Typically, the history is that of a young girl in her teens or early twenties who has decided to diet, as she is concerned about being overweight. In some instances this is a reality problem, but occasionally the patient may never have been overweight. Dieting continues after satisfactory weight loss has been achieved, and may go on even to the point of emaciation. Many patients state that they feel hungry but cannot eat, and they may feel guilty if they do take
food. All fattening foods are omitted from the diet and many patients work out the exact calorie equivalent of their food intake. Sometimes they show excessive zeal in ensuring that members of their family, especially the mother, have a nourishing diet, often with abundance of calories. Patients with this syndrome rarely admit to being ill and, in addition to reducing calorie intake, they may resort to extremes of exercise in order to expend energy and lose weight. The weight loss is secondary to the reduced intake of calories. Whilst it is recognised that starvation may produce disturbance in the menstrual cycle, including amenorrhoea, it is thought that the 'secondary' amenorrhoea associated with anorexia nervosa in girls is of essentially endocrine origin, as in over one-third of patients it coincides with, or may precede, the weight loss. Constipation may be an associated symptom and many anorexic patients resort to purgatives in an attempt to increase weight loss further when, in fact, the symptom is due to sheer lack of food intake. Patients who are normally the most open of people before the onset of the illness, will often conceal food and many induce vomiting in order to accelerate weight loss. Patients have a disturbance of their body image and although still emaciated, become convinced that they are fat. Prolonged mirror gazing in the nude is a symptom which is thought to be of serious prognostic import. This symptom is unlikely to be volunteered and the question will have to be asked directly in order to elicit it. A proportion of anorexic patients steal and there may be a compulsive element in thefts, which appear to be more common during a phase of overeating; it is often, but not always, food which is stolen.