Anorexia

Anorexia nervosa (AN), commonly referred to as anorexia, is an eating disorder characterized by predominant food restriction, body image disturbance, fear of gaining weight, and an overwhelming desire to be thin. These characteristics often mean individuals undergo severe malnutrition as a result of the disorder. Individuals with anorexia nervosa have a fear of gaining weight, despite the fact that they are typically underweight. The DSM-5 describes this perceptual symptom as "disturbance in the way in which one's body weight or shape is experienced". Recent research has shown that this disturbance is based not on visual body-size overestimation but rather on body dissatisfaction: individuals with anorexia can accurately visually identify their body size, but find severely underweight bodies the most attractive. Individuals with anorexia nervosa may also deny that their symptoms or behaviors are indicative of illness. They may weigh themselves frequently, eat small amounts, and only eat certain foods in order to be in as much control of their body appearance as possible. Some patients with anorexia nervosa binge eat and purge to further influence their weight or shape. Purging can manifest as induced vomiting, excessive exercise, and/or laxative abuse. Anorexia nervosa has the highest mortality rate of any psychiatric diagnosis.…

Anorexia nervosa (AN), commonly referred to as anorexia, is an eating disorder characterized by predominant food restriction, body image disturbance, fear of gaining weight, and an overwhelming desire to be thin. These characteristics often mean individuals undergo severe malnutrition as a result of the disorder. Individuals with anorexia nervosa have a fear of gaining weight, despite the fact that they are typically underweight. The DSM-5 describes this perceptual symptom as "disturbance in the way in which one's body weight or shape is experienced". Recent research has shown that this disturbance is based not on visual body-size overestimation but rather on body dissatisfaction: individuals with anorexia can accurately visually identify their body size, but find severely underweight bodies the most attractive. Individuals with anorexia nervosa may also deny that their symptoms or behaviors are indicative of illness. They may weigh themselves frequently, eat small amounts, and only eat certain foods in order to be in as much control of their body appearance as possible. Some patients with anorexia nervosa binge eat and purge to further influence their weight or shape. Purging can manifest as induced vomiting, excessive exercise, and/or laxative abuse. Anorexia nervosa has the highest mortality rate of any psychiatric diagnosis. Medical complications may include osteoporosis, infertility, and heart damage, along with the cessation of menstrual periods and death. Complications in males may include lowered testosterone. In cases where the patients with anorexia nervosa continually refuse significant dietary intake and weight restoration interventions, a psychiatrist can declare the patient to lack capacity to make decisions, which results in a medical decision to be fed by restraint via nasogastric tube. Anorexia often develops during adolescence or young adulthood. The causes of anorexia nervosa are complex and vary across individuals, many of which can include genetic, societal, physiological, and environmental causes. Most commonly, the exacerbation of the mental illness is thought to follow a major life-change or stress-inducing events. There is strong evidence, however, that anorexia nervosa also has a genetic component, with identical twins being affected more often than fraternal twins, which sees a large number of genetic risk factors underlying the disorder: similar to other psychiatric disorders with genetic components. Cultural factors also play a very significant role, with societies that value thinness having higher rates of the disease. Anorexia nervosa also commonly occurs in athletes who play sports where a low bodyweight is thought to be advantageous for aesthetics or performance, such as dance, cheerleading, gymnastics, running, figure skating and ski jumping (anorexia athletica). Treatment of anorexia involves restoring the patient back to a healthy weight, treating their underlying psychological problems, and addressing underlying maladaptive behaviors, often with forms of talking therapy; some examples of clinically proven therapies include cognitive behavioral therapy or Maudsley family therapy, an approach where parents assume responsibility for feeding their child. A daily low dose of olanzapine has been shown to increase appetite and assist with some weight gain in patients. Psychiatrists may prescribe patients with anorexia nervosa forms of medication to better manage anxiety or depression, these being disorders often commonly associated with the disorder. However, medications are not considered a cure for anorexia nervosa: such pathways rather address underlying causes for the disorder, which often assist in recovery of it by allowing the individual to have a clearer and healthier mental state to understand the complications of anorexia nervosa. It does not assist those who do not have any other related mental conditions that affect their ability to do so. It has been proven to assist in the recovery of other eating disorders, such as bulimia nervosa and binge eating disorder. In severe cases, individuals may require to be fed by nasogastric tube to restore weight and healthy nutritional levels by force. Evidence for benefit from nasogastric tube feeding is unclear; some individuals recover after the first incident of admission, while others have recurring treatments over many years: sometimes indefinitely. The largest risk of relapse occurs within the first year post-discharge from eating disorder therapy treatment. Within the first two years post-discharge, approximately 31% of anorexia nervosa patients relapse. Many complications, both physical and psychological, improve or resolve with nutritional rehabilitation and adequate weight gain. Anorexia nervosa is estimated to occur in approximately 0.3–4.3% of women and 0.2–1% of men in Western countries at some point in their life. Levels in other countries are unclear due to undiagnosis and a lack of awareness, though it can be presumed it is more present in Western societies due to a higher focus on low body weight and beauty on social media and real life. There is an observation for an increase in the diagnosis of anorexia from the 20th century onwards: it is unclear whether this is due to an actual increase in its frequency or simply due to improved diagnostic capabilities. In 2013, it directly resulted in about 600 deaths globally, up from 400 deaths in 1990. Eating disorders also increase a person's risk of death from a wide range of other causes, including suicide. About 5% of people with anorexia die from complications over a ten-year period with medical complications and suicide being the primary and secondary causes of death respectively. Anorexia has one of the highest death rates among mental illnesses, second only to opioid overdoses.

