Anorexia Nervosa

Aka: Anorexia Nervosa

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II. Epidemiology

  1. Incidence: 0.5 to 1.0% of adolescents
  2. Lifetime Prevalence: 1 per 200 females in U.S. (much more common than Anorexia)
  3. Onset in adolescence and continues until early 20's
    1. Age 12 to 25 years old accounts for 95% of cases
  4. Affects women much more often than men by ratio of 10:1
    1. Incidence in males has been increasing

III. Risk Factors: Associated personality traits

  1. Food and appearance regulation is under the patient's control
  2. Perfectionist
  3. Obsessive-Compulsive Personality
  4. Socially withdrawn
  5. High achiever
  6. Values success and external rewards

IV. Symptoms

  1. Weight loss
  2. Fatigue or weakness
  3. Amenorrhea
  4. Constipation
  5. Headache
  6. Cold intolerance
  7. Epigastric Pain
  8. Abdominal Bloating
  9. Appetite remains normal
  10. Morbid fear of fatness
  11. Disturbed body image (Feel fat when thin)
  12. Concern about weight leads to behavior changes
    1. Dieting
    2. Excessive and compulsive Exercise routines regardless of illness, injury or weather conditions
    3. Diuretic or Laxative abuse
    4. Binge Eating may occur in 50% of cases
  13. Ritual behaviors (e.g. Hand Washing)
  14. Hides disordered eating from others
    1. Surreptitious mealtime behavior
    2. Wearing of baggy clothes
    3. Avoids food related behavior (skips meals)
    4. Limits diet to vegetables, fruit and diet products
    5. Cuts food into small pieces or picks food apart

V. 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. Delayed Wound Healing
  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. Hypoglycemia
    6. Cognitive Impairment (typically subtle)
    7. Loss of strength and endurance
      1. Results in slowed movement and decreased athletic performance

VI. Evaluation Tools

  1. See SCOFF Questionnaire

VII. Diagnosis: DSM V

  1. Major Criteria
    1. Significantly low body weight
      1. Secondary to restriction of Energy Intake relative to requirements
      2. Low weight defined in the context of age, gender, developmental trajectory and physical health
    2. Intense fear of fatness or weight gain
      1. May also be met by persistent behavior interfering with weight gain
      2. Persists despite being at a significantly low weight
    3. Disturbed body self image
      1. Abnormal influence of weight or shape on self evaluation or
      2. Lack of recognition of low body weight seriousness
  2. Subtypes (refers to the last 3 months)
    1. Restricting Type
      1. No Binging and purging (see below)
      2. Excessive weight loss achieved through dieting, Fasting or excessive Exercise
    2. Binge and Purge Type
      1. Self-induced Vomiting or
      2. Laxative, Diuretic or enema use or binge-eating
  3. Remission Criteria
    1. Partial Remission
      1. Previously met full major criteria for Anorexia
      2. Now does not meet significantly low body weight for sustained period
      3. However does have either intense fear of fatness/weight gain OR disturbed body image
    2. Full Remission
      1. Previously met full major criteria for Anorexia
      2. Now meets none of the major criteria for Anorexia
  4. Severity (for adults, use BMI percentiles for children and adolescents)
    1. Mild
      1. BMI >17 kg/m2
    2. Moderate
      1. BMI 16-17 kg/m2
    3. Severe
      1. BMI 15-16 kg/m2
    4. Extreme
      1. BMI <15 kg/m2
  5. References
    1. (2013) DSM V, APA, Washington

VIII. 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

IX. Associated Conditions

  1. Amenorrhea
  2. Osteoporosis (including Stress Fractures)
  3. Overuse injuries
  4. Female Athlete Triad
  5. Psychiatric illness
    1. Suicidality
    2. Major Depression
    3. Anxiety Disorder
    4. Somatization Disorder
    5. Substance Abuse
    6. Obsessive-Compulsive Disorder
    7. Personality Disorder (Cluster C - avoidant, anxious)
    8. Social withdrawal

X. Labs

  1. Complete Blood Count
    1. Leukopenia
  2. Comprehensive Metabolic Panel
    1. Hypoglycemia
    2. Hypochloremic Metabolic Alkalosis
    3. Hypokalemia
    4. Transaminases increased
  3. Serum Phosphorus
  4. Serum Magnesium
  5. Thyroid Stimulating Hormone
    1. TSH decreased
    2. Normal Free T4 and Free T3
  6. Urinalysis
    1. Increased Urine Specific Gravity
    2. Increased Urine Ketones
    3. Decreased Urine pH

XI. Diagnostics: Electrocardiogram

  1. Arrhythmias and EKG changes may also occur specific to Electrolyte disorders
  2. Low voltage
  3. Prolonged QT interval
  4. Bradycardia

