia sufferers includes not acknowledging the seriousness of the symptoms of starvation.
What are the signs and symptoms of anorexia?
Although signs and symptoms vary between anorexia sufferers, commonalities can be drawn between most patients. The following is an extensive list of signs and symptoms that can indicate possible anorexia, as provided by the Center for Eating Disorders at Sheppard Pratt :
- sudden and significant weight loss along with obsessive weighing or exercise
- secretive “body-checking,” which occurs when an individual checks his or her body in a mirror to detect any bodily changes or evidence of weight gain
- increased vocalization about fear of gaining weight or being “fat,” accompanied by body dysmorphia in which the individual believes he or she is overweight, regardless of being underweight
- rigid and obsessive counting and restricting of calories or macro-nutrients
- development of “fear foods” which cause the individual anxiety and often result in his or refusal to eat said foods
- secretive food hoarding, with or without the presence of binge eating, or collecting recipes and pictures of food
- preparing meals for family members without eating the meal
- engaging in food rituals in which the individual presents with abnormal behaviors such as eating small bites, cutting food into small pieces, eating food in a certain order or at specific times, or eating in isolation
- increasing social isolation, moodiness, depression, and anxiety
These signs and symptoms can be present in healthy individuals who are attempting to lose weight or eat healthfully; however, when an individuals are genetically pre-disposed to developing an eating disorders, as indicated by a history of eating disorders or other addictions in the family history, the attempt to lose weight can often trigger the development of anorexia or another dangerous restrictive eating disorder .
How is anorexia treated?
Treatment for anorexia can vary depending on the severity of physical symptoms and mental impairment. If physical and mental health are significantly compromised, medical stabilization within a hospital may be required to regulate address cardiovascular symptoms, correct electrolyte imbalances, or restore weight when the individual is at a dangerously low weight.
However, many individuals are able to recover by admitting to a residential treatment facility, which offers medical supervision in a home-like environment while often providing nutrition education, group and individual therapy, “life skills” for the development of healthy coping mechanisms, and education about addictions. How long a patient stays at a treatment facility will depend on the amount of weight restoration that needs to occur, as well as other co-morbid disorders like anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Most treatment facilities require a minimum stay of at least thirty days, and many facilities care for patients for up to six months.
If possible, an individual can enter into partial-hospitalization programs (PHP) that take place throughout the day, leaving the afternoon and nights free so that he or she eats dinner and sleeps at his or her own home. These programs are less disruptive to the patient and allow him or her to live at home with his or her family. A step down from PHP is intensive outpatient program, which generally takes place for six to eight hours per week; IOP allows the individual the most freedom of any program, so these programs generally only accept patients who are relatively autonomous and motivated toward recovery.
Regardless of treatment setting, patients suffering from anorexia often require individual therapy and nutritional dietitian. Most PHP and IOP programs provide access to these professionals; however, once an individual discharges from the program, he or she may continue to see a dietitian that will monitor weight and food behaviors, as well as a long-term individual therapist that will help determine underlying issues that lead the individual to develop anorexia.
If you are suffering from an eating disorder of any kind and have questions regarding treatment and recovery, please do not hesitate to message me. I am always willing to answer questions regarding eating disorders, especially anorexia, as I have been in recovery from anorexia and sleeping pill addiction for six months and have experience with residential treatment, weight restoration, intensive out-patient, nutrition counseling, and individual therapy to address trauma and interpersonal conflict. You can also e-mail me at firstname.lastname@example.org.
 Tamburrino M. B. and McGinnis R. A. 2002. Anorexia nervosa: a review. Panminerva medica 44(4): 301 - 311.
 Carlat et al. 1997. Review of bulimia nervosa in males. American Journal of Psychiatry 154.
 Author unspecified. 2002. International Journal of Eating Disorders 31: 300 - 308.
 American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
 Hall-Flavin D. K. 2012. Anorexia diagnosis and treatment. Mayo Clinic.*
 Crow et al. 2009. Increased mortality in bulimia nervosa and other eating disorders. American Journal of Psychiatry 66: 1342 - 1346.
 Sharp C. K. and Freeman C. P. 1993. The medical complications of anorexia nervosa. The British Journal of Psychiatry 162: 452 - 462.
 Pomeroy C. and Mitchell J. E.; Fairburn C. G. and Brownell K. G. eds. 2013. "Medical complications of anorexia nervosa and bulimia nervosa" in Eating disorders and obesity (2nd ed.). 278 - 284.
 Mittnacht A. M. and Bulik C. M. 2014. Best nutrition counseling practices for the treatment of anorexia nervosa: a Delphi study. International Journal of Eating Disorders**
 Author unspecified. 2014. Anorexia nervosa. Center for Eating Disorders at Sheppard and Pratt.*
*informal citation for online references
**incomplete citation; no other information provided.
© 2014 Elizabeth Watson