Anorexia nervosa
The key feature of anorexia nervosa is self-imposed starvation, resulting from a distorted body image and an intense, irrational fear of gaining weight, even when the patient is obviously emaciated. A patient with anorexia is preoccupied with her body size, describes herself as “fat,” and commonly expresses dissatisfaction with a particular aspect of her physical appearance. Although the term anorexia suggests that the patient’s weight loss is associated with a loss of appetite, this is rare. Anorexia nervosa and bulimia nervosa can occur simultaneously. In anorexia nervosa, the refusal to eat may be accompanied by compulsive exercising, self-induced vomiting, or laxative or diuretic abuse.
Causes and incidence
No causes of anorexia nervosa have been identified; however, genetic, social, and psychological factors have been implicated. Researchers in neuroendocrinology are seeking a physiologic cause, but have found nothing definite. Clearly, social attitudes that equate slimness with beauty play some role in provoking this disorder; family factors are also implicated. Most theorists believe that refusing to eat is a subconscious effort to exert personal control over one’s life. Anorexia nervosa has been associated with other psychiatric disorders, such as obsessive-compulsive disorder, depression, and anxiety.
Anorexia occurs in 5% to 10% of the population; about 95% of those affected are women. This disorder occurs primarily in adolescents and young adults but may also affect older women. The occurrence among males is rising. The prognosis varies but improves if the patient is diagnosed early or if she wants to overcome the disorder and seeks help voluntarily. Mortality ranges from 5% to 15% — the highest mortality associated with a psychiatric disturbance. One-third of these deaths can be attributed to suicide.
Signs and symptoms
The patient’s history usually reveals a 25% or greater weight loss for no organic reason, coupled with a morbid dread of being fat and a compulsion to be thin. Such a patient tends to be angry and ritualistic. She may report amenorrhea, infertility, loss of libido, fatigue, sleep alterations, intolerance to cold, and constipation.
Hypotension and bradycardia may be present. Inspection may reveal an emaciated appearance, with skeletal muscle atrophy, loss of fatty tissue, atrophy of breast tissue, blotchy or sallow skin, lanugo on the face and body, and dryness or loss of scalp hair. If also bulimic, calluses on the knuckles, and abrasions and scars on the dorsum of the hand may result from tooth injury during self-induced vomiting. Other signs of vomiting include dental caries and oral or pharyngeal abrasions. (See Complications of anorexia nervosa.)
Palpation may disclose painless salivary gland enlargement and bowel distention. Slowed reflexes may occur on percussion. Oddly, the patient usually demonstrates hyperactivity and vigor (despite malnourishment). She may exercise avidly without apparent fatigue.
During psychosocial assessment, the patient with anorexia may express a morbid fear of gaining weight and an obsession with her physical appearance. Paradoxically, she may also be obsessed with food, preparing elaborate meals for others. Social regression, including poor sexual adjustment and fear of failure, is common. Like bulimia nervosa, anorexia nervosa is commonly associated with depression. The patient may report feelings of despair, hopelessness, and worthlessness as well as suicidal thoughts.
Diagnosis
For characteristic findings in patients with this condition, see Diagnosing anorexia nervosa.
Laboratory tests help to identify various disorders and deficiencies and help to rule out endocrine, metabolic, and central nervous system abnormalities; cancer; malabsorption syndrome; and other disorders that cause physical wasting.
Abnormal findings that may accompany a weight loss exceeding 30% of normal body weight include:
❑ low hemoglobin level, platelet count, and white blood cell count
❑ prolonged bleeding time due to thrombocytopenia
❑ decreased erythrocyte sedimentation rate
❑ decreased levels of serum creatinine, blood urea nitrogen, uric acid, cholesterol, total protein, albumin, sodium, potassium, chloride, calcium, and fasting blood glucose (resulting from malnutrition)
❑ elevated levels of alanine aminotransferase and aspartate aminotransferase in severe starvation states
❑ elevated serum amylase levels when pancreatitis isn’t present
❑ in females, decreased levels of serum luteinizing hormone and follicle-
stimulating hormone
❑ decreased triiodothyronine levels resulting from a lower basal metabolic rate
❑ dilute urine caused by the kidneys’ impaired ability to concentrate urine
❑ nonspecific ST interval, prolonged PR interval, and T-wave changes on the electrocardiogram. Ventricular arrhythmias may also be present.
