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3/20/2018 Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis - UpToDate

Authors: Diane Klein, MD, Evelyn Attia, MD


Section Editor: Joel Yager, MD
Deputy Editor: David Solomon, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2018. | This topic last updated: May 27, 2017.

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".)

● (See "Eating disorders: Overview of prevention and treatment", section on 'Anorexia nervosa'.)

● (See "Anorexia nervosa in adults and adolescents: The refeeding syndrome".)

CLINICAL FEATURES

Core features — The essential clinical features of anorexia nervosa are [1,3]:

● Persistent restriction of energy intake that leads to an abnormally low body weight

● Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain

● Distorted perception and/or importance of body weight and shape

Associated features — Anorexia nervosa is associated with other psychological and behavioral signs and
symptoms, including [1-4]:

● Relentless pursuit of thinness

● Obsessional preoccupation with food (eg, collecting recipes or hoarding food)

● Fear of certain foods

● Restricted repertoire of foods

● Preference for low calorie foods (low energy density)

● Overestimating number of calories consumed

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3/20/2018 Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis - UpToDate

● Overusing condiments and/or artificially sweetened products

● Food-related rituals (eg, cutting food into small pieces or refusing to mix different types or colors of food on
the plate)

● Concerns about eating in public

● Social withdrawal

● Exercise-related rituals (eg, walking or running a set distance each day; swimming a specified number of
laps in a pool)

● Restlessness or hyperactivity

● Limited insight into or denial of core clinical features

● Resistance to treatment and weight gain

● Inhibited expression and dysregulation of emotions

● Feelings of ineffectiveness

● Poor sleep

● Low libido

● Dysphoria (eg, depressed or anxious mood)

● Inflexible thinking

● Perfectionism

● Need to control one’s environment

● Behavioral rigidity (eg, purchasing food only in certain stores or from certain salespeople, inability to
accommodate to changes in schedule or environment)

Some of these features can persist in weight-restored patients with anorexia nervosa, reflecting either problems
that predated onset of the eating disorder or long-term “scars” caused by starvation.

In addition, neuropsychological function appears to be impaired in anorexia nervosa. A study compared


patients with anorexia nervosa (n = 40) with healthy controls (n = 40) who were matched for sex and were
comparable in age and education; patients were nutritionally and medically stable, but many had comorbid
illnesses (eg, depression) [5]. Cognitive functioning was worse in patients than controls in multiple domains (eg,
executive functioning [planning, decision making, and response inhibition], visuospatial ability, and motor
function).

One aspect of neurocognitive functioning is decision making, which is also impaired in patients who are actively
ill with anorexia nervosa. A meta-analysis of 16 studies assessed decision making in symptomatic patients (n =
507) and healthy controls (n = 633), using the Iowa Gambling Test (which measures the ability to make
advantageous and disadvantageous choices) [6]. Decision making was moderately to substantially worse in
symptomatic patients, and the effect was independent of the lower body mass index and increased depressive
symptoms observed in patients. By contrast, decision making in patients who had recovered from anorexia
nervosa and in healthy controls was comparable.

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Anorexia nervosa is often accompanied by comorbid psychopathology and general medical disorders, as well
as suicidality. (See 'Comorbidity' below and 'Suicide' below.)

Males — The clinical features of anorexia nervosa for males and females are generally similar. One study of
99 patients hospitalized for anorexia nervosa found that the intensity of the core clinical symptoms and the
frequency of comorbid psychopathology were comparable for males and females, except that concern for
weight was less severe in males than females [7].

Nonsuicidal self-injury — Impulsive or compulsive nonsuicidal self-injury (eg, skin cutting, picking, or burning
with a lit cigarette) is often seen in anorexia nervosa. A meta-analysis of 16 studies (n >1800 patients) found a
lifetime history of nonsuicidal self-injury in 22 percent [8]. However, heterogeneity across studies was moderate
to large.

COMORBIDITY

Mental disorders — Psychiatric comorbidity is common among patients with anorexia nervosa [9]. However,
many comorbid disorders are secondary to the eating disorder and resolve with weight restoration [10]. This is
especially true for comorbid major depression, which is frequent but rarely accompanied by melancholia or
psychosis [3]. Thus, treatment should initially focus upon anorexia nervosa and suicidality. Following remission,
the patient should be reassessed for any comorbidities requiring treatment. Severe substance use disorder is
the one exception, which should be prioritized to manage withdrawal phenomena [11].

