Anorexia Nervosa

College Sophomore Female, Age 19

Michelle Phan

Eating disorders are fairly rare in the general population. Not yet
documented as anorexia nervosa, cases of self-starvation date back to the
17th century (1). Anorexia Nervosa (AN) is the oldest documented eating
disorder (ED) (2) and was first recognized as a psychiatric illness in the late
19th century (3). Until the end of the 20th century, there was no knowledge of
the psychopathology of anorexic patients (1).
AN is described as an extreme psychiatric disorder illustrated by a deep fear
of becoming fat, refusal to maintain a minimally healthy body weight, and a
disturbed body image (4). According to the American Psychiatric Association
(6), the main component of AN is the restriction of caloric intake to
significantly lower body weight. Individuals with anorexia tend to have a
distorted body image and body concept; are obsessed with their body shape
and weight; are in denial of their low body weight; and are ignorant to the
health detriments of AN (6).
Anorexia mostly affects adolescent women with a female to male ratio
between 10:1 and 4:1. In the United States, anorexia has a lifetime
prevalence between 0.9% and 2.2% for women. It is estimated that the
prevalence of AN in young women is 0.3% (4). This disorder has an average
occurrence length of ten years. AN has high rates of morbidity and
comorbidity. Anorexia is typically comorbid with anxiety disorders that often
precede the ED. AN also has the highest mortality rate of any ED and
psychiatric illness with roughly 6% of anorexic women dying per decade of
having anorexia. The suicide rate of anorexic patients is 57 times higher than

in the general population and is one of the most common causes of death in
anorexic patients, along with acute starvation (7).

Etiology The exact cause of AN is still unknown. Anorexia causation most

likely has a combination of biological, environmental/cultural, and
psychological aspects. There are a plethora of risk factors that play into the
development of AN.
According to Bulik, et al. (8), there have been recent studies that show that
genetic heritability can increase the risk of developing an ED by 50-85% and
contributes to neurobiological factors that cause eating disorders. Anorexia
has been identified as a Western illness because of its prevalence and
incidence in the Western World (1, 4). AN occurs in cultures where there is an
ample amount of food; and dieting and weight loss hold special value, mostly
due to the media. Anorexia can develop from young women that begin to
diet to lose weight and gain attractiveness and self-esteem. Psychologically,
dysfunctional food choices are associated to increased levels of distress (9).
Developmental, familial, and sociocultural factors are predisposing factors of
AN. Risk factors for AN have been identified as being female, being
Caucasian (1), being an adolescent, and having an obsessional personality.
However, most obsessional adolescent females do not develop AN (10).
Anorexia is more frequent in young women, in middle and upper social
economic classes (11). Precipitating factors such as life events (family and
environmental changes) and distressing sexual experiences are also risk

factors for those who develop AN. Those with occupations that have an
emphasis on weight or body shape; are valued for bodily appearance or for
physical performance; or are involved in food and weight management are
also more likely to develop this disorder (1).
Pathophysiology There are many medical complications that can occur
from the starvation, purging and/or over exercising associated with AN. The
serotonergic system have been found to be involved with the development of
AN. Several studies have shown that there are elevated levels of 5hydoxyindole acetic acid, the primary serotonin metabolite, in the
cerebrospinal fluid of anorexic individuals. These studies have also shown an
increase in frequency in abnormal serotonin receptor genes (12, 13, 14).
Neuroendocrine abnormalities and increased plasma cortisol have also been
found in those with AN. Endocrine changes makes an anorexic individual
have low serum insulin levels with an increase in glucagon concentration.
Endocrine changes also affect the sympathetic nervous system, gonadal
axis, adipose tissue hormones, thyroid, adrenal cortex, growth hormone,
vasopressin, inflammatory cytokines, hypothalamic control of hunger, and
bone density (9, 11).
The parietal lobe has also been found to be dysfunctional, potentially
affecting an anorexic individuals self-perception of body shape and weight.
Compared to men, the parietal lobe of women also tends to have decreased
volume and surface area, which can explain why females are more affected
than males. There are structural changes in the brain that directly occur from

