Anorexia nervosa differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]


Anorexia nervosa should be differentiated from other diseases that cause chronic nausea and vomiting. Anorexia nervosa must also be differentiated from other diseases such as bulimia nervosa, major depressive disorder, and social anxiety disorder among others.[1]

Differential Diagnosis

Differentiating anorexia nervosa from other diseases

Anorexia nervosa should be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]

Disorder Clinical features Laboratory findings
Chronic nausea Vomiting Diarrhea Retching Lethargy Social withdrawal Photophobia Epigastric pain/burning Lanugo hair Hypogonadism Russel's sign Body mass index (normal range: 18.5 to 24.9) Complete blood count (CBC) Electrolyte imabalance Lipase and amylase levels Gastric scintigraphy Ambulatory esophageal pH and impedance testing
Gastroparesis ✔ (within 1 hour of eating) - - - - - -
  • Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)
  • Periodic measurement of radiolabeled solid meal:  
    • Grade 1 (mild), 11%-20% retention at 4 h
    • Grade 2 (moderate), 21%-35% retention at 4 h
    • Grade 3 (severe), 36%-50% retention at 4 h
    • Grade 4 (very severe), > 50% retention at 4 h
  • Impedance testing (antroduodenal manometery): Loss of normal fasting migratory motor complexes (MMCs) and reduced postprandial antral contractions and, in some cases pylorospasm
Anorexia nervosa - - - -
  • Increased
Bulimia nervosa - - - Normal
  • Increased
Rumination syndrome ✔ (Regurgitation more common- within minutes of meal intake) - - - -
  • Normal
  • Normal
  • Esophageal pH: Fall in esophageal pH immediately after reguritation (occurs while patient is awake and erect; this is in contrast to GERD, where reflux occurs diurnally and supine position)
Functional dyspepsia - - - - - - - Normal
  • Normal
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome - - - - - - -
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis - - - - - Normal
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction ✔ (within 1 hour of eating) - - - - - - - -
  • Esophageal pH: Increased
  • Esophageal manometery:   High manoraetric score

Other differentials

Other differentials of anorexia nervosa include the following:

Diagnostic Issues and Controversies

The distinction between the diagnoses of anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified (EDNOS) is often difficult to make in practice and there is considerable overlap between patients diagnosed with these conditions. Furthermore, seemingly minor changes in a patient's overall behavior or attitude (such as reported feeling of 'control' over any bingeing behavior) can change a diagnosis from 'anorexia: binge-eating type' to bulimia nervosa. It is not unusual for a person with an eating disorder to 'move through' various diagnoses as his or her behavior and beliefs change over time.[34]

Additionally, it is important to note that an individual may still suffer from a health- or life-threatening eating disorder (e.g., subclinical anorexia nervosa or EDNOS) even if one diagnostic sign or symptom is still present. For example, a substantial number of patients diagnosed with EDNOS meet all criteria for diagnosis of anorexia nervosa, but lack the three consecutive missed menstrual cycles needed for a diagnosis of anorexia.[35]

Feminist writers such as Susie Orbach and Naomi Wolf have criticised the medicalisation of extreme dieting and weight-loss as locating the problem within the affected women, rather than in a society that imposes concepts of unreasonable and unhealthy thinness as a measure of female beauty.


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