Definition and Clinical Descriptions

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The disorder of anorexia nervosa (AN) is defined by four major criteria.

1. Refusal to maintain body weight at a minimally normal weight for age and height.

2. An intense fear of gaining weight. This fear, present even in an emaciated condition, may be denied, but it is demonstrated by an intense preoccupation with thoughts of food, irrational worries about gaining weight, and rigorous exercising programs, with severe restriction of total food intake in order to prevent weight gain.

3. A disturbance of body conceptualization. Parts of the body such as the thighs and abdomen are experienced as being excessively large; evaluation of the self is mainly in terms of body weight and shape; and the denial of illness or the underweight condition is a hallmark symptom of this disorder.

4. Amenorrhea or cessation of menstrual cycles.

There are two subtypes of AN: the restrictor type (AN-R) and the binge-purge type (AN-BP). The restrictors lose weight by restricting food intake and exercising; the binge-purge type engages in binge eating, purging behavior (such as self-induced vomiting), laxative abuse, and diuretic abuse.

Impulsive behaviors including stealing, drug abuse, suicide attempts, self-mutilations, and mood lability are more prevalent in AN-BP than in AN-R. The AN-BP types also have a higher prevalence of premorbid obesity, familial obesity, and debilitating personality traits (Halmi, 1999).

Most of the physiological and metabolic changes in AN are secondary to the starvation state or purging behavior. These changes revert to normal with nutritional rehabilitation and the cessation of purging behavior. Hypokalemic alkalosis occurs with purging. These patients may have hy-pokalemia and physical symptoms of weakness, lethargy, and cardiac arrhythmias, which may result in sudden cardiac arrest. Persistent vomiting causes severe erosion of the enamel of teeth, with consequent loss of teeth, and produces parotid gland enlargement (Halmi, 1999). Chronic food restriction produces osteoporosis and fractures.

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