Although the specific rate of comorbid disorders differs between epidemiologic surveys and studies in clinical
settings, there is general agreement that patients with anorexia nervosa often suffer from [12-17]:

● Anxiety disorders

● Obsessive-compulsive disorder

● Body dysmorphic disorder

● Posttraumatic stress disorder

● Depressive disorders

● Substance use disorders

● Disruptive, impulse control, and conduct disorders

Screening for these comorbid disorders and their diagnostic criteria are discussed in separate topics.

A current comorbid disorder is diagnosed if it clearly preceded onset of the episode of anorexia nervosa or if the
symptoms are not explained by starvation and not related to the eating disorder [2]. As an example, compulsive
counting of caloric intake and expenditure is better conceptualized as a feature of anorexia nervosa, whereas
compulsive checking of locks is better thought of as a feature of comorbid obsessive-compulsive disorder.

Most patients with anorexia nervosa have a lifetime history of at least one comorbid mental disorder (table 1). A
nationally representative survey in the United States estimated that 56 percent of patients with anorexia
nervosa had a lifetime history of at least one comorbid mental disorder and that 34 percent had three or more
comorbid disorders [12]. The survey found that unipolar major depression was the most prevalent comorbid
disorder; the lifetime prevalence in patients with anorexia nervosa was 39 percent. In addition, the lifetime rates
for these comorbidities in patients with anorexia nervosa exceed the rates in the general population. As an
example, the estimated lifetime prevalence of unipolar major depression in the general population is 23 percent

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[18]. Shared etiologic factors may account for some of the observed comorbidity involving anxiety and
depressive disorders [11,19].

Lifetime onset of anorexia nervosa often begins prior to the lifetime onset of comorbid mood or substance use
disorders [12,20]. Conversely, comorbid anxiety or impulse control disorders usually predate anorexia nervosa
[12,21].

The association between comorbid mental disorders and the prognosis for anorexia nervosa depends upon the
specific comorbid disorder [22,23]. Comorbid substance use disorder can adversely affect treatment outcome
for eating disorders [9]. In addition, increased severity of comorbid alcohol use disorder is associated with
increased mortality in anorexia nervosa [24]. By contrast, the relationship between comorbid depressive or
anxiety disorders and prognosis for anorexia nervosa is not clear [9,25].

Personality disorders and traits — A variety of comorbid personality disorders and traits can occur in
anorexia nervosa [9], and more than one disorder or trait can occur in the same patient. Diagnosis of a
comorbid personality disorder rests upon the patient’s history prior to onset of anorexia nervosa, given that
anorexia nervosa can affect the patient’s cognitions, emotions, and interpersonal functioning.

In a review of six studies that used diagnostic interviews, the most common personality disorders in patients
with anorexia nervosa were [26]:

● Obsessive-compulsive (15 percent of patients with anorexia nervosa)

● Avoidant (14 percent)

● Dependent (7 percent)

● Narcissistic (6 percent)

● Paranoid (4 percent)

● Borderline (3 percent)

A subsequent study that used diagnostic interviews in 49 patients with anorexia nervosa found that 51 percent
met criteria for at least one personality disorder, including avoidant (31 percent of patients), paranoid (20
percent), obsessive-compulsive (18 percent), dependent (18 percent), borderline (10 percent), and narcissistic
(6 percent) [27].

The classification, diagnosis, and treatment of personality disorders are discussed separately. (See "Overview
of personality disorders".)

Patients with anorexia nervosa may also have comorbid traits that are not severe enough to meet criteria for a
personality disorder, but nevertheless cause distress and impair functioning [9,26]:

● Perfectionism – Pursuing unrealistically high standards despite the occurrence of adverse consequences

● Compulsivity – Insisting upon order, symmetry, exactness, and control

● Narcissism – Craving admiration and external validation from others; excessive concern with physical
appearance

The prognostic significance of comorbid personality disorders and traits is not clear [26,28].

General medical disorders — Patients with anorexia nervosa are at increased risk for general medical
complications and disorders. (See "Anorexia nervosa in adults: Evaluation for medical complications and
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criteria for hospitalization to manage these complications" and "Anorexia nervosa in adults and adolescents:
Medical complications and their management".)

