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PSYCHIATRY

An Overview of the Etiology, Diagnosis, and

Management of Anorexia Nervosa

Neville Golden, MD, Ira M. Sacker, MD

The incidence of anorexia nervosa is increasing in adolescents. The pediatrician caring fort^nagers is often the first professional confronted with the early signs and symptoms of thisdisorder. Clinical features and available literature on the psychological, nutritional, and familydisorganization found in patients with anorexia nervosa are reviewed. Different therapeutic ap-proaches are discussed, and current data on outcome are presented.

LNOREXIA NERVOSA was first described in

1689 by an English physician, Richard Morton,' who

called it "a nervous consumption," but it was not rec-ognized as a clinical entity until the independent de-

scriptions by Gull in England^ and Lasegue in France

in 1 8 7 3 . ' Gull coined the term 'anorexia nervosa, '

which has persisted despite the fact that it is a bit of

a misnomer. Many of these patients are not anorexic,

but rather they experience intense feelings of hunger

that they either actively deny or fulfill by abnormal

eating habits.

Th e condition is primarily seen in young girls (about

10 % of cases are male) and is associated with v oluntary

self-starvation and emaciation, a persistent fear of being

fat, a distorted body image, and a relentless pursuitof thinness. These young girls often have a charac-

teristic premorbid personality associated with a par-

From the Section of Adolescent Medicine. Department of Pe-diatrics. Brookdale Hospital Medical Center. State University ofNew York, Brooklyn, New York.

Correspondence to: Nevil le Golden. MD. Department of Pe-diatrics, Brookdale Hospital Medical Center, State University ofNew York, Brooklyn, NY 11212.

Received for publication May 1983 . revised Ju ne and Septem ber1983 , and accepted November 1983.

ticular family set-up, and they develop definite en-

docrine abnormalities, mainly at the level of the hy-

pothalam us. Thes e can be detected both clinically andon laboratory testing.

In our society, we emphasize thinness, and a norex ia

nervosa seem s to be on th e rise.^ Th er e is a very sig-

nificant mortality of between 5^ and 20 percent."^

Feighner et alP have outlined necessary diagnostic

criteria:

1) Age of onset prior to 25 years;

2) An orexia with weight loss of at least 25 p erc ent

of original body weight;

3) A distorted attitude towards eating, food, or

weight that overrides even the instinctive re-sponses to hunger and threats;

(These first three criteria may be associated with the

following charac teristics: denial of illness; ap pa ren t en-

joyment in losing weight; a desired body image of

extreme thinness, and unusual avoiding or handling

of food.)

4) No known medical illness that would accoun t for

the extreme loss of weight;

5) No overt psychiatric illness; and

CLINICAL PEDIATRICS April 1984 209



GOLDEN AND SACKER

6) At least two of the following conditions: amen-

orrhea, lanugo, bradycardia (persistent resting

pulse <60), hyperactivity despite severe weight

loss, bulimia, and self-induced vomiting.

Premorbid Personality

These young girls are described as having been

"perfect childreri" prior to the illness—compliant, very

successful academically, well liked by their peers, and

good athletes. They are usually of average or above

average intelligence. F urthe r analysis, however, shows

them to be over-achieving, obsessive, dependent, and

psychosexually inadequate.

Family Background

Anorexia nervosa patients often come from uppermiddle-class families with high achievement orienta-

tion. One of the parents, usually the mother, tends to

be dominant and over-protective, while the other par-

ent is weak, submissive, and often absen t from the

home for long periods of time. In a review of the

charts of 34 anorexics, Beumont el al.^ found that in

just over half the patients, at least one of the parents

worked in one of the caring professions (doctors, psy-

chologists, nurses, ministers of religion). Th e patien t's

family is ostensibly stable with few bro ken ma rriag es.

