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Anorexia Nervosa (DSM-IV-TR #307.1)
In anorexia nervosa the patient, usually an adolescent female, embarks upon a relentless pursuit of thinness. By dieting and exercise, sometimes aided by vomiting and purging of the bowels, these patients sustain an alarming degree of weight loss, at times coming to resemble concentration camp survivors.
The name, “anorexia nervosa,” is itself something of amisnomer, for these patients rarely lose their appetite. In fact, they often remain intensely interested in, even preoccupied with, food and food preparation. True anorexia only occurs when the self-induced starvation brings these patients to the point of inanition.
Anorexia nervosa occurs almost exclusively in females; males represent only about 5% of the cases. Estimates as to the lifetimeprevalence of this disorder vary widely, depending on the strictness of the diagnostic criteria used: conservative criteria yield figures of from 0.3 to 0.5% of young females. Evidence suggests that the incidence of anorexia nervosa has increased during the latter part of the twentieth century. The reasons for this are not clear. Although often stated that this rising incidence is secondary to thevalue that modern society places on thinness, this has not been proven.
Premorbidly, most patients are conscientious and perfectionistic. They often excel in academics or athletics, and parents may describe them as having been “model” children; furthermore, these perfectionistic traits typically persist after recovery. In general, there is no prodrome, per se. Most patients are “all right”up until the actual onset of the disorder. Precipitating factors may or may not be present. Occasionally a major event immediately precedes the onset, such as parents’ divorce, a death in the family, or the birth of a new sibling. At times, however, the precipitating factor, though obviously integrally related to the decision to diet, may seem trivial. One teenage girl was trying on a new bathingsuit at a department store. As she looked at herself in the mirror, she seemed to herself to be fat and decided that she must become thinner. Over the ensuing months, though she starved herself into emaciation, she insisted that she was still too fat to wear a bathing suit.
For most patients, actually being overweight is not a precipitating factor. In fact, only about one third of patients areoverweight at onset, and most of them only to a mild degree. Indeed many patients were regarded as thin even before they began to diet. Onset usually occurs in teenage years, for females generally 4 or 5 years after menarche. Some cases with prepubertal or childhood onset have been reported; and at the other extreme are reports of onset as late as the early thirties.
Patientswith anorexia nervosa universally have a distorted body image, and although this is not unique to anorexia nervosa, it is most striking here. These patients persist in their belief that they are fat, no matter how much weight they lose. If asked to draw a self-portrait, an emaciated patient with anorexia nervosa may render a likeness that, if not obese, is at least plump. One cannot reason withpatients on this point; although the physician may be able to circle the patient’s waist with both hands, the patient refuses to give up the belief that she is fat.
In all cases, diet and exercise are utilized in pursuit of thinness. Some patients also attempt to rid themselves of calories by self-induced vomiting or by laxative-induced purging, but these actions generally play only a relativelyminor role.
Patients pursue their diets with a heartbreaking relentlessness. Progressively smaller portions are requested, and a progressively smaller percentage of what they are served is eaten. The food is pushed here and there on the plate. Mealtimes become strained and tense; at times the dinner table may become a veritable battleground as parents insist that the patient eat more. Starches and...
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