Clinical Manifestations and Pathology

In anorexia nervosa, normal dieting escalates into a preoccupation with being thin, profound changes in eating patterns, and a weight loss of at least 25 percent of the original body weight. Weight loss is usually accomplished by a severe restriction of caloric intake, with patients subsisting on fewer than 600 calories per day. Contemporary anorectics may couple fasting with self-induced vomiting, use of laxatives and diuretics, and strenuous exercise.

The most consistent medical consequences of anorexia nervosa are amenorrhea (ceasing or irregularity of menstruation) and estrogen deficiency. In most cases amenorrhea follows weight loss, but it is not unusual for amenorrhea to appear before noticeable weight loss has occurred. The decrease in estrogens causes many anorectics to develop osteoporosis, a loss of bone density that is usually seen only in postmenopausal women (Garfinkel and Garner 1982).

By the time the anorectic is profoundly underweight, other physical complications due to severe malnutrition begin to appear. These include bradycardia (slowing of the heartbeat), hypotension (loss of normal blood pressure), lethargy, hypothermia, constipation, the appearance of "lanugo" or fine silky hair covering the body, and a variety of other metabolic and systemic changes.

In addition to the physical symptoms associated with chronic starvation, anorectics also display a relatively consistent cluster of emotional and behavioral characteristics, the most prominent of which grows out of the anorectic's distorted perception of food and eating. Unusual eating habits may include monotonous or eccentric diets, hoarding or hiding food, and obsessive preoccupation with food and cooking for others.

Emotionally, anorexic patients are often described as being perfectionistic, dependent, introverted, and overly compliant. Although studies have failed to find a consistent psychiatric symptom pattern for the disorder, frequently reported neurotic traits include obsessive compulsive, hysterical, hypochondriacal, and depressive symptoms. A decrease in or disappearance of sexual interest is also a frequent concomitant of anorexia nervosa, according to the 1987 Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association.

A distorted body image is an almost universal characteristic of anorectics, with many patients insisting that they are overweight even when their bodies are extremely emaciated. As a result, most individuals with anorexia nervosa deny or minimize the severity of their illness and are thus resistant to therapy. The anorectic's refusal to acknowledge her nutritional needs, and her steadfast insistence that nothing is wrong, make anorexia nervosa one of the most recalcitrant disorders in contemporary medicine.

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