The parents are proud of both their family and their

child and expect obedience and success from her.Wh at then causes the disintegration of this app aren t

harmony? A dolescence is a time of changing body im-

age, emotional turmoil, and, hopefully, the attainment

of self-identity. These previously over-compliant chil-

dren have always accepted stand ards imposed on them

by others, and now they find tremendous difficulty in

attaining their own identity. They are dependent on

their mothers, but at the same time, they struggle for

independence from their mother's control. Feelings

of hostility toward their mothers are associated with

guilt and anxiety, and may result in the adolescent's

denial of her own sexuality. Hilda Bruch® describesthe anorexic's tremendous fear of loss of control. By

losing weight, she gains control of her own body and,

ultimately, control of the dynamics of the entire family.

T he anorexic pa tient neve r really resolves the tasks

of adolescence and continues to function in the style

of early childhood with the persistence of ego centricity.

She is unable to think abstractly, and her thoughts

and actions tend to be of a concrete nature . Although

the physical and psychological consequences of severe

malnutrition dominate the clinical picture, the primary

disorder is related to deficiencies in the sense of self,

identity, and autonomy.

Nutritional Disorganization

Some investigators have found that the majority ofpatients are premorbidly overweight,"* but this is not

always the case. In one study described by Bruch,^

only six of 45 anorectic patients had a weight above

140 pounds. One third of the patients were described

as "slightly p lum p," but the vast majority were of nor-

mal weight for height and age at the onset of disease.

Nutritional disorganization is characteristic of this

disord er and may be manifested in two forms: a) refusal

to eat and b) uncontrolled impulse to binge without

being aware of hunger. This may be associated with

purging and abuse of laxatives and diuretics. Anorectic

patients are preoccupied with food, and they enjoypreparing meals for others. They deny their hunger

sensations and complain of abdominal pain and bloat-

ing after eating even small portions of food. Many

refuse to eat with other family members. They often

dispose of food down the toilet, and they may go to

excessive lengths to hide their vom iting. They are well

read in lay nutr ition, obsessively m aintain calorie intake

charts, and tend to maintain a diet rich in protein and

vitamins.

Not all anorectic patients are bulimic, and bulimia

exists as a distinct syndrome in women who are notanorectic. "Bu limia" is the condition w hereby an in-

dividual repeatedly loses control of the impulse to bing e

and rapidly consumes a lar gea m ou nt of food in a short

period of time. Vomiting is then self-induced in an

attempt to lose weight. By definition, in anorexia ner-

vosa, a weight loss of 25 percent of original body weight

is necessary for diagnosis, while bulimia can occur at

any body weight.

In four independent reviews,'""' '^ each studying

mo re than 100 patients with the diagnosis of anorexia

nervosa, bulimia was found in approximately 40 per-

cent of the patients. Some authors" believe that bu-limia represents a distinct subgroup of anorexia ner-

vosa. The more prevalent feeling, however, is that

anorexia nervosa and bulimia represent a spectrum of

eating disorders. '-^

Clinical Picture

The primary feature of anorexia nervosa is severe

weight loss in excess of 25 percent of previous body

weight, but despite this emaciated condition, the pa-

tients exhibit endless energy. Most investigators have

2 1 0 Vol. 23 No. 4 CLINICAL PEDIATRICS



ANOREXIA NERVOSA OVERVIEW

found am enorrh ea to be a consistent finding , and thismay even preceed the weight reduction.

Physical examination may reveal dry skin, the pres-ence of lanugo hair over the back and extremities,hypotension, hypothermia, and bradycardia. Edema

may be present, especially after refeeding. T he breastsare atrophic and the uterus is small, but th e distributionof pubic and axillary hair is normal.

Labo ratory values are nonspecific; Anemia is an un-common finding despite the malnutrition, but leu-kopenia, with a relative lymphocytosis, is seen fre-quently. Electrolyte abnormalities may be evident,especially in the presence of vomiting or abuse of lax-atives and diuretics. Blood glucose levels may be low,normal, or elevated, and the glucose tolerance testmay be flat or diabetic in nature. Total protein andalbumen levels are norm al. Some patients may exhibitlow plasma Vit A levels, and hypercarotinemia is afrequent finding, the basis of which is unknown.

