**2. Clinical presentation**

The current definition and clinical presentation of anorexia nervosa is determined by DSM-5 [5]. According to this diagnostic criterion, AN involves the following factors: The first criterion is a refusal to maintain a normal body weight despite being underweight. The factor of underweight or significantly low weight is usually determined by a body mass index (BMI) lower than 18.5 [7]. Nevertheless, not every underweight person is considered to have AN, though in this case being underweight is extremely important and in order to maintain this situation or to lose more weight, compensatory behaviors are evident. These unhealthy weight management strategies include excessive dieting or exercise, self-induced vomiting, and misuse of laxatives and diuretics, which leads to serious health problems including amenorrhea. The absence of at least three consecutive menstrual cycles was a diagnostic criterion for AN in the previous editions of the DSM [8]. Yet some women may have their periods even when they are underweight or there can be other metabolic problems resulting in amenorrhea. Moreover, it was making diagnoses difficult in men. In DSM-5, this original amenorrhea criterion was left out, in order to cover more cases.

Secondly, there is an intense fear of gaining weight or becoming fat, even though the body weight is less than normal. This fear is one of the most important factors that maintain compensatory behaviors and may not change despite weight loss. The third criterion is a disturbance in body image. Body image is a multidimensional framework that contains perceptions, attitudes, cognitions, emotions, and behaviors related to the body [9]. It can be defined as a representation of body in mind and is presumed to be the core psychological problem in AN [10]. People with AN have a body image distortion, resulting in a feeling of fatness independent of their

**69**

common cause of death [26].

*Anorexia Nervosa*

prevalent [15].

*DOI: http://dx.doi.org/10.5772/intechopen.91278*

weight; also negative attitudes towards the body, including body dissatisfaction, are prevalent [11]. Behaviors related with body such as excess weighing, body checking, and avoiding tight clothes might take up a lot of time on a daily basis. Negative body attitudes or body dissatisfaction has become almost a cultural norm in this age, especially for women, but for AN sufferers, these disturbances in body image are multifaceted and time-consuming, and this decreases functionality; also self-

In AN diagnosis, two types were specified: restricting type and binge eating/ purging type. Excessive dieting is prominent in the restricting type, whereas binge eating/purging type is characterized by recurrent binge eating episodes following by purging as a compensative behavior. A common definition for a binge eating episode is eating in a certain (e.g., at least 2 h) period of time an amount of food that is larger than most people would eat in a similar time period or condition accompanied by a sense of lack of control over eating (feeling that one cannot stop eating). Most commonly, self-induced vomiting or excessive dieting/ exercise as purging behaviors follows this type of episode. The subtypes of AN are helpful in defining the clinical presentation of cases, but it should be noted that the predictive validity is weak, as transition between subtypes (both in AN and between AN and BN) is quite common [13]. The difference between the binge eating/purging type of AN and BN is that the AN cases are underweight. Also in AN, binge eating episodes might be subjective and may not always meet a clinical definition. However, there is also evidence that impulsivity, self-harming, social withdrawal, and comorbid psychiatric problems are more common in the binge eating/purging type, whereas perfectionism is more common in the restricting type [14]. Another problem in clinical presentation is that in most cases there is a lack of insight regarding their problem and deficits in treatment motivation are

Patients suffer multiple comorbid medical and psychiatric problems, as eating

Almost every system in the body is affected in AN, including gastrointestinal, cardiovascular, skeletal, nervous, endocrinological, and reproductive [17]. Physical examination results usually show low blood pressure, bradycardia, low body temperature, gastrointestinal problems, dehydration, hormonal deficits, amenorrhea or other menstrual problems, hair loss, and lanugo hair [18]. Cardiovascular problems include irregular heartbeats, heart attacks, and collapse of heart valves and may cause death [19]. Starvation affects menstrual functioning, resulting in poor reproductive health, with infertility problems. Even if anorexic women become pregnant, there is a high possibility of having small babies with complications or unhealthy children [20]. Self-induced vomiting may cause tooth erosion or calluses on hands [21]. AN usually begins at puberty, and this is an important time for the development of bones. Malnutrition can cause stunted growth and osteoporosis in the long term [22]. Anorexia is also associated with changes in the nervous system like loss of grey matter in the brain and reduction in pituitary size, resulting in deficits in attention, learning, memory, and visuospatial analyses [23, 24]. Above all, anorexia has the highest mortality rates among psychiatric disorders [25]. All of these medical problems can cause heart attacks or infections, but suicide is the most

In addition to physical problems, psychological complications are prevalent in AN. Almost half of the cases have a comorbid DSM diagnosis, especially depression

evaluation is mostly influenced by body shape and weight [12].

**3. Comorbid medical and psychiatric conditions**

behavior affects health in multiple ways directly or indirectly [16].

