Dialectical behavior therapy (DBT) has been shown to be effective in treating anorexia nervosa (AN), as patients with the disorder who underwent DBT saw low dropout rates and increased BMIs which were sustained 6 months later. While standard DBT has been shown to be effective, a DBT program that was augmented to focus on overcontrolled emotions and behaviors which contribute to AN was more helpful in encouraging long term results.

Dialectical Behavior Therapy as Treatment for Anorexia Nervosa

While there is a long tradition of studying health inequalities between social classes, the standard approach does not apply for anorexia. The intersection of the social relations of age, gender, and social background, with which they are related, accounts sociologically for the disparities in the frequency of EDs.


Anorexia in Social Relationships

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

1. The individual restricts their consumption of food such that it is significantly lower than their body's energetic demand, resulting in a dramatic reduction in body weight. This reduction is evaluated in reference to the individual's expected weight, which itself varies according to their age, sex, and developmental trajectory.

2. The extreme fear of gaining weight and/or subcutaneous fat, which prevents weight restoration and/or maintenance of a healthy weight.

3. The distortion of the individual's body-image due to the their perception their body's weight or shape, low sense of self-worth because of their body's weight or shape, or the absence of an acknowledgment that their body weight is lower than what is clinically considered to be healthy.

Diagnostic Criteria for Anorexia Nervosa (DSM-V)

Research unfortunately indicates that anorexia nervosa treatment outcomes are not always ideal. Although oftentimes significant weight is restored by the end of treatment, psychological symptoms frequently go largely unaddressed, indicating a gap in current treatment procedures that may leave patients more vulnerable to relapse.

Anorexia Nervosa Treatment Outcomes

A model explaining the intra- and inter-personal maintenance factors for the continued duration of anorexia nervosa, not bound by Western sociocultural limitations. Intrapersonal factors combine to predispose individuals to anorexia nervosa and contribute to its maintenance, eliciting strong reactions from close others which then create interpersonal factors that further perpetuate the illness:

- Perfectionism/cognitive rigidity
- Experiential avoidance
- Pro-anorectic beliefs
- Expressed emotions

Cognitive-Interpersonal Maintenance Model of Anorexia Nervosa

Individuals diagnosed with anorexia nervosa will typically have a distorted body image, which refers to when one feels they look overweight despite not being overweight. Distorted body image is a type of body dysmorphia.

Distorted Body Image

The gut microbiome is a diverse, abundant microbial ecosystem that helps modulate homeostasis via a symbiotic relationship with its host. It has implications in multiple complex diseases by facilitating interactions between genes and the environment, but it is vulnerable to chronic environmental disturbances, such as the dietary fluctuations and nutritional deprivation inherent to anorexia nervosa. It is likely involved in AN pathophysiology by affecting energy metabolism, intestinal permeability, immune function, appetite, and behavior, but complicated by genetic risk factors, eating patterns, etc.. Intestinal bacteria may be involved in appetite and weight regulation along with comorbidities such as mood changes and gastrointestinal symptoms by acting on metabolic, neuroendocrine, and immune pathways.

- Dysbiosis in anorexia nervosa 
- Gut microbiota adaptations to starvation 
- Microbiome-based anorexia nervosa symptom mechanisms 
- Microbiome-based interventions for anorexia nervosa

Anorexia Nervosa and the Gut Microbiome

Individuals with anorexia nervosa face an elevated risk of developing other psychological problems. Commonly co-occurring conditions include anxiety disorders, mood disorders, and issues with substance abuse.

Psychological Comorbidities of Anorexia Nervosa

The prevalence of anorexia nervosa is estimated to range from just under 1% to over 4% among women. The rates of this disorder are significantly lower for men.

Prevalence of Anorexia Nervosa

An example of a public health initiative is an Italian advertising campaign that was created to increase public awareness about anorexia nervosa. This campaign was highlighted in a news story to broaden its reach.

Italian Advertising Campaign for Anorexia Nervosa Awareness

A 19-year-old student is brought in for a consultation by her concerned parents. She is 5'7" tall and weighs 98 pounds. Despite her significantly low body weight, she expresses an intense fear of gaining weight and frequently states that she feels 'fat,' often pointing to her stomach and thighs. Her parents report that she eats very small portions, avoids high-calorie foods entirely, and engages in a rigorous two-hour exercise routine every day. Based on this information, which psychological disorder is most likely being described? Justify your answer by identifying at least two key features from the scenario that align with the typical presentation of this disorder.

Clinical Scenario Analysis

The medical consequences of anorexia nervosa are primarily caused by severe starvation, as well as purging behaviors.