Endocrine Abnormalities

Investigators have found abnormalities in thermo-regulation, thyroid function, and the secretion of go-nadotropin, cortisol, growth h orm one , and vasopressin.These findings, togethe r with the eating disorder an damenorrhea, have led to the belief in a hypothalamicdisorder. Some of these abnormalities will be consid-ered briefly.

Thermoregulation

Patients with an orexia nervosa exhibit abnorm al re-sponses to exposure to heat and cold w hen com paredwith control subjects.'*'^ These changes are reversiblewith restoration of normal body weight. As the hy-pothalamus is primarily responsible for thermoregu-lation, this evidence suggests hypothalamic dysfunction.

Thyroid Function

Amenorrhea, dry skin, constipation, bradycardia,and low basal metabolism rate suggest that these pa-

tients might be hypothyroid, but most investigatorshave found normal levels of thyroxine (T4) and thyroidstimulating hormone (TSH). Administration of thy-rotropin releasing hormone to patients with anorexianervosa results in increased plasma TSH levels, butthe peak response tends to be delayed.'* Serum tri-iodothyronine (T3) levels have been found to be low,and this is accompanied by a corresponding increasein its metabolically inactive mirror-image form, reverseT3. This may be due to deficient peripheral deiodin-ation of T4 to T3.'® A similar situation is found in

many malnourished states and appears to be a pro-tective mechanism to decrease the body's oxygen con-sumption. This is not specific to anorexia nervosa.

Gonadotropin Secretion

Basal plasma levels of follicular stimulating hormone(FSH), luteinizing hormone (LH), and estradiol havebeen found to be consistently low,""^^ and adminis-tration of gonadotropin releasing hormone (GnRH)results in a delayed rise in plasma FSH and LH lev-els."'^' Both of these abnormalities are resolved onresumption of normal body weight.

In norm al individuals, the adm inistration of clomi-phene citrate stimulates gona dotropin release by com-peting with endogenous estrogen and testosteronefeedback at the hypothalamic receptor sites. In patients

with anorexia nervosa, clomiphene administration doesnot increase plasma FSH and LH levels,'^'^^ whichfurther implicates a hypothalamic defect. This, too,reverts to normal after adeq uate weight gain and seemsto be inextricably linked with the malnutrition.

Growth Hormone

Resting levels of growth horm one (GH) may be sig-nificantly elevated,'^'^^ and they appear to be higherin patients with a low calorie intake. The majority ofpatients respond to at least one ofth e GH stimulationtests, implying normal pituitary function.

Adrenal Function

Basal plasma cortisol levels tend to be elevated inpatients with anorexia nervosa,'*'^* and there may bea loss of diurnal variation.^^ Boyar et al.^^ demonstrateda normal p roduction rate of cortisol but a prolongationof the cortisol half-life associated with decreased met-abolic turnover. Similar findings have been demon-strated in patients with protein calorie malnutrition.'^''

Vasopressin

Four of five patients tested in Mecklenberg's series'•*and 44 percent of patients in Vigersky's series^'^ dem-onstrated a defective urinary concentrating mecha-nism, indicating partial diabetes insipidus. This re-sponded to exogenous vasopressin adm inistration andis further evidence to support a hypothalamic dys-function in anorectic patients.

Pathogenesis

In light of the above findings, can we better un-derstand the pathophysiology of this condition? We