COURSE OF ILLNESS

Recovery — Among patients with anorexia nervosa, approximately 50 percent have good outcomes (including
weight gain), 25 percent have intermediate outcomes, and 25 percent have a poor outcome [29]. Better
outcomes are associated with insight and successful interpersonal relationships; poor outcomes are associated
with later age at onset of the eating disorder, longer duration of the illness, lower minimal weight, lower percent
body fat after weight restoration, and comorbidity (eg, mood disorders, personality disorders, and alcohol and
substance use disorders) [24,30-34].

Patients with anorexia nervosa who recover may nevertheless suffer persisting psychiatric problems. In a
retrospective study of 70 female patients, those who no longer met criteria for anorexia nervosa still manifested
relatively low body weight and cognitive features (perfectionism and cognitive restraint) of the disorder, as well
as high rates of lifetime comorbid major depression, alcohol dependence, and anxiety disorders [35].

Many studies that examined course of illness in anorexia nervosa were performed at referral centers that
specialized in treatment resistant patients who were often hospitalized, and outcomes may be better in
community-based samples. In an 18-year, prospective observational study of a community based sample of
individuals with anorexia nervosa (n = 51), most of whom received treatment, there were no deaths (see
'Mortality' below) and good outcomes occurred in 84 percent [36]. In addition, a retrospective population based
study identified individuals with anorexia nervosa (n = 40) who were largely untreated and followed for up to 10
years; generally good outcomes were observed, including no deaths and weight restoration (body mass index
≥18.5 kg/m2) in nearly 90 percent [37].

Mortality

All cause — Observational studies indicate that anorexia nervosa is associated with increased rates of all-
cause mortality:

● All-cause mortality is 4 to 14 times greater in patients with anorexia nervosa, compared with the general
population [33,38-41]. Medical complications (eg, cardiovascular) of anorexia nervosa account for
approximately 60 percent of the deaths in patients with anorexia nervosa [41]. (See "Anorexia nervosa in
adults and adolescents: Medical complications and their management".)

● One registry study found that all-cause mortality was approximately two to three times greater in anorexia
nervosa than in bipolar disorder, depression, and schizophrenia [39]. Other studies indicate that mortality is
three to four times greater in anorexia nervosa than bulimia nervosa and binge eating disorder [38,41].

Most mortality studies for anorexia nervosa were performed at referral centers that specialized in treatment
resistant patients who were often hospitalized, and mortality rates may be lower outside of these centers [37].
As an example, a retrospective community study examined mortality in 208 patients with relatively mild
anorexia nervosa (most had never seen a psychiatrist and few had been hospitalized for the disorder) over a
median follow-up of 22 years; all-cause mortality for patients and for the general population were comparable
[42].

Suicide — Anorexia nervosa is often accompanied by suicidality, including suicidal ideation, action to
prepare for an attempt, nonfatal attempt or self-harm, or death. Compared with the general population, patients
with anorexia nervosa have an elevated rate of suicide attempts and deaths. However, a registry study found
that the rate of suicide deaths in anorexia nervosa was approximately half of that observed in bipolar disorder,
depression, and schizophrenia [39].

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● Suicide attempts – A lifetime history of attempted suicide is found in roughly 10 to 25 percent of patients
with anorexia nervosa [43-46]. One national registry study identified individuals with anorexia nervosa (n
>8000) within a general population cohort (n >2,000,000); after adjusting the analyses for comorbid
depressive disorders, anxiety disorders, and substance use disorders, the investigators found that suicide
attempts were 1.7 times more likely among individuals with anorexia nervosa than the general population
(odds ratio 1.7, 95% CI 1.6-1.9) [46].

Factors that are associated with suicide attempts in anorexia nervosa include comorbid substance use
disorders and a history of sexual abuse, as well as having a sibling with an eating disorder [43-49].

● Suicide deaths – Some studies have found that suicide accounts for approximately 25 percent of deaths
in anorexia nervosa [38,40]. Other studies have found that the rate of suicide is roughly five times greater
in patients with anorexia nervosa, compared with the general population [39,40,50]. As an example, a
national registry study identified individuals with anorexia nervosa (n >8000) in a general population cohort
(n >2,000,000). Death by suicide was six times greater in those with anorexia nervosa than the general
population (odds ratio 6); after the analyses were adjusted for comorbid psychopathology, the risk of
suicide deaths was three times greater among individuals with anorexia nervosa (odds ratio 3) [46].

