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According to the DSM-IV, the four main diagnostic features of Anorexia Nervosa are: A) maintaining a body weight at a level less than 85% of normal weight for age and height, B) an intense fear of fatness, C) disturbed experience of one's body weight or shape, and D) amenorrhea (absence or suppression of normal menstrual flow) for at least three consecutive menstrual cycles. Criterion A, a body weight at a level less than 85% of normal weight for age and height, is usually determined using one of the several common published pediatric growth charts (e.g., Centers for Disease Control, Metropolitan Life). An alternative to this criterion, used in the ICD-10, is a Body Mass Index equal to or below 17.5 kg/m2. These weight cutoffs are to be used as guidelines for clinicians. Additional factors, such a body build and weight history, should also be considered when determining underweight status.
Another psychological feature of the disorder is the disturbed experience of one's body weight or shape (Criterion C). Persons with Anorexia Nervosa may believe that they are overweight and see themselves as fat despite the fact that they are severely underweight compared to others. Alternatively, they may recognize that they are thin yet place excessive concern in the way that their stomach, hips or thighs look to them. Persons with Anorexia Nervosa may spend a great deal of time and energy checking, evaluating and criticizing parts or all of their body. They may avoid situations in which their body may be seen (e.g., going swimming, wearing shorts in public) for fear that it is too fat. Not only do persons with Anorexia Nervosa have a distorted perception of their body weight and size, they also place a great degree of value on their perceived size and shape in determining their self-worth and self-esteem. For example, the Eating Disorders Examination, a frequently used diagnostic tool developed by Christopher Fairburn and Zafra Cooper has several questions designed to have the person with Anorexia Nervosa list and then rank order various domains with which they determine their self-worth. For example, they may include domains such as their academic abilities, athletic accomplishments, and/or the quality of their relationships, etc. With individuals with eating disorders, it is common to have weight, shape, and ability to control intake among the top three domains used to determine self-worth and to have far less domains overall than their non-eating disordered peers.
Amenorrhea (lack of menses) for at least three consecutive menstrual cycles, is the fourth criterion for Anorexia Nervosa (Criterion D). This criterion has been a topic of much debate in the field. In postmenarcheal females, a loss of menses is indicative of the damaging physiological effects of starvation. For prepubertal females, menarche may be delayed due to a malnourished state. For female athletes, the combination of disordered eating, amenorrhea and osteoporosis (bone loss) has been referred to as the female athlete triad.
Typically, persons with Anorexia Nervosa will lack insight into the severity of their eating disorder. Persons with Anorexia Nervosa may attempt to hide or conceal their eating disorder symptoms and it is rare for them to seek treatment on their own. The disease may often become an integral part of their identity. For these reasons, Anorexia Nervosa has often been referred to as an ego syntonic disorder, which means that the disorder is consistent with the individuals ego or self-concept. It is often up to parents, teachers, friends and loved ones to recognize the symptoms of the eating disorder and help the individual get into treatment.
While excessive thinness is perhaps the most obvious symptom of Anorexia Nervosa, there are other early indicators of the disease. Some warning signs of Anorexia Nervosa may include a markedly increased concern about food composition (fat, calories, carbohydrates), increased interest in dieting, and significant changes in eating behaviors such as cutting major food groups out of the diet, skipping meals, making excuses for not eating, pushing food around on the plate rather than eating it, and depriving oneself of celebratory foods such as birthday cake or an occasional fresh baked chocolate chip cookie. Individuals may engage in obsessive-compulsive and ritualistic behaviors surrounding food, eating, and exercise. For instance, copious amounts of time may be spent watching televised food programs, or cutting out, saving and organizing recipes, or preparing and eating food a certain fixed or repetitive way.
As malnutrition increases and weight decreases, there are other obvious signs that there is a serious problem. For instance, the person with Anorexia Nervosa may often complain of being cold as there is not enough fat to insulate the body. The body may attempt to compensate for this loss of fat by growing soft, fuzzy hair on the chest, back, arms, neck and face. This hair is referred to as lanugo and is normally found on babies in the womb. The primary goal of lanugo is insulation. Healthy adults do not need lanugo to insulate their bodies and so it is a telltale sign of Anorexia Nervosa. The skin of persons with Anorexia Nervosa is sometimes dry and yellowish and may bruise easily. They may have dry, brittle, thin hair on their head. They may complain of lack of energy.
Other psychological factors associated with Anorexia Nervosa include depressed mood and anxiety. Anorexia Nervosa robs its victims of their personality. They may seem like a mere fragile shell of the person they once were. It is not uncommon for persons with Anorexia Nervosa to isolate themselves from family and friends and avoid engaging in activities they once enjoyed. They become completely consumed by the illness.
The medical complications associated with Anorexia Nervosa can be severe and often fatal. Over time, Anorexia Nervosa can lead to infertility, osteoporosis, heart problems, kidney failure, and death. Other effects of Anorexia Nervosa include tooth decay and gum damage from malnutrition and vomiting, and damage to the esophagus and larynx from acid reflux.
Article by Lindsey Ricciardi, Ph.D
|Lindsey Ricciardi, Ph.D., is a licensed clinical psychologist specializing in eating disorders and obesity. She is the Behavioral Services Director of MindBody Bariatrics and the Clinical Director for Center for Change, both in Las Vegas, NV. She has recently co-authored a book, Obesity Surgery: Stories of Altered Lives, with Marta Meana, Ph.D.|
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