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Anorexia Nervosa

Anorexia Mentalis

Anorexia nervosa is an eating disorder characterized by a pathological fear of weight gain and usually excessive weight loss. There are two subtypes of anorexia nervosa: restricting type and binge eating–purging type.


Presentation

Anorexia nervosa patients present physical symptoms as well as behavioural and emotional symptoms.

Physical signs and symptoms of anorexia are [7]:

Emotional and behavioural symptoms associated with anorexia nervosa include:

  • Rejection of meals
  • Hiding hunger
  • Excessive fear of gaining weight
  • Dishonesty when discussing how much food has been consumed
  • Frequent, strenuous, or compulsive exercise
  • Signs of social withdrawal
  • Constant experimentation with food
  • Irritability
  • Constant display of uninterest
  • Lack of interest in sexual activities
  • Use of herbal products, laxatives, etc. 
Weight Loss
  • A rare diagnosis that is also associated with weight loss is a trichobezoar, a collection of hair or hair-like fibers in the gastrointestinal tract, primarily in the stomach.[ncbi.nlm.nih.gov]
  • Abstract It is important to recognise that patients who seek weight loss surgery may have a history of restrictive eating or anorexia nervosa.[ncbi.nlm.nih.gov]
  • OBJECTIVE: Patients with atypical anorexia nervosa (AN) have many features overlapping with AN in terms of genetic risk, age of onset, psychopathology and prognosis of outcome, although the weight loss may not be a core factor.[ncbi.nlm.nih.gov]
  • Of note, the elevated TSH that would be expected in Hashimoto's thyroiditis was blunted by weight loss associated with AN.[ncbi.nlm.nih.gov]
Underweight
  • Abstract Anorexia nervosa is a medical and psychological disorder classically seen in young women who present with significant weight loss, a distorted body image, and an intense fear of gaining weight despite being underweight.[ncbi.nlm.nih.gov]
  • Previous neuroimaging studies have found consistent global reductions in global grey matter volume of underweight girls with AN; however, differences in regional grey matter volumes are less consistent.[ncbi.nlm.nih.gov]
  • The current study conducted a comprehensive assessment of attention networks in adolescents with AN who were not severely underweight during the study using an approach that permits disentangling independent components of attention.[ncbi.nlm.nih.gov]
  • Eating disorder-related impairment in AN was not related to the severity of underweight or purging behaviors, but was uniquely and positively associated with weight/shape concerns and binge eating frequency. Copyright 2018 Elsevier Ltd.[ncbi.nlm.nih.gov]
  • Cycles of overweight and underweight due to natural states of starvation and refeeding are normal in many vertebrates in their ecological niches.[ncbi.nlm.nih.gov]
Malnutrition
  • KEYWORDS: Anorexia Nervosa; Comorbidity; Family Physicians; Feeding and Eating Disorders; Inpatients; Morbidity; Protein-Energy Malnutrition [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • Pathology was consistent with liver injury secondary to severe malnutrition rather than from refeeding syndrome.[ncbi.nlm.nih.gov]
  • , Malnutrition, Severe Weight Loss, Extreme Weight Loss) Progression of Anorexia Nervosa (Self-Starvation, Malnutrition, Severe Weight Loss, Extreme Weight Loss) Symptoms of Anorexia Nervosa (Self-Starvation, Malnutrition, Severe Weight Loss, Extreme[myvmc.com]
  • CASE PRESENTATION: A 21-year-old Caucasian woman was admitted in an intensive care unit for severe malnutrition in anorexia nervosa.[ncbi.nlm.nih.gov]
  • Abstract Anorexia nervosa (AN) has the highest mortality rate of all psychiatric illnesses due to the widespread organ dysfunction caused by the underlying severe malnutrition.[ncbi.nlm.nih.gov]
Anemia
  • Other medical complications included pericardial tamponade that was treated with an open window pericardiocentesis, hepatitis, and anemia.[ncbi.nlm.nih.gov]
  • Other medical conditions may also be present, such as anemia, dry skin and scalp, osteoporosis, lowered body temperature and blue fingertips, and slow thinking due to brain shrinkage.[emilyprogram.com]
  • Hematological (blood): About one-third of anorexic adolescents have mild anemia (low red blood cell count). Leukopenia (low white blood cell count) occurs in up to 50 percent of anorexic adolescents.[childrenshospital.org]
  • We also treat co-occurring medical issues, such as gastroparesis, dehydration, bradycardia, edema, anemia, and hypotension.[magnolia-creek.com]
Hypothermia
  • Vitals on presentation were notable for hypothermia, hypotension, and bradycardia. Initial exam was significant for emaciation, lethargy, and lower extremity edema.[ncbi.nlm.nih.gov]
  • Physical ( for nasogastric resuscitation ) Bradycardia ( 50 bpm) Postural hypotension (fall in systolic BP lying to standing 20 mmHg) Dehydration Hypothermia (temp.[rch.org.au]