Treatment
Appropriate treatment aims to promote weight gain or control the patient’s compulsive binge eating and purging. Malnutrition and the underlying psychological dysfunction must be corrected. Hospitalization in a medical or psychiatric unit may be required to improve the patient’s precarious physical condition. The hospital stay may be as brief as 2 weeks or may stretch from a few months to 2 years or longer.
A team approach to care — combining aggressive medical management, nutritional counseling, and individual, group, or family psychotherapy or behavior modification therapy — is most effective in treating anorexia. Treatment results may be discouraging. Many clinical centers are now developing inpatient and outpatient programs specifically aimed at managing eating disorders.
Treatment may include behavior modification (privileges depend on weight gain); curtailed activity for physical reasons (such as arrhythmias); vitamin and mineral supplements; a reasonable diet with or without liquid supplements; subclavian, peripheral, or enteral hyperalimentation (enteral and peripheral routes carry less risk of infection); and group, family, or individual psychotherapy.
All forms of psychotherapy, from psychoanalysis to hypnotherapy, have been used in treating anorexia nervosa, with varying success. To be successful, psychotherapy should address the underlying problems of low self-esteem, guilt, anxiety, feelings of hopelessness and helplessness, and depression.
Special considerations
❑ During hospitalization, regularly monitor the patient’s vital signs, nutritional status, and intake and output. Weigh the patient daily — before breakfast if possible. Because she fears being weighed, vary the weighing routine. Keep in mind that weight should increase from morning to night.
❑ Help the patient establish a target weight and support her efforts to achieve this goal.
❑ Negotiate an adequate food intake with the patient. Make sure she understands that she’ll need to comply with this contract or lose privileges. Frequently offer small portions of food or drinks if the patient wants them. Allow the patient to maintain control over the types and amounts of food she eats, if possible.
❑ Maintain one-on-one supervision of the patient during meals and for 1 hour afterward to ensure compliance with the dietary treatment program. For the hospitalized patient with anorexia, food is considered a medication.
❑ During an acute anorexic episode, nutritionally complete liquids are more acceptable than solid food because they eliminate the need to choose between foods — something the patient with anorexia may find difficult. If tube feedings or other special feeding measures become necessary, fully explain these measures to the patient and be ready to discuss her fears or reluctance; limit the discussion about food itself.
❑ Expect a weight gain of about 1 lb (0.5 kg) per week.
❑ If edema or bloating occurs after the patient has returned to normal eating behavior, reassure her that this phenomenon is temporary. She may fear that she’s becoming fat and stop complying with the plan of treatment.
❑ Encourage the patient to recognize and express her feelings freely. If she understands that she can be assertive, she may gradually learn that expressing her true feelings won’t result in her losing control or love.
❑ If a patient receiving outpatient treatment must be hospitalized, maintain contact with her treatment team to facilitate a smooth return to the outpatient setting.
❑ Remember that the patient with anorexia uses exercise, preoccupation with food, ritualism, manipulation, and lying as mechanisms to preserve the only control she thinks that she has in her life.
❑ Because the patient and her family may need therapy to uncover and correct dysfunctional patterns, refer them to Anorexia Nervosa and Related Eating Disorders, a national information and support organization. This organization may help them understand what anorexia is, convince them that they need help, and help them find a psychotherapist or physician who’s experienced in treating this disorder.
❑ Teach the patient how to keep a food journal, including the types of food eaten, eating frequency, and feelings associated with eating and exercise.
❑ Advise family members to avoid discussing food with the patient.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
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