CLINICAL PEDIATRICS April 1984 211



GOLDEN AND SACKER

know that some of the endocrine abnormalities can

be explained on the basis of malnutrition, weight loss,

and low calorie intake, and similar findings have been

found in other malnourished states. Other findings,

however, are indicative of an independent hypotha-

lamic dysfunction. Is the hypothalamic insult seco ndary

to the mental disorder or to starvation itself, or could

this be a primary hypothalamic disorder of unknown

etiology? This problem has been discussed at length

elsewhere,''''^*'^® but at this stage, it is probably sim-

plistic to theorize on a particular sequential patho-

genesis. It is clear that the mental disorder, the hy-

pothalamic dysfunction, and malnutrition can individ-

ually result in some of the clinical manifestations of

anore xia nerv osa, and the total pictu re is proba bly a

result of an intricate interaction of all three mecha-

nisms.In an attempt to explain both the psychiatric and

hypothalamic dysfunction on a molecular level, Barry

and Klawans^' have proposed an abnormality of neu-

rotransmitter regulation, postulating that many ofthe

manifestations of anorexia nervosa can be explained

on the basis of increased activity of dopam ine at central

dopamine receptors in the brain. This postulated in-

creased dopaminergic activity may play a role in the

pathogenesis of anorexia nervosa, but further research

is required to elucidate the matter.

Treatment

Tre atm ent is aimed at restoring normal nutrition

and body weight, resolving psychiatric abnormalities,

and maintaining body weight and a state of well being

over a long-term period.

Most investigators feel that medical admission into

a hospital is necessary for the initial weight gain. This

additionally serves to remove the patient from her

home environment, provides good supportive nursing

care, and allows the initiation of psychotherapy. Star-

vation itself causes psychological disorganization, and

in the m alnou rished state, it is very difficult to accom -plish effective psychotherapy. In the literature, how-

ever, there are no treatment studies comparing the

effectiveness of initial inpatient management with that

of an outpatient program. Halmi^® has suggested that

initial outpatient therapy may be successful in adoles-

cents who fulfill th e following cr iteria: thos e who h ave

had anorexia nervosa for less than four months, those

who are not binging or vomiting, and those who have

parents who are cooperative in family therapy. There

are several approaches to treatment. Many regimens

utilize a multifaceted approach incorporating medical

management for nutritional restoration, individual

psychotherapy, and family therapy aimed at the dys-

functional family unit.

Th e patient is adm itted to a general pediatric floor,

and m edical man agem ent is aimed at correction of

electrolyte abnormalities and the restoration of body

weight. Weight gain should not be encouraged at too

rapid a pace as this may result in edema, congestive

cardiac failure,^^ acute gastric dilatation,'**•*' or pre-

cipitate confusion, depression, and even suicide,'^

Weight gain of a quarter to half a pound per day is

recomm ended, and the involvement of a qualified nu-

tritionist is advisable. Daily weights, intake and output

charts, and calorie counts should be monito red. Serum

electrolytes should be followed closely, especially in

those patients who have been vom iting or abusing lax-atives.

In the medical management of anorexia nervosa,

behavior modification is a very efficient means of re-

storing life-threatening weight loss without resorting

to tube feeding or intravenous Buids, It is based on

operan t conditioning with reward dep ende nt on weight

gain,'^''"* Weight loss results in loss of privileges, A

contract is agreed upon by both th e physician and th e

patient with a certain predetermined weight gain ex-

pected of her. Initially, the p atient is placed in an empty

room with no visitors, no television, no telephone, and

no bathroom privileges. Privileges are earned by ap-propriate daily weight gain.

Treatment should always be accompanied by psy-

chotherapy to correct the basic underlying psychiatric

proble m. Psychotherapy should be perform ed by a

psychiatrist with expertise in treating ano rexics. Pro b-

ably the m ost difficult aspect of this is deali ng w ith t he

patient's denial and helping her develop an awareness

of her own feelings in order that she may attain her

own identity and autonomy. Psychotherapy should be

initiated while the patient is still in the hospital and

often needs to be continued for months to years,

Minuchin and co-workers'*~' ' stress the importance

of the dysfunctional family unit and the necessity to

address this in the treatment of anorexics. Anorexics,

as well as adolescents with psychosomatic disorders,

have been studied, and a very definite pattern of or-

ganization within these families has been detec ted. Such

families exhibit the characteristics of enmeshment,

overprotectiveness, rigidity, and lack of conflict res-

olution. In addition, the child appears to be involved

in the parental conflict in such a way that she can

detour, avoid, or suppress the conflict. Furthermore,

212 Vol, 23 No. 4 CLINICAL PEDIATRICS



ANOREXIA NERVOSA OVERVIEW

the patient's illness plays a role in maintaining familyhomeostasis. This type of family tends to support so-matic expression and anorectic behavior.^^ Familytherapy is aimed at restructuring the dysfunctionalfamily system.