  • […] electrolyte disturbances, arrested growth and development, and acute food refusal, as well as social concerns and mental illness, should be considered when deciding on admitting adolescents with anorexia nervosa. 11 Conclusion While severe weight loss, hypothermia[cfp.ca]
  • […] alkalosis, hypokalaemia hypocalcaemia ECG: AV block, ST depression, TWI, prolonged QT, arrhythmias MANAGEMENT rehydrate fix electrolytes cautious fluid therapy as can precipitate cardiac failure loss of lung elasticity - high AWP RSI pressure cares hypothermia[lifeinthefastlane.com]
Vomiting
  • She presented with dehydration, vomiting, weakness, a body mass index of 13 kg/m 2 and was treated with intravenous and enteral supplementation. During admission her vomiting worsened and she developed visual hallucinations and confabulation.[ncbi.nlm.nih.gov]
  • Self-induced vomiting and purging are secondary devices used by the patients to counteract the effects of overeating and prevent a gain in weight.[ncbi.nlm.nih.gov]
  • KEYWORDS: Barrett's esophagus; anorexia; vomiting[ncbi.nlm.nih.gov]
  • Abstract A rare case combining pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, pneumorrhachis, air in retroperitoneum and extensive subcutaneous emphysema simultaneously in a severely anorectic male with BMI 9.2 (22.8 kg) and multiple vomitings[ncbi.nlm.nih.gov]
  • There are two types of anorexia nervosa : Restricting type: People limit how much they eat but do not regularly binge eat or purge—for example, by making themselves vomit (called self-induced vomiting) or taking laxatives. Some exercise excessively.[merckmanuals.com]
Constipation
  • They include: Anaemia (iron deficiency) Compromised immune system (e.g. getting sick more often) Intestinal problems (e.g. abdominal pain, constipation, diarrhoea) Loss or disturbance of menstruation in girls and women Increased risk of infertility in[nedc.com.au]
  • Makes frequent comments about feeling “fat” or overweight despite weight loss Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy Denies feeling hungry Develops food rituals (e.g., eating foods in certain orders[nationaleatingdisorders.org]
  • […] weight loss Very low body weight Fatigue Insomnia Abnormal blood counts Fainting or dizziness Thin or brittle hair Fine hair that covers your body Blue fingers Dry, blotchy, or yellow skin Irregular menstrual periods (in women) Feeling cold all the time Constipation[everydayhealth.com]
Abdominal Pain
  • They include: Anaemia (iron deficiency) Compromised immune system (e.g. getting sick more often) Intestinal problems (e.g. abdominal pain, constipation, diarrhoea) Loss or disturbance of menstruation in girls and women Increased risk of infertility in[nedc.com.au]
  • Makes frequent comments about feeling “fat” or overweight despite weight loss Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy Denies feeling hungry Develops food rituals (e.g., eating foods in certain orders[nationaleatingdisorders.org]
  • This may eventually result in permanent constipation and also sometimes abdominal pains. Swelling of hands, feet and face This is usually due to fluid disturbances in the body.[patient.info]
Loss of Appetite
  • The term anorexia literally means "loss of appetite." However, this definition is misleading as people with anorexia nervosa are often hungry but refuse food anyway.[my.clevelandclinic.org]
  • When Gull reported about his work to the Clinical Society of London, he used the term anorexia nervosa, which literally means “nervous loss of appetite ,” to describe the condition. He was the first to do so.[britannica.com]
  • In true anorexia nervosa there is no real loss of appetite, but rather a refusal to eat or an aberration in eating patterns; hence, the term anorexia is probably a misnomer.[medical-dictionary.thefreedictionary.com]
Nausea
  • Apart from inducing nausea, high PYY levels were also found to be associated with decreased body weight, body mass index and bone composition in subjects with anorexia.[garvan.org.au]
  • […] any mental disorder. (1, 5 ) Starvation is a major cause of death, but one in five anorexia deaths is due to suicide. (4,2) Other complications include: Organ damage Anemia Heart problems Bone loss Stomach issues, such as bloating, constipation, or nausea[everydayhealth.com]
  • […] prolapse, abnormal heart rhythms or heart failure Bone loss (osteoporosis), increasing the risk of fractures Loss of muscle In females, absence of a period In males, decreased testosterone Gastrointestinal problems, such as constipation, bloating or nausea[mayoclinic.org]
  • Stopping them suddenly can cause problems, such as nausea and constipation Gaining weight safely Your healthcare professional will give you advice on how to increase the amount you eat so you can gain weight safely.[nhsinform.scot]
Hypotension
  • In AN various cardiac complications may occur: hypotension, bradycardia, life-threatening ventricular arrhythmias, pericardial effusion, reduction of left ventricular mass and impairment of its function.[ncbi.nlm.nih.gov]
  • Vitals on presentation were notable for hypothermia, hypotension, and bradycardia. Initial exam was significant for emaciation, lethargy, and lower extremity edema.[ncbi.nlm.nih.gov]