ASSESSMENT — The initial clinical evaluation of patients with a possible diagnosis of anorexia nervosa
includes a psychiatric and general medical history, mental status and physical examination, and focused
laboratory tests [51,52]. The clinical interview may be augmented with a self-report screening measure and a
structured interviewing instrument. The initial assessment should address the diagnostic criteria, associated
clinical features, comorbid psychopathology, and medical complications of anorexia nervosa, and may require
multiple interviews [9]. Subsequently, the clinician should monitor the patient’s response to treatment and
assess the patient for new illnesses.

Many patients with anorexia nervosa are not forthcoming about their illness [3,53]. Symptoms of anorexia
nervosa are often ego-syntonic, and thus the patient’s presenting complaint may be anxiety, depression, or
somatic discomfort due to medical complications such as pain with eating, bloating, or “inability to keep food
down.” In addition, some patients are ashamed of the disorder and may attempt to conceal their thinness by
wearing bulky clothes and may inflate their body weight by hiding objects in their clothes and drinking water
[54]. Denial of the illness may delay assessment until family members or friends are compelled to obtain
psychiatric and medical care for the patient.

Establishing rapport with the patient can help elicit more information. At the beginning of the interview, simple
questions about the patient’s age, occupation, marital status, and referral source can put the patient at ease. In
addition, directed and focused questions about eating disorder psychopathology may be helpful for patients
who do not respond to open-ended questions [55]. Conveying a nonjudgmental, supportive, and knowledgeable
attitude also helps. Collateral information should be sought from family members, who may more accurately
report the patient’s nutritional and exercise habits, and at times be the only informants to report the presence of
vomitus in the house, finding laxatives or diuretics, or the patient regularly departing to the bathroom after
meals [3]. Assessment of the family also engages them to support efforts at nutritional rehabilitation and other
aspects of recovery.

Clinicians should also evaluate the patient’s medical status [54,56]. Assessing and managing the medical
complications of anorexia nervosa are discussed separately. (See "Anorexia nervosa in adults: Evaluation for
medical complications and criteria for hospitalization to manage these complications" and "Anorexia nervosa in
adults and adolescents: Medical complications and their management".)

Screening instruments — Among the self-report measures that screen for eating disorders, we suggest the
five-item SCOFF, which is discussed separately. (See "Eating disorders: Overview of epidemiology, clinical
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features, and diagnosis", section on 'Screening'.)

The diagnostic interview can be facilitated by first administering a self-report screening instrument [57]. Patients
who screen positive for an eating disorder should be asked about the DSM-5 diagnostic criteria for anorexia
nervosa (table 2) and bulimia nervosa (table 3). Self-report instruments can save interviewer time, but are more
prone to yielding false positives than clinician-administered instruments. Interviewer-administered instruments
are discussed separately. (See "Bulimia nervosa in adults: Clinical features, course of illness, assessment, and
diagnosis", section on 'Structured instruments'.)

Clinical evaluation — The clinical evaluation should assess [9,58,59]:

● Height and weight.

• Current body weight and desired weight. Clinicians should measure weight and height as well as ask
about them because the patient’s self-report is often unreliable. Body mass index (calculator 1) should
then be determined for comparison to population norms.

• Recent weight changes, lifetime highest and lowest weights at adult height, stability of weight over
time, and history of efforts to control weight and shape. A chronology should be established to
determine whether current symptoms are acute or chronic.

● Frequency of self-weighing.

● Meal pattern.

• Estimate typical daily caloric and nutrient (carbohydrates, fat, and protein) intake from both foods and
beverage, and assess pattern of consumption, including times, amounts, and context.

● Present and past eating disorder symptoms.

• Dietary restriction

• Attitudes about food, eating, body weight, and shape (including fear of becoming fat and resistance to
gaining weight)

• Binge eating

• Compensatory behaviors such as purging (self-induced vomiting or misuse of laxatives, diuretics, or


enemas), fasting, and exercise

• Ritualistic eating behaviors (eg, cutting food into extremely small pieces or refusing to mix different
types or colors of food on the plate)

● Fear of gaining weight or becoming fat.

● Self-evaluation, self-esteem, and perception of body weight and shape.

● Menstrual status.

