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Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis

Authors
Diane Klein, MD
Evelyn Attia, MD
Section Editor
Joel Yager, MD
Deputy Editor
David Solomon, MD

INTRODUCTION

Anorexia nervosa is characterized by an abnormally low body weight, intense fear of gaining weight, and distorted perception of body weight and shape [1]. The disorder has been recognized for hundreds of years across different cultures [2]. However, the term “anorexia” is a misnomer because patients often retain their appetite [3].

This topic reviews the clinical features, comorbid psychopathology, course of illness, assessment, diagnosis, and differential diagnosis of anorexia nervosa. The epidemiology, potential medical complications, evaluation for detecting medical complications, and treatment of anorexia nervosa are discussed separately, as is the refeeding syndrome as a complication of treatment.

(See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis".)

(See "Anorexia nervosa in adults and adolescents: Medical complications and their management".)

(See "Anorexia nervosa in adults: Evaluation for medical complications and criteria for hospitalization to manage these complications".)

                             

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Literature review current through: Nov 2016. | This topic last updated: Tue Jan 12 00:00:00 GMT+00:00 2016.
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References
Top
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  2. Keel PK, McCormick L. Diagnosis, assessment, and treatment planning for anorexia nervosa. In: TheTreatment of Eating Disorders: A Clinical Handbook, Grilo CM, Mitchell JE (Eds), The Guilford Press, New York 2010. p.3.
  3. Andersen, AE, Yager, J. Eating disorders. In: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Volume I, Ninth Edition, Sadock, BJ, Sadock, VA, Ruiz P (Eds), Lippincott Williams & Wilkins, Philadelphia 2009. p.2128.
  4. Weider S, Indredavik MS, Lydersen S, Hestad K. Neuropsychological function in patients with anorexia nervosa or bulimia nervosa. Int J Eat Disord 2015; 48:397.
  5. Guillaume S, Gorwood P, Jollant F, et al. Impaired decision-making in symptomatic anorexia and bulimia nervosa patients: a meta-analysis. Psychol Med 2015; 45:3377.
  6. Strober M, Freeman R, Lampert C, et al. Are there gender differences in core symptoms, temperament, and short-term prospective outcome in anorexia nervosa? Int J Eat Disord 2006; 39:570.
  7. Mehler, PS, Anderson, AE. Eating Disorders: A guide to medical care and complications, 2nd ed, The Johns Hopkins University Press, Baltimore, MD 2010.
  8. Mehler PS, Birmingham LC, Crow SJ, Jahraus JP. Medical complications of eating disorders. In: The Treatment of Eating Disorders: A Clinical Handbook, Grilo CM, Mitchell JE (Eds), The Guilford Press, New York 2010. p.66.
  9. Södersten P, Nergårdh R, Bergh C, et al. Behavioral neuroendocrinology and treatment of anorexia nervosa. Front Neuroendocrinol 2008; 29:445.
  10. Eating Disorders: Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals with Eating Disorders. Academy for Eating Disorders, 2010, 2nd edition. http://www.aedweb.org/web/downloads/Guide-English.pdf (Accessed on December 04, 2014).
  11. American Psychiatric Association, Practice Guideline for the Treatment of Patients With Eating Disorders, Third Edition, 2006 http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on February 16, 2011).
  12. Meehan KG, Loeb KL, Roberto CA, Attia E. Mood change during weight restoration in patients with anorexia nervosa. Int J Eat Disord 2006; 39:587.
  13. Devlin, MJ, Jahraus, JP, DiMarco, ID. Eating disorders. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine, Second Edition, Levenson, JL (Eds), American Psychiatric Publishing, Inc, Washington, DC 2011. p.305.
  14. Franko DL, Keel PK. Suicidality in eating disorders: occurrence, correlates, and clinical implications. Clin Psychol Rev 2006; 26:769.
  15. Sansone RA, Levitt JL. Self-harm behaviors among those with eating disorders: an overview. Eat Disord 2002; 10:205.
  16. Bulik CM, Thornton L, Pinheiro AP, et al. Suicide attempts in anorexia nervosa. Psychosom Med 2008; 70:378.
