Physical signs and symptoms. Many of the physical signs and symptoms of anorexia nervosa are attributable to starvation. Amenorrhea is commonly present and appears to be an indicator of physiological dysfunction. If present, amenorrhea is usually a conse- quence of the weight loss, but in a minority of individuals it may actually precede the weight loss. In prepubertal females, menarche may be delayed. In addition to amenorrhea, there may be complaints of constipation, abdominal pain, cold intolerance, lethargy, and excess energy.
The most remarkable finding on physical examination is emaciation. Commonly, there is also significant hypotension, hypothermia, and bradycardia. Some individuals develop lanugo, a fine downy body hair. Some develop peripheral edema, especially during weight restoration or upon cessation of laxative and diuretic abuse. Rarely, petechiae or ecchymoses, usually on the extremities, may indicate a bleeding diathesis. Some individ- uals evidence a yellowing of the skin associated with hypercarotenemia. As may be seen in individuals with bulimia nervosa, individuals with anorexia nervosa who self-induce vomiting may have hypertrophy of the salivary glands, particularly the parotid glands, as well as dental enamel erosion. Some individuals may have scars or calluses on the dorsal surface of the hand from repeated contact with the teeth while inducing vomiting.
Suicide risk is elevated in anorexia nervosa, with rates reported as 12 per 100,000 per year.
Comprehensive evaluation of individuals with anorexia nervosa should include assess- ment of suicide—related ideation and behaviors as well as other risk factors for suicide, in— cluding a history of suicide attempt(s).
Functional Consequences of Anorexia Nervosa
Individuals with anorexia nervosa may exhibit a range of functional limitations associated with the disorder. While some individuals remain active in social and professional func- tioning, others demonstrate significant social isolation and / or failure to fulfill academic or career potential.
Other possible causes of either significantly low body weight or significant weight loss should be considered in the differential diagnosis of anorexia nervosa, especially when the presenting features are atypical (e.g., onset after age 40 years).
Medical conditions (e.g., gastrointestinal disease, hyperthyroidism, occult malignan- cies, and acquired immunodeficiency syndrome [AIDS]). Serious weight loss may oc- cur in medical conditions, but individuals with these disorders usually do not also mani- fest a disturbance in the way their body weight or shape is experienced or an intense fear of weight gain or persist in behaviors that interfere with appropriate weight gain. Acute weight loss associated with a medical condition can occasionally be followed by the onset or recurrence of anorexia nervosa, which can initially be masked by the comorbid medical condition. Rarely, anorexia nervosa develops after bariatric surgery for obesity.
Major depressive disorder. In major depressive disorder, severe weight loss may occur, but most individuals with major depressive disorder do not have either a desire for exces- sive weight loss or an intense fear of gaining weight.
Schizophrenia. Individuals with schizophrenia may exhibit odd eating behavior and oc- casionally experience significant weight loss, but they rarely show the fear of gaining weight and the body image disturbance required for a diagnosis of anorexia nervosa.
Substance use disorders. Individuals with substance use disorders may experience low weight due to poor nutritional intake but generally do not fear gaining weight and do not manifest body image disturbance. Individuals who abuse substances that reduce appetite (e.g., cocaine, stimulants) and who also endorse fear of weight gain should be carefully evaluated for the possibility of comorbid anorexia nervosa, given that the substance use may represent a persistent behavior that interferes with weight gain (Criterion B).