Review ❚ Anorexia nervosa
Anorexia nervosa: diagnosis, risk
factors and evidence-based treatments
Sara Kakhi MBBS, Jacinta McCann MB, BAO, BCh, FRCPsych
As part of the series on managing neurological and psychiatric conditions in children and
adolescents, Dr Sara Kakhi and Dr Jacinta McCann cover recent updates in epidemiology,
risk factors, common comorbidities and treatment options for anorexia nervosa.
A
norexia nervosa (AN) is a severe psychiatric
disorder with substantial morbidity and the
highest mortality of all mental disorders. The standardised mortality rate for AN is higher than that
for asthma or type 1 diabetes mellitus. 1 About
one-fifth of those who die do so by suicide.2 Additionally, the estimated financial cost associated with
disability-­adjusted life years attributable to eating
disorders is higher than that of depression and anxiety combined.3
Eating disorders are the third most common
chronic illness among adolescents, after obesity
and asthma. The peak age of onset occurs between 14
and 19 years.4 Although approximately 10% of the
general population suffers from some type of eating
disorder, only a minority of these individuals ever
seek treatment.5
Several studies were able to demonstrate that the
highest incidence rates are found in the 15–19 years
age group, with approximately 40% of all new cases
appearing between 15–19 years of age.6,7 There is
some evidence that the age of onset of AN has been
decreasing in recent decades8,9 and that childhood
and adolescent AN are on the rise.7
Prevalence rates among females remain significantly higher than males. In clinical samples, increasing prevalence of AN is found in males, but there
are few population prevalence data.10–12 A greater
proportion of younger males present with restrictive
eating disorders. 13–15 Although incidence rates
of AN have largely been stable, there has been a notable increase in incidence in 15- to 19-year-old
females. 16 UK study based on primary care data
demonstrated that the incidence of the diagnosed
eating disorder was highest for girls aged 15–19 years
and for boys aged 10–14 years.6
Increased prevalence rates have been found
in males and ethnic/racial minorities (Latino,
Asian American and Latinos in the US population),17–20 as well as in countries where eating disorders were not previously reported such as India,
China and Japan.21–25
24
F (50.0): ICD 10 diagnostic criteria for anorexia nervosa
(World Health Organization,1992 – Clinical Descriptions
and Diagnostic Guidelines)
• Actual body weight at least 15% below expected
weight, or body mass index 17.5 or less (in adults)
• Weight loss is caused by the avoidance of high-­
calorie foods and at least one of the following:
- Self-induced vomiting
- Self-induced purging
- Excessive exercise
- Use of appetite suppressants and/or diuretics
• Distorted body image as a specific psychological
disorder
• Endocrine disorder, manifest in the female as amenorrhea and in the male as a loss of libido
• If onset is pre-pubertal, the puberty in boys and girls
may be delayed (growth ceases; in girls the breasts do
not develop).
DSM-5 diagnostic criteria – American Psychiatric
Association (2013)
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in
the context of age, sex, developmental trajectory, and
physical health. Significant low weight is defined as a
weight that is less than minimally normal.
B. Intense fear of gaining weight or becoming fat or
persistent behaviour that interferes with weight gain
even though at a significant low weight.
C. Disturbance in a way which one’s body weight
or shape is experienced, under influence of body
weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current body
weight.
Anorexia nervosa: DSM-IV to DSM-5
There have been major changes from DSM-IV to
DSM-5, leading to a potential increase in the prevalence of anorexia nervosa and bulimia nervosa.
The most important changes from DSM-IV to
DSM-5 are:
• Removal of a specific weight threshold for diagnosis
Progress in Neurology and Psychiatry November/December 2016
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Anorexia nervosa ❚
• Increased reliance on behavioural manifestations in
addition to cognitive symptoms
• Elimination of amenorrhea as a criterion necessary
for the diagnosis.
