History

Fact Explanation
Loss of weight Self induced weight loss is a main symptom of anorexia nervosa. Patient usually avoids 'flattening food' in order to lose weight and avoid weight gain[1][3][4][5]
Negative self-image This is common among patients with anorexia nervosa. It exists in the form of a specific psychpathology (i.e an overvalued idea) [1][3][5]
Being too worried about body weight and shape Patients with anorexia nervosa are always worrying about the way they look. They have unrealistic expectations as to what their body weight and shape should be. This idea of a very slim shapely figure drives them to follow drastic measures in order to achieve it [1][2][3]
Having intense fear of gaining weight or becoming fat, even when underweight This is a common finding in patients with anorexia nervosa. This fear leads the patient to refuse food, do excessive exercise etc even when she is way below the expected weight fro her age and height[1][2]
Refuse to keep weight at what is considered normal for her age and height These patients usually are convinced they are fat and need to lose weight even when their body weight is 15% or more less than what is expected for that patient[1][2]
Being a female Anorexia nervosa may occur in males but is commonly involves females[1][3][4][5]
Being a teenager or young adult Anorexia nervosa can affect all ages but is seen commonly in this age group[1][3][4][5]
Loss of appetite This is a very common presenting symptom [3][4]
Severely limitation of the amount of food they eat Patients with anorexia nervosa severely limit the amount they eat in order to stop gaining weight. They also develop odd food habits such as cutting, mixing, moving the food around the plate etc. without eating. They may also refuse to eat around other people, where it is difficult to follow their eating routine[1][3][4][5]
Self -induced vomiting These patients eat and then vomit what they have just eaten in order to lose weight [1][3][4][5]
Indulge in excessive exercising Patients with anorexia nervosa are involved in excessive exercise compared to a normal healthy person[1][3][5]
Self-induced purging, diuresis, appaetite suppression These patients may abuse laxatives, diuretics, appetite suppressants hoping to lose body weight [1][3][4][5]
Extreme sensitivity to cold Is a presenting symptom in some patients[3][4]
Having a family history of anorexia nervosa Studies have shown that occurrence of anorexia nervosa has an association with having a positive family history. it may be attributed to some family characteristics such as promoting perfectionism, being highly goal oriented etc. [1][3][4]
Amenorrhoea Due to endocrine disturbance involving the e hypothalamic - pituitary - gonadal axis, amenorrhoea is seen in post-menarche females. Delayed menarche will be the presentation in pre-pubertal girls[1][3][4][5]
Symptoms of depression Symptoms such as insomnia, loss of libido, reduced energy,social withdrawal may indicate the presence of depression. Recognizing this is important in the patient management.[3][4]
Lethargy Can be a presenting symptom in patients with anorexia nervosa[3][4]
Faintng attacks/dizziness This can be a symptom in patients with anorexia nervosa[3][4]
Constipation Is present in some patients with anorexia nervosa[3][4]
Hair loss Can be a complaint of patients with anorexia nervosa[3][4]
References
  1. ATTIA E, WALSH BT. Behavioral management for anorexia nervosa. N Engl J Med [online] 2009 Jan 29, 360(5):500-6 [viewed 31 May 2014] Available from: doi:10.1056/NEJMct0805569
  2. WILLIAMS PM. JEFFREY GOODIE J. MOTSINGER CD.Treating Eating Disorders in Primary Care. Am Fam Physician.[online] 2008 Jan 15;77(2):187-195.[viewed on 2 June 2014] Available from; http://www.aafp.org/afp/2008/0115/p187.html
  3. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  4. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012
  5. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 2 June 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf

Examination

Fact Explanation
Pallor Can be present in anorexia nervosa patients who have developed anemia.[2][3][4]
Emaciated Patient may appear emaciated due to excessive loss of weight[3][4]
Dry mouth, sunken eyes and dry skin Indicates dehydration[2][3][4]
Blotchy or yellow skin with yellow palms and soles Indicate carotinemia [2][3][4]
Tooth decay Erosion of inner surface of the front teeth or perimyolysis is seen in patients who vomit frequently[2][3][4]
Arrythmiasbradycardia, hypotension, dehydration, electrolyte disturbances, especially in the presence of . Osteopenia, osteoporosis, additional cardiac arrhythmias (including a prolonged QT interval), slowed gastric motility, elevated hepatic aminotransferase levels, renal insufficiency, hair loss, and the presence of lanugo (a fine hair pattern on the face, neck, and trunk) are also associated with severe anorexia nervosa.
Body covered with fine thin lanugo hair Is seen in some patients with anorexia nervosa[1][2][3][4]
Brittle hair and nails Is indicative of malnutrition[2][3][4]
Cold hands and feet Occurs due to hypothermia[3][4]
Dependent oedema Results from low serum protein levels[3][4]
Low body-mass index (BMI) A BMI of less than 17.5 kgm-2 is found in patients with anorexia nervosa [3][4][5]
Proximal muscle weakness This is elicited when the patient has difficulty in standing from squatting position. Results from muscle mass loss[3][4]
Breast atrophy Is seen in patients with advanced anorexia nervosa[2][3][4]
Low blood pressure Hypotension is seen in some patients with anorexia nervosa[1][2][3][4]
Bradycardia Is the most common arrhythmia seen in these patients. Exact cause for this is not known but it is thought to be a physiological adaptation to increased vagal tone and decreased metabolism of energy utilization, due to the low caloric intake in these patients. It is also thought to results from structural changes in the heart, such as a decrease in the left ventricular muscle mass, secondary to malnutrition which may be a compensatory mechanism to prevent heart failure. [1][2][3][4][6]
Parotid enlargement Parotitis is seen in advanced cases of anorexia nervosa[2]
References
  1. ATTIA E, WALSH BT. Behavioral management for anorexia nervosa. N Engl J Med [online] 2009 Jan 29, 360(5):500-6 [viewed 31 May 2014] Available from: doi:10.1056/NEJMct0805569
  2. WILLIAMS PM. JEFFREY GOODIE J. MOTSINGER CD.Treating Eating Disorders in Primary Care. Am Fam Physician.[online] 2008 Jan 15;77(2):187-195.[viewed on 2 June 2014] Available from; http://www.aafp.org/afp/2008/0115/p187.html
  3. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  4. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012
  5. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical descriptions and diagnostic guidelines. World Health Organization publications.[online]. Released 1994; Updated in 2010[viewed on 2 June 2014] Available from; http://www.who.int/classifications/icd/en/bluebook.pdf
  6. YAHALOM M, SPITZ M, SANDLER L, HENO N, ROGUIN N, TURGEMAN Y. The Significance of Bradycardia in Anorexia Nervosa Int J Angiol [online] 2013 Jun, 22(2):83-94 [viewed 02 June 2014] Available from: doi:10.1055/s-0033-1334138

Differential Diagnoses

Fact Explanation
Chronic debilitating illnesses Chronic infections, malignancies etc. can present with anorexia and weight loss[1]
Inflammatory bowel disease Crohn disease and ulcerative colitis can present with anorexia and weight loss[1][2]
Coeliac disease Malabsorption diseases like Coeliac disease may cause severe weight loss[1]
Brain tumors Can cause metabolic disturbances similar to those seen in anorexia nervosa[1]
Hypothyroidism Can present with similar clinical features[3]
Loss of appetite secondary to medication Treatment with drugs such as SSRIs and amphetamines can cause anorexia[1]
Depression Can present with similar clinical findings[1]
References
  1. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  2. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012
  3. Hypothyroidism. A.D.A.M. Medical Encyclopedia.[online] Last reviewed: June 7, 2013.[viewed on 2 July 2014] Available from; http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001393/

Investigations - for Diagnosis

Fact Explanation
Thyroid function test Done to assess thyroid function in order to exclude hypothyroidism. The findings in anorexia nervosa will be low T3 with normal T4 and TSH levels.[1][2][3]
Erythrocyte sedimentation rate Should be normal in patients with anorexia nervosa. If levels are elevated, must exclude organic causes for anorexia[2][3]
Serum FSH, LH and estradiol Done to differentiate anorexia nervosa as the cause for amenorrohea. All three hormone level will be lower than the normal levels in patients with anorexia nervosa[2][3]
References
  1. WILLIAMS PM. JEFFREY GOODIE J. MOTSINGER CD.Treating Eating Disorders in Primary Care. Am Fam Physician.[online] 2008 Jan 15;77(2):187-195.[viewed on 2 June 2014] Available from; http://www.aafp.org/afp/2008/0115/p187.html
  2. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  3. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012

