Anorexia Nervosaddddsa

Definition/Description

Anorexia nervosa is an eating disorder in which the individual exhibits

severe weight loss without any indication of underlying systemic causes.
Individuals with anorexia nervosa have a distorted view of their own body
image and an extreme fear of gaining weight. [1][2][3][4][5]  Anorexia nervosa is
diagnosed according to the DSM IV criteria listed below. 

DSM IV-TR Diagnostic Criteria of Anorexia Nervosa

1. "Refusal to maintain body weight at or above a minimally normal

weight for age and height: Weight loss leading to maintenance of body
weight <85% of that expected or failure to make expected weight gain
during period of growth, leading to body weight less than 85% of that
expected." [4]
2. "Intense fear of gaining weight or becoming fat, even though under
weight."[4]
3. "Disturbance in the way one's body weight or shape are experienced,
undue influence of body weight or shape on self evaluation,or denial of the
seriousness of the current low body weight." [4]
4. "Amenorrhea (at least three consecutive cycles) in postmenarchial
girls and women.  Amenorrhea is defined as periods occurring only
following hormone (e.g., estrogen) administration." [4]

Two sub-types of anorexia nervosa have been recognized by the Diagnostic

and Statistical Manual of Mental Disorders.  These sub-types include the
restricting type and the binge-eating-purging type. Restricting subtype is
characterized by an individual with anorexia nervosa who has not regularly
taken part in bingeing or purging behaviors during the current episode. 
Bingeing and purging behaviors include the use of laxatives, diuretics,
enemas, and self-induced vomiting to restrict weight gain.  Binge-eating-
purging subtype is characterized by an individual who has regularly taken
part in binge-eating or purging behaviors in the current episode of anorexia
nervosa.  [4][2]

Prevalence

Individuals with anorexia nervosa typically are young girls or women a part
of the middle to upper-class families.  Males also suffer from anorexia
nervosa, but the prevalence is much lower, 5-10% of cases. [2]  The female to
male ratios range from 6:1 to 10:1 in the United States. However, the
 characteristics and behaviors of males and females with anorexia nervosa
are similar. 0.9% of American women suffer from anorexia in their lifetime.
[6]

 1 in 5 anorexia deaths is by suicide. [7]

 Standardized Mortality Ratio (SMR) is a ratio between the observed
number of deaths in an study population and the number of deaths would
be expected. SMR for Anorexia Nervosa is 5.86. [7]
 33-50% of anorexia patients have a co-morbid mood disorder, such
as depression. Mood disorders are more common in the binge/purge
subtype than in the restrictive subtype. [8]
 About half of anorexia patients have co-morbid anxiety disorders,
including obsessive-compulsive disorder and social phobia. [9]

The most common age for onset of anorexia nervosa is in the mid-teens
and the disorder is most common in industrialized cultures such as United
States, Canada, Europe, Australia, New Zealand, and South Africa. 
Anorexia nervosa is present in approximately 4% of young adolescents and
adults in the United States. [4]

When a closer look at individuals with anorexia nervosa is taken, a

correlation can be seen between the number of diagnosed cases and
athletes of specific sports.  Anorexia nervosa is more commonly seen in
athletes who partake in sports that exist with the view point that a leaner
appearance enhances performance.  Such sports include gymnastics, ballet,
running, body building, and wrestling. [4]

Characteristics/Clinical Presentation

Anorexia nervosa typically develops in adolescence around the onset of

puberty.  This is believed to develop due to the increased deposition of fat
that commonly coincides with puberty.  Adolescents are more likely to
succumb to peer pressure and societal pressures to be thin at this age.  An
increased awareness of body shape and size is also present at this age
period.  Early recognition of anorexia nervosa is very important in order to
prevent the devastating physical and emotional symptoms caused by
starvation, malnutrition, and purging. [2][1]

The following characteristics can be present in individuals with anorexia

nervosa, however not all signs and symptoms may be present at the same
time in one individual. 