  • Physical ( for nasogastric resuscitation ) Bradycardia ( 50 bpm) Postural hypotension (fall in systolic BP lying to standing 20 mmHg) Dehydration Hypothermia (temp.[rch.org.au]
  • Hypotension and orthostatic change in pulse and blood pressure are key indicators for hospitalization for adolescents with eating disorders. 14 A study by Hudson et al 19 suggests hospitalization when systolic blood pressure is less than 80 mm Hg.[cfp.ca]
Tachycardia
  • Physical signs and symptoms of anorexia are: Severe weight loss Emaciated appearance Extreme fatigue Insomnia Dizziness or fainting Bluish discoloration of the fingers Weak hair Amenorrhea Dry skin Extreme discomfort in cold conditions Bradycardia or tachycardia[symptoma.com]
  • Associated arrhythmias include: sinus arrest, wandering atrial pacemakers, nodal escape beats, supraventricular tachycardia, and ventricular tachycardia.[academic.oup.com]
Dry Skin
  • Other medical conditions may also be present, such as anemia, dry skin and scalp, osteoporosis, lowered body temperature and blue fingertips, and slow thinking due to brain shrinkage.[emilyprogram.com]
  • Physical signs and symptoms of anorexia are: Severe weight loss Emaciated appearance Extreme fatigue Insomnia Dizziness or fainting Bluish discoloration of the fingers Weak hair Amenorrhea Dry skin Extreme discomfort in cold conditions Bradycardia or[symptoma.com]
  • Physical symptoms may include very dry skin, belly pain, and constipation. A mental health expert can diagnose anorexia. Treatment may include therapy and nutritional rehab. Family therapy may be an important part of treatment.[hopkinsmedicine.org]
  • Symptoms Weight loss of 15% or more of body weight Fear of gaining weight Lack of menstrual periods in women Problems with digestion, energy, memory and concentration Feeling cold all the time Loss of sex drive Dental cavities Hair loss Dry skin Constipation[psychassociates.net]
  • […] only having a period while on hormonal contraceptives (this is not considered a “true” period) Cuts and calluses across the top of finger joints (a result of inducing vomiting) Dental problems, such as enamel erosion, cavities, and tooth sensitivity Dry[nationaleatingdisorders.org]
Lanugo
  • […] the risk for osteoporosis/osteopenia increases as bone density decreases Muscle loss and weakness Dehydration (which can result in kidney failure) Fainting, fatigue, and overall weakness Dry hair and skin, hair loss Growth of a downy layer of hair (lanugo[magnolia-creek.com]
  • Purging by vomiting or taking laxatives or diuretics • Cooking for others but not eating the food • Feeling sad, anxious or irritable • Feeling cold all the time • Tremendous weight loss • Exhaustion • Dizziness • Fine, soft hair on the body called lanugo[ulifeline.org]
  • Growth of a downy layer of hair called lanugo all over the body, including the face. Important Facts: It typically develops in early to mid-adolescence.[pbs.org]
  • […] period) Cuts and calluses across the top of finger joints (a result of inducing vomiting) Dental problems, such as enamel erosion, cavities, and tooth sensitivity Dry skin Dry and brittle nails Swelling around area of salivary glands Fine hair on body (lanugo[nationaleatingdisorders.org]
Alopecia
  • Patients may also suffer from bone loss, dry mouth, low blood pressure, and alopecia. Female patients usually experience missing or stopped periods. All other symptoms characteristic to malnutrition may appear in a person with anorexia nervosa.[bulimia.com]
Low Self-Esteem
  • The most common element surrounding ALL Eating Disorders, including Anorexia, is the inherent presence of a low self esteem Anorexia Nervosa Those who are suffering with this illness have a low self-esteem and often a tremendous need to control their[something-fishy.org]
  • self-esteem Reluctance to express feelings Warning signs: Extreme weight loss Increasing rigidity of the diet Preoccupation with weight, food or counting calories Wearing multiple layers of clothing Excessive or compulsive exercise Multiple excuses for[uclahealth.org]
  • Goals of treatment include restoring the person to a healthy weight, treating emotional issues such as low self-esteem, correcting distorted thinking patterns, and developing long-term behavioral changes.[my.clevelandclinic.org]
  • Some predisposing factors in eating disorders include: Female sex Difficulty discussing negative emotions Low self-esteem Family history of any kinds of eating disorders Perfectionistic personality Difficulty resolving conflict Maternal encouragement[symptoma.com]
  • Personality traits of perfectionism and fear of failure, low self esteem, emotion avoidance and obsessionality are very common in individuals with anorexia.[nzeatingdisordersclinic.co.nz]
Denial
  • […] intake, resulting in significantly low body weight Intense fear of gaining weight or becoming fat (despite significantly low body weight) Disturbance in the experience of body weight or shape; undue influence of weight or shape on self-evaluation, or denial[magnolia-creek.com]
