Eating Disorders - Anorexia Nervosa

Anorexia

without appetite (although not always true)

Nervosa

with nervous origin

3 essential criteria of Anorexia

behavioral
psychopathological
physiological

Behavioral (AN)

self induced starvation to a significant degree

psychopathological

relentless drive for thinness or morbid fear of fatness

physiological

presence of medical signs and symptoms resulting from starvation

2 subtypes of Anorexia Nervosa

Restricting
Binge/Purge

Restricting AN

purposefully reducing or limiting the amount of food consumed but does not engage in binging or purging

Binge/Purge AN

restricts intake or diets much of the time
eats excessive amount of food during binging episodes
induces vomiting or misuses laxative, diuretics or enemas

Higher risk of AN in

Females
activities with weight limits (ballerinas, models, wrestlers)

AN excessively preoccupied with

weight, food and body shape

Outcome of AN

varies from spontaneous recovery to episodic flareups to death

AN is associated with

underlying psychological disturbance often associated with transition from childhood to adulthood
typical onset 14-18 yrs old

Risk Factors and Causes AN

-attempt to control 1 area of life when another area is perceived to be out of control
-struggling with transition from child to adult
-social media (media) giving unrealistic expectations about boy image and expectations
-the use of airbrushing and filters in photos
-celebratory rsponse to weight loss. thin-spriational stories about how weight loss improved lives
responding to parental expectations and ideals
-emotional triggers - loss, end of relationship, conflict

Emotional Triggers of AN

loss
end of relationship
conflict

Possible causes of AN

combination of biological, social and psychological
run in families
environmental pressures -friends, fam, class
reduced Norepinephrine turnover and activity
possibly reduced Serotonin
Ego-syntonic which makes tx challenging because the pt sees value in the illness

Biological Factors associated with AN

-endogenous opioids may contribute to reduced hunger. when receiving opioid antagonist they seem to gain weight
-cortisol & thyroid function suppressed during periods of starvation
Amenorrhea and lowered hormonal levels (LH, FSH, GnRH)
CT reveals enlarged CSF spaces in sulci and ventricles during starvation, yet reversed when sufficient intake is restored
possible dysfunction in hypothalamic pituitary axis

Social Factors of AN

-society values diet and exercise
-tend to have close dysfunctional relationship with parents
-particularly in binge eating disorder, child may come from family with high levels of chaos, hostility and isolation and low levels of nurturance and empathy
-may start with symptoms during parental divorce
-involvement in activities that have weight requirements
-higher risk in males with homosexual orientation when compared to hetero males, yet lower risk In females with homosexual orientation.

DSM 5 AN

1. restriction of intake leading to low body weight. (less than minimally expected)
2. intense fear of gaining weight or of becoming fat. or persistent behavior that interferes with weight gain, even though at a significanly low weight.
3. disturbance in way body body weight or shape on self eval. or persistent lack of recognition of seriousness of curernt low body weight
SPECIFY TYPE: restricting or binge/purge

Specifiers AN

- in partial remission: after full criteria for AN were previously met, criteria A(low body weight) has not been met for sustained period but criteria B or C still met
-in full remission: after full criteria for AN were previously met, NONE of criteria have been met for a sustained period of time.

Severity

mild: BMI ≥ 17
moderate:BMI 16-16.99
Severe: BMI 15-15.99
Extreme: BMI < 15

Cultural Consideration AN

-diagnosis and tx is guided by BMI
-consider whether BMI results are appropriate for cultural and ethnic backgrounds
-eating disorders dont discriminate (emily project)

Presentation of AN

-many behvaiors take place in private
-food focused, talking about food, cookinng elaborate meals for others, watching food network
-lack of appetite does not take place until late in d/o
-refuse to eat with family or in public
-very cautious with food items consumed
-candies in pokcet or purse
-spend mealtime cutting and reorganize meal
-may hid efood for disposal later
-if confronted may use reverse logic (suggesting parent is guilty of maintaining unhealhty diet)
-intense exercise regimen
-regimented and perfectionistic

Physical Indicators as AN progresses

Amenorrhea
vitals
CV
GI
metabolic
endocrine
hematologic

Amenorrhea

usually initial reason for seeking treatment, may present before significant weight loss is evident

vitals

bradycardia, orthostatic hypotension, hypothermia

CV

peripheral edema, decrease cardiac diameter, narrowing of left ventricle, rhythm changes

GI

delayed gastric emptying
decreased lipase and lactase

Metabolic

increased cholesterol
hypoglycemia (asymptomatic at times)
elevated liver enzymes
decreased bone mineral density

endocrine

low estrogen or testosterone
low LH
low thyroxine
increased prolactin
partialdiabetes insipidus

Hematologic

leukopenia
lymphocytosis
hypokalemia alkalosis

cardiac monitoring AN

-EKG may show ST and T wave changes (typically caused by electrolyte disturbances)
-QT prolongation
-mitral valve motion abnormalities
-bradycardic
-hypotensive
-risk for sudden death

Interventions for AN

-Exclude underlying medical cause for weight loss (hyperactivity of vagus nerve, cancer, tumor)
-be prepared for parent with eating disorder to deny condition
-family members may be resistive as well
-look for signs that problem is anorexia and decrease appetite is not due to depression
-differentiate from psychotic symptoms (poisoned food)

Prognosis

-may spontaneously resolve or may wax and wane or could lead to death
-majority of hospitalized pt respond well to treatment during stay
-admission of hunger, accepting dx, and working on self esteem/coping strageies are consistent with a more favorable prognosis
-treat underlying psychopathology to improve outcomes

Hospitalization of AN

-20% below expected weight/height
-30% below are likely to require more prolonged admission (2-6 months)
-tx goals are to restore nutitional state, treat dehydration and resotre electrolyte imbalance
-must be medically cleared before entering tx program
-weigh daily backwards
-if hx of purging bathroom access should be restricted after meals
-target goal is often to provide 500 kcal more than caloric amount necessary to maintain current weight
-consider liquid supplements

Treatment Options AN

-individual and fam therapy
NO FDA APPROVED MEDICATION

Off label medication for AN

Cypoheptadine (periactin)
Pimozide (orap)
TCA
Fluoxetine
thorazine
ariprazole

Cypoheptadine (periactin)

Off label for AN
non selectively antagonizes central and peripheral histaimne H1 receptors, used off label for those with restricting AN

Pimozide (orap)

thought to selectively antagonize D2 receptors

TCA

thought to offer potential benefit especially amitriptyline and clomipramine(anafranil). however rule out hypotension/cardiac rhythm issues first/replace potassium

Fluoxetine

demonstrated potential to promote weight gain and if depression is a possibly may benefit that well.

Chlorpromazine) Thorazine

although risk for metabolic syndrome/EPS/TD is a consideration

Aripiprazole

demonstrated improvement in symptoms with weight gain (treatment success)