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CRS - Anorexia Nervosa

Diagnosis results

The GP makes the following diagnosis of Alice’s condition:

Mechanism

Intentional weight loss as a result of dietary restriction and high levels of exercise, which followed an episode of gastroenteritis. There are no ongoing gastrointestinal symptoms but sometimes an episode of weight loss due to an incidental illness can appear to be the trigger for ongoing weight loss, or at least be the explanation that the young person uses for the initial weight loss. From the history so far, the significant findings that specifically meet the DSMIV criteria for Anorexia Nervosa as listed below are the secondary amenorrhoea and the denial of the seriousness of the low bodyweight.

Currently her BMI of 16kg/m2 is on the 3rd centile for age and this along with the history of weight loss, is significantly abnormal and also meets criteria. It is likely that she will also meet the criterion of fear of weight gain but sometimes it is not until the patient is required to actually gain weight in treatment that this is well expressed.

It will be important to further evaluate other aspects of Alice’s behaviour and mood as other psychiatric conditions may also be present in young people with anorexia nervosa ( depression, anxiety and obsessive-compulsive disorder most commonly ).

In children and adolescents the DSMIV criteria may not be fully met, in particular the weight criteria. It should be remembered that in children and adolescents, any weight loss during a time when you would be expecting growth and weight gain, should be considered as significant. In that case, for classification purposes that will be considered as having Eating Disorder Not Otherwise Specified (EDNOS) however the approach to treatment will be the same.

Presentation

Loss of weight, reduced food intake, high exercise level, secondary amenorrhoea, denial of the significance of her weight loss

Supporting Data

The diagnostic criteria for Anorexia Nervosa (according to DSMIV, The Diagnostic and Statistical Manual of Mental Disorders 4th ed. 2000) are:

• Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g: weight loss leading to maintenance of body weight < 85% of that expected), or failure to make expected weight gain during period of growth, leading to body weight < 85% of that expected.
• Intense fear of gaining weight or becoming fat, although underweight.
• Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation or denial of the seriousness of current low body weight.
• In post menarchal females, amenorrhea, that is, the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, eg oestrogen administration.)

Two types of anorexia nervosa

• Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge eating or purging (ie self induced vomiting or the misuse of laxatives, diuretics or enemas).
• Binge eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge eating or purging (ie self induced vomiting or the misuse of laxatives, diuretics or enemas).

There is an eventual admission by Alice of voluntary reduction in food intake.

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