20 Chapter 1 INTRODUCTION Anorexia Nervosa (AN) is a severe psychiatric disorder characterized by an intense fear of gaining weight com- bined with a failure to maintain a minimally normal body weight (85% of the expected standard for age and height/ ideal body weight). Patients with AN have a disturbed body image, are obsessed with weight and body shape, and are in a state of a denial with regard to their low body weight and its adverse impact on health (1). In a subgroup of patients AN is associated with characteristic compulsive behaviors such as dieting, exercise, and/or purging with or without binge eating. Amenorrhea is often present in female patients but no longer required for the diagnosis (2) . With a narrow age of onset, a stereotypic presentation of symptoms and course, and a relative gender specificity AN is possibly the most homogenous of all psychiatric disorders. The average point prevalence rate of AN is 0.3% in young females (3, 4) and the lifetime prevalence is 2.2% among females (5). The condition largely affects young adolescent females, with a female–male ratio between 10:1 and 4:1 (3, 6). Medical complications AN is often associated with medical complications resulting from starvation, purging and/or over exercising. Common signs and symptoms include cardiovascular complications such as bradycardia, prolonged QTc and orthostatic hypotension, loss of subcutaneous fat tissue, impaired menstrual function, hair loss, and hypothermia (7). With improved nutritional status or with remittance of abnormal eating and purging behaviours, most pathophysiological complications are reversible. Nevertheless, some physical consequences of AN can be life-threatening, such as electrolyte imbalances, severe bradycardia, and hypotension. Moreover, nutritional deficiencies may increase the risk of cardiac arrhythmias and intercurrent infection. Some medical consequences of eating disorders may be irreversible or have later serious consequences on health, especially osteoporosis, growth retardation, malfunctioning of the reproductive system and neurobiological changes of the brain caused by malnutrition (8, 9). Mortality, course and comorbidity AN is associated with the highest rate of mortality among all mental disorders, with a crude mortality rate of 5,9% and a mortality rate of 5,6% per decade (10, 11). Other studies found mortality rates in the same range (12-17). Steinhausen found a mean crude mortality rate of 5,0% (13). Causes of death ranged from eating disorder complications to suicide. The majority of individuals with eating disorders reported suicidal thoughts and about 22% attempt to commit suicide (18, 19). In an extensive literature review Steinhausen showed that less than half (46,9%) of the surviving patients recover on average from AN, one-third (33,5%) improve partially, and in 20,8% (0-79%) the disease takes on a chronic course (13). It had to be noted that the criteria used to define recovery
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