Read the following clinical description. In addition to the clear signs of an eating disorder characterized by severe weight loss and a distorted body image, what other type of psychological disorder is most likely present? Explain your reasoning by referencing specific details from the description.

Clinical Scenario: Identifying Co-occurring Conditions

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.

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 •An eating disorder marked by the pursuit of extreme thinness, purposeful maintenance of a significantly low body weight, intense fear of becoming overweight, distorted view of of body weight, and the placement of inappropriate emphasis on body weight or shape in the evaluation of one self.

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.

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

What Are Eating Disorders?, https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders. 

What are Eating Disorders

Cognitive Remediation and Emotion Skills Training (CREST) is an individualized treatment low in intensity meant for patients that suffer from Anorexia Nervosa. This training regimen places importance on the development of emotion recognition skills in the patients and those around the patients as well. It also aims to target the management and expression of emotion in Anorexia Nervosa. CREST places importance on understanding and identifying emotions in a safe space, in order to help patients regulate emotions associated with Anorexia Nervosa and others as well.  CREST training sessions include thinking exercises, group discussions and games that aim to identify and develop strategies for managing emotions and 

Cognitive Remediation and Emotion Skills Training (CREST )

Kids in grades 5-8 were surveyed about their body satisfaction and their weight control behaviors. More than 40% of respondents reported feeling fat or having the desire to lose weight. Of the girls surveyed, 31.4% reported dieting, 8.7% reported fasting, 2.4% used diet pills, 4.8% used vomiting, and 1.5% used diuretics. 

Eating Disorder Symptoms in Middle Schoolers

Reference for Eating Disorder Symptoms in Middle Schoolers

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

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

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.

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