Overall DSM-5 has taken a less restrictive approach,
compared with the last version of DSM, towards the
criteria threshold for eating disorders.26
Guideline suggests that being underweight must
take into consideration the ‘context of age, sex, developmental trajectory and physical health’.27
Risk factors
A national Danish study of risk factors for AN concluded that AN risk factors are: having a sibling with
AN; affective disorders in family members, and
comorbid affective, anxiety, obsessive-compulsive personality, or substance use disorders. Furthermore,
female sex and ascending year of birth were significantly associated with having AN. Urbanisation was
not related to the family load of AN and case relatives
did not develop AN earlier than control relatives.28
The aetiology of disordered eating and eating disorder is likely to involve a complex interplay of
biopsychosocial effects. Genetic and environmental/
nongenetic influences on eating disorders do not
operate in isolation. Indeed, environmental experiences (eg abuse history) and developmental changes
appear to interact with and influence the expression
of genes.
• Confirmed risk factors for eating disorders include
sociocultural influences, specifically media exposure,
pressures for thinness, thin-ideal internalisation, thinness expectancies and nonspecific personality factors,
including negative emotionality/neuroticism, perfectionism, negative urgency.29
• Rodhe et al. reported that elevated body dissatisfaction at ages 13, 14, 15 and 16 years predicted DSM-5
eating disorders onset in the four-year period after
each assessment. BMI did not predict eating disorders at any age.30
• Correlational studies of adult women and experimental studies of animals provide evidence for the
effects of reproductive hormones on the emergence
of eating disorder symptoms.31
• In an 18-year follow-up study of adolescent AN subjects, difficulties in mentalising tasks remained in several subjects after recovery and were independent of
body weight loss and the duration of the eating disorder.32 Wentz et al. showed that autistic traits in childhood were found to be predictive of a poor global
outcome in the eating disorder in adulthood.33
• A large multigenerational Swedish study (n=286 232),
found that eating disorder in either parent is
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independently associated with eating disorder developing in their female children (hazard ratio [HR] 1.97
(95% confidence interval [CI]: 1.17–3.33), p=0.01)
and that eating disorder in mothers is independently
associated with eating disorder in their female children (HR 2.35 [95% CI: 1.39–3.97] p=0.001).34
Treatment
NICE recommendations35
• In assessing whether a person has AN, attention
should be paid to the overall clinical assessment
(repeated over time), including rate of weight loss,
growth rates in children, objective physical signs and
appropriate laboratory tests.
• Patients with enduring AN not under the care of a
secondary care service should be offered an annual
physical and mental health review by their GP.
• Children and adolescents with AN should be offered
individual appointments with a healthcare professional separate from those with their family members.
The therapeutic involvement of siblings and other
family members should be considered in all cases
because of the effects of AN on other family members. Outpatient psychological treatment for AN
should normally be of at least six months’ duration.
• For inpatients with AN, a structured symptom-­
focused treatment regimen with the expectation of
weight gain should be provided in order to achieve
weight restoration. It is important to carefully monitor the patient’s physical status during refeeding. The
length of outpatient psychological treatment and
physical monitoring following inpatient weight restoration should typically be at least 12 months.
• When a young person with AN refuses treatment
that is deemed essential, consideration should be
given to the use of the Mental Health Act 1983 or the
right of those with parental responsibility to override
the young person’s refusal.
• Relying indefinitely on parental consent to treatment should be avoided. It is recommended that the
legal basis under which treatment is being carried out
should be recorded in the patient’s case notes, and
this is particularly important in the case of children
and adolescents.
• Feeding against the will of a patient should be
an intervention of last resort in the care and management of AN. NICE recommended that this ‘is a
highly specialised procedure requiring expertise in
the care and management of those with severe
eating disorders and the physical complications
associated with it’, also that there needs to be a
clear legal basis for this action and that the relevant
mental health legislation and associated procedures
are followed.
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Review
Review ❚ Anorexia nervosa
Outpatient treatment (OP)
Outpatient setting remains the ideal setting for management of AN. NICE recommends outpatient treatment for most patients with AN, with a special
modification for young patients (‘the need for IP and
the need for urgent weight restoration should be balanced alongside the educational and social needs of
the young person’).
Inpatient treatment (IP)
In the UK, admission rates for AN have increased substantially in recent years. From 2012 to 2013, there
was a national rise of 8% in the number of admissions
to hospital for an eating disorder in comparison with
the year before, which had already seen an increase.
