Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Eating Disorders (B7)

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ANOREXIA NERVOSA

Anorexia nervosa is an eating disorder primarily affecting young women that is characterized by self-induced weight loss; various psychological disturbances including distorted body image, or denial of the seriousness of weight loss, fear of obesity, active pursuit of thinness, a loss of recognition of a number of body enteroreceptive sensations; and secondary physiological abnormalities. The condition is subdivided into restrictive and binge eating/purging types. The condition involves both psychological and physiological functions. Anorexia nervosa is a condition that leads to significant confusion and frustration on the patients', parents' and clinicians' part. It requires a comprehensive intervention approach. With good treatment programs, success rates have been improving.

Other "para" eating disorders include:

  • Weight preoccupied: Individuals who are constantly aware of body weight but without a loss of control.
  • Food faddism: Individuals become preoccupied with the type of food rather than the amount.
  • Fat phobia: Individuals who have an increased awareness of food content through labeling of food products and who avoid and restrict fat content for health reasons.
  • Finicky eater: Individuals who eat only small amounts of food or certain types of food but in adequate quantities to maintain a body weight. There is no distorted body image.

Etiology

The exact cause of anorexia nervosa is unknown. Many theories have been discussed over numerous years that involved pituitary failure, psychoanalytic theories and family dysfunction. There is evidence that starvation, bingeing and excessive exercising can lead to changes in neurotransmitters and conversely there is evidence that such changes can lead to these behaviors. The etiology of anorexia nervosa probably involves a combination of biological, psychological, and social factors. Perhaps biological vulnerability, family problems, and emotional problems combine in a given social climate to cause the typical dieting of an individual with anorexia nervosa. The weight loss, in turn, leads to malnutrition, which contributes to the physical and emotional changes of the patient with anorexia nervosa and perpetuates a vicious cycle.

Epidemiology

  • Incidence: The exact incidence is unknown but worldwide incidence estimates are approximately 1 per 100,000; while, the incidence among white, pubertal females in developed countries may be as high as 1 per 200.
  • Sex: Anorexia nervosa is about ten times more common in females
  • Age: The mean age of onset is 13.75 years with a range from 10 to 25 years.
  • Risk factors: Risk factors have been proposed that include cultural, familial, and individual factors. These include:
    • Cultural risk factors: Cultures that emphasize thinness and that disseminate these values through the media.
    • Family risk factors: Typical familes are achievement oriented, overprotective, rigid, unable to resolve conflicts, give little child encouragement, overinvested in food, and are overinvested in appearance or physical fitness. Families are often described as "perfect families" in their communities.
    • Individual risk factors: female sex, adolescent age, slightly overweight before onset, low self-esteem, conflicts and doubts about sense of personal identity and autonomy, obsessional personality.

Clinical Manifestations

Typical Presentation

  • Often starts when a patient decides to lose weight after a critical comment by a family member or peer.
  • Initial weight loss turns into relentless pursuit of thinness after initial positive reinforcement by peers or family.
  • Food faddism and rituals may begin as eating behaviors change. This may include hiding food and breaking up food into tiny parts. Also may include eating very low-caloric foods.
  • There may be increased interest in cooking and preparing food for others
  • There is usually significant increase in physical activity
  • Purging behaviors may begin through catharsis, diruesis or emesis.

Presenting Symptoms

  • Weight loss
  • Amenorrhea: Almost 100% prevalence but precedes weight loss in 25% of patients.
  • Hyperactivity
  • Preoccupation with food
  • Abdominal symptoms including constipation, bloating, pain and nausea and vomiting
  • Postural dizziness and fainting
  • Easy bruising
  • Blue hands and feet
  • Cold intolerance
  • Hair loss
  • Fatigue, muscle weakness, and cramps
  • Frequent fractures

Presenting Physical Signs

Most are related to the weight loss and have been reported in starvation states.

