Anorexia nervosa is a serious eating disorder that results from an individual's intense preoccupation with body weight. Individuals with anorexia have difficulty maintaining a normal body mass index score, and frequently make continued efforts to lose weight even if their weight is abnormally low. The psychological factors that precipitate anorexia can be quite complex, and as a result the diagnosis and treatment of the disorder often require thorough psychological assessment, differential diagnosis, and long-term therapy. This paper will explore current research on anorexia and investigate how medical and mental health professionals are using this research to inform their work with anorexic patients (Smith et. al, 2011).
According to the American Psychiatrics DSM-IV-TR (American Pyschiatric Association [APA], 1994) a diagnosis of anorexia requires the following criteria:
"Refusal to maintain body weight at or above a minimally normal weight for age and height, for example, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. A woman having periods only while on hormone medication (e.g. estrogen) still qualifies as having amenorrhea.
Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
Binge Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior."
While the diagnostic criteria have been clearly outlined for mental health clinicians, many professionals note that it can be quite difficult to make a definitive diagnosis in patients due to factors such as resistance to treatment and denial of the disorder. According to Halse, Honey and Boughtwood (2008), many patients with anorexia will blame their lack of appetite and weight loss on stomach pains, or intolerance to certain foods. In addition, criterion such as amenorrhea require patient disclosure, and an individual who is struggling with the compulsion to lose weight many not be willing to disclose this information to a medical provider.
When a patient's physical symptoms lead medical professionals towards a diagnosis other than anorexia, such as a food allergy, the individual may ultimately use this misdiagnosis to justify her inadequate food consumption. In addition, patients with anorexia may engage in purging behaviors, such as excessive exercise that they explain as athletic training for s specific sport or event. For example, an anorexic patient may eat adequate calories, but if she engages in a running workout for excessive distance or time periods, she may burn far more calories than she consumes. Thus, patients can use seemingly reasonable explanations to prevent diagnosis, and this often occurs, as patients typically have a deep psychological need to control and reduce their weight. The potential resistance, evasive behaviors, and lack of proper diagnosis of anorexic individuals may also be complicated by their age. In the United States, patients who are over the age of 18 can make their own medical decisions, meaning that family members cannot compel them to seek a proper diagnosis or treatment. In some cases individuals may live with the disease for years and avoid any contact with mental health or medical professionals (Halse, Honey, & Boughtwood, 2008).
In addition to these diagnostic difficulties, many professionals note that the current DSM-IV criteria for Anorexia Nervosa (AN) have some significant classification problems that make a proper diagnosis very difficult. First, there is no reference provided for the weight criteria, so clinicians can have difficulty knowing if a patient's weight falls within the criterion. Secondly, the subtypes of anorexia are not particularly useful for the diagnosis of younger patients because these individuals typically exhibit resistricting behavior. As a result, many young patients are diagnosed with Eating Disorder Not Otherwise Specified (EDNOS) rather than AN, which often blocks proper treatment and research. Many clinicians have called for a revision of the diagnostic criteria in the DSM-V, which will be released in 2012 (Knoll, Bulik, & Hebebrand, 2010).
According to Keski-Rahkonen, et al., (2007), delays in diagnosis and misdiagnosis of anorexia can have serious consequences. A patient's weight may fall to a dangerously low level, and this may often result in electrolyte imbalances, heart irregularities, kidney damage, seizures, and extreme fatigue. The fatigue produced by the advancement of the disease can contribute to emotional issues such as depression and anxiety, and it may also result in neurological issues that are often irreversible.
A complete and accurate diagnosis of anorexia will often require the participation of family members or significant others, as a clinician attempts to gather personal information, and medical data regarding the patient. A variety of physical tests, such as BMI calculations and blood chemistry analysis in addition to many tests that may be required to make a differential diagnosis (Knoll, Bulik, & Hebebrand, 2010).
As previously noted, many individuals with anorexia make extensive efforts to hide or deny their condition. Frequently, they may blame their weight loss and poor diet on a variety of other health conditions. As such, a differential diagnosis is essential, and must be conducted with the utmost care (Halse, Honey, & Boughtwood, 2008).
The majority of patients who have an underlying medical condition will express concern about their weight loss, while individuals with anorexia may express a distorted body image, a desire to lose more weight, or a discomfort or resistance to discussing the topic of weight loss. Weight loss and a loss of appetite can be linked to a wide variety of medical illnesses, including diabetes, gastrointestinal disorders, endocrine disorders, chronic infections, malignancy, and even parasitic infections. A medical doctor must first rule out the presence of these conditions through diagnostic tests, such blood testing, ultrasound, stool testing, and even colonoscopy. A thorough physical exam is the first step towards and effective and error-free diagnosis, and physicians should be particularly aware of physical symptoms such as very dry skin, low body fat, abnormal heart rate, low blood pressure, and possibly hypothermia (Pritts & Susman, 2003).
In addition to physical illnesses, many psychiatric disorders can cause some symptoms of anorexia. Major Depressive Disorder and Generalized Anxiety Disorder can both result in loss of appetite, weight loss, fatigue, and obsessive-compulsive behaviors. An individual suffering from a major depressive event may experience a significant drop in body weight, and if she is not fully cognizant of her condition or is resistant to treatment she may underplay the severity of her depression. A number of psychiatric screening tools are available for the assessment and differential diagnosis of anorexia. One tool, the SCOFF questionnaire, has been widely used by clinicians for screening in the primary care setting. Research shows, however, that it is quite challenging to develop interview tools that will not elicit false positives or allow subjects to provide misleading answers (Pritts & Susman, 2003).
In addition to making a careful differential diagnosis, clinicians must consider the possible presence of comorbid psychiatric disorders. In a 2003 review of eating disorder diagnostics, Pritts and Susman noted that,
"Major depression is the most common comorbid condition among patients with anorexia, with a lifetime risk as high as 80%. Anxiety disorders, especially social phobia, also are common. Obsessive-compulsive disorder has a prevalence of 30% among patients with eating disorders. Substance abuse prevalence is estimated at 12 to 18% in patients with anorexia…"
Studies also show that personality disorders, especially borderline personality disorder, have a very high rate of comorbidity with anorexia. The complexity of both substance abuse and personality disorders can present major barriers in the proper diagnosis and assessment of anorexia because many individuals with these disorders may be resistant to treatment and avoidant or misleading with practitioners (Pritts & Susman, 2003)
Assessment and Etiology
Upon making a clear diagnosis of anorexia a clinical team must complete a thorough assessment of the severity and etiology of the disorder in order to design an effective treatment plan. Keel and McCormick (2010) suggest that should typically be conducted with the use of unstructured clinical interview questions, and clinicians should consider factors such as age, family history, medical history, and the possible presence of trauma when planning and conducting the assessment interview.
Assessment of the severity and nature of anorexia must be completed on a very individualized basis. A treatment team must careful assess factors such as body weight, overall physical condition, and the patient's attitude towards her weight. Factors such as the patient's self-concept, attitudes towards food, and any significant history of medical or psychiatric treatment should also be considered. In addition, a family assessment can help clinicians identify any relevant behavioral patterns or environmental stressors that made further inform the treatment…