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Jan 18, 2021 in Healthcare

Literature Review of Anorexia Nervosa

Abstract

Anorexia nervosa is usually associated with a generalized anxiety disorder. This review will focus on the genetic and behavioral mechanisms involved and the similarities of anorexia nervosa with General Anxiety Disorder associated with young adults. This review will focus on what is prevalent in diagnosing and treating Anorexia nervosa and individuals with anxiety are prone to eating disorders.

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Literature Review

Anorexia nervosa (AN) is an anxiety disorder that has an adaptive warning in young adults. When uncontrollable and excessive, this disease can become a pathologic disorder that is manifested by numerous affective and physical symptoms, on top of requiring no particular external stimulus. The symptoms of Anorexia nervosa change in cognition and behavior and are thus believed to be behavioral and genetic. Studies have depicted a connection between Anorexia nervosa and General Anxiety Disorder, which is reflected by the similarities between the two illnesses (Focker, Knoll & Hebebrand, 2012).

The Diagnostic and Statistical Manual of Mental Disorders outlines many anxiety disorders, among them, the general anxiety disorder. The prevalence of diagnosing and treating Anorexia nervosa has displayed some eating patterns in individuals with eating disorders. It means that the treatments for Anorexia nervosa are effective for patients with eating disorders. The availability of similar treatment of these disorders has a significant basis on its developmental trajectory. An analysis of the genetic and behavioral mechanisms involved and the similarities of Anorexia nervosa with General Anxiety Disorder will help to review the prevalence in diagnosing and treating the victims of both diseases.

Several studies have depicted some relations between Anorexia nervosa and General Anxiety Disorder. According to Alcock and LeGrand, individuals lose appetite due to ordinary symptoms during illness (2014). It is apparent that a sudden loss in appetite results in a reduction in nutrient intake causing the inability to take food. One of the symptoms that are known for sickness behaviors is anorexia.

It is believed to be a part of the Acute-Phase Response (APR) and involves iron sequestration, anorexia, and fever. The induction of APR entails tumors such as interleukin-1, tumor necrosis, and interleukin-6. Hart, in his study, suggested that iron sequestration acts jointly with anorexia to limit the pathogens which deprive other micronutrients (Alcock and LeGrand, 2014).

Straub, another researcher, also argued that the immune system gets activated when people redistribute energy to the entire body (Alcock and LeGrand, 2014). The body obtains the potential to conduct this function from the brain, muscles, and abdominal organs. Both Hart and Straut established that sickness behavior is the key consequence of anorexia. It might be contradictory to assume that energy conservation is obtained through eating. The symptomology of Anorexia encompasses cognitions of mental and physical symptoms that result from interwoven features and starvation. Anorexia and the general eating disorder differ depending on the stage of the patient and the stage of the disorder.

Alcock and LeGrand (2014) reveal that the weight criterion of anorexia lacks standard procedures and references. The fourth edition shows the weight criterion of the DSM and founds the considerable alterations available in the fifth edition. The researchers have established a significant reduction in the context of age, sex, developmental trajectory, and physical health. Low weight, according to the fifth edition of DSM, is defined as that which is lower than the minimal normal. It is also believed to the weight that is less expected in children and adolescents.

In the fifth edition of the DSM, Focker, Knoll & Hebebrand (2012) note that the diagnostic criteria for Anorexia nervosa are in an even underweight situation, gaining weight or becoming fat, and individuals refuse to maintain their body weight. The low current body weight seriously affects women's health because they may suffer from amenorrhea if hormonal factors cause them to miss their periods.

Eating Disorder Not Otherwise Specified (EDNOS)

In another research article, the authors revealed that Eating Disorder Not Otherwise Specified (EDNOS) is more prevalent than anorexia because less reliance is required by their heterogeneity due to the broad diagnostic category used in the diagnostic criteria of DSM-IV. The authors investigated a study that compared women suffering from anorexia nervosa with those suffering from EDNOS. The study was multisite and involved eating-related measures in addition to the general psychology of females. In this study, an equal number of women were established on their DSM-IV and EDNOS-AN. 59 women had DSM-IV Nervosa (Grange et al., 2013).