the malnourishment of AN. There is gray and white matter loss; an increase
in cerebrospinal fluid volume; and enlarged sulci in the brains of anorexic
individuals (7).
The nutritional deficits may increase the chance of cardiac arrhythmias and
infection. There can be decreases in cardiac muscle mass, chamber size, and
cardiac output; with a prolapse in the mitral valve frequently detected (12).
Individuals with AN can also have bone mass loss, orthostatic hypotension,
severe bradycardia, loss of subcutaneous fat tissue, abnormal menstrual
function in females, decreased testosterone in males, hair loss, hypothermia,
and electrolyte imbalances. Many of these consequences may not be
reversible and can lead to more serious health conditions later on in life(15).
Clinical Manifestations The American Psychiatric Associations 5th edition
of the Diagnostic and Statistical Manual of Mental Disorders criteria for
anorexia indicates body weights that are significantly below expectations
considering age, height, sex, physical health, and developmental level. AN is
separated into two types by the current classification system: restricting type
and binge eating-purging type. The restricting type is the anorexic individual
that maintains a low body weight by extreme methods of food restriction and
in some, excessive exercise. The binge eating-purge type is the anorexic
individual who meets the weight criteria for anorexia but also binge eats and
purges (5, 7).
Symptoms and signs in anorexic individuals may be mild and temporary or
severe and long lasting. Physical signs and symptoms of anorexia may

include, but are not limited to extreme weight loss, emaciated appearance,
fatigue, insomnia, dizziness, fainting, thinning/loss of hair, dehydration,
constipation, irregular heart rhythms, osteoporosis, and/or low blood
pressure (1, 16). Behavioral symptoms and signs may include an absence of
emotion, refusal to eat, denial of hunger, fear of becoming fat, and/or
preoccupation with food (16). Malnourishment can lead to psychological
symptoms, such as depression, obsessional rituals, reduced alertness, social
withdrawal, and reduced concentration (5). Those with AN tend to have an
enhanced interest in cooking and nutrition. Despite the restriction of food
consumption, anorexic individuals are often very knowledgeable about the
nutritional components of food and use this knowledge to select low-energy
foods for consumption (11).
Medical Diagnosis In order to be diagnosed with anorexia nervosa, the
patient must meet the criteria in the Diagnostic and Statistical Manual of
Mental Disorders. The criteria includes the limitation of caloric intake
resulting in a considerably low body weight, fear of gaining weight with
behaviors that interfere with weight gain, and a disturbance in the
perception of the patients body image or denial of illness (5). If AN is
suspected, tests and exams will be conducted to help diagnose AN, rule out
underlying medical causes for the weight loss, and check for other
complications that may have ensued. A physical exam could include
assessment of the abdomen; measurement of heart rate, blood pressure,
and temperature; skin and nail health; heart and lung sounds; and height

and weight. Low body weight in adults is described, as a body mass index
(BMI) of less than or equal to 17 kg/m2 is considered significantly low. Age is
a crucial consideration in making a diagnosis because of the BMI range
during the time that AN is typical; in late childhood, adolescence, or early
adulthood (17). Lab tests may include a complete blood count; specialized
blood tests to check electrolytes, protein, and liver, kidney and thyroid
health; and a urinalysis. There may also be a psychological evaluation to
assess the patients thoughts, feelings, and eating habits. X-rays may be
conducted to check bone density and examine potential stress fractures or
broken bones. X-rays may also be used to check for cardiothoracic issues,
electrocardiograms may be used to look for irregularities in the heart (1, 14,
17). A 19 year old, college sophomore female patient has been diagnosed
with anorexia. Her physical exam could show a low BMI, while her
psychological evaluation has the potential of pinpointing the onset of AN to
her going away to college or using anorexia as a weight-management
technique. College students with anorexia typically become unusually lean,
but still talk about feeling overweight (18).
Treatment and Effects Many patients with anorexia do not know or deny
that they have anorexia, presenting a challenge in treating AN. Patients
typically undergo treatment only when their condition is serious. There are
inpatient and outpatient treatments; course of action should be arranged
with a team of medical providers. Hospitalization may be required and
nutritional supplementation would be provided in those cases. Evidence-