In addition, the length of hospital stays increased substantially during the last decade.36
• Gowers et al. compared IP with two different forms
of outpatient care (a specialised eating disorder outpatient treatment with emphasis on cognitive behavioural therapy [CBT] and treatment as usual in child
and adolescent mental health services).37 There were
no differences in clinical outcomes between the three
groups. The study faced a limitation of poor treatment adherence in the IP arm.
• Recent research supports initiating higher caloric
prescription on admission to the hospital, starting
patients on 1400–2000kcal per day with close medical
monitoring.38 This is reported to shorten hospital
stay39,40 and increase the rate of weight gain39,41 without increasing the rate of refeeding syndrome.
• The rates of dropout from IP programs are up
to 25%.42,43
Recommendations for weekly weight gain
NICE guidelines recommend 0.5–1.0kg weekly
weight gain in an inpatient setting, 0.5kg in an outpatient setting. NICE only mentions an additional
• In the first phase, the therapist focuses on the dangers of severe
malnutrition associated with AN. Aim is to help the parents in their
joint attempt to restore their adolescent’s weight. A family meal is
typically conducted during this phase.
• In the second phase, weight gain with minimum tension is
encouraged. In addition, all other general family relationship
issues can now be brought forward for review. This occurs only in
relationship to the effect these issues have on the parents in their task
of assuring steady weight gain.
• Phase three is initiated when the adolescent is able to maintain
weight above 95% of ideal weight and entails a review of central issues
of adolescence and includes supporting increased personal autonomy
for the adolescent, appropriate parental boundaries, as well as the
need for the parents to reorganise their life together after their
children’s prospective departure.79
Box 1. Three stages of family-based treatment
26
amount of 3500–7000 calories per week without differentiating between in- and outpatient treatment or
between adolescents and adults. An expert group of
the Royal College of Psychiatrists (Junior MARSIPAN
[Management of really sick patients with anorexia
nervosa]) estimated 20kcal/kg body/weight/day as
safe, but advised less (5–10kcal/kg/body weight) for
individuals with very low initial weight or comorbid
somatic disorders.44
Weight gain during inpatient or outpatient treatment and the maintenance of weight gain after discharge from treatment have been proven to be
important prognostic factors for the short- and longterm course of adolescent AN.45–47
The primary goal of medical hospitalisation is
to safely restore physiological stability through
nutritional rehabilitation. This process should be
approached with caution as it can result in the refeeding syndrome.48–50
Refeeding syndrome
This is characterised by a variety of metabolic and
clinical features, including but not limited to
hypophosphatemia, cardiac arrest, and delirium.51–53
Refeeding syndrome primarily develops during the
first fortnight after starting refeeding. Most guidelines recommend a stepwise increase of daily intake
such as 200kcal/day.44
Recent studies have not found any difference in
the rates of refeeding syndrome between adolescents
who were started on a low-calorie diet compared with
those on a high-calorie diet.54,55 Hypophosphatemia,
a major symptom of refeeding syndrome, was associated with low BMI at intake but not related to the
amount of calories consumed.54,56
Patient motivation to change is an important predictor of short-term outcome. A study by Hillen et al.
reports those patients with a greater motivation to
change at admission exhibited a higher weekly weight
gain during treatment but did not show better outcome in eating disorder-specific psychopathology
and depression.54
Does admission to hospital for eating disorders under the
Mental Health Act increase mortality rates?
Approximately 20 years follow-up in a UK mortality
study demonstrated that although the mortality
in the five years following a compulsory admission
was higher than non-compulsory patients, this
difference was attenuated over time. The standardised mortality rate in the compulsory treatment group
no longer differed significantly from that of the non-­
compulsory group. The suicides were not linked with
compulsory admission.55
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Anorexia nervosa ❚
Day patient treatment (DP)
DP for anorexia may be an alternative to IP or may be
useful as an approach following IP.56 It is certainly a
less restrictive option and is helpful in building family
and patient confidence.