Medical Consequences of Anorexia Nervosa

Anorexia nervosa is an eating disorder defined by maintaining a body weight significantly below average, which is achieved through methods like starvation or excessive exercise. A central characteristic of this disorder is a distorted body image, a form of body dysmorphia, where individuals perceive themselves as overweight despite being underweight.

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In contrast to the widespread issue of being overweight, a significant minority of the population suffers from eating disorders, which commonly lead to being underweight. These conditions, such as bulimia nervosa and anorexia nervosa, are often characterized by an intense fear of gaining weight and can result in numerous negative health effects.

Eating Disorders 

The DSM-5-TR separates Feeding and Eating disorders into the following specific disorders:
-	Pica
-	Rumination Disorder
-	Avoidant / Restrictive Food Intake Disorder
-	Anorexia Nervosa
-	Bulimia Nervosa
-	Binge-Eating Disorder
-	Other Specified Feeding or Eating Disorder
-	Unspecified Feeding or Eating Disorder


[DSM-5-TR] List of Feeding and Eating Disorders

Petre, A. (2019, October 30). Learn about 6 common types of eating disorders and their symptoms. Healthline. https://www.healthline.com/nutrition/common-eating-disorders#what-they-are. 

Eating disorders general summary

Anorexia Signs &amp; Symptoms. Eating Disorder Solutions. (2021, June 29). https://eatingdisordersolutions.com/anorexia-treatment/signs-and-symptoms/. 

Anorexia image citation

Anorexia Nervosa. National Eating Disorders Association. (2018, February 28). https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia. 

National Eating Disorders Association: Anorexia

Spielman, R. M., Jenkins, W. J., & Lovett, M. D. (2020, April 22). Psychology (2nd ed.). OpenStax. https://openstax.org/books/psychology-2e/pages/1-introduction

OpenStax Psychology (2nd ed.) Textbook

Bulimia nervosa is an eating disorder characterized by a cycle of binge eating—consuming a large amount of food—followed by attempts to compensate for it. These compensatory behaviors are intended to prevent weight gain.

Bulimia Nervosa

Binge eating disorder (BED), officially recognized by the American Psychiatric Association in the DSM-5 since 2013, is characterized by recurrent episodes of consuming large amounts of food. Unlike bulimia nervosa, these binges are not followed by compensatory behaviors such as purging. A key diagnostic feature is the significant psychological distress, including feelings of guilt and embarrassment, that occurs after a binge, which distinguishes the disorder from simple overeating.

Binge Eating Disorder (BED)

References for Bulimia Nervosa 

Pica is an eating disorder in which an individual compulsively consumes inedible items. The inedible items consumed vary by those with the disorder.

Pica

Rumination disorder is an eating disorder where an individual unconsciously regurgitates food immediately after eating. This eating disorder is rare and is most common in children.

Rumination Disorder

A disorder commonly found in children, ARFID can be described as extremely picky eating, though fear foods differ significantly from those with anorexia nervosa and bulimia nervosa. Although ARFID involves food restriction and thus shares some features with anorexia nervosa, the fear and restriction surrounding food is not due to concerns about weight or body image. 

Avoidant/Restrictive Food Intake Disorder (ARFID)

Bulimia nervosa. Johns Hopkins Medicine. (2023, January 31). https://www.hopkinsmedicine.org/health/conditions-and-diseases/eating-disorders/bulimia-nervosa 

Cleveland Clinic. (2022). Pica. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/22944-pica 

Mayo Foundation for Medical Education and Research. (2018, May 5). Binge-eating disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/binge-eating-disorder/symptoms-causes/syc-20353627 

Mayo Foundation for Medical Education and Research. (2020a, October 14). Rumination syndrome. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/rumination-syndrome/symptoms-causes/syc-20377330 

Meczekalski, B., Podfigurna-Stopa, A., & Katulski, K. (2013). Long-term consequences of anorexia nervosa. Maturitas, 75(3), 215–220. https://doi.org/10.1016/j.maturitas.2013.04.014

References for Eating Disorders: Consequences

Other Specified Feeding and Eating Disorder (OSFED) is a category of eating disorders in which individuals do not meet full criteria for other eating disorders. Around 30% of individuals diagnosed with an eating disorder fall into this classification.

Other Specified Feeding and Eating Disorder

Eating disorders, particularly conditions like bulimia nervosa and anorexia nervosa, are associated with a wide range of severe and adverse health consequences.

Adverse Health Consequences of Eating Disorders

Anorexia Nervosa

A person begins a new diet and exercise regimen with the goal of losing 10 pounds. They start counting calories and increase their physical activity. Which of the following additional observations would be the strongest indicator that this behavior is evolving into a clinical eating disorder?

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