• Last menstrual period

• Regularity and extent of menses

• Weight at which spontaneous menses occur

● Prescription medications.
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• Oral contraceptives can produce withdrawal bleeding that simulates menstrual periods

• Emetics may be used to stimulate purging

● Suicidality – Anorexia nervosa may be accompanied by suicidality, including suicidal ideation, action to
prepare for an attempt, and nonfatal attempt or self-harm. Patients with suicidality should be seen more
frequently and perhaps hospitalized, depending upon the estimated level of risk (table 4) [9,53,60]. A
specific suicide plan of high lethality or intent indicates the need for hospitalization. Risk factors, evaluation,
and management of suicidality are discussed separately. (See "Suicidal ideation and behavior in adults".)

● Comorbid disorders, such as anxiety, mood, impulse control, substance use (nicotine, caffeine, cocaine,
and stimulants may be used to curb appetite), and personality disorders.

● Psychosocial functioning.

● Prior treatment.

• Psychotherapy

• Pharmacotherapy

• Self-help groups

● Family history of eating disorders and other psychopathology.

In discussing onset of anorexia nervosa, the clinician should ask about interpersonal problems at that time [9]. It
is worth noting that family members should not be blamed for causing the illness because there is no evidence
that families cause eating disorders; however, there are families who are not supportive and who may
contribute to problems with self-esteem and body image.

As part of the mental status examination, the clinician should note behavioral restlessness or fidgeting.
Impaired attention, concentration, and thought process can indicate cognitive impairment, including delirium
related to medical complications of low weight and/or purging. Anxious or depressed affect should be assessed.
Insight and judgment can be evaluated by asking about the patient’s target weight and treatment-seeking
behaviors.

Medical complications of anorexia nervosa that can be found on history and physical examination are
discussed separately. (See "Anorexia nervosa in adults: Evaluation for medical complications and criteria for
hospitalization to manage these complications", section on 'Medical evaluation'.)

Structured instruments — Structured, interviewer-administered instruments are available for diagnosing


anorexia nervosa and other eating disorders, but are seldom used in routine clinical practice. These structured
instruments are discussed separately. (See "Bulimia nervosa in adults: Clinical features, course of illness,
assessment, and diagnosis", section on 'Structured instruments'.)

Measurement-based care — We suggest that at each visit, clinicians weigh the patient wearing as little
clothing as appropriate (eg, hospital gown) and after voiding. Clinicians should also ask about daily caloric
intake, the number of hours spent exercising and walking each day, and the number of binge-eating and
purging episodes that occurred each week since the last visit. Measurement-based care can help identify
nonresponders and detect residual symptoms. Symptomatic change over time can also be assessed with self-
report measures [61], such as the 36-item Eating Disorder Examination Questionnaire (EDE-Q) [62,63].

DIAGNOSIS — The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) and the World Health Organization's International Classification of Diseases-10th
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Revision (ICD-10) can each be used to diagnose anorexia nervosa. We use the DSM-5 criteria; however, the
two sets of criteria overlap considerably.

Diagnostic and Statistical Manual — A DSM-5 diagnosis of anorexia nervosa requires each of the following
criteria (table 2) [1]:

● Restriction of energy intake that leads to a low body weight, given the patient’s age, sex, developmental
trajectory, and physical health

● Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite
being underweight

● Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or
denial of the medical seriousness of one’s low body weight

There is no single standard for what constitutes a minimally normal weight [1,3]. Determining whether body
weight is abnormally low depends upon individual factors such as body frame, skeletal structure, and racial
ethnicity. DSM-5 suggests that a minimally normal weight for height is a body mass index (ratio of weight in kg
divided by height in m2; BMI) (calculator 1) equal to 18.5 kg/m2; this is consistent with ICD-10 as well as the
United States Centers for Disease Control and Prevention. Some clinicians obtain normal adult weight for
height by using standardized tables such as the Metropolitan Life Insurance Height-Weight Tables (table 5),
which are actuarial tables developed in 1983 to predict the longest lifespan [64-66].