  • Decreased weight and cachexia, Body Mass Index (BMI) 14 - 17
  • Decreased temperature – may be as low as 35° C
  • Bradycardia and hypotension (often significant postural changes)
  • Acrocyanosis
  • Edema, usually dependent
  • Dry skin with hyperkeratotic areas (dirty skin)
  • Cold extremities
  • Yellowish discoloration of the skin (carotenemia)
  • Nail changes: Pitting, ridging
  • Increased lanugo hair
  • Scalp hair loss
  • Superior mesenteric artery syndrome
  • Systolic murmur sometimes associated with mitral valve prolapse

Laboratory Features Laboratory findings in anorectic patients can include:

  • Endocrine: Most changes are related to malnutrition and conservation of energy and these include:
  • Thyroid: Normal or low thyroxine and low Triiodothyronine (T3)
  • Growth hormone: Normal or high levels and decreased somatomedin
  • Prepubertal levels of LH and FSH
  • Sex steroids: Low estradiol in females and low testosterone in males
  • Cortisol: Decreased response of ACTH to corticotropin-releasing hormone
  • Chemistries: increased BUN, SGOT, SGPT, cholesterol and serum carotene. Decreased serum magnesium, phosphate, calcium, zinc, copper.
  • Hematologic: mild anemia, leukopenia, thrombocytopenia, decreased serum complement C3 and decreased erythrocyte sedimentation rate.
  • Cardiac: Bradycardia, low-voltage changes, T –wave inversions, and occasional ST segment depression
  • Gastrointestinal : occasional hypomotility of upper GI tract
  • Renal and metabolic : Decreased glomerular filtration rate, elevated BUN, decreased maximum concentration ability (nephrogenic DI) and chloride-responsive metabolic alkalosis
  • Bone Density - Decreased bone density

Diagnosis and Assessment

The diagnosis of anorexia nervosa should be suspected in any adolescent with unexplained weight loss, hyperactivity, and food avoidance. Considered in the differential diagnosis should be inflammatory bowel disease, early pregnancy, hyperthyroidism, tuberculosis, collagen vascular disease , brain tumors, Addison's disease and depression.

Diagnostic and Statistical Manual of Mental Disorders Criteria The American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for anorexia nervosa include:

  • Refusal to maintain body weight over a minimal normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
  • Intense fear of gaining weight or becoming fat, even though underweight.
  • Disturbance in the way in which one's body weight, size, or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
  • In postmenarchal females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea).

Two types are defined:

  • Restricting type: During the current episode the person has not regularly engaged in binge-eating or purging behavior
  • Binge-eating or purging type: During the current episode the person has regularly engaged in binge-eating or purging behavior.

Evaluation The evaluation of the anorectic patient should include a comprehensive history and physical examination with questions regarding weight history, eating, weight control behavior, exercise behaviors, ideal body weight goals, binge/purge behaviors, psychiatric history and substance abuse history. Standardized eating disorder questionnaires may also be used. Baseline laboratory should include at least a CBC, sedimentation rate, BUN and creatinine, urinalysis, electrolyes, liver function tests, serum calcium, phosphate and magnesium, serum albumin, T 4, TSH. Other tests to consider would be serum estradiol level, prothrombin time and partial thromboplastin time if easy bruising is a problem, electrocardiogram, chest x-ray and bone mineral density test (DEXA scan). Scan should be measured in females with anorexia nervosa and who have been amenorrheic for more than one year.

Treatment

Therapies for anorexia nervosa have included individual psychotherapy, cognitive behavioral therapy, drug therapy, hyperalimentation, and family therapy. Interventions must include correction of malnutrition and the associated psychological symptoms of starvation as well as working on the resolution of the psychological dysfunction within the patient and family. Psychotropic medications may have a role in individuals with anorexia nervosa or bulimia nervosa but are not a cure and should be used only after nutritional repletion has begun, the medical evaluation is complete and therapy has begun.