XII. Management: Inpatient Indications

  1. Suicidal Ideation with plan
  2. Refusal to eat
  3. Failed outpatient management
  4. Intense supervision required
  5. Severe Dehydration
  6. Serious renal, hepatic or cardiac complications
  7. Severe weight loss (e.g. Weight <75% Ideal Body Weight)
  8. 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. Serum Potassium <3 mg/dl
      6. Temperature <96 F
    2. Children
      1. Heart Rate < 50 bpm
      2. Blood Pressure <80/50 mmHg
      3. Hypokalemia
      4. Hypophosphatemia
      5. Temperature <96 F
  9. References
    1. (2000) Am J Psychiatry 157(suppl 1):20 [PubMed]
    2. Campbell (2014) Pediatrics 134(3): 582-92 [PubMed]

XIII. Management: Weight gain

  1. Identify initial target weight
    1. Initial weight goal is typically 90% of Ideal Weight for age, height and gender
  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. Meal plans are established based on calorie counts
      1. Calories are divided among three meals and two scheduled snacks (monitored)
      2. Calorie counts are not typically discussed with patients
    2. Start at 800 to 1000 kcals per day
    3. Increase by 200 to 300 kcals per 3-4 days
    4. Goal: 3000 to 3500 kcals per day
  4. Adjunctive therapy
    1. Multivitamin
    2. Calcium supplement
    3. Vitamin D Supplement
    4. Metoclopramide may 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

XIV. Management: Psychiatric

  1. Multiple modality approach (variable efficacy)
    1. Cognitive Behavioral Therapy (CBT)
      1. Focus on cognitive distortions around food and weight
      2. Implement experimental model of change
    2. Psychotherapy (e.g. focal psychodynamic therapy)
      1. Re-engage socially
      2. Resume regular physical activities
      3. Increase insight
        1. Reduce distorted body image
        2. Reduce dysfunctional eating habits
    3. Family-Based Treatment (first-line treatment for teens and some young adults)
      1. Parents play a role in assisting weight gain until patient gradually self-manages fully
      2. Maudsley Method is one effective approach
      3. Couturier (2013) Int J Eat Disord 46(1): 3-11 [PubMed]
    4. Mindfulness activities (e.g. yoga, meditation)
    5. Avoid self-help (ineffective)
  2. Medications used in Anorexia
    1. Olanzapine (Zyprexa) 10 mg orally daily may be effective for mood and weight gain
    2. Barbarich (2004) J Clin Psychiatry 65(11):1480-2 [PubMed]
  3. Medications for comorbid Depression (not effective for Anorexia without Major Depression)
    1. Desipramine
    2. Effexor
    3. Selective Serotonin Reuptake Inhibitors (SSRI)
  4. Medications to avoid
    1. Avoid Bupropion (Wellbutrin, Seizure risk)
    2. Avoid Drugs That Prolong the QTc Interval

XV. 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
      1. Contraception recommended for sexually active patients
  3. General Management
    1. Menses resume when >90% of Ideal Body Weight
    2. Calcium Supplementation
    3. Vitamin D Supplementation
  4. Hormonal Therapy
    1. Combination Estrogen and Progesterone
      1. Transdermal 17-beta Estradiol 100 mcg patch (decreased dose if Bone Age <15) AND
      2. Medroxyprogesterone (Provera) 2.5 mg orally daily for 10 days of month
      3. Misra (2011) J Bone Miner Res 26(10): 2430-8 [PubMed]
    2. Oral Dehydroepiandrosterone
      1. Currently studied for Osteoporosis Prevention
      2. May prevent bone loss in Anorexia
    3. Oral Contraceptives are not routinely recommended for improving bone mass
      1. Does not prevent Osteoporosis
      2. Masks normal Menses as a marker of regained health

XVI. Prognosis

  1. Treatment outcomes
    1. Full recovery: 50%
    2. Partial recovery: 30%
    3. Chronically ill: 20%
  2. Associated with increased mortality (highest of any mental health disorder)
    1. Incidence of premature death: 10-18%
    2. All cause increased mortality Relative Risk: 1.7 to 5.9
    3. Causes of death
      1. Cardiac and metabolic (observe for Prolonged QT)
      2. Suicide
  3. Increased Morbidity
    1. Gynecologic Disorders
    2. Osteoporosis and pathologic Fractures
    3. Mental Health disorders
    4. Cardiovascular disease
    5. Gastrointestinal disease

XVII. Resources: Patient Education

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

XVIII. References

  1. (1994) DSM IV, APA, p. 544-5
  2. Renbarger and Pearson (2021) Crit Dec Emerg Med 35(8): 17-23
  3. Bulik (2007) Int J Eating Disord 40:310-20 [PubMed]
  4. Gordon (1999) J Bone Miner Res 14:136-45 [PubMed]
  5. Harrington (2014) Am Fam Physician 91(1): 46-52 [PubMed]
  6. Hobbs (1996) Am Fam Physician, 54(4): 1273-9 [PubMed]
  7. Klein (2021) Am Fam Physician 103(1): 22-32 [PubMed]
  8. Mehler (2001) Ann Intern Med 134:1048-59 [PubMed]
  9. Seidenfeld (2001) Am Fam Physician 64(3):445-50 [PubMed]

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