  • Self-denial was continued until her planned discharge; however, positive behavioural change was recorded whilst her blood showed normokalaemia for a whole week until her discharge.[ncbi.nlm.nih.gov]
  • Disturbance in the experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight. Loss of menstrual periods in girls and women post-puberty.[studenthealth.sa.ucsb.edu]
  • Anorexia nervosa is an illness of obsessive self-starvation characterized by: refusal to maintain a minimally normal weight; intense fear of weight gain or being "fat," even when underweight; and distorted perception of the body or denial of the seriousness[uclahealth.org]
  • Disturbance in the way in which 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.[nationaleatingdisorders.org]
Preoccupation with Food
  • The Shape and Weight Concern items primarily loaded together on one factor, along with preoccupation with food and fear of losing control over eating, two Eating Concern items.[ncbi.nlm.nih.gov]
  • BACKGROUND: A constant preoccupation with food and restrictive eating are main symptoms of anorexia nervosa (AN).[ncbi.nlm.nih.gov]
  • The signs and symptoms of anorexia nervosa can include: sudden or significant weight loss sudden or significant reduction in amount of food eaten or in types of foods eaten loss of menstrual period preoccupation with food and weight weight and body shape[healthywa.wa.gov.au]
  • Some signs to look out for A preoccupation with food, bodyweight, shape and appearance Rapid weight loss A low BMI for their age Restrictions in food intake and/or changes in eating habits Social withdrawal and isolation Disturbances in endocrine functioning[firststepsed.co.uk]
  • Warning Signs of Anorexia Nervosa Preoccupation with body shape, weight and/or appearance Intense fear of gaining weight Preoccupation with food or food related activities Negative or distorted body image; perceiving self to be fat when at a healthy weight[eatingdisorders.org.au]
Compulsive Behavior
  • Also eating disorder-specific cognitions and compulsive behaviors remitted. DISCUSSION: Previous studies have applied much lower doses and showed no effect of dronabinol upon the urge to be physically active.[ncbi.nlm.nih.gov]
  • The restrictive eating behaviors associated with anorexia may therefore result from an imbalance between inhibitory and reward systems, which leads to a shift to compulsive behaviors.[brainblogger.com]
  • By understanding a woman’s entire history of addictive and/or compulsive behavior, we are able to customize her treatment plan to address all of her concerns and provide a holistic treatment experience.[timberlineknolls.com]
Lethargy
  • Initial exam was significant for emaciation, lethargy, and lower extremity edema. Laboratory work-up revealed markedly elevated LFTs, hypoglycemia, thrombocytopenia and elevated INR and lipase. ECG showed sinus bradycardia with prolonged QTc.[ncbi.nlm.nih.gov]
  • Makes frequent comments about feeling “fat” or overweight despite weight loss Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy Denies feeling hungry Develops food rituals (e.g., eating foods in certain orders[nationaleatingdisorders.org]
  • […] increased risk of heart failure and death Reduction of bone density (osteopenia and osteoporosis) which results in dry, brittle bones Muscle loss and weakness Severe dehydration, which can result in kidney failure Edema (swelling) Fainting, fatigue, lethargy[eatingdisorder.org]
Amenorrhea
  • KEYWORDS: Anorexia nervosa; Bone metabolism; Hypothalamic amenorrhea; Low bone density[ncbi.nlm.nih.gov]
  • A histological examination of the ovary suggested that she had been suffering from amenorrhea. The thyroid gland was atrophic, and marked variations in follicle size were observed.[ncbi.nlm.nih.gov]
  • Amenorrhea: The illness also causes a woman's menstrual cycle to stop, a condition called amenorrhea. Impotence: Men with anorexia often become impotent.[pamf.org]
  • DISCUSSION: Anorexia nervosa is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea.[ncbi.nlm.nih.gov]
  • Endocrine (hormones): One of the most telling symptoms of anorexia is amenorrhea, or when the menstrual cycle is missed for three or more consecutive cycles without any other underlying cause.[childrenshospital.org]
Irregular Menstruation
  • Visible signs that she is starving herself include extreme weight loss, abnormal thinness, brittle nails, hair loss, constipation, irregular menstruation, and swelling.[childmind.org]
  • menstruation Amenorrhea (loss of menstruation) is sometimes but not always present Wearing baggy clothes to hide weight loss Frequently checking weight on scale Fainting spells and dizziness Difficulty eating in public Very secretive about eating patterns[mirror-mirror.org]
  • menstruation Excessive facial/body hair Binge eating alternating with fasting Vomiting or taking laxatives after over-eating Compulsive or excessive exercise Self-worth determined by weight or shape Persons with anorexia nervosa may also be socially[urmc.rochester.edu]

