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Reviews and Overviews   |    
The Enigmatic Persistence of Anorexia Nervosa
B. Timothy Walsh, M.D.
Am J Psychiatry 2013;170:477-484. doi:10.1176/appi.ajp.2012.12081074
View Author and Article Information

Dr. Walsh receives research support from AstraZeneca.

Supported in part by NIMH grant MH79397.

From the Department of Psychiatry, Columbia University, and the New York State Psychiatric Institute, New York.

Presented in part at the 2012 International Conference on Eating Disorders, Austin, Tex., May 3–5, 2012, and at the 164th annual meeting of the American Psychiatric Association, Philadelphia, May 5–9, 2012.

Address correspondence to Dr. Walsh (btw1@columbia.edu).

Copyright © 2013 by the American Psychiatric Association

Received August 16, 2012; Revised October 08, 2012; Accepted October 12, 2012.

Abstract

Objective  In this review, based on recent advances in cognitive neuroscience, the author presents a formulation in which the marked persistence of anorexia nervosa can be usefully understood as a well-ingrained maladaptive habit.

Method  The author reviewed the relevant literature on the development and course of anorexia nervosa and interpreted critical features in light of developments in cognitive neuroscience.

Results  Anorexia nervosa is a well characterized disorder with remarkable persistence both across history and among affected individuals. Food restriction, the salient behavioral feature of the disorder, often begins innocently but gradually takes on a life of its own. Over time, it becomes highly entrenched and resistant to change through either psychological or pharmacological treatment. Cognitive neuroscience has described two related but distinct processes that underlie the acquisition of new patterns of behavior, namely, action-outcome and stimulus-response learning. It is likely that both processes are engaged in the development of anorexia nervosa and that stimulus-response learning (that is, habit formation) is critical to the persistence of the dieting behavior.

Conclusions  The formulation of the dieting behavior characteristic of anorexia nervosa as a well-entrenched habit provides a basis for understanding the striking persistence of this disorder. This model helps explain the resistance of anorexia nervosa to interventions that have established efficacy in related disorders and implies that addressing the dieting behavior is critical, especially early in the course of the illness, before it has become ingrained.

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Which of the following is known to increase the risk of developing anorexia nervosa?
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Which of the following characteristics of anorexia nervosa is consistent with dietary behavior being a well-entrenched habit?
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