eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder: Anorexia

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Contributor Information and Disclosures

Updated: Mar 31, 2008

Introduction

Background

Anorexia nervosa is an eating disorder characterized by a weight loss of at least 15% of expected body weight,1 a devastating fear of weight gain, relentless dietary habits preventing weight gain, and a disturbance in the way in which body weight and shape are experienced. It has potentially life-threatening physiologic effects as well as enduring psychological disturbance.

Although anorexia nervosa is often heralded by a desire to lose an insignificant amount of weight through dieting, once the weight loss is in progress, immunological and hormonal factors that may play a role in the malignant spiral down and maintenance of anorexia nervosa include leptins (involved with signally satiety) as well as alpha melanocyte stimulating hormone.2

According to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), anorexia nervosa is defined as "the refusal to maintain body weight about 85% of predicted, an intense fear of gaining weight, undue influence of body shape or weight on self image, and missing at least 3 consecutive menstrual periods."3 An increase in morbidity and mortality is present in anorexia nervosa compared with other psychiatric disorders.

Pathophysiology

Anorexia nervosa is a disease that affects all organ systems. The principal systems affected are the cardiovascular and the endocrine systems. However, complications from other systems, including the GI, renal, reproductive, neurologic, orofacial, dermatologic and hematologic, are noted as well.

Frequency

United States

The prevalence of anorexia nervosa is 1%, with a bimodal pattern of onset, occurring in people aged 14 and 18 years. A point prevalence study performed in Rochester, Minnesota showed a prevalence of 145 and 113 cases per 100,000 people in 1988 and 1991, respectively. The disease is more common in industrialized countries where food is abundant and an emphasis is placed on a slender body shape and an overall thin appearance.

Although more common in women, with a female-to-male ratio of 10:1, approximately 10% of cases involve men. Gay and bisexual males are more likely to have an eating disorder than heterosexual males but they are more likely to have bulimia than anorexia.4

Anorexia nervosa is found mainly in the white (>95%) adolescent (>75%) populations of the middle and upper socioeconomic classes, although it can be observed in either sex and in people of any race, age, or social stratum.5

No influences have been found with respect to the month or season of birth.6

A 7% increased incidence in first-degree relatives may be related to an area on chromosome 1p at the DF1153721 locus.7

According to Mehler in 1997, certain groups are especially at risk, including dancers, long-distance runners, skaters, models, actors, wrestlers, gymnasts, flight attendants, college sorority members, and others for whom thinness is emphasized and overly rewarded.8

International

As mentioned above, anorexia nervosa is observed mostly in industrialized countries. However, a study performed in suburban London reported a prevalence of only 20.2 cases per 100,000 people, a much smaller figure than that observed in the United States.9

Mortality/Morbidity

Prognosis is guarded, and poor outcome is associated with longer duration of illness, late onset of illness, and more severe weight loss. Morbidity rates range from 10-20%; only 50% of patients completely recover. Of the remaining 50%, 20% remain emaciated, and 25% are thin.10 The remaining 10% become overweight or die of starvation.

The following are prognostic factors and how they affect anorexia nervosa:

  • Onset of anorexia nervosa before adulthood carries a more favorable outcome. However, onset at an age younger than 11 years is a poor prognostic factor.
  • Although the degree of weight loss at the clinically noted onset of the involvement of the patient's organic systems is not predictive of outcome, a high weight loss at presentation predicts a poor outcome.
  • Both a short duration of involvement of the patient's organic systems before admission and a short inpatient treatment period are associated with a favorable outcome.
  • A good relationship between the parent and child tends towards a more favorable outcome. Bryant-Waugh et al found a poor prognosis for patients from one-parent families, from families in which parents had been married before, and from families in which several generations lived together.11

Race

As mentioned earlier, no discrimination in race with respect to anorexia nervosa is observed, although the disease is observed more often in white adolescents than in black adolescents.

Sex

A predominance of anorexia nervosa in females is observed. Studies have reported a 10:1 female-to-male ratio. Treatment plans remain the same for both sexes.

Age

Although it is more frequently observed in the adolescent age group, anorexia nervosa has no age restrictions and can be observed in the young child and adult as well. Onset in both of the latter groups carries a poor prognosis.

Clinical

History

Obtain patient history with the goal of developing a treatment plan and not with the thought of merely ruling out an eating disorder. With medical assessment, focus on the medical complications of altered nutrition. Seek a careful history detailing weight changes, dietary patterns, and excessive exercise. Determine weight and height.