Herpertz-Dahlamann et al. investigated the safety
and efficacy of day treatment settings, after short
inpatient care, compared with continued inpatient in
a multicentre, randomised, open-label trial in Germany. They concluded that DP was not inferior to IP
with respect to symptom reduction, BMI at the
12-month follow-up.57
Two small uncontrolled studies from Australia and
the US demonstrated preliminary efficacy of a day
patient program in younger patients.58 The authors
reported that the 12–18-year-old Australian female
patients enrolled in the study benefitted from DP, as
evidenced by their significant weight gain and reduction in eating disorder behaviour.59 In a US family-­
centred day patient program for children with a mean
age of 13 years, participants showed significant
improvement in weight and psycho­logical outcomes at
discharge. Unfortunately, there was no follow-up
assessment in either study.58
on how patients think, rather than on what patients
think. It is hypothesised that CRT training works by proliferating and refining neural connections and by teaching new, adaptive strategies, thus making individuals
more flexible in the way they think and behave.74
Preliminary results show small to medium effects
of CRT on various measures of cognitive flexibility in
adolescents, both in groups or individual settings, as
an adjunct to other treatments.75,76
Randomised controlled trials (RCTs) demonstrate
that CRT has the potential of enhancing the effectiveness of current treatments, reduce attrition, increase
cognitive set-shifting abilities and quality of life, as
well as reduce eating disorder psychopathology.77
Family-based treatment (FBT)
FBT is an outpatient-based intervention that has the
strongest evidence of effect in adolescents with AN
(see Box 1).73,78
The Maudsley FBT is the most established treatment
model for adolescents with AN, and several RCTs have
demonstrated evidence for symptom remission and
weight rehabilitation.
Le Grange suggests that most young patients with
AN require, on average, no more than 20 treatment
Psychological interventions
sessions over the course of 6–12 months.80
Most therapeutic recommendations are primarily based The Maudsley approach holds great promise for
on mainstream expert opinion with little empirical evi- most adolescents who have been ill for a relatively
dence. Only 12 papers in the top 100 cited papers pub- short period of time (eg less than three years). This
lished in the AN field address therapeutic strategies.60
can prevent hospitalisation and assist the adolescent
So far studies have provided little support for in her/his recovery, provided that parents take an
specialised psychotherapies or pharmacotherapies, active role in treatment.81
conducted with both underweight and weight-­restored Eisler et al. showed that approximately two-thirds
individuals.61–69 However, the Maudsley family-based of adolescent AN patients are recovered at the end of
therapy approach is one of the few empirical, evidence-­ FBT while 75–90% are fully weight recovered at fivebased studies showing effectiveness in young people year follow-up.82
with AN under the age of 18 years.70,71
The majority of trials only report mean participant
ages in the 12–18 years range. It should be noted
Cognitive behavioural therapy (CBT)
that these findings come only from a small number
Due to some diagnostic uncertainties, an enhanced, of trials with small sample sizes, where risk of bias
‘trans­diagnostic’ approach to CBT has been estab- is notable.83
lished (CBT-E).72 CBT-E for adolescents consists of
three phases:
Dynamic family therapy
1. Thinking afresh on the current state and maintain- A RCT by Godart et al. involving 60 female adolescents
ing processes of the eating disorder, including analy- with DSM-IV AN, aged 13–19 years, compared ‘treatses of pros and cons.
ment as usual’ (TAU) with adjunctive family therapy.
2. Modification of concerns surrounding weight and This included sessions for the adolescent alone and
shape.
sessions with a psychiatrist for the adolescent with her
3. Maintaining changes and developing strategies to parents (TAU + FT), which included a family therapy
handle setbacks.73
component targeting intrafamilial dynamic but not
eating disorder symptoms. Results showed that focusCognitive remediation therapy (CRT)
ing on the intrafamilial dynamic improves treatment
CRT was developed with the aim of improving cognitive effectiveness in severe AN patients even after 13 years
flexibility and thereby functioning. The focus of CRT is follow up.84
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Review
Review ❚ Anorexia nervosa
Multiple family therapy (MFT)
Preliminary research suggests that MFT, which involves
several families being treated together as a group, may
be an effective intervention for adolescent AN.85
Marzola et al. followed up 54 adolescents, 30
months after a brief intensive MFT intervention,
reporting 59.3% remission (>95% expected body
weight [EBW]) rates and a further 27.7% partial remission (>85% EBW).86 MFT-AN is a highly acceptable
intervention to families, with more than 90% completing the treatment, with significant improvement in
weight and other patient symptoms, improvements in
parents’ mood and better family relationships.87,88
Pharmacological treatment – efficacy of antidepressants and
atypical antipsychotics
NICE does not support medication as a primary or
only treatment for AN. However, use of medication
such as olanzapine might be necessary intermittently
in highly anxious and agitated patients who otherwise
would resist refeeding.89
In AN, atypical antipsychotics and selective serotonin reuptake inhibitors (SSRI) are the most commonly used medications.