Physical examination

Blinded weight: The patient will strip and put on a surgical gown alone. The patient will step backwards onto the scale as the healthcare provider blocks the reading from the patient's line of vision. Orthostatic vitals: The patient lies completely flat for five minutes, and then, the medical provider measures the patient's blood pressure and heart rate. The patient stands up and stays stationary for two minutes. Then, the blood pressure and heart rate are assessed again, making note of any patient symptoms upon standing like dizziness. According to the College of Family Physicians of Canada, a change in orthostatic heart rate greater than 20 beats/minute or a change in orthostatic blood pressure greater than 10mmHg can warrant admission for an adolescent. Examination of hands and arms for brittle nails, Russell's sign, swollen joints, lanugo, and self harm. Auscultation of the chest for rubs, gallops, thrills, murmurs, and apex beat. Examination of the face for puffiness, dental decay, swollen parotid glands, and conjunctival hemorrhage.

Blood tests

Complete blood count (CBC): a test of the white blood cells, red blood cells and platelets used to assess the presence of various disorders such as leukocytosis, leukopenia, thrombocytosis and anemia which may result from malnutrition. Chem-20: Chem-20, also known as SMA-20, is a group of twenty separate chemical tests performed on blood serum. Tests include protein and electrolytes such as potassium, chlorine and sodium, and tests specific to liver and kidney function. Glucose tolerance test: Oral glucose tolerance test (OGTT) used to assess the body's ability to metabolize glucose. Can be useful in detecting various disorders such as diabetes, an insulinoma, Cushing's Syndrome, hypoglycemia and polycystic ovary syndrome. Lipid profile: includes cholesterol (including total cholesterol, HDL and LDL) and triglycerides. Serum cholinesterase test: a test of liver enzymes (acetylcholinesterase and pseudocholinesterase) useful as a test of liver function and to assess the effects of malnutrition. Liver function tests: A series of tests used to assess liver function some of the tests are also used in the assessment of malnutrition, protein deficiency, kidney function, bleeding disorders, and Crohn's Disease. Luteinizing hormone (LH) response to gonadotropin-releasing hormone (GnRH): Tests the pituitary glands' response to GnRh, a hormone produced in the hypothalamus. Hypogonadism is often seen in anorexia nervosa cases. Creatine kinase (CK) test: measures the circulating blood levels of creatine kinase an enzyme found in the heart (CK-MB), brain (CK-BB) and skeletal muscle (CK-MM). Blood urea nitrogen (BUN) test: urea nitrogen is the byproduct of protein metabolism first formed in the liver then removed from the body by the kidneys. The BUN test is primarily used to test kidney function. A low BUN level may indicate the effects of malnutrition. BUN-to-creatinine ratio: A BUN to creatinine ratio is used to predict various conditions. A high BUN/creatinine ratio can occur in severe hydration, acute kidney failure, congestive heart failure, and intestinal bleeding. A low BUN/creatinine ratio can indicate a low protein diet, celiac disease, rhabdomyolysis, or cirrhosis of the liver. Thyroid function tests: tests used to assess thyroid functioning by checking levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3).