All the women completed the questionnaires, structure interviews, and physical examination. Each of them was also instructed to carry handheld computers for not less than two weeks before they could provide information concerning the Ecological Momentary Assessment (EMA). The EMA is effective in providing crucial information regarding the mood and the eating disorder behaviors (Grange et al., 2013).

The study by Grange also affirms that there were no significant or major differences between the EDNOS and ordinary Anorexia nervosa. The EMA provided information that focused on self-report, interview measures, and mood assessments. The participants with AN were reported to have huge differences which were based on the purging on the ecological momentary assessment and the binge eating compared to the women who had EDNOS Anorexia nervosa.

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Higher rates of the thighs and the checking joint were reflected among the participants suffering from EDNOS Anorexia nervosa. These were evident in the ecological momentary assessment of the women with AN. Compared to them, the EDNOS-AN patients had higher counts of white blood cells when established under the physiological parameters.

Grange et al. (2013) note that EDNOS-AN is not as important as reflected by the conclusion of the research findings. The existing definition of AN obtains a closer look at the findings and helps to provide a definition to the proposed DSM-V. Another study by Holsen et al. (2012) scanned a group of women suffering from active Anorexia nervosa. With the use of a 3-T magnetic resonance, the researchers viewed the high-calorie images and the low-calorie ones based on foods and objects.

The images were viewed before and after the 400kcal meal. In the study, 10 women who had restored weight were tested against 12 women who had active Anorexia nervosa. The control group for the study consisted of 11 women. According to this article, Anorexia nervosa does not conserve energy since individuals must eat exclusively to gain net energy.

General Eating Disorder

People with Anorexia nervosa and the General Eating Disorder are diagnosed with the diagnostic criteria of DSM-IV. Anorexia is still a rare disorder that has a 2.2% lifetime prevalence rate among females (Freidl & Hoek, 2012). It is acknowledged that there was a gradual increase in the incidence of Anorexia nervosa in the 1970s. Nevertheless, the incidence stabilized during the 1970s. Across communities, the demand for care among young adults is estimated to 0.4% as reflected by the prevalence of the one-year period which is rate-based.

Only one-third of the young females suffering from Anorexia nervosa receive mental health care facilities. The DSM-IV is responsible for providing an outline of the diagnostic criteria for Anorexia nervosa that focuses on low weight and pursuit thinness as the core symptoms. The criteria for DSM-IV capture consistent and reliable samples of people who suffer from Anorexia nervosa. According to the DSM-IV diagnostic criteria, individuals should strive to meet the set criteria if their minimal weight does not correspond to age and height (Focker, Knoll & Hebebrand, 2012). The diagnostic criteria do not pertain to all people who experience shape disturbance and body weight. As a result, Anorexia nervosa concerns individuals with a low weight (Freidl & Hoek, 2012).

Treasure & Landau (2015) depict that it is difficult to treat AN because it puts young adults at the risk of disability, death, or poor change motivation. The authors communicate the line treatment of Anorexia nervosa, psychological therapies, and unfavorable outcomes of the Anorexia nervosa. There is limited evidence concerning the number of high school dropouts who are examples of the above-mentioned risks. According to the authors, the randomized control trial that is displayed as a result of the psychological therapies is discovered in patients with AN. The young adults who suffered from Anorexia nervosa had comparable results to the optimized treatment, psychodynamic therapy, and enhanced cognitive-behavioral therapy. The confirmation of any leading treatment of Anorexia nervosa is absent (Treasure & Landau, 2015).

For this reason, it is essential to use new interventions while handling patients with Anorexia nervosa. The interventions should maintain the specific characteristics and factors that relate to the AN disorder. The type of comparison to use is among the important things to consider when handling the psychotherapy situation. The article also indicates that the use of TAU is not straightforward unless there is standardization.

The article dwells upon the use of SSCM is a manual version of Treatment As Usual (TAU) which focuses on improving the nutritional health of a patient as a way of recovering from the Anorexia nervosa. SSCM also recommends the delivery which is patient-centered, authoritative, and that which supports experienced experts in addition to managing the disorder and the associated risks.

