DSM anorexia nervosa Flashcards
(10 cards)
diagnostic criteria AN
Diagnostic criteria:
- Criterion A: A restriction of energy intake relative to requirements that leads to a significantly low body weight in the context of age, sex, development, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected.
- Criterion B: Intense fear of gaining weight or of becoming fat. Or persistent behaviour that interferes with weight gain, even though patients have a significantly low body weight.
- Criterion C: Disturbance in the way in which one’s body weight or shape is experienced, inappropriate influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
There are two types of anorexia nervosa that can and need to be specified:
- Restricting type: This type can be specified when during the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behaviour, this behaviour can for example include self-induced vomiting. This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
- Binge-eating/ purging type: this subtype can be specified when, during the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behaviour, such as self-induced vomiting or the misuse of laxatives. Crossover between the two types is common.
Then is it also necessary to specify the state of the current remission:
- In partial remission can be specified when after full criteria for AN were previously met, criterion A (low body weight) has not been met for a period of time, but either criterion B or criterion C is still met.
- In full remission can be specified when, after full criteria for AN were previously met, none of the criteria have been met for a sustained period of time.
The current severity also needs to be specified. The minimum level of severity is based, for adults, on the current body mass index (BMI), and for children and adolescents on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.
- Mild: BMI ≥ 17 kg/m2.
- Moderate: BMI 16–16.99 kg/m2.
- Severe: BMI 15–15.99 kg/m2.
- Extreme: BMI < 15 kg/m2.
diagnostic features
Diagnostic features
There are three essential features of Anorexia Nervosa that were mentioned already in the diagnostic criteria which are consistent energy intake restriction, being scared of gaining weight or getting fat and showing consistent behaviour that interferes with weight gain. On top of that there are disturbances in how one perceives their weight and shape. The individual must be critically underweight which followed a period of significant weight loss . Among children and adolescents Instead of weight loss there might be failures to gain weight or have a normal developmental trajectory, whereas they still grow in height.
associated features of anorexia nervosa
Associated features of anorexia nervosa
The semistarvation of anorexia nervosa, and the purging behaviours sometimes associated with it, can result in significant and potentially life-threatening medical conditions. Physiological disturbances, including amenorrhea and vital sign abnormalities, are common. While most of the physiological disturbances associated with malnutrition are reversible with nutritional rehabilitation, some, including loss of bone mineral density, are often not completely reversible.
When patients are seriously underweight, many of them show depressive signs and symptoms. These symptoms can include things such as depressed mood, social withdrawal and insomnia and arise due to semi-starvation or due to the fact that the individual has major depressive disorder (MDD).
Obsessive-compulsive features, both related and unrelated to food, are often prominent. Most individuals with anorexia nervosa are preoccupied with thoughts of food. Some collect recipes or hoard food. When individuals with anorexia nervosa exhibit obsessions and compulsions that are not related to food, body shape, or weight, an additional diagnosis of obsessive-compulsive disorder (OCD) may be warranted.
Other features sometimes associated with anorexia nervosa include concerns about eating in public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression. People with the binge-eating/purging type have higher rates of impulsivity and are more likely to abuse substances.
Individuals with AN may misuse medication in order to achieve weight loss or avoid weight gain.
prevalence
The 12-month prevalence of anorexia nervosa is 0.4% in young females. There is less known about the prevalence of men. The female to male ratio is 10:1.
Anorexia nervosa appears to be most prevalent in post industrialised, high-income countries. The occurrence in most low and middle income countries is uncertain
Anorexia nervosa occurs across U.S. ethnoracial groups; however, its prevalence seems to be lower among Latinx and non-Latinx Black Americans than among non-Latinx Whites.
De levensprevalentie is 0.5-2.% met een piekbeginleeftijd van 13-18 jaar.
Het sterftecijfer (CMR) is 5-6% per decennium, dit is vaak door medische complicaties of zelfmoord. Dit is het hoogste sterftecijfer van alle psychiatrische stoornissen.