  17. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry 2009; 166:1342.
  18. Keel PK, Dorer DJ, Eddy KT, et al. Predictors of mortality in eating disorders. Arch Gen Psychiatry 2003; 60:179.
  19. Franko DL, Keel PK, Dorer DJ, et al. What predicts suicide attempts in women with eating disorders? Psychol Med 2004; 34:843.
  20. Fedorowicz VJ, Falissard B, Foulon C, et al. Factors associated with suicidal behaviors in a large French sample of inpatients with eating disorders. Int J Eat Disord 2007; 40:589.
  21. Pompili M, Girardi P, Tatarelli G, et al. Suicide and attempted suicide in eating disorders, obesity and weight-image concern. Eat Behav 2006; 7:384.
  22. Eating Disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders. National Clinical Practice Guideline Number CG9 http://guidance.nice.org.uk/CG9/Guidance/pdf/English (Accessed on January 11, 2011).
  23. American Psychiatric Association. Treatment of patients with eating disorders,third edition. American Psychiatric Association. Am J Psychiatry 2006; 163:4.
  24. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348.
  25. Kaye WH, Bulik CM, Thornton L, et al. Comorbidity of anxiety disorders with anorexia and bulimia nervosa. Am J Psychiatry 2004; 161:2215.
  26. Kollei I, Schieber K, de Zwaan M, et al. Body dysmorphic disorder and nonweight-related body image concerns in individuals with eating disorders. Int J Eat Disord 2013; 46:52.
  27. Bulik CM, Klump KL, Thornton L, et al. Alcohol use disorder comorbidity in eating disorders: a multicenter study. J Clin Psychiatry 2004; 65:1000.
  28. Root TL, Pinheiro AP, Thornton L, et al. Substance use disorders in women with anorexia nervosa. Int J Eat Disord 2010; 43:14.
  29. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
  30. Altman SE, Shankman SA. What is the association between obsessive-compulsive disorder and eating disorders? Clin Psychol Rev 2009; 29:638.
  31. Fernandez-Aranda F, Pinheiro AP, Tozzi F, et al. Symptom profile of major depressive disorder in women with eating disorders. Aust N Z J Psychiatry 2007; 41:24.
  32. Fernández-Aranda F, Pinheiro AP, Thornton LM, et al. Impulse control disorders in women with eating disorders. Psychiatry Res 2008; 157:147.
  33. Milos GF, Spindler AM, Buddeberg C, Crameri A. Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychother Psychosom 2003; 72:276.
  34. Fichter MM, Quadflieg N, Hedlund S. Long-term course of binge eating disorder and bulimia nervosa: relevance for nosology and diagnostic criteria. Int J Eat Disord 2008; 41:577.
  35. Raney TJ, Thornton LM, Berrettini W, et al. Influence of overanxious disorder of childhood on the expression of anorexia nervosa. Int J Eat Disord 2008; 41:326.
  36. Cassin SE, von Ranson KM. Personality and eating disorders: a decade in review. Clin Psychol Rev 2005; 25:895.
  37. Jordan J, Joyce PR, Carter FA, et al. Specific and nonspecific comorbidity in anorexia nervosa. Int J Eat Disord 2008; 41:47.
  38. Grilo CM. Recent research of relationships among eating disorders and personality disorders. Curr Psychiatry Rep 2002; 4:18.
  39. Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002; 159:1284.
  40. Golden NH, Katzman DK, Kreipe RE, et al. Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health 2003; 33:496.
  41. Mayer LE, Roberto CA, Glasofer DR, et al. Does percent body fat predict outcome in anorexia nervosa? Am J Psychiatry 2007; 164:970.
  42. Saccomani L, Savoini M, Cirrincione M, et al. Long-term outcome of children and adolescents with anorexia nervosa: study of comorbidity. J Psychosom Res 1998; 44:565.
  43. Franko DL, Keshaviah A, Eddy KT, et al. A longitudinal investigation of mortality in anorexia nervosa and bulimia nervosa. Am J Psychiatry 2013; 170:917.
  44. Keski-Rahkonen A, Raevuori A, Bulik CM, et al. Factors associated with recovery from anorexia nervosa: a population-based study. Int J Eat Disord 2014; 47:117.
  45. Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcome of anorexia nervosa: a case-control study. Am J Psychiatry 1998; 155:939.
  46. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011; 68:724.
  47. Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. Int J Eat Disord 2014; 47:507.
