We searched PubMed for articles published between Jan 1, 2010, and Dec 31, 2014, covering the time period since the review by Treasure and colleagues,4 published in The Lancet. We combined the search term “anorexia nervosa” each with “chronicity”, “comorbidity”, ”epidemiology“, “prognosis”, or “mortality”, “risk factor” or “maintaining factor”, “treatment” or “psychotherapy” or “pharmacological”, “prevention”. We narrowed the search to titles and abstracts. We used no language restriction. From
ReviewAnorexia nervosa: aetiology, assessment, and treatment
Introduction
Anorexia nervosa is a highly distinctive serious mental disorder. It can affect individuals of all ages, sexes, sexual orientations, races, and ethnic origins; however, adolescent girls and young adult women are particularly at risk. This disorder is characterised by an intense fear of weight gain and a disturbed body image, which motivate severe dietary restriction or other weight loss behaviours such as purging or excessive physical activity.1, 2, 3 Additionally, cognitive and emotional functioning are markedly disturbed in people with this disorder. Serious medical morbidity and psychiatric comorbidity are the norm.4, 5 Anorexia nervosa in adults and older adolescents commonly has a relapsing or protracted course,6 and levels of disability and mortality are high,7, 8 especially without treatment. Even partial syndromes (ie, sub-syndromal anorexia nervosa) are associated with adverse health outcomes.9 Quality of life is poor and the burden placed on individuals, families, and society is high.10
This Review, like the Lancet Seminar published in 2010,4 which included all eating disorders, focuses on factors associated with anorexia nervosa that are of particular relevance to clinicians, such as recent developments in diagnosis, epidemiology, pathogenesis, treatment, and prognosis.
Section snippets
Classification and diagnosis
Low bodyweight or low body-mass index (BMI) is the central feature of anorexia nervosa. Table 1, Table 2 give an overview of diagnostic criteria for anorexia nervosa according to DSM2 and ICD11. Restricting and binge-purge subtypes and remission and severity specifiers exist. Amenorrhoea is no longer required in the new DSM-5 diagnostic criteria and is also expected to be dropped in ICD-11.12 Main reasons for eliminating this criterion are based on conflicts with inclusion of male individuals,
Epidemiology
In high-income countries, the lifetime prevalence of anorexia nervosa in the general population is reported to be around 1% in women and less than 0·5% in men.9 Accurate point prevalence has been more difficult to calculate, with studies often failing to identify any cases of DSM-IV-defined anorexia nervosa. If the broader DSM-5 criteria A and C (low weight in the presence of overvaluation of weight or shape) are applied, the point prevalence is about 0·3–0·5%.16 Some studies,17 but not all
Psychiatric and physical comorbidity
Nearly three-quarters of patients with anorexia nervosa report a lifetime mood disorder, most commonly major depressive disorder.22 Between 25% and 75% of patients with anorexia nervosa report a lifetime history of at least one anxiety disorder,23 which typically precedes anorexia nervosa and starts in childhood.24 Obsessive-compulsive disorder occurs in 15–29% of individuals with anorexia nervosa,25 with up to 79% experiencing obsessions or compulsions at some point in their lives.26 In
Prognosis
Regarding the core anorexia nervosa-psychopathology, Steinhausen and colleagues21 analysed 119 studies covering 5590 patients with anorexia nervosa and reported that 59·6% of those patients showed a weight normalisation, accompanied by a normalisation of menstrual status in 57·0%, and a normalisation of eating behaviour in 46·8% of the whole group of patients with anorexia nervosa. In general, patients with an illness onset before their 17th birthday achieve a better outcome than adult onset,
Genetic factors
Anorexia nervosa is strongly familial43 and heritability estimates range from 28% to 74%.44 Two genome-wide association studies (GWAS),45, 46 currently understood to be underpowered in view of the presumed genetic architecture of anorexia nervosa, predictably did not detect genome-wide significant loci. Boraska and colleagues45 conducted sign tests to compare results from the discovery sample with those from the replication sample, and 76% of the results from the replication sample were in the
Initial assessment and investigations
Initial assessment of the patient with anorexia nervosa includes an in-depth interview, a physical examination, and investigations to establish severity and nature of eating disorder symptoms and diagnosis, comorbid psychological and physical symptoms, diagnoses and risk, past treatments, current motivation for treatment, and available supports. An early task is to build good rapport with the patient, as they are often highly ambivalent about and fearful of treatment.72 Whenever possible, it is
Evidence-based prevention programmes
Prevention efforts can be divided into universal, selective, and indicated, depending on whether they address the general population or populations with increased risk (eg, children of eating disordered mothers; elite athletes) or those exhibiting early signs of a disorder. Eating disorder prevention has focused on either risk factors (eg, body dissatisfaction) or eating disorder pathology or caseness. A systematic review116 of eating disorders prevention programmes for young people between the
Conclusions
The past 5 years have seen substantial advances in the knowledge of anorexia nervosa. Recent treatment studies suggest that patients with anorexia nervosa have a realistic chance of recovery, especially if treated early, or at least, to achieve substantial improvement. However, there is widespread agreement that several challenges remain in the management of anorexia nervosa (panel 3) and new interventions are needed to improve outcomes, especially in adults with the disorder. Such
Search strategy and selection criteria
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