Anorexia Nervosa

Incidence & Prevalence

The incidence of anorexia nervosa is 8 cases per 100,000 population per year An average
prevalence rate for anorexia nervosa of 0.3% was found for young females. Estimated
mean yearly incidence is 20 per 100,000 people a year in women, and 2 per 100,000
people a year in men. The most substantial increase was among females aged 15-24
years, for whom a significant increase was observed from 1935 to 1999. The condition
largely affects young adolescent females, with females between 15 and 19 years old
making up 40% of all cases.

Diagnostic Criteria

DSM-IV-TR criteria are:

 Refusal to maintain body weight at or above a minimally normal weight for age
and height (e.g. weight loss leading to maintenance of body weight less than 85% of
that expected; or failure to make expected weight gain during period of growth,
leading to body weight less than 85% of that expected).
 Intense fear of gaining weight or becoming fat, even though underweight.
 Disturbance in the way in which one's body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.
 Amenorrhea (at least three consecutive cycles) in postmenarchal girls and women.
Amenorrhea is defined as periods occurring only following hormone (e.g., estrogen)
administration.

The ICD-10 criteria are similar, but in addition, specifically mention

1. The ways that individuals might induce weight-loss or maintain low body
weight (avoiding fattening foods, self-induced vomiting, self-induced purging,
excessive exercise, excessive use of appetite suppressants or diuretics).
 2. Certain physiological features, including "widespread endocrine disorder
involving hypothalamic-pituitary-gonadal axis is manifest in women
as amenorrhoea and in men as loss of sexual interest and potency. There may
also be elevated levels of growth hormones, raised cortisol levels, changes in the
peripheral metabolism of thyroid hormone and abnormalities of insulin
secretion".
3. If onset is before puberty, that development is delayed or arrested.

Risk Factors
 Body dissatisfaction
 Dieting
 Low self-esteem
 Perfectionism
 Childhood sexual abuse
 Family history of eating disorders

Signs & Symtpoms

The severe calorie restriction of anorexia has dire physical effects. When the body
doesn’t get the fuel it needs to function normally, it goes into starvation mode. It slows
down to conserve energy and turns in on itself for essential nutrients. In essence, the body
begins to consume itself. As the self-starvation continues and more body fat is lost, the
medical complications pile up.
The first physical signs and effects of anorexia are:
 Constipation and abdominal pain
 Loss of menstrual periods
 Restlessness and insomnia
 Lack of energy and weakness
 Dizziness, fainting, and headaches
 Feeling cold all the time
 Growth of fine hair all over the
 Dry, yellowish skin
body and face
Source: WomensHealth.gov
If anorexia continues unchecked, the health problems only get worse. Over time, anorexia
causes hair loss, infertility, stunted growth, osteoporosis, heart problems, kidney failure,
and death. Other effects of anorexia include tooth decay and gum damage from
malnutrition and vomiting, and damage to the esophagus and larynx from acid reflux.
Anorexia can also lead to depression, severe mood swings, and thoughts of suicide.

Investigations
• An ESR and thyroid function tests are a useful screen for other causes of
weight loss.
• Other tests will depend on the individual presentation.
• In patients with eating disorders, frequent testing for FBC, ESR, urea,
electrolytes, creatinine, glucose, liver function tests and thyroid function tests is
required.
Management
• Mild anorexia nervosa (body mass index above 17 kg/m2) and no
significant co-morbidities can be managed in primary care with support and
monitoring.
• But if patients don't respond within eight weeks you should make a routine
referral to specialist services.
• Refer patients with moderate anorexia nervosa (body mass index 15-17
2
kg/m ) and no significant co-morbidities non-urgently to specialist services.
• Refer patients with severe anorexia nervosa (body mass index less than 15
2
kg/m ), rapid weight loss, or evidence of system failure urgently to specialist
services, or a medical unit if the physical status of the patient is life threatening.
• Self help (with or without guidance from a therapist) may have some
utility as a first step in treatment and may have potential as an alternative to formal
therapist-delivered psychological therapy.
• Psychological treatments of anorexia nervosa include cognitive analytic
therapy, cognitive behaviour therapy, interpersonal psychotherapy, focal
psychodynamic therapy and family interventions focused explicitly on eating
disorders.
• Family interventions that directly address the eating disorder should be
offered to children and adolescents with anorexia nervosa. Family members,
including siblings, should normally be included in the treatment of children and
adolescents with eating disorders. Family therapy is one of the few therapies with
good evidence of benefit.
• There is a very limited evidence base for the pharmacological treatment of
anorexia nervosa.Medication for co-morbid conditions such as depressive or
obsessive-compulsive features should be used with caution as they may resolve
with weight gain alone, and side effects of drug treatment (in particular, cardiac
side effects) should be carefully considered because of the compromised
cardiovascular function of many people with anorexia nervosa.
• Managing weight gain:
o In most patients: an average weekly weight gain of 0.5-1 kg in
inpatient settings and 0.5 kg in outpatient settings should be an aim of
treatment (this requires about 3500 to 7000 extra calories a week).
o Regular physical monitoring.
o Multi-vitamin and mineral supplements.
• Managing risk:
o Risk should be very closely monitored.
o If all efforts of discussion and concordance break down and
essential treatment is refused, then very occasionally there is a need to use
the Mental Health Act, or the right of those with parental responsibility to
override the young person's refusal, or even legal advice may be needed in
order to consider proceedings under the Children Act 1989