#### *Anorexia Nervosa DOI: http://dx.doi.org/10.5772/intechopen.91278*

*Weight Management*

tation of anorexia nervosa.

**2. Clinical presentation**

order to cover more cases.

cases were defined in 1873 and 1874 [2, 3]. The term anorexia nervosa means "nervous loss of appetite"; thus the early descriptions focused on food avoidance as the core problem. Then it was realized that people with AN do not suffer a loss of appetite; indeed their mind is extremely preoccupied with food. Hence, the psychological component became prominent, and the problem was conceptualized as a weight phobia and self-control. In fact, AN has been known about since the seventeenth century but was observed in the 1960s in western society and characterized as leading to a significantly low body weight because of restricting energy intake or compensating to an excessive rate intentionally, in order to attain or maintain an unrealistically thin ideal weight [4]. In the fifth edition of the *Diagnostic and Statistical Manual of Mental Disorders* (*DSM-5*), the title Feeding and Eating Disorders covers problems related to eating behaviors and unhealthy strategies for weight management [5]. Feeding disorders include pica, rumination disorder, and avoidant/restrictive food intake and can usually be seen in children, resulting in malnutrition or delay in growth due to unhealthy feeding behaviors. On the other hand, EDs are mostly seen in teenagers and adults. Their onset usually falls during puberty when body changes gain importance. DSM-5 defines three types of EDs, AN, BN, and BED. The underlying psychological mechanism is similar between these types as an intense fear of gaining weight and preoccupation with weight, body, and eating that leads to weight management strategies also known as compensatory behaviors like dieting, exercise, self-induced vomiting, misuse of laxatives, and diuretics [6]. The subtypes of EDs differ in body weight and weight management strategies. BN, BED, and other problems related to eating are beyond the scope of this chapter. Thus, we will first take a closer look at the clinical presen-

The current definition and clinical presentation of anorexia nervosa is determined by DSM-5 [5]. According to this diagnostic criterion, AN involves the following factors: The first criterion is a refusal to maintain a normal body weight despite being underweight. The factor of underweight or significantly low weight is usually determined by a body mass index (BMI) lower than 18.5 [7]. Nevertheless, not every underweight person is considered to have AN, though in this case being underweight is extremely important and in order to maintain this situation or to lose more weight, compensatory behaviors are evident. These unhealthy weight management strategies include excessive dieting or exercise, self-induced vomiting, and misuse of laxatives and diuretics, which leads to serious health problems including amenorrhea. The absence of at least three consecutive menstrual cycles was a diagnostic criterion for AN in the previous editions of the DSM [8]. Yet some women may have their periods even when they are underweight or there can be other metabolic problems resulting in amenorrhea. Moreover, it was making diagnoses difficult in men. In DSM-5, this original amenorrhea criterion was left out, in

Secondly, there is an intense fear of gaining weight or becoming fat, even though the body weight is less than normal. This fear is one of the most important factors that maintain compensatory behaviors and may not change despite weight loss. The third criterion is a disturbance in body image. Body image is a multidimensional framework that contains perceptions, attitudes, cognitions, emotions, and behaviors related to the body [9]. It can be defined as a representation of body in mind and is presumed to be the core psychological problem in AN [10]. People with AN have a body image distortion, resulting in a feeling of fatness independent of their

**68**

weight; also negative attitudes towards the body, including body dissatisfaction, are prevalent [11]. Behaviors related with body such as excess weighing, body checking, and avoiding tight clothes might take up a lot of time on a daily basis. Negative body attitudes or body dissatisfaction has become almost a cultural norm in this age, especially for women, but for AN sufferers, these disturbances in body image are multifaceted and time-consuming, and this decreases functionality; also selfevaluation is mostly influenced by body shape and weight [12].

In AN diagnosis, two types were specified: restricting type and binge eating/ purging type. Excessive dieting is prominent in the restricting type, whereas binge eating/purging type is characterized by recurrent binge eating episodes following by purging as a compensative behavior. A common definition for a binge eating episode is eating in a certain (e.g., at least 2 h) period of time an amount of food that is larger than most people would eat in a similar time period or condition accompanied by a sense of lack of control over eating (feeling that one cannot stop eating). Most commonly, self-induced vomiting or excessive dieting/ exercise as purging behaviors follows this type of episode. The subtypes of AN are helpful in defining the clinical presentation of cases, but it should be noted that the predictive validity is weak, as transition between subtypes (both in AN and between AN and BN) is quite common [13]. The difference between the binge eating/purging type of AN and BN is that the AN cases are underweight. Also in AN, binge eating episodes might be subjective and may not always meet a clinical definition. However, there is also evidence that impulsivity, self-harming, social withdrawal, and comorbid psychiatric problems are more common in the binge eating/purging type, whereas perfectionism is more common in the restricting type [14]. Another problem in clinical presentation is that in most cases there is a lack of insight regarding their problem and deficits in treatment motivation are prevalent [15].
