Saturday, May 27, 2017

Anorexia nervosa

The key feature of anorexia nervosa is self-imposed starvation resulting from a distorted body image and an intense and irrational fear of gaining weight, even when the patient is obviously emaciated. An anorexic patient 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. With anorexia nervosa, the refusal to eat may be accompanied by compulsive exercising, self-induced vomiting, or abuse of laxatives or diuretics.

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.
Although the prognosis varies, it 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.

No one knows what causes anorexia nervosa. 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 also are implicated. Most theorists believe that refusing to eat is a subconscious effort to exert personal control over one’s life.

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. 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.
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) and may exercise avidly without apparent fatigue.

Psychosocial assessment
During psychosocial assessment, the anorexic patient may express a morbid fear of gaining weight and an obsession with her physical appearance. Paradoxically, she also may 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.

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 of more than 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 also may be present.
Appropriate treatment aims to promote weight gain or control the patient’s compulsive binge eating and purging and to correct malnutrition and the underlying psychological dysfunction. Hospitalization in a medical or psychiatric unit may be required to improve the patient’s precarious physical condition. The facility stay may be as brief as 2 weeks or may stretch from a few months to 2 years or longer.

Team approach
The most effective treatment for anorexia combines aggressive medical management, nutritional counseling, and individual, group, or family psychotherapy or behavior modification therapy. 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 individual, group, or family 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.

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