  48. Suokas JT, Suvisaari JM, Gissler M, et al. Mortality in eating disorders: a follow-up study of adult eating disorder patients treated in tertiary care, 1995-2010. Psychiatry Res 2013; 210:1101.
  49. Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry 1995; 152:1073.
  50. Korndörfer SR, Lucas AR, Suman VJ, et al. Long-term survival of patients with anorexia nervosa: a population-based study in Rochester, Minn. Mayo Clin Proc 2003; 78:278.
  51. Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006; 163:3.
  52. American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition, 2006. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
  53. Crow, SJ, Brandenburg, B. Diagnosis, assessment, and treatment planning for bulimia nervosa. In: The Treatment of Eating Disorders, Grilo, CM, Mitchell, JE (Eds), The Guilford Press, New York 2010. p.28.
  54. Peterson, CB, Mitchell, JE. Self-report measures. In: Assessment of Eating Disorders, Mitchell, JE, Peterson, CB (Eds), New York 2005. p.98.
  55. Assessment of Eating Disorders, Mitchell, JE, Peterson, CB (Eds), Guilford Publications, New York 2005.
  56. Peterson, CB. Conducting the diagnostic interview. In: Assessment of Eating Disorders, Mitchell, JE, Peterson, CB (Eds), Guilford Publications, New York 2005. p.32.
  57. Peterson CB, Mitchell JE. Self-report measures. In: Assessment of Eating Disorders, Mitchell JE, Peterson CB (Eds), Guilford Publications, New York 2005. p.98.
  58. Mond JM, Hay PJ, Rodgers B, et al. Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples. Behav Res Ther 2004; 42:551.
  59. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord 1994; 16:363.
  60. 1983 metropolitan height and weight tables. Stat Bull Metrop Life Found 1983; 64:3.
  61. Pai MP, Paloucek FP. The origin of the "ideal" body weight equations. Ann Pharmacother 2000; 34:1066.
  62. Harrison GG. Height-weight tables. Ann Intern Med 1985; 103:989.
  63. Kaye WH, Weltzin TE, Hsu LK, et al. Amount of calories retained after binge eating and vomiting. Am J Psychiatry 1993; 150:969.
  64. Doufas AG, Mastorakos G. The hypothalamic-pituitary-thyroid axis and the female reproductive system. Ann N Y Acad Sci 2000; 900:65.
  65. Vyver E, Steinegger C, Katzman DK. Eating disorders and menstrual dysfunction in adolescents. Ann N Y Acad Sci 2008; 1135:253.
  66. Attia E, Roberto CA. Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord 2009; 42:581.
  67. Roberto CA, Steinglass J, Mayer LE, et al. The clinical significance of amenorrhea as a diagnostic criterion for anorexia nervosa. Int J Eat Disord 2008; 41:559.
  68. Attia E, Becker AE, Bryant-Waugh R, et al. Feeding and eating disorders in DSM-5. Am J Psychiatry 2013; 170:1237.
  69. Eddy KT, Keel PK, Dorer DJ, et al. Longitudinal comparison of anorexia nervosa subtypes. Int J Eat Disord 2002; 31:191.
  70. Eddy KT, Dorer DJ, Franko DL, et al. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. Am J Psychiatry 2008; 165:245.
  71. Peat C, Mitchell JE, Hoek HW, Wonderlich SA. Validity and utility of subtyping anorexia nervosa. Int J Eat Disord 2009; 42:590.
  72. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on September 27, 2012).
  73. Tozzi F, Thornton LM, Klump KL, et al. Symptom fluctuation in eating disorders: correlates of diagnostic crossover. Am J Psychiatry 2005; 162:732.
  74. Castellini G, Lo Sauro C, Mannucci E, et al. Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study. Psychosom Med 2011; 73:270.
  75. Milos G, Spindler A, Schnyder U, Fairburn CG. Instability of eating disorder diagnoses: prospective study. Br J Psychiatry 2005; 187:573.
  76. Monteleone P, Di Genio M, Monteleone AM, et al. Investigation of factors associated to crossover from anorexia nervosa restricting type (ANR) and anorexia nervosa binge-purging type (ANBP) to bulimia nervosa and comparison of bulimia nervosa patients with or without previous ANR or ANBP. Compr Psychiatry 2011; 52:56.
  77. Milos GF, Baur V, Muehlebach S, Spindler A. Axis-I comorbidity is linked to prospective instability of diagnoses within eating disorders. BMC Psychiatry 2013; 13:295.
  78. Strober M, Freeman R, Morrell W. Atypical anorexia nervosa: separation from typical cases in course and outcome in a long-term prospective study. Int J Eat Disord 1999; 25:135.