Zelfmoordcijfers zijn 12 per 100.000 per jaar.
development and course
Development and course
Anorexia nervosa commonly begins during adolescence or young adulthood. It does not often begin before puberty or after age 40. The onset of this disorder is often associated with a stressful life event, such as leaving home for college. The course and outcome of anorexia nervosa are highly variable. Younger individuals may manifest atypical features, including denying “fear of fat.” Older individuals more likely have a longer duration of illness, and their clinical presentation may include more signs and symptoms of long-standing disorder.
Many individuals show a period of changed eating behaviour before being diagnosed. Some recover completely after one episode while others might experience a chronic course over years. If required, hospitalization might be used to restore the weight. The crude mortality rate for anorexia nervosa is approximately 5% per decade. Death most commonly results from medical complications associated with the disorder itself or from suicide.
risk and prognostic factors
- Temperamental: Individuals who develop anxiety disorders or show obsessional traits as children are at increased risk for developing AN.
- Environmental: Occupations that encourage thinness, such as modelling and athletics, are also lead to an increased risk for developing AN
- Genetic and physiological: There is an increased risk for anorexia nervosa and for other eating and psychiatric disorders among biological relatives of individuals with anorexia nervosa, especially for the binge-eating/purging type.
Suicide risk is elevated in anorexia nervosa. In individuals with AN approximately 12 out of 100000 commit suicide. Therefore it is important to assess suicide ideation, behaviour and previous suicide attempt in individuals with AN.
diagnostic markers
The following laboratory abnormalities may be observed in anorexia nervosa:
- Haematology: leukopenia (loss of all cell types, but often lymphocytosis), mild amnesia (anaemia) and thrombocytopenia may occur, blood problems are rare.
- Serum chemistry: dehydration might lead to elevated blood nitrogen level, hypercholesterolemia is common, hepatic enzyme level can be elevated, self induced vomiting can lead to metabolic alkalosis.
- Endocrine: serum thyroxine levels are low to normal, triiodothyronine levels are lower. Women have lower oestrogen levels and men lower testosterone levels.
- Electrocardiography: sinus bradycardia is common, sometimes significant prolongation of QTc interval and arrhythmia is rare.
- Bone mass: low bone mineral density, with specific areas of osteopenia or osteoporosis. The risk of fractures is also higher.
- Electroencephalography: diffuse abnormalities due to fluid and electrolyte disturbances.
- Resting energy expenditure: significant reduction in resting energy expenditure.
- Physical signs and symptoms: amenorrhoea, constipation, abdominal pain, cold intolerance, lethargy (languor) and excess energy, emaciation, in pubertal females menarche may be delayed, etc.
functional limiations
Individuals with AN may exhibit a range of functional limitations that are associated with the disorder. Some are able to remain active in social and professional functioning, whereas others show significant social isolation and are not able to fulfil their academic or career potential.
differential diagnosis
Differential diagnosis
It is important to consider other possible causes of either significantly low body weight or significant weight loss when the presenting features are atypical. Differential diagnoses can be:
- Medical conditions: weight loss can occur in medical conditions, but there’s no disturbed body image or fear of gaining weight.
- Major depressive disorder: there is weight loss, but no desire for weight loss or fear of gaining weight.
- Schizophrenia: strange eating behaviour and occasional weight loss is associated with schizophrenia, but no disturbed body image or fear of gaining weight.
- Substance use disorder: weight loss, but no disturbed body image or fear of gaining weight. However, it may interfere with weight gain.
- Social anxiety disorder (SAD), OCD and body dysmorphic disorder: not liking to eat in public, obsessions and compulsions to eat, among other things, and disturbed body image.
- Bulimia nervosa: inappropriate behaviour against weight gain and overanxiousness about the body, but with bulimia, weight remains at or normal or above normal levels.
- Avoidant/restrictive food intake disorder: weight loss or nutritional deficiency, but there is no disturbed body image or fear of gaining weight.
comorbidity
Comorbidity
Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms of anxiety prior to onset of their eating disorder. OCD is described in some individuals with anorexia nervosa, especially those with the restricting type. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type.