Complications

Complications can include cardiovascular (arrhythmias, heart muscle damage), renal (decreased GFR, calculi, edema and renal concentrating defect), gastrointestinal (constipation, delayed gastric emptying, elevated liver enzymes and amylase levels), hematologic (anemai, leukopenia, neutropenia, thrombocytopenia), endocrine (hypokalemia, hypontremia, hypomagnesemia, hypoglycemia, hypthermia, hypercortisolism, low estradiol and/or testosterone levels, elevated cholsterol, amenorrhea), neuromuscular (generalized muscle weakness, peripheral neuropathies, myopathy secondary to ipecac abuse, syncope in absence of orthostatic hypotension) dental (dental and enamel erosions from vomiting, caries and periodontal disease)

Prognosis

  • Mortality: Majority of studies have mortality rates of less than 4%.
  • Nutritional: At follow-up, 22-79% of patients are within normal limits for weight, 15-43% are 11-21% below normal, 2-10% were overweight.
  • Menses: Thirty-eight percent to 95% of anorectic patients are menstruating at follow-up.
  • Eating difficulties: Fifteen percent to 82% are eating normally at follow-up, 23-67% have restricted food intake, 11-50% are still vomiting or abusing laxatives.
  • Psychological disturbances: Psychiatric disturbances are common in follow-up studies, however, the majority of anorectic patients are engaged in full-time employment, with good work attendance.

Good prognosis is associated with early intervention, less comorbid psychological diagnoses, infrequent or no purging behavior, early age of onset and short duration of symptoms.

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BULIMIA NERVOSA

Bulimia nervosa is an eating disorder characterized by binge eating coupled with behavior intended to promote weight loss such as self-induced vomiting, laxative abuse, excessive exercise, or prolonged fasting.

Epidemiology

  • Onset: Onset is usually during late adolescence or early adulthood but ranges from 13 to 58 years.
  • Sex: Ninety percent to 95% are female
  • Prevalence: Estimates are that approximately 1-3% of young females in developed countries have bulimia.
  • There is an increased prevalence of a major affective disorder in individuals with bulimia.

Clinical Manifestations

The DSM-IV diagnostic criteria for bulimia are as follows:

  • Recurrent episodes of binge eating. An episode of binge eating is characterized by both:
    • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
    • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
  • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.

Two types identified:

Purging Type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Nonpurging Type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Symptoms

  • Swelling of hands and feet
  • Weakness and fatigue
  • Headaches
  • Abdominal fullness
  • Nausea
  • Irregular menses
  • Muscle cramps
  • Chest Pain and heartburn
  • Easy bruising (from hypokalemia/platelet dysfunction)
  • Bloody diarrhea (in laxative abusers)

Signs

  • Skin changes: Primarily on the dorsum of the fingers related to self-induced vomiting; may include elongated superficial ulceration to hyperpigmentation, calluses, or scarring
  • Enlargement of the salivary glands, particularly the parotid glands; usually bilateral and painless
  • Dental enamel erosion (perimyolysis) : Usually occurs in the lingual, palatal, and posterior occlusal surfaces of the teeth

Evaluation

Evaluation includes complete history and physical examination. Laboratory screening includes complete blood count, electrolytes, BUN and creatinine, glucose, calcium, electrolytes, calcium and phosphate, serum amylase (to confirm vomiting), electrocardiogram with rhythm strip, and possibly urine samples to detect laxative or diuretic abuse.

Treatment

  • Focus on decreasing the bulimic eating and avoiding foods that trigger a binge.
  • Treat the depression that often accompanies bulimia.
  • Have the adolescent participate in individual psychotherapy with or without family therapy.
  • Encourage the adolescent to exercise in moderation:
  • Antidepressants: The use of psychotropic agents appear to be more successful in treating individuals with bulimia nervosa than in those with anorexia nervosa.
  • Referral to groups and self-help organizations may be of benefit to some individuals.
  • Referral for dental consultation for those teens with dental damage secondary to vomiting.

Prognosis

  • Mortality: None
  • Weight: Most studies reported normal body weights at follow-up.
  • Psychologic state: Fifteen percent to 36% reported depression.

The full recovery rate of women with BN is significantly higher than that of women with AN.