The initial treatment for Anorexia nervosa is found in various observational studies. According to Yager & Andersen (2005), individuals with AN should build their focus on the prompt restoration of weight. Due to this incidence, patients suffering from AN should engage in the process of treatment. Motivational factors are used in the treatment process and should not be a concern for the failure to participate in the process. The authors note that family members are a part of the treatment as they are involved in the treatment strategies for young children and adolescents.

The initial treatment of Anorexia nervosa involves a psychiatrist or a psychologist who is conversant with the disorder. A perfect example is the primary care physician or registered dietician. It is also essential to teach the patient as well as his or her family members on the outlook of Anorexia nervosa, its effective treatment, serious health risks, and the significance of follow-ups (LeGrand & Alcock, 2014).

In conclusion, the above-mentioned studies have pointed out that there is a great similarity between Anorexia nervosa and the General Eating Disorder. However, a number of them have also depicted that there is no close relation between the two disorders. As a result, there is a prerequisite for a wide organization of Anorexia nervosa to reflect on the complexities of the interwoven behavior as well as other accessible aspects such as the cross-cultural differences that are pertinent to the study of AN.

Second, anorexia should be classified to make it uncomplicated to relate the replicate diagnostic criteria for clinicians and researchers. Third, it should be broadly classified to ensure high sensitivity and specificity. Lastly, Anorexia nervosa is difficult to study and treat; hence, it requires psychological therapies to reduce the risks associated with the disorder. The analyzed authors also recommend the use of SSCM to provide the delivery which is patient-centered, authoritative, and that which supports experienced experts in addition to managing the disorder and the associated risks.

The diagnostic criteria for AN reveal that there is a lack of references or standard procedures for weight criterion in the study of anorexia. They show the weight criterion used in the fourth edition of the DSM has been altered considerably in the fifth edition of the DSM. Within the context of age, sex, developmental trajectory, and physical health the above-mentioned authors have realized the criterion of significantly reducing the weight criterion.

The fifth edition has been defined by the minimal normal weight which is less than the expected height and age of the children and the adolescents. In the treatment of Anorexia nervosa, it is crucial to educate the patient as well as their family members regarding the nature of the disease, its serious health risks, effective treatment, and the importance of follow-ups. In the future, there should be new interventions for handling adults suffering from Anorexia nervosa. Additionally, the interventions should be based on theories to improve the outcomes. They should also target the maintaining factors and specific characteristics of the Anorexia nervosa.

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Annotated Bibliography

Alcock, J. & LeGrand, E. (2014). Evolution, Medicine, and Public Health: Anorexia. EMPH Clinical Briefs Journal

According to Alcock and LeGrand, it is common for an individual to lose appetite during illness, a condition that is scientifically known as anorexia. The sudden loss of appetite causes a reduction in nutrient intake due to the inability to eat food. The article reveals that anorexia is one of the symptoms that are collectively known as sickness behaviors that are known to be part of the APR, an acronym for Acute-Phase Response. The components of the APR include; anorexia, iron sequestration, and fever, which their induction is by the pro-inflammatory cytokines such as tumor necrosis, interleukin-1, and interleukin-6.

It continues to be a controversial matter whether to classify anorexia as a mere secondary side effect of inflammation, or it is adaptive in an infection. It is controversial because meeting the nutritional requirements of a strong immune response requires an individual to increase his or her food intake. However, Alcock and LeGrand argue that some uncertainty exists regarding whether to give a critically ill patient more nutritional support or less nutritional support. They reveal that two trials that were controlled and randomized proved that lower-calorie delivery leads to fewer complications in patients suffering from anorexia. (Behavioural)

Regarding the evolutionary perspectives of anorexia, the authors reveal that a study conducted by Hart suggested that anorexia may act jointly with the iron sequestration in the Acute-Phase Response to deprive the pathogens of micronutrients for limiting growth. Alcock and LeGrand also reveal that another researcher called Straub argued that during inflammation, anorexia benefits people by redistributing energy to the body has activated immune system.