Workup

Although there is no clear evidence to show that any particular treatment for anorexia nervosa works better than others, evidence shows that early intervention and treatment often prove effective in handling of the condition [9]. In general, anorexia nervosa treatment is focused on addressing these three main areas:

  • Restoration of the individual to a healthy weight
  • Treatment of psychological disorders related to the ailment
  • Reduction or eradication of behaviours responsible for the disorder in the first instance
Prolonged QT Interval
  • An ECG may show bradycardia or a prolonged QT interval in those with more severe anorexia.[patient.info]
  • Some patients have prolonged QT intervals (even when corrected for heart rate), which, with the risks imposed by electrolyte disturbances, may predispose to tachyarrhythmias. Sudden death, most likely due to ventricular tachyarrhythmias, may occur.[msdmanuals.com]

Treatment

Treatment of this condition requires a physical, social and psychological assessment of the individual by health professionals, especially an eating disorder specialist. This assessment is important to decide the most suitable care plan to follow.

Generally, treatment of the condition will involve a combination of psychological therapy and individually tailored advice on eating and nutrition. This will help the patient gain weight safely.

Psychiatrists, specialist nurses and dietitians contribute at different stages to the treatment of anorexic individuals. The treatment is done on an outpatient basis except in serious cases where the individual must be treated in a hospital or specialist eating disorder clinics.

Prognosis

The prognosis of anorexia nervosa varies. Morbidity rates often range from 10 to 20% with only 50% of patients being able to recover fully. Of the remaining, 20% remain emaciated while another 25% still present thin body. The remaining either dies of starvation or become overweight [6].

However, mortality following complications as a result of starvation is far less frequent in patients with anorexia nervosa as death arising from suicide which is the chief source of mortality incidence. Suicide attempts are higher in people with a history of artificial inducement of physical pain, drug use, and laxative use.

Etiology

Anorexia nervosa is as a result of a complex interchange between social biologic and psychological factors [3]. It affects more women than men and in women it is mostly seen in adolescents.