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BINGE EATING DISORDER (BED)

Individuals who binge eat but who do not use compensatory mechanisms (fasting or purging) to lose weight. This type of eating pattern can lead to significant weight problems and obesity. BED is not an official diagnosis in DSM IV but it is listed as a category for proposed diagnoses and further research.

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EATING DISORDERS NOT OTHERWISE SPECIFIED

These are individuals who have problems with eating or disordered eating in need of treatment but who do not meet the DSM-IV criteria for anorexia nervosa or bulimia nervosa. These individuals usually fall short of some essential feature of anorexia nervosa or bulimia. Examples of individuals with EDNOS are:

  • Teens with what appears to be anorexia nervosa but who have menses
  • Individuals who appear to have anorexia nervosa and despite significant weight loss are still in a normal weight range
  • Individuals who purge but who never binge
  • Individuals who appear to have bulimia nervosa but do not meet the criteria for frequency and duration of symptoms or
  • Individuals who consume a lot of food but who chew and spit out the food.

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ACTIVITY DISORDER OR COMPULSIVE EXERCISING

While there is no DSM-IV diagnosis or criteria for this disorder, there has been an increase in the number of individuals with compulsive exercise behaviors in order to control or alter their weight, self-esteem and/or mood. These individuals continue to exercise to the point where they are no longer choosing to exercise but have become addicted to exercise despite adverse consequences.

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Questions

Question #1
List several risk factors for developing anorexia nervosa

Answer #1

  • Female gender: Ten times more common in females
  • Living in a culture that emphasize thinness and that disseminate these values through the media
  • Low self-esteem
  • Obsessive personality
  • Overweight teen following a diet
  • Overprotective, rigid families with difficulty in conflict resolution
  • Highly achievement oriented families

Question #2
Name the four components of the DSM-IV criteria for diagnosis of anorexia nervosa

Answer #2

  • Weight loss leading to body weight less than 85% of expected
  • Fear of gaining weight
  • Distrubance in perception of ones body weight
  • Amenorrhea

Question #3
List five common physical findings in a teen with anorexia nervosa

Answer #3

  • Decreased weight -Body Mass Index (BMI) 14 - 17
  • Decreased temperature – may be as low as 35° C
  • Bradycardia and hypotension (often significant postural changes)
  • Acrocyanosis
  • Edema, usually dependent
  • Dry skin with hyperkeratotic areas (dirty skin)
  • Cold extremities
  • Yellowish discoloration of the skin (carotenemia)
  • Nail changes: Pitting, ridging
  • Increased lanugo hair
  • Scalp hair loss
  • Superior mesenteric artery syndrome
  • Systolic murmur sometimes associated with mitral valve prolapse

Question #4
What are common hormonal changes in teens with anorexia nervosa

Answer #4

  • Thyroid: Normal or low thyroxine and low Triiodothyronine (T3)
  • Growth hormone: Normal or high levels and decreased somatomedin
  • Prepubertal levels of LH and FSH
  • Sex steroids: Low estradiol in females and low testosterone in males
  • Cortisol: Decreased response of ACTH to corticotropin-releasing hormone

Question #5
What are the key features of bulimia nervosa?

Answer #5

  • Recurrent episodes of binge eating - Eating, in a brief period of time an amount of food much larger than most people would eat and with a sense of loss of control.
  • Recurrent inappropriate purge behaviors to compensate for the binging such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
  • Both behaviors occur at least twice a week for 3 months.
  • The behaviors do not occur exclusively during episodes of anorexia nervosa

Question #6
List several physical findings associated with teens who are binging and purging?

Answer #6

  • Skin changes on the dorsum of the fingers related to self-induced vomiting and include elongated superficial ulcerations, hyperpigmentation, calluses, or scarring
  • Enlargement of the salivary glands, particularly the parotid glands
  • Dental enamel erosion (perimyolysis)

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Cases

A 15 year old adolescent female is brought to you by her mother as she is concerned her teen might be losing a bit too much weight. Her mother states that the teen has lost about 40 pounds in the past year after going on a diet. She has gone from about 135 pounds to 90 pounds. Both the mother and the teen were very happy about the weight loss but the mother feels it may be a bit much at this point.

