Anorexia nervosa is an eating disorder characteristic of abnormally low weight attributed to a distorted perception of weight and an intense fear of gaining weight. The eating disorder is common among women. Individuals diagnosed with this eating disorder are overly concerned about controlling their body shape and weight, thus often practice extreme eating habits that adversely impact their health (American Psychiatric Association, 2016). Some of these extreme eating habits include exercising excessively, misusing laxatives, or vomiting after eating in a bid to control their calorie intake to prevent weight gain. The condition can be diagnosed by observing physical signs and symptoms as well as behavioral and emotional issues characteristics of the eating disorder. Some of the physical symptoms include a thin appearance, extreme weight loss, insomnia, fatigue, dizziness, abnormal blood counts, absence of menstruation, bluish discoloration of the fingers, low blood pressure, intolerance of cold, dehydration, irregular heart rhythms, and swelling of legs or arms (Walsh, Attia, Glasofer, & Sysko, 2016). Meanwhile, behavioral and emotional symptoms include exercising excessively, attempts to restrict food intake through fasting or dieting, binge on food followed by self-induced vomiting or use of laxatives to get rid of the food consumed. The individual is also overly preoccupied with food, often taking time to prepare food but failing to consume any of it in addition to frequently refusing or skipping meals. It is also common for the individual to make excuses for not eating and only eating certain foods that they consider safe as they have low calories and fat (Anderson, Murray, & Kaye, 2018). Moreover, the individual frequently checks their weight and perceived flaws in the mirror. This is besides being socially withdrawn and experiencing insomnia.
A positive diagnosis of anorexia nervosa presents three essential features, namely intense fear of becoming fat or gaining weight, persistent efforts to restrict energy intake, and a disturbance in perceived shape or weight. The individual makes an effort to maintain a body weight that is significantly below the normal level for their sex, age, physical health, and developmental trajectory. More often than not, the individual’s body weight needs this diagnosis criterion by maintaining a significant weight loss (American Psychiatric Association, 2016). Among adults and children, however, there may be instances when this failure to maintain a normal developmental trajectory or make the expected weight gain.
Anorexia nervosa is common among young females with an annual prevalence of 0.4%. However, very little is known about the prevalence of anorexia nervosa among males as it is far less common among males in comparison to females (Cuzzolaro & Fassino, 2018). Indeed, clinical populations reflect a disproportionately skewed ratio of 10 females for every male diagnosed with this eating disorder.
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Development and Course
In most cases, early onset of the eating disorder begins during adolescence and young adulthood. As such, it is rare for the onset of the eating disorder to commence before puberty or above the age of 40 years. In most cases, the onset of anorexia nervosa is attributed or associated with a stressful event such as the death of a loved one. However, there is a high variability regarding the cause and outcome of the eating disorder (Levine, 2017). While young individuals may exhibit atypical features such as refusing to take food high in fat, older individuals experience a longer duration of the illness coupled with a clinical presentation characteristic of more symptoms and signs of a long-standing disorder.
Risk and Prognostic Factors
There are a number of risk and prognostic factors that predispose some individuals to experience an early onset of anorexia nervosa. For instance, individuals who display obsessional traits or develop anxiety disorders during childhood are at a higher risk of developing this eating disorder. In addition, there is evidence that environmental factors also contribute to the early onset of anorexia nervosa among young females (Anderson, Murray, & Kaye, 2018). In cultures where thinness is highly valued, the prevalence of anorexia nervosa is high because of continuous encouragement to be thin. Genetic and physiological factors also contribute to the early onset of anorexia nervosa. First-degree biological relatives of individuals diagnosed with the eating disorder are at a higher risk of developing the condition (Levine, 2017). In addition, there is evidence that concordance rates for the eating disorder in dizygotic twins are significantly lower than monozygotic twins.
A number of comorbidities are associated with anorexia nervosa. Anxiety and depressive disorders, as well as bipolar, are common comorbidities associated with anorexia nervosa. Self-reports of individuals diagnosed with anorexia nervosa indicate the presence of either an anxiety disorder or symptoms before the onset of the eating disorder (Cuzzolaro & Fassino, 2018). In some individuals diagnosed with anorexia nervosa, OCD is an associated comorbidity, particularly among individuals with restrictive behaviors to limit food intake. Substance use disorder, including alcohol use disorder, are also common comorbidities associated with anorexia nervosa.
Diagnosis of anorexia nervosa is influenced by cultural-related factors even though it occurs across socially and culturally diverse populations. Available evidence indicates a high prevalence of anorexia nervosa in post-industrialized, high-income nations in Europe, the United States, Japan, Australia, and New Zealand (Walsh, Attia, Glasofer, & Sysko, 2016). However, the findings regarding the prevalence of anorexia nervosa in low and middle-income nations are inconclusive. Although the prevalence of the eating disorder is comparatively low among African-Americans, Latinos, and Asians in developed economies such as the United States, clinicians should be aware that there is low utilization of mental health services among individuals of these demographic groups (Levine, 2017). Therefore, the low rates of prevalence may reflect ascertainment bias. For instance, the perception and presentation of which concerns among individuals exhibiting eating and feeding disorders vary widely across cultural contexts.
Diagnostic Criteria for the Diagnosis
The American Psychiatric Association published in 2013 the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) detailing the diagnostic criteria for the diagnosis of anorexia nervosa (American Psychiatric Association, 2016). According to the 2013 DSM-5 manual, a positive diagnosis for anorexia nervosa must meet the following criteria:
- The individual must demonstrate restrictive behavior regarding food intake leading to weight loss or a failure to gain weight resulting in significantly low body weight of what would be expected of someone’s sex, age, and height.