A review of systems may reveal many positive responses. The following are symptoms commonly observed in patients with anorexia nervosa:

  • Physical health concerns
  • Mental health concerns
  • Amenorrhea
  • Concentration concerns
  • Cold hands or feet
  • Decision-making concerns
  • Constipation
  • Irritability
  • Dry skin or hair loss
  • Depression12
  • Headaches
  • Social withdrawal
  • Fainting or dizziness
  • Obsessiveness (food)
  • Lethargy

Physical

Focus the physical examination on the changes commonly observed in anorexia nervosa. Vital sign changes include hypotension, bradycardia, and hypothermia. Other changes include dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, atrophy of the breasts, and swelling of the parotid and submandibular glands. ECG reveals a prolonged cardiac output (QT) interval,13 and echocardiography (ECHO) reveals a decreased ventricular mass and mitral valve prolapse (see Other Tests). GI signs include intestinal dilation from constipation and diminished intestinal motility.

Mental health assessment

When performing a mental health assessment, focus on making a diagnosis, identifying concurrent emotional-behavioral illnesses, evaluating for the risk of suicide,14,15 and exploring the psychosocial context of the symptoms.

The following are characteristic signs of inadequate energy (caloric) intake observed in patients with anorexia nervosa that are due to starvation-induced changes:

  • Positive
    • Hypothermia
    • Acrocyanosis
    • Resting bradycardia (resting heart rate often 40-49 beats per minute)
    • Hypotension
    • Orthostatic lowered blood pressure or pulse
    • Loss of muscle mass
    • Low blood glucose (impaired insulin clearance)
    • Low parathyroid hormone levels
    • Elevated liver function
    • Low WBC count
  • Negative
    • Normal fundi or visual fields
    • No organomegaly
    • No lymphadenopathy

Causes

Anorexia nervosa is a complex condition based on various biologic, psychologic, and social issues. As such, referring to anorexia nervosa as a developmental condition rather than a mental condition is preferable. Therefore, commenting about predisposing, precipitating, and perpetuating factors is more useful than commenting about actual causes.

  • Predisposing factors include the following factors that make a patient more vulnerable to developing an eating disorder:
    • Female sex
    • Family history of eating disorders16
    • Perfectionistic personality
    • Difficulty communicating negative emotions
    • Difficulty resolving conflict
    • Low self-esteem
  • Precipitating factors relate most often to developmental tasks that cause intense intrapsychic conflict and unconscious feelings of anxiety related to developing into a mature sexual person; these factors interact with physiological and biological factors.
    • In individuals aged 10-14 years, these factors are related to sexual development and menarche, which is associated with a spurt in weight gain. Societal influences intensify the fear of becoming "fat." This feeling is often intensified by a peer group that comments in a rejecting fashion. These individuals often diet and receive peer acceptance for weight loss; this emotional reinforcement combined with the physiological response of the body to the sudden loss of weight (when >5 lb) intensifies the likelihood of continued weight loss. Sudden weight loss with loss of fat causes a decrease in body temperature, which physiologically causes a subjective feeling of chills; this discomfort is relieved by increased physical activity, which causes further weight loss. The continuous downward spiraling of weight loss then causes secondary amenorrhea and loss of secondary sexual characteristics, which further worsens weight loss.
    • In individuals aged 15-16 years, precipitating factors stem from independence and autonomy struggles. Ambivalence about growing up is present, and an abnormal transition from dependence to interdependence rather than independence occurs.
    • In individuals aged 17-18 years, identity conflicts are more common. These patients do not make healthy transitions from leaving home to going to college or getting married.
  • Perpetuating factors maintain the eating disorder.
    • Biologic issues refer to the signs and symptoms of starvation and to the aspects involved in refeeding the malnourished patient.
    • Psychologic issues encompass the coping strategies engendered by the eating disorders. According to Kreipe et al in 2000, the treating clinician may threaten the homeostatic balance that has been achieved within the family system secondary to dealing with the patient with anorexia; negative emotions, such as anger and denial, may be directed at the clinician.17

More on Eating Disorder: Anorexia

Overview: Eating Disorder: Anorexia
Differential Diagnoses & Workup: Eating Disorder: Anorexia
Treatment & Medication: Eating Disorder: Anorexia
Follow-up: Eating Disorder: Anorexia
References
Further Reading
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Further Reading

The SCOFF questionnaire is a screening tool for eating disorders. One point is awarded for every positive reply. A score greater than 2 indicates likely anorexia nervosa or bulimia. The questionnaire is as follows: 45

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you lost more than One stone in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

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Keywords

anorexia, anorexia nervosa, eating disorders, excessive weight loss, anorexiant, anorexic, anorectic, diminished appetite, aversion to food, psychiatric disorder, fear of weight gain, dieting, amenorrhea, constipation, hypotension, bradycardia, hypothermia, dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, breast atrophy, mitral valve prolapse, hypokalemic hypochloremic metabolic alkalosis, acidosis, leukopenia, thrombocytopenia, dehydration, distorted body image, congestive heart failure, CHF, edema, psychosis

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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