While still in the hospital, family lunch sessions areheld where the patient, her parents, and siblings arepresent, and the therapist can observe the family in-teractions in response to the eating habits of the patient.Th e therapist intervenes where necessary, and the ul-timate aim is to restructure the family grou p. On dis-charge of the patient, the family is given tasks to carryout at hom e, and a behavior modification program iscontinued outside the hospital. Family therapy dealswith the anorectic's symptoms and with the parents'marital problems and usually has to be continued for

at least 6 months. Using such a program with 53 an-orexics, Rosman et alr"^ were successful in 88 percentof their patients.

Pharmocotherapeutic adjuncts to treatment utilizingphenothiazines,̂ * antidepressants,'^ cyproheptadine,*"*and metochlopramide"" have been discussed elsewhere,but further studies are required to demonstrate theirimproved effectiveness over other regimens.

Th e modalities described above have been used sin-gly and in combination, and the success rate for initialrestoration of body weight is high, irrespective of themethod employed. With weight gain, there is a reversal

of many of the hormonal abnormalities. Russell"*^ hasdiscussed the problems associated with comparisonsbetween the different treatment programs. Probablythe largest variable is patient selection. In addition,many of the studies either utilize too small a numberof patients, or the patients are receiving more thanone modality of treatment. Better designed, well-con-trolled studies with follow-up extending for at least 4years are required before reasonable inferences canbe made.

Outcome and PrognosisIt is widely recognized that most patients gain weight

on admission to the hospital irrespective of the treat-ment modality utilized. Russell, however, points outthat their initial response to in-hospital treatment doesnot predict the ultimate outcome.""^ Recently, Garnerand Garfinkef̂ '"''' developed a self-report Eating At-titudes Test (EAT), which appears to be a reliableobjective measure of the symptomatology of anorexianervosa. They suggest that both the initial EA T scoreand the score after treatm ent may be used as a prog-

no.stic index. The EAT may prove to be a useful in-strument in evaluating outcome after discharge fromthe hospital. In comparing the outcome of anorexicsfrom different series, one has to consider patient sam-pling, length of follow-up, and the parameters being

assessed (for example body weight, menstrual history,eating difficulties, or psychiatric outcome).

Hsu''^ reviewed the literature from 1954 to 1978,and the combined results showed that at least 75 per-cent of the patients had shown improvement in bodyweight (body weight at least 75% of average) at follow-up of at least 2 years, but only one third were eatingnormally. The remaining patients were still avoidinghigher calorie foods and 14 to 50 percen t had becomebulimic. One half of those showing improvement inbody weight were m enstruating at follow-up. T his usu-

ally occurred after improvement of the psychiatric dis-order and attainment of a certain minimal weight forheight.''^ Between one half and two thirds of the pa-tients, however, still suffered from psychiatric symp-toms. Long illness before admission, later age of onse t,a distorted family background, and bulimia tend to beassociated with a poorer prognosis.""^

In adolescents with anorexia nervosa, death mayoccur as a result of inanition, infection, suicide, andcardiac arrest, probably on the basis of electrolyte ab-normalities. Hsu's figures'*"* reveal that despite initialimprovement in the condition, 25 to 50 percent of

these patients experience a relapse and up to 38 percentrequire medical readmission with 2 years. It is evidentthat anorexia nervosa tends to be a chronic condition,and long-term psychotherapy and follow-up are re-quired even after apparent improvement.

Acknowledgments

The authors would like to thank Mrs. Marsha Nager for liersecretarial assistance.

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