In more than 95% of patients, anorexia nervosa begins with a conscious wish to lose weight through dieting, often combined with exercise, and occasionally augmented by self-induced vomiting and abuse of laxatives, diuretics, or diet pills. The disorder generally takes root after months or years of self-critical scrutiny of body size and shape. Some patients begin dieting because their friends or family members are dieting or are making comments about the patient's appearance. The peaks of onset of primary anorexia nervosa are the early and late teens, (14 and 18 years of age). Onset is possible as early as age seven and as late as the 70's. Persons especially predisposed are young women with sensitive, self-critical, and sometimes compulsive aspects to their personality, who come from families with a history of depressive disorder as well as an "enmeshed" (living in each other's pockets without freedom to grow separately; having excessive reactivity to each others moods and behaviors" style of family functioning. Participation in sports, ballet, modeling, wrestling, and other activities that promote thinness accentuates the drive to lose weight.

Anorexic individuals usually come to medical attention because of concern by family, friends, teachers, and sometimes coaches, rather than because the patients themselves are worried. Anorexia nervosa, although often concealed by layers of clothing, is a relatively public disorder. Driving their weight loss is the excessive and unrealistic fear of fatness, a symptom clearly differentiating anorexia nervosa from other psychiatric and medical causes of weight loss.

Two major classes of patients with anorexia nervosa have been identified: those who solely restrict their food intake (restricting subtype), and those who binge while at low weight, and then induce vomiting or abuse laxatives or diuretics (binge/purge subtype). Patients with both subtypes organize their behaviors, social lives, thinking, and ultimately their identity around promoting and maintaining weight loss and resisting weight gain. Families are distressed by the anorexic behavior, which resists both entreaties and threats. This usually makes families feel helpless, angry, or defeated, and occasionally provokes abuse.

The final, chronic stage of the disorder has two features. The illness becomes autonomous, resisting change, and the patient develops an identity based on the anorexia nervosa, a "sick role" that derails normal social and psychological development. The chronically low weight may also be sustained by the pathophysiologic effects of malnutrition, such as slowed gastric emptying and severe abdominal distress.

Patients' emaciated state has characteristic signs, including hypotension, bradycardia, decreased core temperature, and loss of both intra-abdominal and subcutaneous body fat as well as decreased muscle mass. Radiographic and laboratory studies may reveal osteoporosis, brain shrinking, and variable degrees of anemia and endocrine dysfunction. Gonadotropins and sex steroid concentrations are low, as can be the serum T3 but thyroxine is usually normal. Circulating cortisol and growth hormone concentrations are often high.

Management of Anorexia Nervosa
Most patients meeting the full criteria for anorexia nervosa need to be treated as inpatients for several weeks to months. Patients are first stabilized medically, and then started on nutritional rehabilitation. The best approach to feeding is persuading patients to accept healthy amounts of food, prescribed as medicine, with the promise that they will not be allowed to become fat. Nasogastric tubes are rarely necessary, and parenteral hyperalimentation is fraught with potential complications. Feeding may cause abdominal distress as well as mild peripheral edema, which responds to elevation of the feet; rarely, the stomach dilates. Education and support help patients understand their illness and need for treatment.

Nutritional rehabilitation is only the prelude to definitive management. The central challenge is persuading patients to think differently about their body size and nutritional needs, and to appreciate the role that their illness has come to serve in their life. Management is also directed toward identifying and treating coexisting mood, anxiety, and personality disorders, and alcohol or other substance abuse. After the patient's weight has been restored to a healthy range, intensive practice in patterns of healthy daily living consolidates the treatment gains. Treatment of individuals under 18 year old seldom succeeds unless it includes the whole family. Aftercare usually requires two to three years, and may involve individual, group, or family treatment.

The death rate from anorexia nervosa is as high as 18%, primarily from medical complications and suicide. Most patients who survive eventually improve, but improvement occurs over a broadly disparate time frame from years to decades later. Coexisting psychiatric conditions, especially mood disorders, personality disorders, and substance abuse, often prove to be the most difficult aspects of long-term treatment. Mortality can be reduced by prompt medical stabilization of low weight and hypokalemia, and by recognition and treatment of co-occurring depressive illness (30-50% of cases). The good news is that with effective treatment (acute plus relapse prevention), the disorder is curable, not merely subject to improvement.

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