DSM-5 classifies current severity of anorexia nervosa according to BMI (calculator 1):

● Mild – BMI 17 to 18.49 kg/m2

● Moderate – BMI 16 to 16.99 kg/m2

● Severe – BMI 15 to 15.99 kg/m2

● Extreme – BMI <15 kg/m2

Patients lose weight and/or maintain a low body weight in various ways that typically include reducing total food
intake. Patients may begin by excluding highly caloric foods, but dietary restraint usually leads to a restricted
diet that is sometimes limited to only a few foods. Patients may also fast for a day or longer and exercise
excessively such that it interferes with important activities, or occurs at inappropriate times, in inappropriate
settings, or despite injury. In addition, patients may purge, ie, induce vomiting or misuse laxatives, diuretics, or
enemas. Purging with laxatives, diuretics, or enemas does not rid the body of unwanted calories, but does
cause a temporary loss of bodily fluids that may result in a lower measured weight and feeling of relief [67].
Self-induced vomiting is also associated with significant retention of calories. Medical complications of purging
are discussed separately within the context of bulimia nervosa. (See "Bulimia nervosa and binge eating
disorder in adults: Medical complications and their management", section on 'Medical complications of bulimia
nervosa'.)

Fear of gaining weight or becoming fat usually does not abate with weight loss; rather, the fear often increases
despite continued weight loss [1].

Disturbed body image manifests in different ways [1]. Some patients believe they are overweight, while others
are concerned that specific body parts are fat. As a result, patients may excessively weigh themselves,
measure body parts, or view themselves in a mirror. In addition, self-esteem depends upon body weight and
shape; weight loss is viewed as an achievement and sign of self-discipline, whereas weight gain is a failure of
self-control. Patients may concede that they are emaciated, but usually deny the medical complications of

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starvation. Some authorities view distorted body image as an overvalued idea rather than a delusion, even
when the distortion is expressed as a false, fixed belief [3].

Anorexia nervosa usually causes a functional hypothalamic amenorrhea in postmenarchal females,


characterized by low levels of luteinizing hormone and follicle-stimulating hormone (despite low estrogen levels)
[68,69]. Although amenorrhea was required in previous editions of the Diagnostic and Statistical Manual for
diagnosing anorexia nervosa, this is no longer the case in DSM-5 because patients who menstruate but
otherwise meet criteria for anorexia nervosa have outcomes similar to patients who do not menstruate [1,70-
72]. (See "Anorexia nervosa: Endocrine complications and their management".)

DSM-5 describes two subtypes of anorexia nervosa, based upon symptoms during the past three months:
restricting and binge-eating/purging [1]. The restricting subtype is characterized by dieting, fasting, or excessive
exercise, and the absence of recurrent binge-eating (eating an amount of food that is definitely larger than most
people would eat under similar circumstances) or purging. The binge-eating/purging subtype is characterized
by recurrent (eg, once per week) episodes of binge-eating or purging. Crossover between the two subtypes of
anorexia nervosa occurs often, especially from the restricting subtype to the binge/purge subtype; this raises
questions about their predictive validity for course of illness [73-75].

Patients who meet some but not all of the diagnostic criteria for anorexia nervosa are given the diagnosis of
other specified feeding or eating disorder [1]. (See 'Other specified feeding or eating disorder' below.)

International Classification of Diseases — The ICD-10 diagnostic criteria for anorexia nervosa overlap
considerably with the DSM-5 criteria [1,76]. ICD-10 does not specifically operationalize the diagnosis of
anorexia nervosa, but does describe the following clinical features that are found in patients:

● Deliberate weight loss to a low weight

● Fear of fatness

● Excessive concern with body shape

● Restricted diet

● Undernutrition that causes medical complications (eg, endocrine)

● Excessive exercise

● Purging (eg, self-induced vomiting or abuse of diuretics)

Diagnostic stability — The diagnosis of anorexia nervosa often changes to bulimia nervosa [77-80]. As an
example, a prospective observational study followed 88 patients with anorexia nervosa at intake for up to seven
years, and found that diagnostic crossover to bulimia nervosa occurred in 34 percent [74]. Among the 34
percent, approximately half subsequently crossed back over to anorexia nervosa. Diagnostic crossover may be
more likely to occur in patients with comorbid psychopathology (eg, depression or substance use disorders)
[77,78,81].

DIFFERENTIAL DIAGNOSIS — Anorexia nervosa is the most common cause of substantial weight loss in
young adolescent females in western countries, and the diagnosis is often clear because patients present with
emaciation in conjunction with self-induced starvation and intense fear of fatness [3]. However, specific
symptoms of anorexia nervosa (eg, weight loss) may overlap with symptoms of other psychiatric and medical
illnesses [1,11]. Patients with these other illnesses are generally concerned about their weight loss and do not
restrict their diet or exercise excessively; in addition, body image is usually not distorted. Some of the illnesses

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that resemble anorexia nervosa can also occur in conjunction with anorexia nervosa (eg, unipolar major
depression). (See 'Comorbidity' above.)

