The current requirements for a diagnosis of anorexia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV; American Psychiatric Association [APA], 1994) are summarized as follows: (1) refusal to maintain a body weight over a minimally normal weight for age and height; (2) intense fear of gaining weight or becoming fat, even though underweight; (3) disturbance in the way body weight, size, or shape is experienced; and (4) amenorrhea in females (absence of at least three consecutive menstrual cycles). The DSM-IV suggests that weight loss leading to maintenance of a body weight 15% below norms and failure to achieve expected weight gain during a period of growth are also indicative of anorexia nervosa. The failure to achieve expected weight gain during a period of growth is particularly important in addressing anorexia nervosa in adolescents whose growth and development may have been interrupted by the onset of their disorder. Severe dieting because of a fear of fatness has been shown to lead to short-stature syndrome and delayed puberty in a subgroup of young children (Puglifse, Lifshitz, Grad, Fort, & Marks-Katz, 1983). Weight loss or active weight suppression may lead to a cessation of normal growth and menstruation as well as osteoporosis, scoliosis and vulnerability to fractures, and stunting of growth (Grinspoon, Herzog, & Klibanski, 1997; Warren, Brooks-Gunn, Hamilton, Warren, & Hamilton, 1986).

The DSM-IV (APA, 1994) divides anorexia nervosa into two diagnostic subtypes: restricting type and binge eating/purging type. The restricting type is defined by rigid restriction of food intake without bingeing or purging. The binge eating/ purging type is defined by stringent attempts to limit intake, punctuated by episodes of binge eating as well as self-induced vomiting and/or laxative abuse. This diverges from previous conventions in which anorexia nervosa was subdivided simply on the basis of the presence or absence of binge eating. The rationale for dividing anorexia nervosa patients on the basis of bingeing and purging rather than binge eating alone rests on two observations. First, there are significant medical risks associated with compensatory behaviors such as self-induced vomiting and laxative abuse. Second, recent research has indicated that patients who purge, even if they do not engage in objective episodes of binge eating, display significantly more psychosocial disturbance than nonpurging patients (Garner, Garner, & Rosen, 1993). Patients who regularly engage in bulimic episodes report greater impulsivity, social/sexual dysfunction, substance abuse, general impulse control problems (e.g., lying and stealing), family dysfunction, and depression as part of a general picture of more conspicuous emotional disturbance when compared to patients with the restricting subtype of anorexia nervosa (Garner et al., 1993). In contrast, restricting anorexia nervosa patients have been described as being overly compliant but at the same time obstinate, perfectionistic, obsessive-compulsive, shy, introverted, interpersonally sensitive, and stoical. . .

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