Clinical Presentation of Anorexia
Nervosa and Bulimia Nervosa
PIERRE J. V. BEUMONT
Anorexia nervosa is a condition of self-engendered weight loss, usually seen in adolescent girls and young women, and less commonly in prepubertal children and middle-age women or men. It has been recognized in medicine for more than 150 years, but for much of that time was largely confined to affluent societies that espouse Western cultural ideals (see Chapter 27 for a discussion of the history of anorexia nervosa and bulimia nervosa). It now occurs at all socioeconomic levels, and there are increasing reports of anorexialike illnesses from non-Western societies (see Chapter 47). The criteria that have been proposed for its diagnosis point to three sets of related features: (1) an intense preoccupation with weight and shape; (2) behaviors directed at the relentless pursuit of thinness; and (3) the physical consequences of these behaviors, such as emaciation, disturbed endocrine function, and other nutritional abnormalities. (The diagnostic criteria for anorexia nervosa and bulimia nervosa are discussed in Chapter 28.)
The objective psychopathology is difficult to label. It has been termed hysterical, a phobia of weight gain, an obsession, or even a delusion, but perhaps an overvalued idea is best. Patients are overwhelmed by concerns about their bodies and protest that they feel themselves to be fat even when they are actually emaciated. They are preoccupied with ways to reduce their weight further or, at the least, to prevent any gain. Patients appear genuinely terrified at the prospect of being overweight, and some state openly that they would rather be dead than fat. Although so extreme as to be pathological, such beliefs represent an exaggeration of the widespread concern about weight control that has been engendered in our community.