Eating disorders

Bulimia nervosa — Bulimia nervosa (table 3) and anorexia nervosa (table 2) are both marked by
overvaluation of body shape and weight [1]. In addition, patients with bulimia nervosa binge eat and purge, as
do many patients with anorexia nervosa. Making the correct diagnosis is essential for treatment.

The key distinguishing feature of anorexia nervosa is an abnormally low body weight (body mass index <18.5
kg/m2), given the patient’s age, sex, developmental trajectory, and physical health. By contrast, patients with
bulimia nervosa usually maintain a body weight at or above a minimally normal level [1]. Secondarily, the low
weight that occurs in anorexia nervosa is accompanied by structural and physiologic sequelae (eg, reduced
cardiac mass and bone density) that are not found in bulimia nervosa. Additional information about the
differential diagnosis between anorexia nervosa and bulimia nervosa and their medical complications is
discussed separately. (See "Bulimia nervosa in adults: Clinical features, course of illness, assessment, and
diagnosis", section on 'Anorexia nervosa' and "Anorexia nervosa in adults and adolescents: Medical
complications and their management" and "Bulimia nervosa and binge eating disorder in adults: Medical
complications and their management".)

Avoidant/restrictive food intake disorder — Patients with avoidant/restrictive food intake disorder have
poor energy and nutritional intake that can lead to low body weight, as occurs in anorexia nervosa [1]. However,
restriction of energy intake in avoidant/restrictive food intake disorder is due a lack of interest in food, aversion
to the sensory characteristics (eg, appearance, smell, or taste) of food, or concern about aversive
consequences of eating (eg, choking or vomiting). By contrast, restricted energy intake in anorexia nervosa is
accompanied by fear of gaining weight or becoming fat, and disturbance in the way that body weight and shape
are perceived and experienced. (See "Eating disorders: Overview of epidemiology, clinical features, and
diagnosis", section on 'Avoidant/restrictive food intake disorder'.)

Other specified feeding or eating disorder — For patients who meet some but not all of the diagnostic
criteria for anorexia nervosa, clinicians can diagnose other specified feeding or eating disorder, along with the
reason that the criteria are not met [1]. As an example, obese patients who demonstrate the signs and
symptoms of anorexia nervosa during rapid weight loss to a normal weight are given the diagnosis, “other
specified feeding or eating disorder, atypical anorexia nervosa.” Another example of atypical anorexia nervosa
is described in an observational study of 20 patients who were severely malnourished and amenorrheic with no
other identified psychiatric or medical cause for their weight loss, but who otherwise acknowledged their
emaciation and denied fear of weight gain and distorted perception of their body weight and shape [82].

In addition, the diagnosis “unspecified feeding or eating disorder” can be used in situations in which patients
meet some but not all of the diagnostic criteria for anorexia nervosa, and clinicians choose not to specify the
reason that the criteria are not met [1]. This includes cases in which information is lacking to diagnose anorexia
nervosa (eg, in an emergency department).

Patients with clinically meaningful symptoms of anorexia nervosa that do not rise to the level of meeting criteria
for the diagnosis are nevertheless treated for the disorder. (See "Eating disorders: Overview of prevention and
treatment", section on 'Anorexia nervosa'.)

Other psychiatric disorders — Specific symptoms of anorexia nervosa are similar to symptoms that occur in
[1,2]:

● Unipolar major depression – Decreased weight often occurs in major depressive disorder. However, the
weight loss in major depression is due to loss of appetite and is not intentional, and reluctance to gain
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weight and distorted body image are not present. In addition, depressed patients are usually anergic; by
contrast, anorexia nervosa patients often exercise excessively.

● Social phobia – Patients with either social phobia or anorexia nervosa may be embarrassed to eat in
public. However, patients with social phobia recognize that the fear is excessive or unreasonable, and they
are not emaciated.

● Obsessive-compulsive disorder – Obsessions and compulsions regarding food can occur in both
anorexia nervosa and obsessive-compulsive disorder. However, patients with obsessive-compulsive
disorder are not emaciated and recognize that the preoccupations and behaviors are excessive or
unreasonable.