Question :
What would be critical to be exploring in the history?

Answer
There are numerous issues to explore with this teen including:

  • History of the weight loss
  • What is her ideal weight
  • How does she feel about her weight now
  • What does she eat in typical day
  • What are her exercise patterns
  • Is there any bingeing or purging behaviors
  • What medications is she on and is she using any illicit drugs
  • Review of systems for any evidence of any infectious diseases or chronic diseases.
  • Menstrual history and sexual activity
  • Mental status including symptoms of depression
  • History of physical or sexual abuse
  • Family functioning including her perceptions of how the family functions

History according to the teen:

  • History of the weight loss
    Teen mentions that some of her friends mentioned she was getting a bit fat and they all suggested some diets. She went on a diet lost weight and was told by her parents, teachers and friends how much better she looked.
  • What is her ideal weight?
    She thinks she is probably about there
  • How does she feel about her weight now?
    She thinks she is probably in about the right range.
  • What does she eat in typical day?
    She likes lots of salads. She usually has a salad and a diet drink for lunch. She likes vegetables and a salad for dinner. She states she thinks that is probably a healthy diet.
  • What are her exercise patterns?
    She jogs each morning for 30-60 minutes.
  • Is there any bingeing or purging behaviors?
    She denies any binge/purge behaviors
  • What medications is she on and is she using any illicit drugs?
    She denies any medications or drug use
  • Review of systems for any evidence of any infectious diseases or chronic diseases?
    Her review of systems is negative except for some midepigastric discomfort and constipation
  • Menstrual history and sexual activity?
    Menarche was age 12 with regular menses from 12.5 to about 6 months ago when her menses stopped. She denies having a boyfriend or being sexually active.
  • Mental status including symptoms of depression?
    She states she is usually fairly happy except she feels she should even do better than her A- average in school. She is anxious about school. She denies being depressed
  • History of physical or sexual abuse?
    None
  • Family functioning including her perceptions of how the family functions?
    She states that she is one of three siblings in the family. She is the oldest and her family expects a lot of her. She mentions that there is occasional fighting between siblings and her parents and that has not changed much. She states her father is the judge for the city court and is away a lot. She talks a lot with her mother.

Question
What would be particularly important to evaluate on her physical examination?

Answer

  • Vital signs including her temperature, pulse, weight, height and BMI. Blood pressure and pulses should be evaluated standing and lying down
  • Skin changes for any signs of edema, acrocyanosis, yellowish discoloration, dry skin, or irritation on her palms from any vomiting
  • Hair: Hair loss on scalp, lanugo hair on body
  • Murmurs consistent with mitral valve prolapse
  • Sexual maturity rating

Vital signs:

  • Temperature 97
  • BP and pulse: lying 90/60 and 60, standing: 80/50 and 64
  • Weight 90 pounds,
  • Height: 63 inches
  • BMI: 16 (below 3 rd percentile for age)
  • Weight for age: 5 th percentile
  • Height for age: between 25 th and 50 th percentile

Skin:
Skin appears slightly dry without any other abnormalities.

Hair:
Normal

Cardiac exam:
no murmurs or abnormal heart sounds

Abdominal exam:
Normal

Sexual maturity rating:
SMR 5 for pubic hair and breasts.


Question:
What would be your next steps with this teen?

Answer

  • Ruling out other disorders: Based on the history and physical examination, there is strong clinical evidence that this teen has an eating disorder and most likely consistent with anorexia nervosa. However, some screening laboratory would be valuable. This might include:
  • CBC
  • Sedimentation rate
  • Urinalysis
  • Chemistry panel including calcium, phosphorous, BUN, creatinine, albumin.
  • TSH and T4
  • Liver enzymes
  • Serum electrolytes

It would also be reasonable to get an EKG in this teen checking for any significant abnormalities related to her weight loss or possible abnormal eating behaviors or purging that she has denied. One could also consider an estradiol level as it is quite possible she has low levels and is at risk for osteoporosis. A DEXA scan might be reasonable if this were low to document the degree of her osteoporosis and for comparison later.