- The individual must also exhibit a sustained fear of gaining weight or becoming fat.
- Self-reports should indicate a distorted view of the individual and their condition. For example, the individual might perceive themselves to be overweight when they’re actually underweight or believe they can gain weight by consuming a single meal. The individual may not also recognize that they have a problem of having a low body weight for someone of their age, height, and sex
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Example From one movie or show illustrating the Diagnosis – To the Bone
To the Bone is a film that features an anorexic 20-year old girl named Eli. She is the protagonist of the film, although they are multiple other characters that display core features of anorexia and other eating disorders (Gilbert, 2017). Eli is a white young woman born in a privileged but dysfunctional family who struggles with her body image and weight. Throughout the film, Eli is institutionalized at a treatment center where she meets a doctor who encourages her to choose life.
The diagnosis employed in the film reveals Eli’s physical, emotional, and behavioral signs and symptoms associated with anorexia nervosa. In accordance with the DSM-5 manual, Eli has an abnormally low body weight for her age and sex as she persistently limits what she eats and participates in excessive exercise (Cuzzolaro & Fassino, 2018). In one instance, she chews and spits out an entire meal at a restaurant. In addition, Eli is anxious about eating and frequently uses her forefinger and thumb to measure the circumference of her arms out of fear of gaining weight. Focusing on Eli’s obsessive measuring of selected parts of her body concurs with a key criterion of anorexia nervosa diagnosis regarding the distorted perception of body shape and weight (American Psychiatric Association, 2016). She also confesses to having lost her menstruation and her body hair becoming increasingly fine and soft.
Eli also exhibited behavioral signs associated with anorexia, such as wearing loose clothing. It is common for an anorexic individual to wear loose clothing as a way to hide his/her weight loss and keep warm since his/her body has low levels of insulating fat. She is also overly concerned about counting her calorie intake, a sign that she is preoccupied with food (Levine, 2017). In one conversation with her sister, she demonstrates her ability to estimate the calorie count of any food by just looking at it. She is also quick to point out the number of calories provided in feeding tubes when another girl in the same treatment center experiences the same problem.
Besides her preoccupation with food, she also exercises frequently to avoid gaining weight. Consequently, she has developed chronic bruises on her spine as a result of completing several sit-ups daily. In one scene in the film, Eli is doing sit-ups in a way that looks compulsive. OCD is a common behavioral change associated with anorexia nervosa (Gilbert, 2017). Eli also exhibits depressive warning signs such as irritability, expressing more negative thoughts and positive thoughts, and being socially withdrawn in addition to experiencing insomnia.
Screening Tool or Symptom Checklist
Below is a list of symptoms that can be used to make the correct diagnosis for anorexia nervosa. It is a list of questions inquiring about different signs and symptoms that the individual must provide a yes or no answer.
- Intense worrying about becoming fat or gaining weight even though the individual may be below normal weight
- Persistent refusal to maintain a healthy weight, taking into consideration the individual’s age and height, 85% or less is expected.
- Overly concerned about body weight and image that leads to self-critical thoughts
- A distorted perception of one’s own body shape and weight
- Absence of menstruation in women who are menstruating
(Nicholls & Barrett, 2015)
The study presents the findings of a systematic review of studies investigating the effectiveness of psychotherapeutic treatment approaches in anorexia nervosa. Weight gain was selected as the primary outcome criterion. The study also evaluated the efficiency of the treatment approach based on the service level (inpatient vs. outpatient) and age group (adolescent versus an adult). The study concluded that numerous specialized psychotherapeutic interventions yield positive outcomes when used to treat anorexia nervosa (Zeeck et al., 2018). However, there is a need to separate patients according to their age groups for better outcomes. This is because different age groups differ in terms of treatment response. The study noted that there is a need for future trials to replicate the findings in a multi-center trial with large sample numbers to allow for subgroup analysis.
Internet Sources for Client Education on Diagnosis
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American Psychiatric Association. (2016). Feeding and eating disorders. Arlington, VA: American Psychiatric Association Publishing.
Anderson, L., Murray, S., & Kaye, W. H. (2018). Clinical handbook of complex and atypical eating disorders. New York: Oxford University Press.
Cuzzolaro, M., & Fassino, S. (2018). Body image, eating, and weight: a guide to assessment, treatment, and prevention. Cham, Switzerland: Springer.
Gilbert, S. (2017, July 14). To the Bone: The Trouble With Anorexia on Film. Retrieved from The Atlantic: https://www.theatlantic.com/entertainment/archive/2017/07/to-the-bone-review-netflix/533517/
Levine, M. P. (2017). Communication Challenges Within Eating Disorders: What People Say and What Individuals Hear. New York: Springer.
Nicholls, D., & Barrett, E. (2015). Eating Disorders in Children and Adolescents. BJPscyh Advances, 21, 206-216.
Walsh, B. T., Attia, E., Glasofer, D. R., & Sysko, R. (2016). Handbook of assessment and treatment of eating disorders. Arlington, Virginia: American Psychiatric Association Publishing.
Zeeck, A., Herpertz-Dahlmann, B., Friederich, H.-C., Brockmeyer, T., Resmark, G., Hagenah, U., . . . Hartmann, A. (2018). Psychotherapeutic Treatment for Anorexia Nervosa: A Systematic Review and Network Meta-Analysis. Front Psychiatry, 9, 158.