It does this away from the muscles, brain, and abdominal organs. The article concludes that both Straub and Hart agreed that energy conservation is a key consequence of anorexia, as well as general sickness behavior. The article points out; it may seem contradictory to suggest that anorexia conserves energy because eating increases the net energy. Concerning the future implications of anorexia nervosa. The authors reveal that the idea of underfeeding patients who are critically ill is a controversial matter that should wait for definitive trials to reveal the outcomes.

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Focker, M., Knoll, S. & Hebebrand, J. (2012). Anorexia Nervosa

In the article, Focker, Knoll, and Hebebrand disclose, the anorexia's symptomatology comprises of cognitions with physical and mental symptoms that occur due to starvation and interwoven features of primary behavior. They differ depending on the stage of the disorder as well as the age of the patient. There is a requirement for a broad classification for anorexia nervosa to consider such complexity as well as other existing aspects such as the cross-cultural differences that are relevant to the study of anorexia.

Second, anorexia should be broadly classified to make it easy to apply to replicate diagnostic criteria for researchers and clinicians. Third, it should be broadly classified to ensure high specificity and sensitivity. The authors reveal there is a lack of references or standard procedures for weight criterion in the study of anorexia. They show, the weight criterion used in the fourth edition of the DSM, has been altered considerably in the fifth edition of the DSM.

They have noticed that the weight criterion has been reduced significantly in the context of sex, age, physical health, and developmental trajectory. Subsequently, the fifth edition of the DSM has defined low weight as a weight that is less than the minimally normal. Or the weight that is less than the minimum expected level for the adolescents and children.

In the fifth edition of the DSM, the diagnostic criteria for anorexia nervosa are as follows: Intense fear of becoming fat or gaining weight, even in an underweight situation, and the refusal of an individual to maintain his or her body weight above. Also, or at the normal weight that is minimal for height and age and disturbance in the manner an individual's body shape or weight is experienced. Also, denial of the seriousness of the body's current low body weight, and a woman is considered to be suffering from amenorrhea if she misses her periods due to hormonal factors.

Freidl, E. & Hoek, H. (2012). Anorexia Nervosa in DSM-5. CME Journal

In this article, the authors acknowledge that anorexia is still an infrequent disorder that is having a 2.2% lifetime prevalence rate among females when the DSM-IV criteria are in use. The authors acknowledge that there was a gradual increase in the Anorexia Nervosa's incidence till in the 1970s. However, the incidence has stabilized since the 1970s. The demand for care in the community for young females is reported to be approximately 0.4% as indicated by the prevalence rate based on a one-year period. Out of all the community cases of anorexia nervosa, it is estimated that only a third of the young females receive medical care in the community mental health care facilities.

The DSM-IV clearly outlines diagnostic criteria for anorexia nervosa that focus on pursuit thinness and low weight as the core symptoms. The DSM-IV's criteria capture reliable and consistent samples of people suffering from anorexia nervosa. According to the DSM-IV diagnostic criteria, an individual is deemed to meet the set criteria if he fails to maintain his body weight at, or above the weight that is minimally normal for the height and the age of an individual.

A person may also qualify for the diagnostic criteria if one experiences body weight or body shape disturbance. Post-menarcheal females may also be considered for these diagnostic criteria if they have amenorrhea. The DSM-IV may not be there in children, males, adolescents, and people who do not identify the fear of being fat as the main reason that has driven them to engage in eating disorder.

In such situations, the diagnosis of anorexia nervosa using the DSM-IV is normally missed, and the EDNOS diagnostic criterion is in use instead. Low weight is a very significant feature of anorexia nervosa. However, there are issues regarding the definition of less-than-normal weight and normal weight due to the Criterion A wording in the DSM-IV diagnostic criteria that fails to a weight that is minimally normal. The article suggests that the weights that are significantly lower should be determined using sex, age, physical health, and the developmental trajectory.

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Grange, D. et al. (2013). DSM-IV-Defined Anorexia Nervosa Versus Sub-threshold Anorexia Nervosa

In this research article, the authors reveal that EDNOS is more prevalent than anorexia nervosa. However, its heterogeneity needs less reliance on the broad diagnostic category used in the DSM-IV. The authors looked at a study that compared women suffering from anorexia nervosa with women suffering from EDNOS. It was a multisite study whose base was on general psychology and eating-related measures in women. The study used an equal number of women with DSIM-IV AN and EDNOS-AN to participate the study, 59 women with DSM-IV anorexia nervosa and 59 women with EDNOS anorexia nervosa.

