Anorexia Nervosa

Basics
DESCRIPTION
DSM-IV criteria:

Refusal to maintain body weight at or above a minimally normal weight (i.e., weight loss or failure to gain weight
during a period of growth leading to maintenance of body weight <85% of expected)

Intense fear of gaining weight or becoming fat, even though underweight

Disturbance in the way in which ones body weight, shape, or size is perceived; undue influence of body weight or
shape on self-esteem; or denial of seriousness of current low body weight

In postmenarchal females, amenorrhea

Types: Restricting (no binge eating or purging) or binge eating/purging

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(Copyright 2000). American Psychiatric Association.
GENERAL PREVENTION
When counseling on obesity, take care not to foster overaggressive dieting. Help children and adolescents build self-esteem
while addressing their weight concerns.
EPIDEMIOLOGY
BASICS-EPIDEMIOLOGY-Prevalence

Typically, adolescent girls or young women, although 515% of cases are in male patients.

Estimated 0.51% of adolescents have an eating disorder.

Studies indicate that >50% of children and adolescents presenting with a concern of an eating disorder do not meet
the full DSM-IV diagnostic criteria but still require treatment.
RISK FACTORS

More prevalent in industrialized societies; occurs in all US household income levels and major ethnic groups
Genetics
Family and twin studies indicate a genetic component. A relative of a person with an eating disorder has a 10 greater
lifetime risk of developing an eating disorder.
PATHOPHYSIOLOGY

Physical manifestations are generally due to weight loss and malnutrition. In an attempt to conserve energy, the
body becomes functionally hypothyroid (euthyroid sick syndrome). Body temperature and heart rate decrease. As
cardiac function becomes impaired, orthostasis and hypotension occur. Reduced peripheral circulation causes hair
thinning, brittle nails, dry skin, and lanugo.

Hypothalamic hypogonadism results from malnutrition and stress, and causes delayed puberty and amenorrhea.
Decreased estrogen and testosterone also contribute to osteoporosis.

Electrolyte abnormalities generally develop as a result of malnutrition. However, sodiumabnormalities may

develop due to dehydration or excess water intake, and hypokalemia can develop secondary to vomiting and/or
laxative or diuretic use.
ETIOLOGY

Multifactorial including genetic, neurochemical, psychodevelopmental, and sociocultural factors

Adolescents participating in activities which emphasize maintaining a certain weight (e.g., gymnastics, ballet, ice
skating, wrestling) are at increased risk.

Personality traits such as low self-esteem, difficulty expressing negative emotions, difficulty resolving conflict and
perfectionist tendencies are associated with an increased risk.
BASICS-ASSOCIATED-CONDITIONS

Depression

Anxiety disorders

Substance abuse

Diagnosis
SIGNS AND SYMPTOMS
History

Question: Have you ever weighed much less than other people thought you should?
1. Patients may try to hide their illness. A negative response does not negate an eating disorder.

Question: What is the least amount you have weighed in the past year?
1. The reported weight should be used to calculate a BMI.

Question: Are you afraid of gaining weight?

1. Patients will often report an intense fear of gaining weight.

Question: How do you think you look?

1. A patients perceived body image is often distorted. Perceived body image may be significantly
misaligned with reality.

Question in postmenarchal females: Have you ever missed menstrual periods? Have you ever missed 3 in a row?
1. 3 or more missed periods in a row is an indication of amenorrhea.

Obtain a diet history, including 24-hour diet, history of binge-eating or purging; use of diuretics, laxatives, diet pills
or emetics such as ipecac; and exercise history (i.e., how much, intensity).
Physical Exam

All patients should have a full physical exam with special emphasis on:
1. Vital signs, weight, height, BMI: May have bradycardia, hypotension, or hypothermia; BMI is needed to
determine if weight is <85% expected
2. Physical and sexual growth and development: May be emaciated, have atrophic breasts or delayed puberty
3. Cardiovascular system: May detect a cardiac arrhythmia, murmur, or evidence of congestive heart failure

4. Lanugo
5. Salivary gland enlargement or Russell sign (scarring on dorsum of hand): Suggests purging behavior.
6. Muscular irritability or weakness: May occur with severe malnutrition or use of ipecac.
7. Evidence of self-injurious behavior: May indicate previous suicide attempts.

All patients need dental examination for enamel erosion, tooth loss due to purging behavior or insufficient calcium
intake, respectively.
TESTS

LABORATORY

All patients with anorexia nervosa

1. Serum electrolytes, BUN/creatinine: Most are normal, may show dehydration or sodium
or potassiumabnormalities
2. TSH, if indicated, free T4, T3: Rule out thyroid disease.
3. CBC with differential: Mild anemia is common due to iron or folate deficiency; WBC count is generally
low due to malnutrition.
4. ESR: Generally low due to malnutrition
5. AST, ALT, alkaline phosphatase: Occasionally abnormal due to fatty liver
6. Urinalysis: Evaluate specific gravity to assess for dehydration that may be seen with purging or diuretic
use.

