Anorexia Nervosa

1. Epidemiology
   1. Incidence: 0.5 to 1.0% of adolescents
   2. Onset in adolescence and continues until early 20's
   3. Affects women much more often than men by ratio of 10:1
2. Risk Factors: Associated personality traits
   1. Perfectionist
   2. Obsessive-Compulsive Personality
   3. Socially withdrawn
   4. High achiever
3. Symptoms
   1. Weight loss
   2. Fatigue or weakness
   3. Amenorrhea
   4. Constipation
   5. Headache
   6. Cold intolerance
   7. Appetite remains normal
   8. Morbid fear of fatness
   9. Disturbed body image (Feel fat when thin)
   10. Concern about weight leads to behavior changes
       1. Dieting
       2. Exercise
       3. Diuretic or Laxative abuse
       4. Binge Eating may occur in 50% of cases
   11. Ritual behaviors (e.g. hand washing)
   12. Hides disordered eating from others
       1. Surreptitious mealtime behavior
       2. Wearing of Baggy clothes
       3. Avoids food related behavior
4. Signs
   1. Cachexia (bone showing through)
   2. Acrocyanosis
   3. Weight 15% below Ideal Weight
   4. Skin changes
      1. Carotene pigment (yellow discoloration of skin)
      2. Lanugo hair (fine hair on back and cheeks)
      3. Hair Loss
      4. Dry Skin
   5. Induced Vomiting signs
      1. Calluses at Fingernails
      2. Chipmunk cheeks (parotid hypertrophy)
      3. Dental enamel Erosion
   6. Severe anorexia (starvation signs)
      1. Edema
      2. Bradycardia
      3. Hypothermia
      4. Orthostatic Hypotension
5. Evaluation Tools
   1. See SCOFF Questionnaire
6. Diagnosis: DSM IV
   1. Major Criteria
      1. Body weight maintained less than 85% of expected
      2. Intense fear of fatness
      3. Disturbed body self image
      4. Amenorrhea for at least 3 consecutive months
   2. Subtypes
      1. Restricting Type
         1. No Binging and purging (see below)
      2. Binge and Purge Type
         1. Self-induced Vomiting or
         2. Laxative, Diuretic or enema use or binge-eating
7. Differential Diagnosis
   1. Other eating disorder (i.e. Bulimia)
   2. Hyperthyroidism
   3. Addison's Disease
   4. Diabetes Mellitus
   5. Malignancy
   6. Inflammatory Bowel Disease
   7. Immunodeficiency
   8. Malabsorption
   9. Chronic infections
8. Associated Conditions
   1. Amenorrhea
   2. Osteoporosis
   3. Female Athlete Triad
   4. Psychiatric illness
      1. Affective Disorder
         1. Major Depression
         2. Anxiety Disorder
      2. Somatization Disorder
      3. Substance Abuse
      4. Obsessive-Compulsive Disorder
      5. Personality Disorder (Cluster C - avoidant, anxious)
9. Labs
   1. Chemistry panel
      1. Hypoglycemia
   2. Complete Blood Count
      1. Leukopenia
   3. Liver Function Tests
      1. Transaminases increased
   4. Thyroid Function Tests
      1. TSH decreased with normal Free T4 and Free T3
10. Diagnostics: Electrocardiogram
    1. Same as in anorexia
    2. Low voltage
    3. Prolonged QT interval
    4. Bradycardia
11. Management: Inpatient Indications
    1. Suicidal Ideation with plan
    2. Intense supervision required
    3. Severe dehydration
    4. Serious renal, hepatic or cardiac complications
    5. Physical signs
       1. Adults
          1. Weight <75-80% of Ideal Weight
          2. Heart Rate < 40 bpm
          3. Blood Pressure <90/60 mmHg
          4. Glucose <60 mg/dl
          5. Potassium <3 mg/dl
          6. Temperature <97 F
       2. Children
          1. Heart Rate < 50 bpm
          2. Blood Pressure <80/50 mmHg
          3. Hypokalemia
          4. Hypophosphatemia
    6. References
       1. (2000) Am J Psychiatry 157(suppl 1):20
12. Management: Weight gain
    1. Identify target weight
    2. Review weight gain goals
       1. Outpatient: 1 lb (0.45 kg) per week
       2. Inpatient: 2 to 3 lb (0.9 to 1.35 kg) per week
    3. Increase intake slowly
       1. Start at 800 to 1000 kcals per day
       2. Increase by 200 to 300 kcals per 3-4 days
       3. Goal: 3000 to 3500 kcals per day
    4. Adjunctive therapy
       1. Metoclopramide mat reduce bloating with refeeding
    5. Complication: Refeeding Syndrome
       1. Occurs with early high caloric intake
       2. Monitor electrolytes in early refeeding
          1. Observe for Hypophosphatemia
       3. Risk of cardiovascular collapse
          1. Prolonged QT interval (Risk of sudden death)
          2. Bradycardia with Heart Rate <40 beats per minute
13. Management: Psychiatric
    1. Multiple modality approach (variable efficacy)
       1. Psychotherapy
       2. Cognitive behavioral therapy
       3. Family therapy
       4. Avoid self-help since it is ineffective
    2. Medications used in anorexia
       1. Olanzapine (Zyprexa) may be effective
       2. Barbarich (2004) J Clin Psychiatry 65(11):1480-2
    3. Medications for comorbid Depression (not effective for anorexia without depression)
       1. Desipramine
       2. Effexor
       3. Selective Serotonin Reuptake Inhibitors (SSRI)
       4. Avoid Wellbutrin
14. Management: Secondary Amenorrhea
    1. Diagnostics
       1. Follicle Stimulating Hormone (FSH) low
       2. Luteinizing hormone (LH) low
       3. Estrogen low
       4. No withdrawal bleed on Progesterone (Estrogen low)
    2. Risks
       1. Osteopenia
       2. Osteoporosis
       3. Pregnancy may occur despite Amenorrhea
    3. Management
       1. Menses resume when >90% of ideal body weight
       2. Calcium Supplementation
       3. Vitamin D Supplementation
       4. Oral Dehydroepiandrosterone
          1. Currently studied for Osteoporosis Prevention
          2. May prevent bone loss in anorexia
       5. Oral Contraceptives are not routinely recommended
          1. Does not prevent Osteoporosis
          2. Masks normal Menses as a marker of regained health
15. Prognosis
    1. Incidence of premature death: 10-18%
    2. Causes of death
       1. Cardiac and metabolic (observe for Prolonged QT)
       2. Suicide
    3. Causes of Morbidity
       1. Gynecologic Disorders
       2. Osteoporosis and pathologic Fractures
       3. Mental Health disorders
       4. Cardiovascular disease
       5. Gastrointestinal disease
16. Resources: Patient Education
    1. Information from your Family Doctor
       1. http://www.familydoctor.org/handouts/063.html
17. References
    1. (1994) DSM IV, APA, p. 544-5
    2. Bulik (2007) Int J Eating Disord 40:310-20
    3. Gordon (1999) J Bone Miner Res 14:136-45
    4. Hobbs (1996) Am Fam Physician, 54(4): 1273-9
    5. Mehler (2001) Ann Intern Med 134:1048-59
    6. Seidenfeld (2001) Am Fam Physician 64(3):445-50