They all completed the structured interviews, physical examination at the baseline, and the questionnaires. The participants were also instructed to carry handheld palm computers for two weeks to provide information on the EMA, which stands for the Ecological Momentary Assessment. The EMA would provide crucial information about eating disorder behaviors and mood.

The results of the study revealed that there were no significant or major differences between the normal anorexia nervosa and the EDNOS anorexia nervosa, using information obtained from the interview measures, self-report, and the EMA that focused on the mood assessments. The only differences noticed were that the participants with anorexia nervosa reported they had higher rates of eating binge and purging on the ecological momentary assessment than those women with EDNOS anorexia nervosa.

However, the participants who had EDNOS anorexia nervosa revealed higher rates regarding checking joints and thighs on the ecological momentary assessment than those women who had AN. Concerning physiological parameters, the EDNOS-AN presented with higher counts of white blood cells compared with women who had AN. The conclusion was that the research findings of the study highlighted the clinical importance of the EDNOS-AN. Moreover, the findings support a closer look at the existing definition of the AN as proposed in the DSM-V.

The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC)

Treasure, J. & Landau, S. (2015). The Maudsley Outpatient Study of Treatments for Anorexia Nervosa and Related Conditions (MOSAIC): Comparison of the Maudsley Model of the Anorexia Nervosa Treatment for Adults (MANTRA) With Specialist Supportive Clinical Management (SSCM) in Outpatients With Broadly Defined Anorexia Nervosa: A Randomized Controlled Trial. Journal of Consulting and Clinical Psychology.

This article is of great public health significance because it shows how both SSCM and MANTRA show promise as the first-line outpatient treatment used to treat adults suffering from Anorexia Nervosa. The article shows that the anorexia nervosa in adults is a difficult psychiatric disorder to study and treat. This is because Anorexia Nervosa puts adults at high risk of disability, poor change motivation, or even death. The authors make known; psychological therapies may be used as a first-line treatment of anorexia nervosa though the outcomes may be poor.

It is also characterized by high school dropouts, and even there is a limited evidence base. Treasure and Landau show that the randomized control trial of the psychological therapies used in adults suffering from anorexia nervosa discovered that there were comparable outcomes or results with the focal psychodynamic therapy, optimized treatment, and the Enhanced cognitive-behavioral therapy. They are all similar in that they confirm the absence of any leading treatment for anorexia nervosa.

The article direct, there is a need for new interventions for handling adults suffering from anorexia nervosa. Additionally, the interventions should be based on theories to improve the outcomes. They should also target the maintaining factors and specific characteristics of the AN disorder. The most significant thing to consider when handling the psychotherapy situation should be the type of comparison to use. For instance, the use of waiting lists when handling AN, which is potentially lethal, may be practically and ethically problematic. The article also indicates, the use of TAU is not straightforward unless there is standardization.

Therefore, the authors recommend the use of SSCM, which is a manualized version of the TAU (Treatment As Usual), and it focuses on improving the nutritional health of a patient as a way of recovering from anorexia nervosa. Its delivery is authoritative, patient-centered, and supportive manner by experienced experts, who are familiar with the management of Anorexia Nervosa and its associated risks.

Holsen, L. et al. (2012). Food Motivation Circuitry Hypoactivation Related to Hedonic and Nonhedonic Aspects of Hunger and Safety in Women with Active Anorexia Nervosa and Weigh-restored Women with Anorexia Nervosa

In this document, the authors noted that the previously done studies provide some crucial evidence on the food motivation-circuitry dysfunction among individuals suffering from anorexia nervosa. The article shows the main goal of the study was to conduct an investigation on the appetite dysregulation's neural circuitry across the satiety and hunger states in weight-restored and active phases of the anorexia nervosa. It is by use of the robust methodology that advances understanding of the potential abnormalities of the neural circuitry, which has relation to the hedonic and the non-hedonic trait and state.