Malnourished and severely symptomatic patients:

1. Complement component 3a: May indicate nutritional deficiencies when other markers are within normal
ranges.
2. Serum calcium, magnesium, phosphorous: May all be low; in hospitalized patients follow phosphorous
daily to assess for refeeding syndrome.
3. Serum ferritin: May be low
4. Electrocardiogram: May have bradycardia, ST-T wave abnormalities with hypokalemia, increased PR
interval and 1st-degree heart block, prolonged QTc
5. 24-hour urine for creatinine clearance: Generally low, normal may indicate azotemia

Patients amenorrheic for >6 months:

1. Dual-energy x-ray absorptiometry(DEXA) scan: Evaluates bone densityto determine risk of compression
fracture and bone loss

Nonroutine assessments:
1. Toxicology screen, if suspect substance use
2. Serum amylase, fractionated for salivary gland isoenzyme if available, if suspected vomiting: Will be
elevated
3. Serum LH, FSH, prolactin, if persistent amenorrhea with normal weight: LH and FSH will generally be

low.
4. -HCG: Rule out pregnancy.
5. Stool for guaiac, if suspected GI bleed
6. Stool or urine for bisacodyl, emodin, aloe-emodin, and rhein, if suspected laxative abuse
DIFFERENTIAL DIAGNOSIS

Oncologic: Brain tumor

Gastroenterologic: Inflammatory bowel disease, celiac disease

Endocrinologic: Diabetes mellitus, thyroid disease, hypopituitarism, Addison disease

Psychiatric: Depression, obsessive-compulsive disorder, substance abuse

Other chronic diseases or infections

Superior mesenteric artery syndrome (can also be a consequence of eating disorder)

Treatment
GENERAL MEASURES
DIET
Nutritional treatment:

Goals: Restore weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, correct
malnutrition

Establish target weight and rate of weight gain: Goal is weight at which menstruation is restored or normal physical
and sexual development resume.

Usually begin intake at 3040 kcal/kg/d, may increase to 70100 kcal/kg/d. Weight gain goal of 0.51 lb/wk is
realistic.

In malnourished patients, avoid refeeding syndrome by starting slowly, generally 1,0001,600 kcal/d and
increasing by 200400 kcal/d.

Reserve NG feeds for patients with extreme difficulty recognizing their illness, those refusing treatment, or those
with eating-associated guilt.

Evaluate and treat GI symptoms including constipation, bloating, and abdominal pain.

Add vitamin and mineral supplements (e.g., phosphorous, calcium); may require acute supplementation

When desired weight is achieved, calculate ongoing caloric intake based on weight and activity (usually 4060
kcal/kg/d).
ACTIVITY

Help limit physical activity and caloric expenditure if exercise is a significant component of the patients illness.
SPECIAL THERAPY
Psychosocial treatment:

Goals: Understand and change behaviors and attitudes related to eating disorder, improve interpersonal and social

functioning, address comorbid psychopathology

Psychotherapy: Individual, family, group

MEDICATIONS

Medications should be used in conjunction with nutritional and psychosocial treatment, not as the primary or sole modality
of treatment. If possible, defer medications until weight has been restored.

Antidepressants to treat persistent depression or anxiety

1. SSRIs have the most evidence for efficacy.
2. Do not use bupropion in patients with eating disorders because of an increased risk of seizures in patients
with eating disorders.
3. Avoid tricyclic antidepressants and MAOIs due to potential lethality and toxicity with overdose.

Consider 2nd-generation and low-potency antipsychotics for select patients with severe symptoms such as severe
resistance to gaining weight, severe obsessive thinking, and/or disease denial that approaches delusional status.

Follow-up Recommendations
DISPOSITION
Admission Criteria
Criteria for inpatient hospitalization:

Generally, weight <85% of estimated healthy body weight or acute weight decline with food refusal

Heart rate near 40 bpm

Orthostatic hypotension

BP <80/50 mm Hg

Hypokalemia, hypophosphatemia, hypomagnesemia

Additional factors to consider: Suicidality, other psychiatric disorders requiring hospitalization, severe substance
use disorder, uncontrolled vomiting, hematemesis, weight close to previous weight where patient became medically
unstable
EXPECTED COURSE/PROGNOSIS

Mortality rate 0.56% per year

~50% have full recovery, 30% have partial recovery, 20% have no substantial improvement
POSSIBLE COMPLICATIONS

Fluid and electrolyte imbalances

Rapid refeeding of severely malnourished patients (refeeding syndrome) can cause hypophosphatemia, leading to
cardiac failure, stupor and coma, and hemolytic anemia.

Cardiovascular: ECG abnormalities, pericardial effusion, use of ipecac can cause irreversible myocardial damage
and diffuse myositis

GI: Delayed gastric emptying, slow GI motility, bloating, constipation, fatty liver, hypercholesterolemia from

abnormal lipoprotein metabolism, and esophagitis or Mallory-Weiss tears from chronic vomiting

Endocrine: Euthyroid sick syndrome, amenorrhea, osteopenia

Renal: Increased risk of renal stones, polyuria due to abnormal vasopressinsecretion, in refeeding, 25% develop
peripheral edema due to increased renal sensitivity to aldosterone

Hematologic: Anemia, leukopenia, thrombocytopenia

Neuropsychologic: Cortical atrophy, apathy, poor concentration, cognitive impairment, seizures, peripheral
neuropathy
PATIENT MONITORING

Vital signs and cardiac monitoring

Food/fluid intake/output

Electrolytes, including serum potassium, magnesium, phosphorous on admission then daily for 5 days followed by
3x/week for 3 weeks

Frequently Asked Questions

Q: What is the expected inpatient treatment duration?

A: Duration of hospitalization varies; average is ~56 weeks. However, evidence indicates that patients discharged
at weights lower than their target weights have an increased risk for relapse.

Q: Which specialists should be consulted?

A: The treatment of anorexia generally involves a multidisciplinary team, including the pediatrician, a nutritionist,
and a psychiatrist. In some areas, patients can also be referred to pediatricians who specialize in eating disorders.

Q: When may the patient return to school?

A: When weight is >85% of expected

Q: When may the athlete return to play?

A: When weight is >85% of expected and the patients cardiac and electrolyte status is stable.