based treatment options are very limited but there are several treatment
plans for AN that focus on weight restoration, behavior change, and
pathopsychological reduction. Some studies have shown that psychotherapy,
such as cognitive behavioral therapy (CBT) and family therapy, is successful
in reducing the risk of relapse in adult patients. CBT helps the patient
restructure their thoughts and actions to healthier ones (6). There are no
medications approved for treatment of AN, but psychiatric medications can
help treat other mental disorders that the patient may have. There have
been weak studies that show that the use of selective serotonin reuptake
inhibitors (SSRIs) can help prevent relapse in recovered patients. SSRIs are
ineffective in restoring weight and reducing symptoms of AN. Olanzapine has
also shown to help produce weight gain and relieve anxiety (8, 15). There are
different treatment options within residential treatment facilities that
typically produce long-term positive outcomes (5).
With the college patient, if she seeks treatment early enough, she can
potentially recover completely. College students typically do not receive
treatment until the later stages of their disorder. At this point, the patient
would most likely be at risk of having a serious medical condition, if she does
not already have one. If she were to seek treatment, she would most likely
undergo CBT to negate the distorted views she may have about herself. She
would have to be committed to the treatment for it to be successful. She
may seek help from counselors and support groups so that she does not
relapse (6, 5).

Prognosis and Progression If treatment is sought, the outcomes will vary

by patient. CBT coupled with Olanzapine among anorexic patients has shown
a reduction in the risk of relapse (6, 8). Relapse is common in patients with
AN, despite months of successful treatment (9). If treatment is not sought,
malnourishment can damage almost every organ system in the body and
can be fatal. Death may occur abruptly, as a result of arrhythmias or an
imbalance of electrolytes. Other complications of AN include anemia;
cardiovascular problems; bone loss leading to risk of fractures later in life;
osteoporosis; risk of infection; in females, menstrual absence; in males,
decreased testosterone; gastrointestinal problems; kidney problems; and an
increased risk of suicide (1, 15). The damage that occurs may not be
reversible, even after treatment (15). If the college patient does not relapse
from her CBT then there is a chance that her body may fully recover. If she
does relapse and has AN again then she is putting herself at risk for many
medical complications that can ensue from chronic AN (6).
Current Issues, Research The unknown etiology of AN is a topic of
research. There have been many studies attempting to discover the
underlying physiological cause of AN with little to no success. Little research
has shown that the restriction of food is extremely rewarding to an anorexic
patient and the continuous stimulus forms habitual eating behaviors. Further
research can determine if the cognitive and psychological mechanisms are
linked to the persistence of eating behaviors in AN (9). With an unknown
cause, treatment options and its efficacy seem to be the main focus of

research. Many experimental therapies include antipsychotic medications

and psychotherapy. Small clinical experiments have studied Haloperidol as a
possible treatment for AN (14). CBT is commonly and successfully used for
eating disorders, but there are only a few studies that show the effectiveness
in AN specifically. Oudijn, Storosum, Nelis, and Denys (6) have also
researched deep brain stimulation as a treatment option. Another theme
within AN research is relapse and why it occurs (6).
Summary Anorexia nervosa is the oldest documented eating disorder,
dating back to the late 19th century (3). AN is an intense psychiatric disorder
characterized by a deep fear of becoming overweight, a distorted body
image, and a significantly low body weight (4, 5). The cause of AN is
unknown. There are biological, environmental/cultural, and psychological
factors, as well as risk factors common in individuals with AN. The most
common predisposing factors include being female, being Caucasian, being
an adolescent, and having an obsessional personality (1,8). AN breaks down
into two types: restrictive and binge eating/purging (5,7). Both types have
risks of many medical, physical and psychological complications (5, 16). To
diagnosis AN, many tests have to be conducted to rule out underlying
conditions (1). There are many treatment options for AN that include
different types of psychotherapy and medications. There is risk of relapse
with any treatment option (6,8). If left untreated, AN can lead to a slew of
medical complications later in life, including death and suicide (1, 15).

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