The study scanned a group of women suffering from active anorexia nervosa. It also scanned the weight-restored women suffering from anorexia nervosa. The researchers viewed the low-calorie images as well as the high calories images of objects and foods using a scanner with 3-T magnetic resonance. The viewing of the images was done before and after having a meal of 400kcal. The study involved 12 women with active cases of anorexia nervosa, 10 women with restored weight suffering from anorexia nervosa, and 11 women as the study controls.

Both women with active anorexia nervosa and those women with restored weight showed hyperactivity before a meal in the hypothalamus, anterior insula, and amygdala in the response to the high-calorie foods. The study results disclosed was women with active anorexia nervosa presented with persisted activation in their anterior insula. There was a percentage signal change in anterior insula that was correlated positively with hedonic and non-hedonic appetite ratings as well as food stimuli ratings in the study controls but did not present in women suffering from the active anorexia nervosa.

Therefore, the study supports the importance of examining both trait and state characteristics during the investigation of the phonotypes of the brain of an individual anorexia nervosa. It helps in studying the disruption in stress and neurobiological circuits.

Alcock, J. & LeGrand, E. (2014). Evolution, Medicine, and Public Health: Anorexia

In this article, the authors suggest that it is likely for an individual to lose appetite in the course of illness due to a reduction in the intake of nutrients. There is a group of symptoms that are referred to as the sickness behaviors, of which anorexia nervosa is one of them. Sickness behavior groups form a part of the APR, an acronym that stands for the Acute-Phase Response. The components of the APR are induced by the pro-inflammatory cytokines such as interleukin-1, interleukin-6, and the alpha factor of the tumor necrosis. There is controversy regarding whether anorexia nervosa is an adaptive condition or just a mere side inflammation's secondary side effect.

This is because; a strong immune response needs an increased food intake for the body to meet its nutritional needs. The article reveals that it is still unclear whether to give anorexic patients who are in critical condition less or more nutritional support. However, the authors point out that recently, there are two randomized controlled trials that have shown fewer complications and improved survival when there is a lower delivery of calories. To strengthen this argument, there are some animal studies, which have shown the same results. For instance, mice infected with Listeria underwent higher mortality after being forced to feed to the levels of the pre-infection nutrition.

The article notes that the idea that anorexia nervosa helps the body to conserve energy is a controversial statement because the net energy is increased by typically eating. In the model of the immune brinksmanship, anorexia nervosa is viewed as a gamble, in which an individual host may withstand energy and nutrition deprivation better than the invasion of the organisms. Factors such as fitness differences between the cells of a healthy host and the pathogens, which are amplified by anorexia nervosa, and other Acute-phase response may be used to illustrate the evolution of anorexia nervosa.

Yager, J. & Andersen, A. (2005). Anorexia Nervosa. The New England Journal of Medicine

According to the authors of the article, anorexia nervosa refers to an eating disorder that begins at the adolescent stage and characterized by determining eating, which is accompanied by compulsive exercise. In a sub-group of patients, the purging behavior with binge eating or without binge eating may result in sustained low weight. Other features of anorexia nervosa include increased desire to shed off more weight, disturbed body image, and the pervasive fear of being fat. The lifetime risk of anorexia nervosa in women approximation is between 0.1 and 1 percent.

However, the rate is lower among men, as it stands at approximately a tenth of the women's rate. The article focuses on anorexia nervosa and reveals that there have been some developments in the treatment of the condition, whereby, a few controlled trials have been used to guide the treatment of anorexia. There are various observational studies that suggest the initial treatment of anorexia nervosa should primarily focus on the prompt restoration of weight. For this purpose, the majority of the patients suffering from anorexia nervosa gets involved in the treatment reluctantly.

Therefore, motivational techniques are used to appeal to such patients to engage them in the treatment process. Despite the use of such motivational factors, there are no studies to confirm their value in the treatment process of anorexia nervosa. The authors note that it is important to involve family members of the adolescent or young children suffering from anorexia.

The initial treatment of anorexia nervosa involves a psychologist or psychiatrist who is conversant with the anorexia nervosa, for example, a registered dietician, and primary care physician. It is also crucial to educate the patient as well as his or her family members regarding the nature of anorexia nervosa, its serious health risks, its effective treatment, and the importance of follow-ups.

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