anorexia nervosa
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Introduction
An emotional & nutritional disorder generally of young women who become emaciated by refusing to eat.
Epidemiology
- 1% of teenage girls & young women
- bimodal age distribution, with peaks at age 14 & 18 years
Clinical manifestations
- underlying maternal-daughter conflict
- absence of weakness
- lack of concern for emaciation
- spontaneous or self-induced vomiting
- amenorrhea
- weight loss, as much as 50% of body weight
- loss of breast tissue
- low blood pressure, hypotension, orthostatic hypotension*
- no loss of axillary of pubic hair
- no change in pigmentation
- no edema
- hypothermia
- bradycardia
- perception that one is fat
- may be some overlap with bulimia nervosa
* hospitalize for orthostatic hypotension (NEJM)[11]
Laboratory
- complete blood count (CBC) may reveal anemia
- decreased serum cholesterol
- decreased serum gonadotropins
- decreased urinary 17-ketosteroids
- normal thyroid function tests
- low basal metabolic rate (BMR)
- serum electrolytes
- serum glucose may be low
Diagnostic procedures
- 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
- suicide
- anemia
- osteopenia
- hypotension
- electrolyte disorders
- cardiac arrhythmias
- refeeding syndrome
- highest mortality rate of any mental disorder[2]
Management
- 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
- intensive psychotherapy (cognitive behavioral therapy)
- nutritional support
- replace low magnesium if severe hypokalemia even if serum magnesium is normal[10]
- slow weight gain 1-2 pounds/week
- do not use antidepressants in underweight anorexia
- antidepressants may be effective for control of depression after weight restoration
- selective serotonin-reuptake inhibitor (SSRI)
- often higher dose than for depression
- most effective for controlling bulimic symptoms
- olanzapine (Zyprexa) start 2.5 to 5 mg QD[4]
- drug treatment NOT helpful for anorexia, but may help associated depression[5]
- avoid bupropion & amitriptyline because of high risk of adverse effects (seizures) in the setting of electrolyte imbalance[2]
- selective serotonin-reuptake inhibitor (SSRI)
- estrogen & progesterone replacement to preserve bone mass for patients with amenorrhea
- 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
- screening: SCOFF questionnaire
More general terms
Additional terms
References
- ↑ DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 865
- ↑ 2.0 2.1 2.2 2.3 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 - ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 463
- ↑ 4.0 4.1 Prescriber's Letter 8(9):52 2001
- ↑ 5.0 5.1 Prescriber's Letter 13(8): 2006 Drug Treatment for Eating Disorders Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=220811&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/17370290
- ↑ 7.0 7.1 7.2 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; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27453082 <Internet> http://www.jaacap.com/article/S0890-8567(16)30181-2/abstract
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/27267511
- ↑ 9.0 9.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28238701 <Internet> http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30076-7/fulltext
- ↑ 10.0 10.1 10.2 10.3 10.4 DeFilippis EM, Yeh J Electrocardiographic Changes in a Woman With Anorexia Nervosa. JAMA Intern Med. Published online April 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29710188 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678447
- ↑ 11.0 11.1 11.2 11.3 NEJM Knowledge+ Psychiatry
- ↑ Eating Disorders: Facts About Eating Disorders and the Search for Solutions (NIMH) http://www.nimh.nih.gov/publicat/eatingdisorders.cfm
- ↑ Skeletal Effects of Anorexia http://www.osteo.org/newfile.asp?doc=r709i&doctitle=Skeletal+Effects+of+Anorexia&doctype=HTML+Fact+Sheet