What are the signs and symptoms of anorexia nervosa?

Signs and Symptoms of Anorexia Nervosa

Anorexia nervosa is characterized by persistent restriction of food intake leading to significantly low body weight, intense fear of weight gain, and disturbance in body image perception, with mortality rates among the highest of any psychiatric disorder. 1

Diagnostic Criteria

According to the DSM-5, anorexia nervosa is diagnosed when a patient exhibits:

• Restriction of energy intake leading to significantly low body weight
• Intense fear of gaining weight or becoming fat
• Disturbance in the way one's body weight or shape is experienced
• Undue influence of body shape and weight on self-evaluation
• Persistent lack of recognition of the seriousness of low body weight 2, 1

Anorexia nervosa is classified into two types:

• Restricting type
• Binge-eating/purging type 1

Physical Signs and Symptoms

Vital Signs

• Bradycardia (heart rate <50 beats/minute during the day)
• Hypotension (<90/45 mm Hg)
• Hypothermia (body temperature <96°F [<35.6°C])
• Orthostatic changes (increase in pulse >20 beats/min or decrease in blood pressure >20 mm Hg systolic or >10 mm Hg diastolic on standing) 2

Weight-Related Changes

• Significant weight loss
• Falling off percentiles for weight and BMI
• Low body weight compared to age, sex, developmental trajectory, and physical health 2, 1

Cardiovascular System

• Cardiac arrhythmias
• QTc prolongation (responsible for 50% of deaths) 1, 3

Endocrine System

• Amenorrhea in females
• Hormonal imbalances
• Growth retardation in children and adolescents 2, 1

Gastrointestinal System

• Delayed gastric emptying
• Delayed small and large bowel transit
• Abdominal pain
• Constipation 1, 3

Other Physical Signs

• Lanugo (fine hair growth on body)
• Dry skin
• Brittle hair and nails
• Cold intolerance
• Peripheral edema
• Muscle wasting
• Bone density loss 3, 4

Behavioral and Psychological Signs

Eating Behaviors

• Severe dietary restriction (<500 kcal/day)
• Skipping meals to lose weight
• Prolonged periods of starvation
• Food rituals (cutting food into small pieces, eating foods in certain order)
• Narrowing or elimination of food groups
• Rumination, regurgitation, chewing and spitting 2

Weight Control Behaviors

• Self-induced vomiting
• Use of diet pills, laxatives, or diuretics
• Compulsive and excessive exercise 2

Psychological Signs

• Preoccupation with food, weight, and body shape
• Body image distortion
• Social isolation
• Irritability
• Profound fear of gaining weight
• Denial of the seriousness of low body weight
• Perfectionism
• Post-meal anxiety 2, 5

High-Risk Warning Signs

• Rapid weight loss
• Severe restriction of food intake
• Compulsive exercise despite injury or fatigue
• Syncope or near-syncope
• Suicidal ideation
• Multiple prior treatment failures 2, 4

Complications

Anorexia nervosa can affect nearly every organ system with potentially life-threatening consequences:

• Cardiovascular: bradycardia, hypotension, arrhythmias
• Metabolic: electrolyte abnormalities (particularly with purging)
• Hematologic: anemia, leukopenia
• Musculoskeletal: osteopenia, increased fracture risk
• Neurological: cognitive impairment, structural brain changes
• Psychological: depression, anxiety, obsessive-compulsive behaviors 1, 3

Early recognition of these signs and symptoms is crucial, as anorexia nervosa has one of the highest mortality rates among psychiatric disorders, with a risk of death about 12 times higher than the general population of the same age 3. Medical complications can range from mild to extremely serious and life-threatening conditions.