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anorexia nervosa

An emotional & nutritional disorder generally of young women who become emaciated by refusing to eat. Epidemiology: 1) 1% of teenage girls & young women 2) bimodal age distribution, with peaks at age 14 & 18 years Clinical manifestations: 1) underlying maternal-daughter conflict 2) absence of weakness 3) lack of concern for emaciation 3) spontaneous or self-induced vomiting 4) amenorrhea 5) weight loss, as much as 50% of body weight 6) loss of breast tissue 7) low blood pressure, hypotension, orthostatic hypotension* 8) no loss of axillary of pubic hair 9) no change in pigmentation 10) no edema 11) hypothermia 12) bradycardia 13) perception that one is fat 14) may be some overlap with bulimia nervosa * hospitalize for orthostatic hypotension (NEJM) [11] Laboratory: 1) complete blood count (CBC) may reveal anemia 2) decreased serum cholesterol 3) decreased serum gonadotropins 4) decreased urinary 17-ketosteroids 5) normal thyroid function tests 6) low basal metabolic rate (BMR) 7) serum electrolytes - serum potassium: hypokalemia [10] 8) serum glucose may be low - case report of 40 mg/dL without symptoms [10] Special laboratory: - electrocardiogram: - may show prolonged QT interval - diffuse ST segment depressions & T-wave inversions in leads II, III, aVF, & V3-V6 (case report) (image)* - ST-segment elevation in aVR (case report 10) (image)* * changes thought to be due to hypokalemia [10] Radiology: - bone mineral density (DEXA) of spine & hip [11] Complications: 1) suicide 2) anemia 3) osteopenia 4) hypotension 5) electrolyte disorders 6) cardiac arrhythmias 7) refeeding syndrome - electrolyte imbalances (hypokalemia, hypophosphatemia) - cardiac arrhythmias, including cardiac arrest [2] - delirium 8) highest mortality rate of any mental disorder [2] Management: 1) hospitalize for unstable vital signs (NEJM) [11] - blood pressure < 90/60 mm Hg - orthostatic hypotension - heart rate < 40/min - symptomatic hypoglycemia - temperature < 36.1 C - substantial & rapid weight loss 2) intensive psychotherapy (cognitive behavioral therapy) - family-based therapy for adolescents [7] - parent-focused therapy may be better than family-based therapy - a father with lower levels of hostile, critical expressed emotion predicts better outcomes [7] 3) nutritional support - replace low magnesium if severe hypokalemia even if serum magnesium is normal [10] 4) slow weight gain 1-2 pounds/week 5) do not use antidepressants in underweight anorexia 6) antidepressants may be effective for control of depression after weight restoration a) selective serotonin-reuptake inhibitor (SSRI) 1] often higher dose than for depression 2] most effective for controlling bulimic symptoms b) olanzapine (Zyprexa) start 2.5 to 5 mg QD [4] c) drug treatment NOT helpful for anorexia, but may help associated depression [5] d) avoid bupropion & amitriptyline because of high risk of adverse effects (seizures) in the setting of electrolyte imbalance [2] 7) estrogen & progesterone replacement to preserve bone mass for patients with amenorrhea 8) deep brain stimulation with electrodes implanted in the subcallosal cingulate gyrus along with an implanted pulse generator [9] - well tolerated & at least somewhat effective - complications associated with implanted devices - most serious adverse events related to underlying illness 9) screening: SCOFF questionnaire

Related

bulimia nervosa diagnostic criteria for anorexia nervosa SCOFF questionnaire

General

eating disorder

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 865
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 463
  4. Prescriber's Letter 8(9):52 2001
  5. Prescriber's Letter 13(8): 2006 Drug Treatment for Eating Disorders Detail-Document#: 220811 (subscription needed) http://www.prescribersletter.com
  6. Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007 May;40(4):310-20. PMID: 17370290
  7. Le Grange D et al. Randomized clinical trial of parent-focused treatment and family-based treatment for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry 2016 May 25; PMID: 27453082 http://www.jaacap.com/article/S0890-8567(16)30181-2/abstract
  8. Le Grange D. Anorexia nervosa in adults: The urgent need for novel outpatient treatments that work. Psychotherapy (Chic). 2016 Jun;53(2):251-4. PMID: 27267511
  9. Lipsman N, Lam E, Volpini M et al Deep brain stimulation of the subcallosal cingulate for treatment-refractory anorexia nervosa: 1 year follow-up of an open-label trial. Lancet Psychiatry. Feb 23, 2017 PMID: 28238701 http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30076-7/fulltext
  10. DeFilippis EM, Yeh J Electrocardiographic Changes in a Woman With Anorexia Nervosa. JAMA Intern Med. Published online April 16, 2018 PMID: 29710188 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678447
  11. NEJM Knowledge+ Psychiatry
  12. Eating Disorders: Facts About Eating Disorders and the Search for Solutions (NIMH) http://www.nimh.nih.gov/publicat/eatingdisorders.cfm
  13. Skeletal Effects of Anorexia http://www.osteo.org/newfile.asp?doc=r709i&doctitle=Skeletal+Effects+of+Anorexia&doctype=HTML+Fact+Sheet