Patients who develop anorexia nervosa often display a relatively high incidence of premorbid anxiety disorders. Since most cases of anorexia nervosa are seen within the pubescent years, experts believe that exertion of control over body weight and food consumption is the adolescents attempting to make up for what is seen as absence of selfhood and autonomy.

Some predisposing factors in eating disorders include:

  • Female sex
  • Difficulty discussing negative emotions
  • Low self-esteem
  • Family history of any kinds of eating disorders 
  • Perfectionistic personality
  • Difficulty resolving conflict

Maternal encouragement of weight loss (actively or passively) is also a risk factor for anorexia nervosa especially when the disorder is seen in children. The possibility of genetic predisposition has been pointed out following reported cases of anorexia nervosa in twins and triplets.

In individuals with anorexia nervosa, there is a lifelong incidence of anxiety, depressive disorders as well as obsessive-compulsive disorder. Systemic lupus eythematosus and congenital adrenal hyperplasia are common disorders associated with anorexia nervosa.

Epidemiology

The condition is seen in all developed countries and cuts across all socioeconomic classes. It occurs worldwide around the same rates of incidence of 0.3 to 1% in women and 0.1 to 0.3% in men. It is also seen in developing countries like China and Brazil [4].

Sex distribution
Age distribution

Pathophysiology

A standard case of anorexia begins with a young individual mildly overweight or normal weight going on a diet or exercise regime with a plan to lose weight. Following the initial positive results, he or she receives compliments from peers or family. This is deemed high reward by the individual and makes it difficult for them to stop this behaviour as soon as an ideal weight is achieved [5].

Malnutrition as a result of self-starvation brings about protein deficiency and a disruption of multiple organ systems including the cardiovascular, renal, gastrointestinal, neurologic, endocrine, integumentary, reproductive and hematologic systems.

Prevention

There's no guaranteed way to prevent anorexia nervosa or other forms of eating disorders [10].

Summary

Anorexia nervosa refers is an eating disorder where patients try their best to keep their body weight as low as they can [1]. They achieve this by severely restricting the amount of food they eat and vomiting after meals. They also engage in excessive exercising.

This condition develops as a result of anxiety about the shape of the body and weight and fear of becoming fat. Anorexic individuals often have a false image of themselves [2]. This makes they feel they are fat when in reality, they may be perfectly normal.

Anorexia is seen both sexes and peak age for the condition is 16 to 17 years.

Patient Information

Anorexia nervosa refers to an eating disorder which causes people be overly obsessed with their weight and what they consume. In such people, the focus is on trying to maintain body weight that is well below what is deemed normal for their height and age and they achieve this by starving themselves or exercising excessively.
People who have this problem make the mistake of equating thinness with self-worth.

This condition is difficult to overcome but with the right treatment and psychotherapy, the individual can return to a normal eating habit and also reverse any damages already caused by the condition.

References

Article

  1. Miller KK, Grinspoon SK, Ciampa J, Hier J, Herzog D, Klibanski A. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. Mar 14 2005;165(5):561-6.
  2. Eisler I, Simic M, Russell GF, Dare C. A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. J Child Psychol Psychiatry. Jun 2007;48(6):552-60.
  3. Morris J, Twaddle S. Anorexia nervosa. BMJ. Apr 28 2007;334(7599):894-8.
  4. Herpertz-Dahlmann B, Salbach-Andrae H. Overview of treatment modalities in adolescent anorexia nervosa. Child Adolesc Psychiatr Clin N Am. Jan 2009;18(1):131-45.
  5. E Grange D. The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry. Oct 2005;4(3):142-6.
  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  7. Keel PK, McCormick L. Diagnosis, assessment, and treatment planning for anorexia nervosa. In: TheTreatment of Eating Disorders: A Clinical Handbook, Grilo CM, Mitchell JE (Eds), The Guilford Press, New York 2010. p.3.
  8. Andersen, AE, Yager, J. Eating disorders. In: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Volume I, Ninth Edition, Sadock, BJ, Sadock, VA, Ruiz P (Eds), Lippincott Williams & Wilkins, Philadelphia 2009. p.2128.
  9. Weider S, Indredavik MS, Lydersen S, Hestad K. Neuropsychological function in patients with anorexia nervosa or bulimia nervosa. Int J Eat Disord 2014.
  10. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 61:348.

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Last updated: 2018-06-22 08:26