● Body dysmorphic disorder – Patients with anorexia nervosa may be excessively preoccupied with an
imagined defect in body appearance, as occurs in body dysmorphic disorder. However, the preoccupation
in anorexia nervosa concerns body weight (“fatness”) or shape, whereas in body dysmorphic disorder the
imagined defect typically involves the face or head. In addition, body dysmorphic disorder does not
manifest with emaciation and a fear of becoming fat.

● Psychotic disorders – Psychotic patients may have delusions about food (eg, food is poisoned), refuse to
eat, and lose weight. In contrast to anorexia nervosa, these psychotic disorders usually do not include fear
of gaining weight or distorted body image.

● Attention-deficit/hyperactivity disorder – Restlessness and impaired concentration are common to both


ADD/ADHD and anorexia nervosa. However, in anorexia nervosa, these symptoms are typically due to low
weight and improve with normalization of body weight.

Screening for comorbid disorders and their diagnostic criteria are discussed separately.

General medical disorders — If the diagnosis of anorexia nervosa is not clear, the medical evaluation should
account for general medical illnesses that can present with weight loss, malabsorption, or secondary
amenorrhea. (See "Anorexia nervosa in adults: Evaluation for medical complications and criteria for
hospitalization to manage these complications", section on 'Excluding medical disorders'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and
“Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles
are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
“patient info” and the keyword(s) of interest.)

● Basics topic (see "Patient education: Anorexia nervosa (The Basics)")

SUMMARY

● The core features of anorexia nervosa are persistent restriction of energy intake that leads to an
abnormally low body weight; intense fear of gaining weight or becoming fat, or persistent behavior that
prevents weight gain; and distorted perception of body weight and shape. Other features include
perfectionism, cognitive and behavioral rigidity, feelings of ineffectiveness, inhibited expression of
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emotions, social withdrawal, poor insight, resistance to treatment, restlessness or hyperactivity, as well as
symptoms and signs related to food and eating, such as preoccupation with food and rituals related to
meals. (See 'Clinical features' above.)

● Patients with anorexia nervosa frequently have a lifetime history of comorbid psychiatric disorders,
including anxiety, depressive, impulse control, substance use, and personality disorders. In addition,
patients are at increased risk for general medical complications and disorders. (See 'Comorbidity' above.)

● Among patients with anorexia nervosa, approximately 50 percent have good outcomes (including weight
gain), 25 percent have intermediate outcomes, and 25 percent have a poor outcome. Anorexia nervosa is
associated with increased rates of all-cause mortality, and suicide deaths occur more often in patients than
the general population. (See 'Course of illness' above.)

● The diagnostic interview can be facilitated by first administering a self-report instrument that screens for
eating disorders. We suggest the five-item SCOFF. (See 'Screening instruments' above and "Eating
disorders: Overview of epidemiology, clinical features, and diagnosis", section on 'Screening'.)

● The initial clinical evaluation should assess height, weight, meal patterns, present and past eating disorder
symptoms (dietary restriction; attitudes about body weight and shape, food, and eating; binge eating;
compensatory behaviors such as purging, fasting, and exercise; and ritualistic eating behaviors), menstrual
status, suicidality, comorbid psychiatric disorders, psychosocial functioning, and family psychiatric history.

Clinicians should also assess suicidality, including suicidal ideation, action to prepare for an attempt, and
nonfatal attempt or self-harm. Patients with suicidality should be seen more frequently and perhaps
hospitalized, depending upon the estimated level of risk. A specific suicide plan of high lethality or intent
indicates the need for hospitalization (table 4). (See 'Clinical evaluation' above.)

● The diagnosis of anorexia nervosa according to the Diagnostic and Statistical Manual, Fifth Edition (DSM-
5) is summarized in the table (table 2). The diagnostic criteria of the International Classification of
Diseases-10th Revision (ICD-10) overlap considerably. (See 'Diagnosis' above.)

● Although certain diagnostic criteria for anorexia nervosa (table 2) and bulimia nervosa (table 3) are the
same, body weight is usually low in anorexia nervosa and normal or above normal in bulimia nervosa. The
differential diagnosis for anorexia nervosa also includes other psychiatric and medical disorders, but these
illnesses typically do not present with intentional weight loss or fear of gaining weight. (See 'Differential
diagnosis' above.)

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Topic 14704 Version 20.0

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