Eating

Anorexia Nervosa

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Anorexia Nervosa

  • 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
  • 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 Socially withdrawn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
  • 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
  • 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
  • Evaluation Tools
  • 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
  • Differential Diagnosis
  • Associated Conditions
  • 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
  1. Arrhythmias and EKG changes may also occur specific to electrolyte disorders
  2. Low voltage
  3. Prolonged QT interval
  4. Bradycardia
  • 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. 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]
  • 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
  • Management
  • Psychiatric
  1. Multiple modality approach (variable efficacy)
    1. Psychotherapy
      1. Reduce distorted body image
      2. Reduce dysfunctional eating habits
      3. Re-engage socially
      4. Resume regular physical activities
    2. Cognitive Behavioral Therapy
    3. Family-Based Treatment
      1. Maudsley Method is one effective approach
      2. Couturier (2013) Int J Eat Disord 46(1): 3-11 [PubMed]
    4. Mindfulness activities (e.g. yoga, meditation)
    5. 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]
  3. Medications for comorbid Depression (not effective for Anorexia without depression)
    1. Desipramine
    2. Effexor
    3. Selective Serotonin Reuptake Inhibitors (SSRI)
    4. Avoid Wellbutrin
  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
  • 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
  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/063.html