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Anorexia nervosa physical examination

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

Signs & Symptoms: Overview

Physical examination findings in anorexia nervosa reflect the physiologic consequences of prolonged undernutrition and starvation. Although some individuals may appear deceptively well, careful examination often reveals abnormalities in body weight, vital signs, skin and hair, cardiovascular status, and musculoskeletal health. Physical findings are important for assessing illness severity and identifying medical instability.[1][2][3][4]

General Appearance and Growth

  • Marked underweight or emaciated appearance
  • Low body mass index (BMI)
    • Adults: typically BMI <18.5; severe illness often <15
    • Children and adolescents: <75%–85% of expected weight for age and sex[2][5]
  • Failure to gain expected weight or stunted growth when onset occurs during childhood or adolescence
  • Loss of subcutaneous fat and reduced muscle mass

Vital Signs

  • Bradycardia, often <50 beats/min at rest[1][2]
  • Hypotension, including orthostatic hypotension
  • Hypothermia (core temperature <36 °C)
  • Narrow pulse pressure in severe malnutrition


Vital sign abnormalities are key indicators of medical risk and may warrant urgent intervention or hospitalization.[2][3][4]

Skin, Hair, and Nails

  • Lanugo (fine hair growth on face, trunk, and extremities)[1]
  • Dry, cold skin
  • Hair thinning or hair loss
  • Carotenemia, resulting in yellow-orange discoloration of the skin, particularly on the palms and soles[1]
  • Brittle nails

Head, Mouth, and Dentition

  • Dental enamel erosion, particularly in individuals with binge-eating/purging subtype[6]
  • Salivary gland hypertrophy (parotid enlargement) associated with recurrent vomiting[6]
  • Dry or cracked lips
  • Possible angular cheilitis related to nutritional deficiency

Cardiovascular

  • Bradycardia
  • Prolonged corrected QT (QTc) interval on electrocardiogram review[1]
  • Peripheral edema, particularly in the ankles or periorbital region, which may occur with hypoalbuminemia or during refeeding[1]

Gastrointestinal

  • Abdominal distension
  • Reduced bowel sounds
  • Constipation, commonly reported and supported by examination findings[1]

Musculoskeletal and Endocrine

  • Reduced muscle strength
  • Clinical features suggestive of decreased bone mineral density, including bone pain or fracture history[1]
  • Delayed or arrested pubertal development when onset occurs before puberty[7]
  • Amenorrhea or hypogonadism may be present but is not required for diagnosis[5]

Behavioral and Observational Findings on Examination

Although not strictly physical findings, certain behaviors are commonly observed during clinical encounters and may support the diagnosis or indicate severity:

  • Excessive or compulsive exercise, sometimes observed despite fatigue or injury[5]
  • Food avoidance behaviors during supervised meals
  • Secretive behavior related to eating or exercise
  • Marked distress or irritability when confronted with eating expectations
  • Heightened sensitivity to discussions involving weight, shape, or food
  • Evidence of self-harm, substance misuse, or suicidality in some individuals[8][9]

These observations should prompt careful psychiatric assessment and safety evaluation.

Summary

Physical examination in anorexia nervosa frequently reveals abnormalities across multiple systems, particularly vital signs, skin and hair, cardiovascular status, and growth parameters. Behavioral observations during examination provide additional context but should be interpreted alongside a comprehensive clinical history and mental status assessment.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 SøebyM, Gribsholt SB, Clausen L, Richelsen B. Fracture risk in patients with anorexia nervosa over a 40-year period. J Bone Miner Res. 2023;38(11): 1586-1593. doi:10.1002/jbmr.4901
  2. ↑ 2.0 2.1 2.2 2.3 American Psychiatric Association. Practice Guideline for the Treatment of Patients With Eating Disorders. 4th ed. American Psychiatric Association Publishing; 2023.
  3. ↑ 3.0 3.1 Hornberger LL, Lane MA; Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2021;147(1):e2020040279. doi:10.1542/ peds.2020-040279
  4. ↑ 4.0 4.1 Society for Adolescent Health and Medicine. Medical management of restrictive eating disorders in adolescents and young adults. J Adolesc Health. 2022;71(5):648-654. doi:10.1016/j.jadohealth.2022. 08.006
  5. ↑ 5.0 5.1 5.2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association Publishing; 2022.
  6. ↑ 6.0 6.1 Nitsch A, Dlugosz H, Gibson D, Mehler PS. Medical complications of bulimia nervosa. Cleve Clin J Med. 2021;88(6):333-343. doi:10.3949/ccjm.88a. 20168
  7. ↑ World Health Organization. ICD-11: International Classification of Diseases, 11th Revision. Accessed May 22, 2024. https://icd.who.int/en
  8. ↑ Udo T, Grilo CM. Psychiatric and medical correlates of DSM-5 eating disorders in a nationally representative sample of adults in the United States. Int J Eat Disord. 2019;52(1):42-50. doi:10. 1002/eat.23004
  9. ↑ Mills R, Hyam L, Schmidt U. A narrative review of early intervention for eating disorders: barriers and facilitators. Adolesc Health Med Ther. 2023;14: 217-235. doi:10.2147/AHMT.S415698

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