Recent studies did not support effectiveness of
adjunctive treatment with second-generation anti­
psychotics on weight-related outcomes or eating
disorder-­specific psychopathology.73
In a double-blind placebo-controlled study of risperidone, 40 adolescent patients were randomised to
receive risperidone or placebo plus the normal eating
disorder program. After nine weeks there were no
significant differences between the treatment groups
in weight gain or in eating disorder psychopathology.
The only clinically significant adverse effect was prolactin increase in the risperidone group.90,91
In a placebo-controlled pilot study of adjunctive
olanzapine for adolescents the percentage change in
median body weight did not differ between the two
treatment groups.92
In a recent systematic review and meta-analysis of
the effects of olanzapine, risperidone, and amisulpride in both adolescent and adult samples, no significant increase in BMI or decrease in the drive for
thinness and body dissatisfaction was found.93
There is no clear evidence of whether, and under
what conditions, SSRIs may be beneficial in the treatment of AN. Fluoxetine has been examined during
the weight restoration process and the weight maintenance phase of therapy. SSRIs may be considered if
there is comorbid depressive disorder.
In two early studies, no effect on weight gain
was found.94,95 In a study of relapse prevention, 93
weight-­restored patients including females 16 years
28
• Weight restoration has substantial effects on
mental state therefore this should be observed
before initiating medical treatment.
• At present, medication should not be the first line
treatment or the only treatment and always consider
the patient´s nutritional status.
or older were enrolled in a controlled multicentre
study combining CBT and pharmacotherapy with
fluoxetine. As an adjunctive medication, fluoxetine
was not more effective than the placebo, even for
depressive and anxiety symptoms.96
Novel pharmaceutical substances targeting hormonal circuits of appetite control and food intake may also
be important agents in the future treatment of AN.97
Outcomes of AN
In a recent meta-analysis based on 36 studies, the
standardised mortality rates were 5.86 for AN, 1.93 for
bulimia nervosa (BN), and 1.92 for eating disorder not
otherwise specified (EDNOS) (according to DSM-IV
criteria). The mortality rates for AN showed a significant association with age but not with BMI, underlining the danger of a long-­lasting illness.98
The severity and physical consequences depend
on the extent and rapidity of weight loss, the current
degree of underweight, the duration of the eating
disorder, the intensity of purging, and the age of
the patient.26
A Finnish study assessed mortality, recovery, and
sociodemographic outcomes of AN in a community
sample. Women were followed for 10 years after baseline diagnostic assessment (mean age at follow-­up 34
years, n=2188). They showed that the long-­term prognosis of AN in the community was promising. Weight-­
restoration is common and socio­d emographic
out­­comes were generally favourable. However, women
with a history of AN may be less likely to have children.99
Suicidality is one of the most important reasons
for premature death in AN. Suicidal ideation is found
in about half of adolescent AN patients, and suicide
attempts are observed in 3–7%. Although suicidality
is much lower in adolescent AN than in adult AN, a
strong asso­ciation between depression, the binge/
purge subtype of AN, and the duration of illness has
been reported.100,101
Physical complications
Table 1 covers some common physical complications
of anorexia.
