Anorexia Nervosa: Overview - eMedicine
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#titleblock { background-image: url(); background-repeat: no-repeat; background-position: top right; } eMedicine Specialties> Emergency Medicine> PsychosocialAnorexia NervosaTracy A Farkas, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General HospitalRon Waldrop, MD, Assistant Professor, Department of Emergency Medicine, Louisiana State University, Our Lady of the Lake Regional Medical CenterContributor Information and DisclosuresUpdated: Aug 1, 2006 Print This Email ThisOverviewDifferential Diagnoses & WorkupTreatment & MedicationFollow-upReferencesKeywords
Introduction Background Anorexia nervosa is a psychiatric disorder characterized by the refusal to maintain a minimally normal weight, often with severe physiologic consequences. Patients have a profoundly disturbed body image as well as an intense fear of weight gain despite being severely underweight.Diagnostic criteria for anorexia nervosa in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) include the following:A refusal to maintain body weight at or above a minimally normal weight for age and height (usually less than 85% of ideal body weight)Intense fear of gaining weight or becoming fatDisturbance in the way one's body weight or shape is experienced, with denial of current low body weightAmenorrhea in postmenarcheal females of at least 3 menstrual cyclesThe disorder may be further divided into 2 subtypes: (1) restricting, in which severe limitation of food intake is the primary means to weight loss, and (2) binge-eating/purging type, in which there are periods of food intake that are compensated by self-induced vomiting, laxative or diuretic abuse, or excessive exercise.Other physiologic causes of malnutrition, weight loss, and amenorrhea must be ruled out to make the diagnosis.Patients with anorexia nervosa often display other personality characteristics such as a desire for perfection, academic success, lack of age-appropriate ual activity, and a denial of hunger in the face of starvation. Psychiatric characteristics include excessive dependency needs, developmental immaturity, social isolation, obsessive-compulsive behavior, and constriction of affect. Many patients also have comorbid mood disorders, with depression and dysthymic disorder being most prevalent. Pathophysiology Anorexia nervosa is the result of a complex interplay between biological, psychological, and social factors, which tend to affect women more than men, and adolescents more than older women. Some evidence suggests a higher rate of the disorder in monozygotic twins than in dizygotic twins, which may indicate a biologic predisposition.Psychologically, prepubescent patients who subsequently develop anorexia nervosa have a high incidence of premorbid anxiety disorders. The onset of the disorder during puberty has led to the theory that, by exerting control over food intake and body weight, adolescents are attempting to compensate for a lack of autonomy and selfhood.The patient's altered body image results in a perception of fatness despite being normal or underweight. Attempts to correct this flaw through food restriction or purging lead to progressive starvation. Modern preoccupation with slenderness and beauty in the Western world may contribute to the mindset of slenderness as a valued quality in adolescents; however, this link has not been proven.Malnutrition subsequent to self-starvation leads to protein deficiency and disruption of multiple organ systems. In addition to hypoglycemia and vitamin deficiencies, starvation results in release of endogenous opioids, hypercortisolemia, and thyroid function suppression. Neuroendocrine disturbances result in delayed puberty, amenorrhea, anovulation, low estrogen states, increased growth hormone, decreased antidiuretic hormone, hypercarotenemia, and hypothermia. Decreased gonadotropin levels and hypogonadism may occur among males who are affected.Cardiovascular effects include mitral valve prolapse, supraventricular and ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, and shock due to congestive heart failure.Renal disturbances include decreased glomerular filtration rate (GFR), elevated BUN, edema, acidosis with dehydration, hypokalemia, hypochloremic alkalosis with vomiting, and hyperaldosteronism.Gastrointestinal findings include constipation, delayed gastric emptying, and gastric dilation and rupture. Patients who induce vomiting develop dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory-Weiss lesions, and elevated transaminases. Frequency United States The lifetime prevalence of anorexia nervosa in the United States is estimated at 0.3-1%; however, some studies have shown rates as high as 4% among women. The rates among men are estimated at 0.1%. As many as 5% of young women exhibit symptoms of anorexia but do not meet full diagnostic criteria.International Anorexia nervosa is found in all developed countries and in all socioeconomic classes at similar rates (0.3-1% in women, 0.1% in men). Mortality/Morbidity Anorexia nervosa has one of the highest mortality rates of all psychiatric disorders, with rates reported from 5-18%. Patients with restricting subtype tend to have more resistance to recovery.Approximately 50% of patients will recover with treatment and maintain a normal weight but often not without relapses and multiple treatment modalities. Mortality is often due to suicide and less frequently to complications of starvation. Race Anorexia nervosa is significantly more frequent in white populations than in people of other races, but it has been reported among all races.A link between socioeconomic class and prevalence of eating disorders has not been demonstrated in the literature. Female-to-male ratio is 10-20:1 in developed countries.In some professions, the frequency is much higher among men (wrestling, running, modeling) than the general male population. Age Anorexia nervosa is primarily a phenomenon of puberty and early hood. Eighty-five percent of patients have onset of the disorder between the ages of 13 and 18 years.Anorexia nervosa has been observed in both the very young and very old. Patients who are older at the time of onset of the disorder have a worse prognosis. Clinical History Patients may present to the ED with extreme weight loss, food refusal, dehydration, weakness, or shock. Many present at the urging of family members or friends and are in deep denial of their malnutrition and illness.Patients should be questioned about their current weight, highest weight, lowest weight, exercise habits, and