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ANOREXIA NERVOSA

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DSM-V CRITERIA* FOR ANOREXIA NERVOSA ARE SUMMARIZED BELOW

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  • Restriction of calories compared to requirements which leads to significantly low weight

  • Intense fear of gaining weight

  • Disturbance in the way in which one’s body weight or shape is experienced

  • Restricting type: During the prior 3 months with anorexia nervosa, the person has not achieved weight loss through being regularly engaged in binge eating or purging behavior (self-induced vomiting, use of laxatives/diuretics/enemas) but through dieting and excessive exercise

  • Binge eating/Purging type: During the prior 3 months with anorexia nervosa, the person has regularly engaged in binge eating or purging behavior (self-induced vomiting, use of laxatives/diuretics/enemas)

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*Note: DSM-V no longer sets a specific percent of ideal body weight but states that “significantly low weight” is less than is minimally normal or normally expected (for children and adolescents). DSM-V removes amenorrhea as a criterion for anorexia as it did not apply to males, females on contraceptives, or pre-menarchal females. Also, patients that meet all of the criteria except amenorrhea have the same clinical course as those who meet all four criteria.

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EPIDEMIOLOGY

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  • 1% of adolescent females; female:male = 20:1

  • Age at presentation ranges from 10 to 25 years

  • Increasing incidence in adolescent males, nonwhite populations, and lower socioeconomic groups; more common among individuals involved in sports or activities where size and body shape impact their success

  • Bimodal age of onset at 14 and 18 years corresponding with life transitions (i.e., puberty, moving from high school to college or work)

  • Mortality rates range from 1.8% to 5.9% (usually because of cardiac complications or suicide)

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ETIOLOGY

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  • Genetic: Increased risk in first-degree relatives with an eating disorder

  • Neurotransmitters: Serotonin and its relationship to hunger and satiety

  • Psychologic: Theories range from perfectionism, identity conflicts, history of abuse, negative comments from others about weight or appearance, enmeshed families, and sociocultural influences

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CLINICAL MANIFESTATIONS

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  • Menstrual disorders are the most common presentation

  • Frequently, patients do not have complaints, but family members are concerned about significant weight loss, secondary amenorrhea, dizziness, lack of energy, gastrointestinal complaints (e.g., constipation), and/or pale skin

  • Depending on amount of weight loss, clinical findings can range from normal to findings of orthostasis, bradycardia, hypothermia, hypotension, dry skin, lanugo hair, thinning hair, brittle nails, peripheral edema, acrocyanosis, and findings suggestive of purging such as eroded tooth enamel, scars on knuckles, or parotid enlargement

  • External evidence of self-harm, such as scars from cutting on the extremities

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DIAGNOSTICS

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  • Must consider the differential diagnosis for weight loss and exclude malabsorption and catabolic states

  • Clinical information is vital. Questions should focus on disordered thinking and behavior. Screening questions (e.g., SCOFF questionnaire) can be helpful:

    • ✓ Do you make yourself sick because you feel uncomfortably full?

    • ✓ Do you worry you have lost control over ...

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