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Anorexia Nervosa

Correspondence: Address correspondence to Walter H. Kaye, M.D., Professor of Psychiatry, University of California San Diego, 8950 Villa La Jolla Drive, C-207, La Jolla, CA 92037; e-mail: wkaye{at}ucsd.edu

Anorexia nervosa (AN) is characterized by restricted eating and a relentless pursuit of thinness that tends to present in females during adolescence according to DSM-IV (Table 1). Individuals with AN exhibit an ego-syntonic resistance to eating and a powerful pursuit of weight loss, yet are paradoxically preoccupied with food and eating rituals to the point of obsession. Individuals have a distorted body image and, even when emaciated, tend to see themselves as "fat," express denial of being underweight, and compulsively overexercise. Two types of eating-related behavior are seen in AN. In restricting-type anorexia (AN), individuals lose weight purely by dieting without binge eating or purging. In binge-eating/purging-type anorexia, individuals also restrict their food intake to lose weight but have a periodic disinhibition of restraint and engage in binge eating and/or purging, also seen in bulimia nervosa (BN).

Anorexia nervosa is often kept hidden by patients who are excessively preoccupied by their current body weight/shape and are ashamed of any compensatory behaviors they engage in. Illness often becomes apparent when patients become emaciated from gradually losing weight or in the purging subtype when patients become physiologically unstable from excessive self-induced loss of fluids or electrolytes. Onset is typically around puberty and is usually preceded by anxiety disorders and followed by a prolonged clinical course with the highest mortality for any psychiatric illness.

Outcome is often hindered by an unwillingness to seek treatment. A limited understanding of etiological mechanisms and the lack of powerful treatments are major impediments to providing effective care. Still, there is evidence supporting cautious optimism regarding the development of more effective therapy. For example, although there are no U.S. Food and Drug Administration (FDA) approved medications for AN, some short-term studies suggest that second-generation antipsychotics may be beneficial. For adolescents who develop AN before the age of 18, Maudsley family therapy may be an effective alternative.

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