 Restriction of food eaten or calories eaten

 Excessive exercise to the point of exhaustion
 Use of laxatives, enemas, or diuretics to restrict weight gain
 Elaborate preparation of meals with refusal to eat [1]
 Increased preoccupation with food
 Excessive gum chewing
 Self isolation or decreased interest in social activities
 Decreased motivation
 Decreased sexual interest
 Mood changes especially depression, irritability,anxiety, or apathy [2]
The following physical symptoms may be present in individuals with
anorexia nervosa:

 Severe weight loss

 Abnormal blood counts [3]
 Increased fatigue, insomnia, or dizziness
 Brittle hair and nails
 Amenorrhea
 Irregular heart rhythms
 Low blood pressure
 Edema in the distal extremities or face [3]
 Osteoporosis
 Enlarged ventricles and sulci as seen by CT scans [4]
 Sore throat
 Chest pain
 Calluses on dorsum of the hand (Russell's Sign) [2]
 Dental erosion from gastric acids
 Electrolyte imbalances (Potassium, Sodium, Hydrogen Chloride, and
Magnesium)[1]
 Proximal muscle weakness with use of ipecac [5]
 Abnormal muscle biopsy and electromyograph [5]
 Gait disturbances [5]
 Muscle tetany
 Peripheral paresthesia
 Obsessive-compulsive behaviors [4]

Associated Co-morbidities

Death is the most devastating co-morbidity present with this eating

disorder and most commonly occurs due to symptoms of starvation or
suicide.  Medical conditions typically causing death consist of abnormal
heart rhythms and imbalances of electrolytes.  Mortality rates are as high
as 5.9% in anorexia nervosa diagnoses.
 Co-morbid conditions present in individuals with anorexia nervosa may
also include "major depressive disorder (50-75% of cases), sexual abuse
(20-50% of cases), obsessive compulsive disorder (25% of cases), substance
abuse (12-18% of cases), and bipolar disorder (4-13% of cases)". [4]

Anemia, mitral valve prolapse, osteoporosis, and stress fractures are

examples of co-morbidities that may be present with any eating disorders. 
Many individuals with anorexia nervosa often develop other types of eating
disorders as well.  Up to 50% of individuals with anorexia nervosa develop
characteristics of bulimia nervosa over the span of their lifetime.

Medications

Currently the best evidence shows that selective serotonin reuptake

inhibitors (SSRIs) demonstrate the most statistically and clinically
significant positive effects in the treatment of anorexia nervosa. This
medication has shown to improve mood, reduce obsessive behaviors, and
satisfy hunger. [5][2][1][4]  Little research has been done on the use and efficacy
of other medications in the treatment of anorexia nervosa.  The following
medications have been researched in treatment for signs and symptoms of
anorexia nervosa:

 Antipsychotic drug chlorpromazine: Current standards do not

consider this medication adequate for treatment. [2]
 Antipsychotic drugs pimozide and sulpiride: Evidenced negative
outcomes in RCTs and solely used in rare cases in the treatment of
resistant clients. [2]
 Lithium Carbonate: Rarely used in this population due to increased
risk of cardiovascular events and fluid/electrolyte imbalance. [2]
 Antidepressant drug clomipramine: Evidenced negative results in
RCTs. [2]
 Antidepressant drug amitriptyline: Evidenced positive results when
used at 175mg in RCTs. [2]

For further information on these medications, visit the following

website: www.drugs.com/

Screening/Diagnostic Tests/Lab Tests

Commonly used screening tools include:

 Standardized self-reporting questionnaires

 Observations
 Individual interviews
 Pre-participation physical examinations
 Physiological measurements
 Standardized questionnaires: Eating Disorders Inventory (EDI),
Eating Disorder Examination (EDE-Q), and Eating Attitudes Test (EAT) [1]
 Medical examination (Most Sensitive examination): diet, nutrition,
body mass index, weight fluctuations, exercise habits, and menstrual
history. Physical examination of the patient's height, weight, vitals, skin
and nail observation, auscultation of heart and lung sounds, and abdominal
palpation must be completed routinely throughout treatment.
 Body Mass Index (BMI): A BMI less than 18.5 kg/m 2 for individuals
over 18 years old is considered underweight.  For individuals under 18
years old, a body weight less than the 5th percentile for the age and gender
is considered underweight. [1]
 Body Fat Composition: skinfold thickness, air displacement
plethysmography (BOD POD), bioelectrical impedance, and hydrostatic
weighing
 Lab Tests to determine if visceral dysfunction is present include: a
complete blood count (CBC), basic metabolic profile (BMP), BUN, and
urinalysis
 Radiological Tests: X-Ray, Electrocardiogram (ECG), and bone
density (DEXA) scan.  [3]

Listed below are common red flags Mayo Clinic suggests to screen for
during the examination. [3]
 Cause / Risk Factors

 Biological: Young women and men are at an increased risk to

develop anorexia nervosa if the individual has a biological sibling or
mother with anorexia nervosa.  According to current research, children of
patients with anorexia nervosa have a tenfold increased risk for developing
the eating disorder. [3][4]  An area on chromosome one has also been
associated with increased risk for development of anorexia
nervosa. [3] Varying amounts of the chemical serotonin have shown evidence
in playing a role in anorexia nervosa.  All of the above show a definite
genetic involvement in patients with anorexia nervosa. 

 Genetics: 50-80% of the risk for anorexia and bulimia is genetic.

[9]
 According to research, families in which the condition is reported in
more than one member, a genetic predisposition to AN may be a factor for
the development of anorexia. Although the gene(s) responsible for the
disorder have not yet been identified, research has shown that certain loci
on chromosomes 1, 2, and 13 may be involved in the development of
Anorexia. Recently, a study using targeted sequencing implicated the gene
epoxide hydrolase 2 as increasing the risk of developing anorexia. [10]
 Psychological: Individuals with anorexia nervosa often portray low
self-esteem, low self-confidence, extreme perfectionist qualities, and
obsessive-compulsive behaviors. Higher rates of eating disorders are also
found in individuals who were teased about their weight at a younger age. 
Strict weight control can be used as a means to combat feelings of
inadequacy or identity confusion.
 Sociocultural: A correlation between prevalence rates of anorexia
nervosa and modern western cultures have been evidenced in research
today.  Modern western cultures are theorized to emphasize importance of
thin appearance and associate power or wealth with thinness.  [4]
[3]
 Adolescents who feel pressure from families or peers to appear
unrealistically thin are at an increased risk for developing anorexia
nervosa. 
 Familial: Families who struggle with resolving internal conflicts,
constantly overprotecting their children, limit the autonomy of their
children, or expect extraordinarily high achievements place the children at
a higher risk for developing anorexia nervosa as shown in research
trends. [2]
 Athletics: Individuals who participate in any sport that emphasizes
a thin build or has weight classifications is more likely to develop an eating
disorder.  Again those sports that show higher rates of anorexia nervosa
include ballet, gymnastics, long-distance running, figure skating, wrestling,
body-building, and diving. [5]
 Systemic Involvement

Individuals with anorexia nervosa may exhibit but are not limited to the
systemic complications listed below:

Cardiovascular Complications [2]

 Bradycardia
 Orthostatic Hypotension
 Decreased myocardial contractility
 Delayed capillary refill
 Acrocyanosis
 Mitral valve prolapse
 Ventricular arrythmias
 Abnormal QT intervals

Reproductive Complications [2]

 Amenorrhea
 Decreased testosterone in males

Musculoskeletal Complications [4][3][5]

 Rapid bone loss

 Increased risk for stress fractures
 Proximal muscle weakness
 Osteoporosis
 Linear growth retardation in adolescents

Neurological Complications [5]

 Cerebral atrophy
 Seizures
 Muscle Tetany
 Peripheral paresthesia

Biochemical Complications [4]

 Hypercortisolemia
 Nonsuppression of dexamethasone
 Thyroid suppression
[11]