menstrual cycles. Further questioning should inquire with regard to eating habits, presence or absence of self-induced vomiting/binge eating, etc.Major depression and dysthymic disorder have been reported in up to 50% of patients with anorexia nervosa. Patients should be asked about early morning awakening, tearfulness, and thoughts of suicide or a plan.Review of systems is often positive for constipation, early satiety, hypothermia, nausea, hair loss, and fatigue. Physical Patients may present anywhere along the spectrum of weight loss. They may attempt to hide their weight loss by wearing bulky clothing or many layers.Physical examination may reveal hypothermia, peripheral edema, thinning hair, and obvious emaciation.Behaviorally, a patient may demonstrate a flat affect and display psychomotor retardation, especially in the later stages of the disease.Vital sign abnormalities may include hypothermia, bradycardia, and hypotension.Cardiac examination may reveal the mid-systolic click of mitral valve prolapse.Patients with purging behavior may have parotid gland hypertrophy, dental enamel erosion and, in extreme cases, seizures from electrolyte disturbances.Dermatologic examination reveals dry skin, lanugo (a fine, downy covering of hair on the extremities), and poor skin turgor. Causes Anorexia nervosa is a complex combination of biological, psychological, and social factors, which have devastating physical and mental consequences.Some evidence suggests that biologic risk factors include a first-degree relative with an eating disorder and higher rates of the disorder in monozygotic than dizygotic twins.A psychological profile often demonstrates premorbid anxiety disorders as well as more severe affective disorders such as major depression and dysthymic disorder. Patients may also have symptoms of obsessive-compulsive disorder, with rigid and ritualistic eating behaviors.ReferencesContentsOverview: Anorexia NervosaDifferential Diagnoses & Workup: Anorexia NervosaTreatment & Medication: Anorexia NervosaFollow-up: Anorexia NervosaPrint ThisEmail This
[ CLOSE WINDOW ]ReferencesAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington DC: American Psychiatric Association;1994:539-545.Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med. Apr 8 1999;340(14):1092-8. [Medline].Bochereau D, Clervoy P, Corcos M, Girardon N. [Eating disorders. Anorexia nervosa in adolescents]. Presse Med. Jan 16 1999;28(2):89-99. [Medline].Coxson HO, Chan IH, Mayo JR. Early emphysema in patients with anorexia nervosa. Am J Respir Crit Care Med. Oct 1 2004;170(7):748-52. [Medline].Deep AL, Nagy LM, Weltzin TE, et al. Premorbid onset of psychopathology in long-term recovered anorexia nervosa. Int J Eat Disord. Apr 1995;17(3):291-7. [Medline].Forman, S. Eating Disorders: epidemiology, pathogenesis, and clinical features. Up to Date. 2005;[Full Text].Hartman D. Anorexia nervosa--diagnosis, aetiology, and treatment. Postgrad Med J. Dec 1995;71(842):712-6. [Medline].Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. Dec 2003;34(4):383-96. [Medline].Kaplan, H, Sadock, B. Synopsis of Psychiatry. -8th ed. Williams and Wilkins;. 1998:720-727.Lavelle JM. Adolescent emergencies. In: Fleischer GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins;1993:1503-1526. [Medline].Miller KK, Grinspoon SK, Ciampa J. Medical findings in outpatients with anorexia nervosa. Arch Intern Med. Mar 14 2005;165(5):561-6. [Medline].Nilsson EW, Gillberg C, Rastam M. Familial factors in anorexia nervosa: a community-based study. Compr Psychiatry. Nov-Dec 1998;39(6):392-9. [Medline].Rosenblum J, Forman S. Evidence-based treatment of eating disorders. Curr Opin Pediatr. Aug 2002;14(4):379-83. [Medline].Steinhausen HC. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. Aug 2002;159(8):1284-93. [Medline].Stoving RK, Hangaard J, Hansen-Nord M, et al. A review of endocrine changes in anorexia nervosa. J Psychiatr Res. Mar-Apr 1999;33(2):139-52. [Medline].Vazquez M, Olivares JL, Fleta J, et al. Cardiac disorders in young women with anorexia nervosa. Rev Esp Cardiol. Jul 2003;56(7):669-73. [Medline].[ CLOSE WINDOW ]Further Reading[ CLOSE WINDOW ]Keywords self-starvation, malnutrition, severe weight loss, extreme weight loss, life-threatening weight loss, amenorrhea, eating disorder, intense fear of obesity, primary amenorrhea, secondary amenorrhea, denial of hunger, aual behavior, depression, obsessive-compulsive behavior, developmental immaturity, binge behavior, purge behavior, anxiety disorder, hypoglycemia, vitamin deficiencies, delayed puberty, anovulation, neuropathy, myopathy, encephalopathy, hypothermia, hypogonadism, supraventricular dysrhythmias, ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, shock, congestive heart failure, hypokalemia, hypochloremic alkalosis, hyperaldosteronism, gastric dilation, gastric rupture, dental enamel erosion, palatal trauma, enlarged parotids, esophagitis, Mallory Weiss lesions, diminished gag reflex, elevated transaminases, substance abuse, psychomotor retardation[ CLOSE WINDOW ]Contributor Information and DisclosuresAuthorTracy A Farkas, MD, Staff Physician, Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's Hospital and Massachusetts General HospitalTracy A Farkas, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Women's Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine Disclosure: Nothing to discloseCoauthorRon Waldrop, MD, Assistant Professor, Department of Emergency Medicine, Louisiana State University, Our Lady of the Lake Regional Medical Center Disclosure: Nothing to discloseMedical EditorEdward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins UniversityEdward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclosePharmacy EditorFrancisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine Disclosure: Nothing to discloseManaging EditorRobert C Harwood, MD, MPH, Program Director, Chair, Department of Emergency Medicine, Christ Hospital and Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago Medical SchoolRobert C Harwood, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Chicago Medical Society, Illinois State Medical Society, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to discloseCME EditorJohn D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical CenterJohn D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine Disclosure: Nothing to discloseChief EditorJonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical SchoolJonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine Disclosure: eMedicine.com, Inc. 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