question: What (if any) is the difference between people who regularly fast and people with anorexia?
comment: The first is a dietary discipline that keeps the body in a higher metabolic state and reduces disease, while the second is a mental health issue that starves the body of the nutrition it needs while focusing on attaining an unhealthy body image.
passages: For Caroline Walker Bynum ("Holy Feast and Holy Fast"), "anorexia mirabilis", rather than misdiagnosed anorexia, was a legitimate form of self-expression with motives set in contrast to the modern disease paradigm. She considers cases such as that of Julian of Norwich and other Christian anchorites, as using fasting as a legitimate means for communing with Christ.
   AN has a high mortality and patients admitted in a severely ill state to medical units are at particularly high risk. Diagnosis can be challenging, risk assessment may not be performed accurately, consent and the need for compulsion may not be assessed appropriately, refeeding syndrome may be missed or poorly treated and the behavioural and family problems in AN may be missed or poorly managed. The MARSIPAN guidelines recommend that medical and psychiatric experts work together in managing severely ill people with AN.
  
  Section::::Treatment.:Nutrition.
   BULLET::::- Jane (born c. 1948) was a woman from Chicago who began to restrict her eating at the age of 13 in hopes of being a nun and later, a saint. Her weight worried those at the convent and she was dismissed from her religious training due to concerns over her health. Her malnutrition caused amenorrhea and likely affected her development as she grew to be only 4' 10" tall but did not suffer from any form of dwarfism. At the age of 66, she weighed only 60 pounds.
  
  Section::::Comparing "anorexia mirabilis" and "anorexia nervosa".
   Hepatic steatosis, or fatty infiltration of the liver, can also occur, and is an indicator of malnutrition in children. Neurological disorders that may occur as complications include seizures and tremors. Wernicke encephalopathy, which results from vitamin B1 deficiency, has been reported in patients who are extremely malnourished; symptoms include confusion, problems with the muscles responsible for eye movements and abnormalities in walking gait.
   Anorexia mirabilis is primarily characterized by the refusal to eat, resulting in starvation, malnutrition, and oftentimes, death, but differs from anorexia nervosa in that the disease is associated with religion as opposed to personal aesthetics. Though anorexia mirabilis is, by definition, connected to religion, particularly Catholicism, sufferers have been known to defy the orders of their religious superior to cease fasting and their refusal to eat sometimes preceded their involvement in religious activities. Additionally, sufferers engaged in worrisome and bizarre behaviors designed to cause them pain, so that they might be reminded of Jesus Christ's suffering, and desired to appear unattractive in hopes of avoiding marriage and sexual contact.
   Anorexia is a relatively common condition that can lead patients to have dangerous electrolyte imbalances, leading to acquired long QT syndrome which can result in sudden cardiac death. This can develop over a prolonged period of time, and the risk is further heightened when feeding resumes after a period of abstaining from consumption. Care must be taken under such circumstances to avoid potentially fatal complications of refeeding syndrome.
   BULLET::::- Food avoidance emotional disorder is an eating disorder that affects children which involves a fear of eating which is not accompanied by a fear of weight gain which may be misdiagnosed as anorexia nervosa.
   The anorexia nervosa of the 20th century has historical correlates in the religiously inspired cases of "anorexia mirabilis" in female saints, such as Catherine of Siena (1347–1380) in whom fasting denoted female holiness or humility and underscored purity. The investigation of anorexia nervosa in the 20th century has focused on the psychological, physiological, and various other factors.
   Section::::Causes.
  
  Section::::Causes.:Clinically important causes.
  
  BULLET::::- Acute radiation syndrome
  
  BULLET::::- Acute viral hepatitis
  
  BULLET::::- Addison's disease
  
  BULLET::::- Atypical pneumonia (mycoplasma)
  
  BULLET::::- AIDS
  
  BULLET::::- Anorexia nervosa
  
  BULLET::::- Anxiety
  
  BULLET::::- Appendicitis
  
  BULLET::::- Cancer
  
  BULLET::::- Chronic pain
  
  BULLET::::- Chronic kidney disease
  
  BULLET::::- Celiac disease
  
  BULLET::::- Common cold
  
  BULLET::::- Congestive heart failure, perhaps due to congestion of the liver with venous blood.
  
  BULLET::::- Crohn's disease
  
  BULLET::::- Dehydration
  
  BULLET::::- Dementia
  
  BULLET::::- Depression
  
  BULLET::::- Drug addiction
  
  BULLET::::- Ebola
  
  BULLET::::- Fever
  
  BULLET::::- Foodborne illness
  
  BULLET::::- Hypervitaminosis D
  
  BULLET::::- Ketoacidosis
  
  BULLET::::- Kidney failure
  
  BULLET::::- Mental disorders, such as depression, bipolar disorder, schizophrenia, etc.
   BULLET::::- Binge-eating/purging type: the individual utilizes binge eating or displays purging behavior as a means for losing weight. It is different from bulimia nervosa in terms of the individual's weight. An individual with binge-eating/purging type anorexia can maintain a healthy or normal weight, but is usually significantly underweight. People with bulimia nervosa on the other hand can sometimes be overweight.
   BULLET::::- Self-help and guided self-help have been shown to be helpful in AN, BN and BED; this includes support groups and self-help groups such as Eating Disorders Anonymous and Overeaters Anonymous.
  
  BULLET::::- Psychoanalysis
  
  BULLET::::- Inpatient care
  
  There are few studies on the cost-effectiveness of the various treatments. Treatment can be expensive; due to limitations in health care coverage, people hospitalized with anorexia nervosa may be discharged while still underweight, resulting in relapse and rehospitalization.
   Furthermore, those who suffer from drunkorexia, have a greater likelihood of developing a more serious eating disorder.
  