Investigations - Fitness for Management

Fact Explanation
Complete Blood Count Done to detect normocytic normochromic anemia seen in anorexia nervosa. Mild leukopenia with relative lymphocytosis and thrombocytopenia can also be present.[2][4][5]
Electrocardiogram (ECG) Done to detect arrhythmias including bradycardia, conduction defects (e.g., QT prolongation) and other ECG abnormalities such as low voltage, T-wave inversions, ST-segment depression.[2][3][4][5]
Serum electrolytes Done to detect serum electrolyte disturbances which occur as a result of self-induced purging and diuresis.[2][3][4]
Renal function tests Blood urea nitrogen will be elevated in patients with dehydration[2]
Serum liver enzyme levels Mildly elevated liver enzyme levels is seen in patients with anorexia nervosa[2]
Random blood sugar level Done to detect hypoglycemia[2]
Bone density test (DEXA scan) Done to look for bone thinning as osteoporosis is seen in these patients[2]
References
  1. ATTIA E, WALSH BT. Behavioral management for anorexia nervosa. N Engl J Med [online] 2009 Jan 29, 360(5):500-6 [viewed 31 May 2014] Available from: doi:10.1056/NEJMct0805569
  2. WILLIAMS PM. JEFFREY GOODIE J. MOTSINGER CD.Treating Eating Disorders in Primary Care. Am Fam Physician.[online] 2008 Jan 15;77(2):187-195.[viewed on 2 June 2014] Available from; http://www.aafp.org/afp/2008/0115/p187.html
  3. YAHALOM M, SPITZ M, SANDLER L, HENO N, ROGUIN N, TURGEMAN Y. The Significance of Bradycardia in Anorexia Nervosa Int J Angiol [online] 2013 Jun, 22(2):83-94 [viewed 02 June 2014] Available from: doi:10.1055/s-0033-1334138
  4. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  5. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012

Management - Specific Treatments

Fact Explanation
Restoring normal body weight and eating habits First a healthy target weight has to be established.Patients are provided with adequate calories to begin controlled weight gain. Patient is started with a lower calorie level of about 1800 kcal per day in solid food. When the patient is medically stable the calories in the diet is increased by 400 kcal per day every 48 to 72 hours until it reaches 3800 kcal per day. Mostly in the form of solid food, with little provided as a liquid supplement. Meals are divided to 3-4 times a day and is taken under supervision. Patients are weighed three times per week and are expected to gain at least 0.3 kg at each weighing.Vitamin and mineral supplements are given as needed. It is also important to monitor and treat symptoms and conditions associated with gaining weight such as anxiety, abdominal pain, constipation[1][2][3][4]
Setting physical activity Patients with anorexia nervosa are used to carry out excessive exercise. this has to be limited to scheduled, limited exercise programs.[1][2][3][4]
Correction of associated biochemical and cardiac abnormalities This may require admission to an inpatient unit. (inward treatment is also recommended for patients who have lost a substantial amount of weight,[i.e. body weight is less than 75% of ideal weight or BMI less than 16.5] , if there was rapid weight loss, if the patient has severe depression, if there is a high risk to commit suicide etc.) Patients with severe anorexia nervosa are at risk of developing arrhythmia, heart failure, electrolyte disturbances and even sudden death. These patients should be closely monitored and managed appropriately. [2][3][4][5]
Rehydration treatment Dehydrated patients need rehydration treatment. this has to be done gradually with close monitoring of serum electrolyte (especially potassium).[2][3][4]
Psychosocial interventions For children and adolescents family psychotherapy can be tried. Family group psychoeducation is suitable for adolescents. Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT) and/or psychodynamically oriented individual or group psychotherapy may be suitable for adults. Joining support groups led by professionals may also help these patients to achieve therapeutic goals.[1][2][3][4]
Treatment of depression and anxiety Medications such as selective serotonin reuptake inhibitors (SSRIs), second generation antipsychotics, benzodiazepines can be given to treat depression and anxiety encountered in patients with anorexia nervosa.[2][3][4]
References
  1. ATTIA E, WALSH BT. Behavioral management for anorexia nervosa. N Engl J Med [online] 2009 Jan 29, 360(5):500-6 [viewed 31 May 2014] Available from: doi:10.1056/NEJMct0805569
  2. Practice guideline for the treatment of patients with eating disorders. U.S Department of Health and Human services. National guideline clearinghouse.[online] 2011[viewed on 31 May 2014] Available from; http://www.guideline.gov/content.aspx?id=9318
  3. COWEN P, HARRISON P,BURNS T, Anorexia nervosa. Shorter Oxford textbook of psychiatry. Sixth edition: Oxford University press; 2012
  4. SEMPLE D, SMYTH R. Anorexia nervosa. Oxford handbook of Psychiatry. Second edition: Oxford University Press; 2011
  5. YAHALOM M, SPITZ M, SANDLER L, HENO N, ROGUIN N, TURGEMAN Y. The Significance of Bradycardia in Anorexia Nervosa Int J Angiol [online] 2013 Jun, 22(2):83-94 [viewed 02 June 2014] Available from: doi:10.1055/s-0033-1334138