cases (Jacobson, 2003). For any athlete present-
ing with amenorrhea the differential diagnosis
should always include anorexia nervosa.- Physical signs of anorexia nervosa may include sig-
nificant weight loss, hyperactivity, distorted body
image, rough and/or dry skin, vellous hair on back
and extremities, atrophy of breast tissue, bradycar-
dia, hypothermia, low blood pressure/orthostasis,
thinning of scalp hair, and carotenemia (Jacobson,
2003).- Symptoms of bulimia nervosa can include fatigue,
sore throat/chest pain, difficulty swallowing and
retaining food, constipation/diarrhea, bloating and
abdominal pain, irregular menses, a noticeable
weight loss or gain, excessive concern about
weight, increasing criticism of one’s body/over-
concern with personal appearance, secretive
behavior, trips to bathroom after meals, weakness,
headache, and dizziness (Jacobson, 2003;
Wilmore, 1991). - Physical signs of bulimia nervosa can include
parotid/salivary gland enlargement, puffiness
around the face (below cheeks), frequent weight
fluctuations, abrasions on the back of the knuckles
from inducing vomiting, loss of tooth enamel, and
halitosis (Jacobson, 2003).
- There are three main categories of sports where ath-
letes are at greatest risk for developing eating disor-
ders (Sundgot-Borgen, 1993; Jacobson, 2003):
- Sports emphasizing a lean appearance, such as
swimming, diving, synchronized swimming, figure
skating, and gymnastics. - Sports emphasizing leanness for performance such
as track, long distance running, swimming, and
cross-country skiing. - Sports in which athletes are classified based on
weight such as weightlifting, boxing, wrestling,
and rowing.
- Early identification and treatment by a multidisci-
plinary team including a physician, psychotherapist
(e.g., psychologist), nutritionist, coaches, and
family members has the best prognosis (Jacobson,
2003). Treatment consisting of both individual and
group cognitive-behavioral therapy and nutritional
counseling has been effective for athletes (Sundgot-
Borgen and Sundgot-Schneider, 2001). Continued
participation in training and competition must be
contingent on adherence with the treatment pro-
gram.
PERFORMANCE ANXIETY- Optimal performance comes with a certain level of
tension and mental activation (Howe and Ogilvie,
1994; p. 71). For athletes struggling with arousal
control, educationally based psychologic interven-
tions have yielded significant improvements in per-
formance. Specifically, Weinberg and Comar (1994)
450 SECTION 5 • PRINCIPLES OF REHABILITATION
TABLE 74-4 DSM-IV-TR (2000) Criteria for Anorexia
Nervosa and Bulimia Nervosa
Anorexia Nervosa
- Refusal to maintain body weight at or above a minimally normal
weight for age and height (e.g., weight loss leading to maintenance
of body weight less than 85% of that expected: or failure to make
expected weight gain during period of growth, leading to body
weight less than 85% of that expected). - Intense fear of gaining weight or becoming fat, even though
underweight. - Disturbance in the way one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial
of the seriousness of the current low body weight. - In postmenarcheal females, amenorrhea, i.e., the absence of at least
three consecutive menstrual cycles.
Specify type:
Restricting type:during the current episode of Anorexia Nervosa,
the person has not regularly engaged in binge-eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas).
Binge-Eating/Purging type:during the current episode of Anorexia
Nervosa, the person has regularly engaged in binge-eating or
purging behavior (i.e., self-induced vomiting or the misuse of
laxatives, diuretics, or enemas).
Bulimia Nervosa - Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
a. Eating, in a discrete period of time (e.g., within any 2-hour
period), an amount of food that is definitely larger than most
people would eat during a similar period of time and under
similar circumstances.
b.A sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much
one is eating). - Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting, misuse of laxatives,
diuretics, enemas, or other medications; fasting; or excessive
exercise. - The binge eating and inappropriate compensatory behaviors both
occur, on average, at least twice a week for 3 months. - Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of
Anorexia Nervosa.
Specify type:
Purging type:during the current episode of Bulimia Nervosa, the
person has regularly engaged in self-induced vomiting or the
misuse of laxatives, diuretics, or enemas.
Nonpurging type:during the current episode of Bulimia Nervosa,
the person has used other inappropriate compensatory behaviors,
such as fasting or excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse of laxatives,
diuretics, or enemas.
SOURCE: APA: Diagnostic and Statistical Manual of Mental Disorders,
4th ed. Text Revision, Washington, DC, American Psychiatric
Association, 2000.