Anorexia Nervosa Clinical Presentation

Updated: Jun 22, 2023
  • Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD  more...
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Obtain the patient's history with the goal of developing a treatment plan rather than with the objective of merely ruling out an eating disorder.

A study by Nicholls et al found that about 21% of individuals with a childhood eating disorder had early feeding difficulties that predated the disorder’s diagnosis. In the study, the incidence of eating disorders was 3 per 100,000 youth; of that group, the criteria for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified were met by 37%, 1.4%, and 43% of individuals, respectively. [81]

A psychological profile for a patient with anorexia nervosa often demonstrates premorbid anxiety disorders, as well as more severe affective disorders, such as major depression and dysthymic disorder. Patients may also have symptoms of obsessive-compulsive disorder, with rigid and ritualistic eating behaviors. The study by Nicholls and colleagues found that of 208 individuals who met the criteria for an eating disorder, 41% had significant comorbidity (other psychiatric diagnoses) and 44% had a family history of psychiatric disorders. [81, 59, 60, 82, 83, 84, 85]

Pay careful attention to the patient's self-image and self-esteem, even if the patient identifies that he or she has an eating disorder. This may help to stratify the risk of mortality, which is 18 times higher when anorexia nervosa is comorbid with significant psychiatric disorders such as major depressive disorder. Patients should be asked about early morning awakening, tearfulness, and thoughts of suicide or a plan for it.

It is also important to focus on self-image in the treatment of anorexia nervosa because control-submission interactions between patient and therapist must be handled with care. [47, 86]

This interview can also help to identify an increased risk of dropping out from inpatient treatment. For example, the presence of anxiety or other mental health conditions can help to predict a response to treatment and assess motivation for changing behavior.

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. [86] Low body mass index (BMI) often relates to preexisting body dysmorphic disorder. [87, 88] The presence or absence of self-induced vomiting/binge eating and laxative use should also be ascertained.

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

  • Physical health and mental health concerns (including depression [89] )

  • Amenorrhea

  • Concentration and decision-making concerns

  • Headaches

  • Irritability

  • Cold hands or feet

  • Constipation

  • Dry skin or hair loss

  • Social withdrawal

  • Fainting or dizziness

  • Obsessiveness (food)

  • Lethargy

SCOFF questionnaire

The SCOFF questionnaire, as follows, is a screening tool for eating disorders, with 1 point awarded for every positive reply and a score greater than 2 indicating likely anorexia nervosa or bulimia [90] :

  • 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?

* One stone is approximately 14 lb, or 6.35 kg.


Physical Examination

Although patients with anorexia nervosa may show obvious emaciation, they can present anywhere along the spectrum of weight loss. Moreover, they may attempt to hide their weight loss by wearing bulky clothing or many layers.

Focus the physical examination on the changes commonly observed in anorexia nervosa. Vital sign changes include hypotension, bradycardia, and hypothermia. Other changes include the following [1] :

  • Dry skin

  • Hypercarotenemia

  • Lanugo body hair

  • Acrocyanosis

  • Atrophy of the breasts

  • Swelling of the parotid and submandibular glands

  • Peripheral edema

  • Thinning hair

Patients with purging behavior may have callouses to the dorsum of their dominant hand and dental enamel erosion.

Characteristic signs of inadequate energy (caloric) intake observed in patients with anorexia nervosa that are due to starvation-induced changes are summarized below. Positive signs include the following:

  • 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 white blood cell (WBC) count

Negative signs include the following:

  • Normal fundi or visual fields

  • No organomegaly

  • No lymphadenopathy

Behaviorally, a patient may demonstrate a flat affect and display psychomotor retardation, especially in the later stages of the disease. Cases of acute psychosis in anorexia nervosa from Wernicke-Korsakoff syndrome due to severe thiamine deficiency have been reported. [91]



Diagnosis of anorexia nervosa continues to include an early (or mild) stage, when there has not yet been any treatment initiated and the patient has significant signs and symptoms involving fear and disturbance of perception regarding normal body weight status, including dietary habits to prevent weight gain. Additional significant criteria include the presence of a body mass index (BMI) less than the third percentile and an established/severe stage (sometimes labelled stage 6 by some investigators) in which end-organ complications that involve the cardiac, renal, and endocrine systems can place the person at risk of death or significant morbidity. [92, 93, 94]

Early stage is defined by the following:

  • Mildly distorted body image

  • Weight 90% or less of average weight for height

  • No symptoms or signs of excessive weight loss

  • Use of potentially harmful weight-control methods or a strong drive to lose weight

Established or moderate stage features include the following:

  • Definitely distorted body image that has not diminished with weight loss

  • Weight goal less than 85% of average weight for height associated with a refusal to gain weight

  • Symptoms or signs of excessive weight loss associated with a denial that any problems are present

  • Unhealthy means of losing weight, such as eating fewer than 1000 calories per day, purging, or excessive exercise



There has been a case report of a patient with anorexia nervosa presenting with pancytopenia mimicking aplastic anemia. [95]