  • Family history from parent(s)
  • Discussion with teen and her parent(s) about your suspension of the diagnosis
  • Follow-up appointment in a week or less to discuss lab results and potential treatment plan.

Lab results:

  • CBC: Hemoglobin 12.0 with 4,000 WBC and normal differential and platelet count
  • Sedimentation rate - 6
  • Urinalysis: normal
  • Chemistry panel: normal
  • TSH and T4: normal TSH and T4
  • Liver enzymes: normal
  • Serum electrolytes: normal
  • EKG: bradycardia, otherwise normal
  • Estradiol: low normal level

You discuss your concerns with the teen and her mother. You discuss that given her history and laboratory, you consider that anorexia nervosa is the likely diagnosis. You consider that treatment is available and that if she is to become healthy, it will involve meeting with the teen and her parents on a regular time frame. You discuss that she is in a critical metabolic/weight zone and that further weight loss could be a serious threat to her health and life and it is critical to not lose further weight. You set up appointments for individual and family therapy with a therapist, an appointment with nutritionist to review her diet and a follow-up with you to review her weight and health status. It would be important to also consider increased calcium in her diet and perhaps the addition of birth control pills to help with her low estrogen state.

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Web Sites

http://www.anad.org/
National Association of Anorexia Nervosa and Associated Disorders: ANAD operates an international network of support groups for sufferers and families, and offers referrals to health care professionals, who treat eating disorders, across the U.S. and in fifteen other countries.

http://www.aacap.org/cs/root/resources_for_families/glossary_of_symptoms_and_illnesses/anorexia_nervosa
American Academy of Child and Adolescent Psychiatry

http://www.mentalhealth.com/
Information from National Institute of Mental Health

www.iaedp.com
International Association of Eating Disorder Professionals: IAEDP's mission is to promote a high level of professionalism among practitioners who treat those suffering from eating disorders by emphasizing ethical and professional standards,

http://www.psychiatryonline.com/pracGuide/pracGuideTopic_12.aspx
Practice Guidelines for Patients with Eating disorders from American Psychiatric Association

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References

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4 th ed.

Washington DC : American Psychiatric Association, 1994.

Anonymous. Practice guideline for the treatment of patients with eating disorders (revision). American Psychiatric Association Work Group on Eating Disorders. Am J Psychiatry. 2000;157(1 Suppl):1-39.Atkins DM, Silber TJ. Clinical spectrum of anorexia nervosa in children. J Dev Behav Pediatr 1993;14:211.

Brown JM. Mehler PS. Harris RH. Medical complications occurring in adolescents with anorexia nervosa Western J Med 2000;172:189.

Fairburn CG. Cooper Z. Doll HA et al. Risk factors for anorexia nervosa: three integrated case-control comparisons Arch Gen Psychiatry 1999;56:468.

Garfinkel PE , Garner DM. Anorexia nervosa: a multidimensional perspective. New York :Brunner/Mazel, 1982.

Kreipe RE. Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am 2000;84:1027.

Neinstein LS: Adolescent Health Care, A Practical guide, chapter 34: Eating disorders, MacKenzie R, Neinstein LS. Lippincott Williams Wilkins, Philadelphia , 2002.

Nilsson E, Gillberg C, Gillberg Iet al. Ten-Year Follow-Up of Adolescent-Onset Anorexia Nervosa: Personality Disorders. J Am Acad Child Adolesc Psychiatry 1999;38:11.

Schwitzer AM. Bergholz K. Dore T et al. Eating disorders among college women: prevention, education, and treatment responses. J Am College Health 1998;46:199.

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Copyright (©) 2004-2013 Lawrence S. Neinstein, University of Southern California . All rights reserved. Republication or redistribution of the text, table, graphs and photos is expressly prohibited. The University of Southern California shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.