Medical Management

Clients with anorexia nervosa can be treated in outpatient or inpatient

facilities, however the approach is similar in both
instances. Hospitalization may be required for individuals who are not
medically stable.  A more restrictive approach may be more beneficial for
individuals who continue to refuse to eat orally, decline in weight despite
supplementation, electrolyte imbalance, heart arrythmias, or unresponsive
to previous treatment. Indications for hospitalization suggested by the
Cleveland Clinic are as follows: [4]
The main goals for treatment of anorexia nervosa include patient's
recognition of eating disorder, identification of triggers, improvement of
delusional thoughts and feelings towards body image and shape,
achievement and maintenance of healthy weight, and preventing relapse.  A
multi-focal approach is taken for the medical management of anorexia
nervosa in order to combat all symptoms manifested within this disorder.
Behavioral therapy, psychotherapy, family counselling, dietary and
nutritional counseling, and exercise guidance are all recommended in
combination to treat anorexia nervosa.  [5][1][2] Pharmacological treatment is
another aspect that may be necessary in the treatment of the depressive
symptoms found with anorexia nervosa (see medications listed above).

Cognitive behavioral therapy  (CBT) is the most commonly used and

effective psychotherapy to treat this eating disorder especially when
initially supportive and directive.  For younger individuals with anorexia
nervosa, family based therapy is recommended. However, family based
therapy does not show positive results in individuals whose family shows
high levels of expressed emotions.  Family based therapy focuses on
resolving any internal conflicts, monitoring the patient's food intake, and
preventing relapse.  These individuals, as well as individuals over 18 years
old or with a longer duration of anorexia nervosa, benefit more from
individual based psychotherapy. [2] Twelve-step programs can also be
successful with this population in preventing relapse. 

Nutritional therapy guidelines include weight gain of 2-3 lbs per week for
inpatient treatment and 0.5-1 lb per week for outpatient treatment. 
Initially daily caloric goals should reach 1000-1600 kcal in divided meals
and bathroom use should be restricted for two hours following each meal. 
Once a healthy weight is maintained stretching can be reintroduced
followed by aerobic exercise with supervision and counselling on proper
exercise guidelines. [4]
Physical Therapy Management

Physical Therapy is an integral part in rehabilitation of patients with

anorexia nervosa once stretching and exercise is reintroduced.  A health
care provider who has extensive knowledge of proper exercise guidelines
and how to monitor physical signs of fatigue and vitals is needed to treat
these patients.  These skills are important to help the patient learn to
monitor levels of fatigue and heart rate in order to prevent them from over
exercising or exercising to the point of exhaustion.  Patients with anorexia
nervosa are also more susceptible to orthostatic hypotension, bradycardia,
and muscle cramping due to malnutrition and low level caloric diets. A
health care provider, such as a physical therapist, is the best trained
professional to monitor and respond to these medical conditions. 

A physical therapist can also be beneficial during the screening process

because they are educated in their professional programs on how to
recognize the signs and symptoms of this disorder. A therapist may be the
first provider to notice signs and symptoms present with this disorder.  For
example, during a cervical exam the therapist may note edema in the face
or salivary glands or overuse injuries like stress fractures from excessively
exercising. 

When creating exercise programs for these individuals, physical therapists

must take into account bone density levels, orthostatic hypotension,
cardiac status, and lab values.  The program must be adjusted in order to
protect the individual from physical harm or becoming medically unstable. 
Exercise is not recommended if the patients body mass index is less than
18 kg/m 2, and therefore is not introduced until the individual can maintain
a healthy weight and is medically stable.   The ideal exercise program
should include elements of stretching, light upper body weights, breathing
exercises, and aerobic exercise.  It is very important for the physical
therapist to set upper limits on repetitions, sets, or minutes in order to
prevent the individual from over exercising.  Encouraging the individual to
focus on the positive effects of exercise on overall health and not weight is
equally important for the physical therapist. 

References

https://www.physio-pedia.com/Anorexia_Nervosa