Anorexia Nervosa

Anorexia Nervosa: Excerpt from The 5-Minute Pediatric Consult

Candice P. Chen, MD

Anorexia Nervosa - BASICS

Anorexia Nervosa - 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 one’s 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.

Anorexia Nervosa - 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.

Anorexia Nervosa - epidemiology

Anorexia Nervosa - prevalence

• Typically, adolescent girls or young women, although 5–15% of cases are in male patients.
• Estimated 0.5–1% 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.

Anorexia Nervosa - risk factors

More prevalent in industrialized societies; occurs in all US household income levels and major ethnic groups

Anorexia Nervosa - 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.

Anorexia Nervosa - 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, sodium abnormalities may develop due to dehydration or excess water intake, and hypokalemia can develop secondary to vomiting and/or laxative or diuretic use.

Anorexia Nervosa - 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.

Anorexia Nervosa - associated conditions

• Depression
• Anxiety disorders
• Substance abuse

Anorexia Nervosa - DIAGNOSIS

Anorexia Nervosa - signs & symptoms

Anorexia Nervosa - history

• Question: Have you ever weighed much less than other people thought you should?
  • 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?
  • The reported weight should be used to calculate a BMI.
• Question: Are you afraid of gaining weight?
  • Patients will often report an intense fear of gaining weight.
• Question: How do you think you look?
  • A patient’s 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?
  • 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).

Anorexia Nervosa - physical exam

• All patients should have a full physical exam with special emphasis on:
  • Vital signs, weight, height, BMI: May have bradycardia, hypotension, or hypothermia; BMI is needed to determine if weight is <85% expected
  • Physical and sexual growth and development: May be emaciated, have atrophic breasts or delayed puberty
  • Cardiovascular system: May detect a cardiac arrhythmia, murmur, or evidence of congestive heart failure
  • Lanugo
  • Salivary gland enlargement or Russell sign (scarring on dorsum of hand): Suggests purging behavior.
  • Muscular irritability or weakness: May occur with severe malnutrition or use of ipecac.
  • 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.

Anorexia Nervosa - tests

Anorexia Nervosa - lab

• All patients with anorexia nervosa
  • Serum electrolytes, BUN/creatinine: Most are normal, may show dehydration or sodium or potassium abnormalities
  • TSH, if indicated, free TCBC with differential: Mild anemia is common due to iron or folate deficiency; WBC count is generally low due to malnutrition.
  • ESR: Generally low due to malnutrition
  • AST, ALT, alkaline phosphatase: Occasionally abnormal due to fatty liver
  • Urinalysis: Evaluate specific gravity to assess for dehydration that may be seen with purging or diuretic use.
• Malnourished and severely symptomatic patients:
  • Complement component 3^a: May indicate nutritional deficiencies when other markers are within normal ranges.
  • Serum calcium, magnesium, phosphorous: May all be low; in hospitalized patients follow phosphorous daily to assess for refeeding syndrome.
  • Serum ferritin: May be low
  • Electrocardiogram: May have bradycardia, ST-T wave abnormalities with hypokalemia, increased PR interval and 1st-degree heart block, prolonged QT24-hour urine for creatinine clearance: Generally low, normal may indicate azotemia
• Patients amenorrheic for >6 months:
  • Dual-energy x-ray absorptiometry (DEXA) scan: Evaluates bone density to determine risk of compression fracture and bone loss
• Nonroutine assessments:
  • Toxicology screen, if suspect substance use
  • Serum amylase, fractionated for salivary gland isoenzyme if available, if suspected vomiting: Will be elevated
  • Serum LH, FSH, prolactin, if persistent amenorrhea with normal weight: LH and FSH will generally be low.
  • β-HCG: Rule out pregnancy.
  • Stool for guaiac, if suspected GI bleed
  • Stool or urine for bisacodyl, emodin, aloe-emodin, and rhein, if suspected laxative abuse

Anorexia Nervosa - differencial 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)

Anorexia Nervosa - TREATMENT

Anorexia Nervosa - general measures

Anorexia Nervosa - 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 30–40 kcal/kg/d, may increase to 70–100 kcal/kg/d. Weight gain goal of 0.5–1 lb/wk is realistic.
• In malnourished patients, avoid refeeding syndrome by starting slowly, generally 1,000–1,600 kcal/d and increasing by 200–400 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 40–60 kcal/kg/d).

Anorexia Nervosa - activity

Help limit physical activity and caloric expenditure if exercise is a significant component of the patient’s illness.

Anorexia Nervosa - 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

Anorexia Nervosa - medication

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
  • SSRIs have the most evidence for efficacy.
  • Do not use bupropion in patients with eating disorders because of an increased risk of seizures in patients with eating disorders.
  • 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.

Anorexia Nervosa - FOLLOW UP

Anorexia Nervosa - disposition

Anorexia Nervosa - 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

Anorexia Nervosa - prognosis

• Mortality rate 0.56% per year
• ~50% have full recovery, 30% have partial recovery, 20% have no substantial improvement

Anorexia Nervosa - 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 vasopressin secretion, 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

Anorexia Nervosa - 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

Anorexia Nervosa - bibliography

1. American Academy of Pediatrics Committee on Adolescence. Identifying and Treating Eating Disorders. Pediatrics. 2003;111(1):204–211.
2. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd Edition. Am J Psychiatry. 2006
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.
3. Becker AE, Grinspoon SK, Klibanski A, et al. Eating Disorders. N Engl J Med. 1999;340:1092–1098.
Zimmerman M. Interview Guide for Evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination. East Greenwich, RI: Psych Production Press; 1994.

Anorexia Nervosa - CODES

Anorexia Nervosa - icd9

• 307.1 Anorexia nervosa
• 307.50 Eating disorder NOS

Anorexia Nervosa - PATIENT TEACHING-MED

Internet resources for patients and families:

• National Eating Disorders Association (www.nationaleatingdisorders.org)
• National Association of Anorexia Nervosa and Associated Disorders (www.anad.org)

Anorexia Nervosa - FAQ

• Q: What is the expected inpatient treatment duration?
• A: Duration of hospitalization varies; average is ~5–6 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 patient’s cardiac and electrolyte status is stable.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Anorexia Nervosa

• Back to disease: Anorexia Nervosa: Introduction
• Next Book Extract About Anorexia Nervosa: Surveys relating to Anorexia Nervosa
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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