  A previous report published in the American journal Biological Psychiatry found that up to one third of bulimics struggle with alcohol or drug abuse.
  
  A report in the U.S examining the relationship between eating disorders and substance abuse revealed that anorexia and bulimia are the eating disorders most commonly linked to substance abuse, and up to half of the people with eating disorders abuse alcohol or illicit drugs.
  
  Shared risk factors:
  
  BULLET::::- Occur in times of transition or stress.
   Although restoring the person's weight is the primary task at hand, optimal treatment also includes and monitors behavioral change in the individual as well. There is some evidence that hospitalisation might adversely affect long term outcome.
   Section::::Diagnosis.
  
  A diagnostic assessment includes the person's current circumstances, biographical history, current symptoms, and family history. The assessment also includes a mental state examination, which is an assessment of the person's current mood and thought content, focusing on views on weight and patterns of eating.
  
  Section::::Diagnosis.:DSM-5.
  
  Anorexia nervosa is classified under the Feeding and Eating Disorders in the latest revision of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM 5).
   "Anorexia mirabilis" has in many ways, both similarities to and clear distinctions from the more modern, well-known "anorexia nervosa".
  
  In anorexia nervosa, people usually starve themselves to attain a level of thinness, as the disease is associated with body image distortion. In contrast, "anorexia mirabilis" was frequently coupled with other ascetic practices, such as lifelong virginity, flagellant behavior, the donning of hairshirts, sleeping on beds of thorns, and other assorted penitential practices. It was largely a practice of Catholic women, who were often known as "miraculous maids".
   BULLET::::- Emetophobia is an anxiety disorder characterized by an intense fear of vomiting. A person so afflicted may develop rigorous standards of food hygiene, such as not touching food with their hands. They may become socially withdrawn to avoid situations which in their perception may make them vomit. Many who suffer from emetophobia are diagnosed with anorexia or self-starvation. In severe cases of emetophobia they may drastically reduce their food intake.
   EDNOS is the most prevalent eating disorder; about 60% of adults treated for eating disorders are diagnosed with EDNOS. EDNOS occurs in both sexes.
  
  Section::::Signs and symptoms.
  
  Rather than providing specific diagnostic criteria for EDNOS, the fourth revision of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV) listed six non-exhaustive example presentations, including individuals who:
  
  BULLET::::1. Meet all criteria for anorexia nervosa except they have regular menses.
  
  BULLET::::2. Meet all criteria for anorexia nervosa except their weight falls within the normal range.
   Though the disease was most prominent during the Middle Ages, modern cases do exist. Notably, in 2014, medical researchers published an article about the case of an unidentified woman in her sixties, born in Chicago, Illinois, who'd suffered from anorexia mirabilis. The woman entered a convent at the age of 13 and began to restrict her eating in hopes of achieving sainthood.
  
  Section::::Overview.:Notable cases.
   The activity-based anorexia model has been one of the most suitable animal models when studying anorexia nervosa (AN). The important behavioral aspects of AN, the drive for activity, the restricted food intake during hunger, and other physiological consequences of malnutrition, are all reproduced in this model. The “activity/stress” model produces starvation-induced immunodeficiency and various complications not observed in individuals with AN. "Separation" models involve physical separation as a stressor to induce a depression-like condition; this includes decreased feeding, weight loss, and various cognitive changes . Studies with animal models simulating loss of hunger are not well suited to replicate AN because they are essentially based on the assumption of loss of appetite.
   Diet is the most essential factor to work on in people with anorexia nervosa, and must be tailored to each person's needs. Food variety is important when establishing meal plans as well as foods that are higher in energy density. People must consume adequate calories, starting slowly, and increasing at a measured pace. Evidence of a role for zinc supplementation during refeeding is unclear.
  
  Section::::Treatment.:Therapy.
   The lifetime rate of atypical anorexia nervosa, a form of ED-NOS in which not all of the diagnostic criteria for AN are met, is much higher, at 5–12%.
   In 2009, Ursula Philpot, chair of the British Dietetic Association and senior lecturer at Leeds Metropolitan University, described people with orthorexia nervosa as being "solely concerned with the quality of the food they put in their bodies, refining and restricting their diets according to their personal understanding of which foods are truly 'pure'." This differs from other eating disorders, such as anorexia nervosa and bulimia nervosa, where those affected focus on the quantity of food eaten.
   Section::::Signs and symptoms.
  
  Anorexia nervosa is an eating disorder characterized by attempts to lose weight, to the point of starvation. A person with anorexia nervosa may exhibit a number of signs and symptoms, the type and severity of which may vary and may be present but not readily apparent.
   Section::::Early descriptions.:1790: Robert Willan’s case description.
  
  Robert Willan was an English physician based in London who is credited with founding dermatology as a medical speciality. He is one of the first to describe the symptoms of extreme weight loss in males, in his paper “A Remarkable Case of Abstinence,” published in Medical Communications in 1790. This describes the case of a young Englishman who died in 1786 after fasting for 78 days. He wrote:
  
  Section::::19th Century descriptions.
  
  Section::::19th Century descriptions.:1859: Louis-Victor Marcé’s case descriptions.
   BULLET::::- achalasia – There have been cases where achalasia, a disorder of the esophagus which affects peristalsis, has been misdiagnosed as AN. It has been reported in cases where there is sub-clinical manifestation of anorexia nervosa and also in cases where the full diagnostic criteria AN have been met.
  