Additional medical screenings

Urinalysis: a variety of tests performed on the urine used in the diagnosis of medical disorders, to test for substance abuse, and as an indicator of overall health Electrocardiogram (EKG or ECG): measures electrical activity of the heart. It can be used to detect various disorders such as hyperkalemia. Electroencephalogram (EEG): measures the electrical activity of the brain. It can be used to detect abnormalities such as those associated with pituitary tumors.

Cardiac complications

Anorexia nervosa increases the risk of sudden cardiac death, though the precise cause is unknown. Cardiac complications include structural and functional changes to the heart. Some of these cardiovascular changes are mild and are reversible with treatment, while others may be life-threatening. Cardiac complications can include arrhythmias, abnormally slow heart beat, low blood pressure, decreased size of the heart muscle, reduced heart volume, mitral valve prolapse, myocardial fibrosis, and pericardial effusion. Abnormalities in conduction and repolarization of the heart that can result from anorexia nervosa include QT prolongation, increased QT dispersion, conduction delays, and junctional escape rhythms. Electrolyte abnormalities, particularly hypokalemia and hypomagnesemia, can cause anomalies in the electrical activity of the heart, and result in life-threatening arrhythmias. Hypokalemia most commonly results in patients with anorexia when restricting is accompanied by purging (induced vomiting or laxative use). Hypotension (low blood pressure) is common, and symptoms include fatigue and weakness. Orthostatic hypotension, a marked decrease in blood pressure when standing from a supine position, may also occur. Symptoms include lightheadedness upon standing, weakness, and cognitive impairment, and may result in fainting or near-fainting. Orthostasis in anorexia nervosa indicates worsening cardiac function and may indicate a need for hospitalization. Hypotension and orthostasis generally resolve upon recovery to a normal weight. The weight loss in anorexia nervosa also causes atrophy of cardiac muscle. This leads to decreased ability to pump blood, a reduction in the ability to sustain exercise, a diminished ability to increase blood pressure in response to exercise, and a subjective feeling of fatigue. Some individuals may also have a decrease in cardiac contractility. Cardiac complications can be life-threatening, but the heart muscle generally improves with weight gain, and the heart normalizes in size over weeks to months, with recovery. Atrophy of the heart muscle is a marker of the severity of the disease, and while it is reversible with treatment and refeeding, it is possible that it may cause permanent, microscopic changes to the heart muscle that increase the risk of sudden cardiac death. Individuals with anorexia nervosa may experience chest pain or palpitations; these can be a result of mitral valve prolapse. Mitral valve prolapse occurs because the size of the heart muscle decreases while the tissue of the mitral valve remains the same size. Studies have shown rates of mitral valve prolapse of around 20 percent¹ in those with anorexia nervosa, while the rate in the general population is estimated at 2–4 percent. It has been suggested that there is an association between mitral valve prolapse and sudden cardiac death, but it has not been proven to be causative, either in patients with anorexia nervosa or in the general population.

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