I. 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

II. Risk Factors: Associated personality traits

  1. Perfectionist
  2. Obsessive-Compulsive Personality
  3. Socially withdrawn
  4. High achiever

III. 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

IV. 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

V. Evaluation Tools

VI. 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

VII. 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

VIII. 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)

IX. 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

X. Diagnostics: Electrocardiogram

  1. Same as in anorexia
  2. Low voltage
  3. Prolonged QT interval
  4. Bradycardia

XI. 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 [PubMed] (or open in [QxMD Read])

XII. 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

XIII. 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 [PubMed] (or open in [QxMD Read])
  3. Medications for comorbid Depression (not effective for anorexia without depression)
    1. Desipramine
    2. Effexor
    3. Selective Serotonin Reuptake Inhibitors (SSRI)
    4. Avoid Wellbutrin

XIV. 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

XV. 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

XVI. Resources: Patient Education

  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/063.html

Images: Related links to external sites (from Google)

Ontology: Anorexia Nervosa (C0003125)

Definition (NCI) An eating disorder marked by an intense fear of gaining weight, a refusal to maintain a healthy weight, and a distorted body image. People with anorexia nervosa have an abnormal loss of appetite for food, try to avoid eating, and eat as little as possible.
Definition (NCI) A disorder most often seen in adolescent females characterized by a refusal to maintain a minimally normal body weight, an intense fear of gaining weight, a disturbance in body image, and, in postmenarcheal females, the development of amenorrhea.
Definition (PSY) Syndrome in which the primary features include excessive fear of becoming overweight, body image disturbance, significant weight loss, refusal to maintain minimal normal weight, and amenorrhea. This disorder occurs most frequently in adolescent females.
Definition (CSP) syndrome in which the primary features include excessive fear of becoming overweight, body image disturbance, significant weight loss, refusal to maintain minimal normal weight, and amenorrhea; disorder occurs most frequently in adolescent females.
Definition (MSH) An eating disorder that is characterized by the lack or loss of APPETITE, known as ANOREXIA. Other features include excess fear of becoming OVERWEIGHT; BODY IMAGE disturbance; significant WEIGHT LOSS; refusal to maintain minimal normal weight; and AMENORRHEA. This disorder occurs most frequently in adolescent females. (APA, Thesaurus of Psychological Index Terms, 1994)
Concepts Mental or Behavioral Dysfunction (T048)
MSH D000856
ICD9 307.1
ICD10 F50.0 , F50.00
SnomedCT 154926005, 192445002, 56882008
DSM4 307.1
English Anorexia mentalis, Anorexia Nervosas, Nervosa, Anorexia, Nervosas, Anorexia, ANOREXIA, NERVOSA, ANOREXIA NERVOSA, Anorexia nervosa, anorexia nervosa (diagnosis), anorexia nervosa, Anorexia nervosa, unspecified, Anorexia Nervosa [Disease/Finding], anorexia mentalis, AN - Anorexia nervosa, Anorexia nervosa (disorder), nervosa; anorexia, anorexia; nervosa, Anorexia Nervosa
French ANOREXIE MENTALE, Anorexie nerveuse, Anorexie mentale
Portuguese ANOREXIA NERVOSA, Anorexia nervosa, Anorexia Nervosa
Spanish ANOREXIA NERVIOSA, Anorexia nervosa, anorexia nerviosa (trastorno), anorexia nerviosa, Anorexia nerviosa, Anorexia Nerviosa
German ANOREXIA NERVOSA, Anorexia nervosa
Japanese 神経性無食欲症, シンケイセイムショクヨクショウ
Swedish Anorexia nervosa
Czech anorexia nervosa, mentální anorexie, Mentální anorexie
Finnish Laihuushäiriö
Korean 신경성 식욕부진
Polish Anoreksja nerwowa
Hungarian Anorexia nervosa
Dutch anorexie; nervosa, nervosa; anorexie, anorexia nervosa, Anorexia nervosa
Italian Anoressia nervosa