Psychiatric comorbidities
In more recent studies, up to 60% of adolescent patients
with AN display some type of mood disorder.100,101,132
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Anorexia nervosa ❚
Key points
• BMI alone is not a reliable marker for assessment of
eating disorders in young people
• The rate of weight loss is important when assessing
acute presentation of AN
• Junior MARSIPAN is the reference guideline in
medical management of anorexia in the UK
• Community treatment for anorexia nervosa is the
setting of choice
• The effectiveness of building up family resilience
and skills in managing eating disorder is supported by
a strong evidence base
• Safety and utility of pharmacological treatment in
anorexia should be considered on an individual basis
Several studies found an association between
weight loss and depression; for example, patients with
a high degree of starvation also felt more depressed.
Anxiety disorders other than OCDs are very common in AN. About 25% of patients with acute AN
report one or more anxiety disorders.133,134 In many
cases, the anxiety disorders begin in childhood and
pre-date the eating disorder.134
About 25% of AN patients suffer from substance
abuse. The most prevalent substance abuse is amphetamine and cocaine dependence, but many patients
also abuse nicotine.135,136
Prevention
The role of prevention in the development of eating
disorders needs further exploration. Bailey et al. in
their review, failed to identify any controlled trials
investigating prevention strategies involving families.137 Potential prevention components may involve
education and skills training for parents around talking about and identifying risk factors.
Dr Kakhi is a Child and Adolescent Psychiatric
Registrar and Dr McCann is a Consultant Child
and Adolescent Psychiatrist, both at Leigh House
Hospital, Winchester.
References
References are available online at:
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Osteopenia and osteoporosis
Low bone density is generally not completely reversible, even after weight
rehabilitation. Osteoporosis is not only a problem of females but also of
male patients, owing to their deficits in gonadal hormones.102,103
Treatment of bone mineral density (BMD)
• Although calcium and vitamin D supplementation increase BMD in the
short term in healthy adolescents, no RCTs have been done in AN104,105
• Oral oestrogen/progestin has not been found to effectively increase
BMD in AN106–108
• One study found that physiological doses of transdermal oestrogen
increased spine and hip BMD compared with controls109
• Although bisphosphonates have been found to increase BMD in
adolescents and young adults with AN, the effect is modest and their
use is not recommended110,111
Given the increased fracture risk, dual-energy X-ray absorptiometry
scans should be obtained when amenorrhea is present for six months
or more112,113
Cardiovascular system
Patients with eating disorders often present with bradycardia,
hypotension, arrhythmias and changes in heart rate variability114–18
Hypotension and postural changes in heart rate and blood pressure
can result from decreased cardiac mass leading to systolic dysfunction,
in addition to volume depletion and autonomic dysfunction117,119,120
Endocrine
Girls and boys may present with decelerated linear growth, pubertal
delay or pubertal regression, and menstrual dysfunction is common in
females.121–4 Progesterone level is monotonously low and corresponds to
the basal level of first phase of menstrual cycle. Levels of testosterone and
androstendione often correspond to the lower limits of normal. Hormonal
changes include increase in growth hormone (GH) level and in cortisol concentration in blood plasma as well as a decrease in free thyroxine (T4)125
Menstrual function disorder (MFD): Weight loss of 10% or more can lead
to MFD and include secondary amenorrhea or oligoamenorrhea. This
is mainly due to dysfunctional secretion of gonadotropin releasing
hormone (GnRH)27
Renal
Eating disorder patients can develop dehydration and renal
insufficiency due to severe fluid restriction or vomiting. Patients with
AN may lose renal concentrating ability, which can result in high urine
output and inaccurate specific gravity measurements on urinalyses126–30
Acknowledgement
The authors wish to acknowledge Angela Sargent
(Consultant Nurse CAMHS & Service Lead for Eating
Disorder Programme, Leigh House Hospital) for her
help and support in preparing the article.
Declaration of interests
No conflicts of interest were declared.
Review
Haematological
Bone marrow hypoplasia is seen in low-weight eating disorders,
primarily leukopenia and anaemia, with rare cases of thrombo­
cytopenia. All dyscrasias resolve with the reversal of malnutrition. It is
important to evaluate for iron and vitamin B12 deficiency in anaemic
patients because these are easily reversed with supplementation118,130
Neurological
Severely ill patients with AN have been shown to have reduced brain
tissue volume and impaired neuropsychological functioning131
Table 1. Common physical complications of anorexia
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Anorexia nervosa ❚
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