Anorexia Nervosa by Dr. Aryan

Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image
Anorexia nervosa is typically characterized by
voluntary restriction of food intake ,distorted body image and fear of gaining weight

1. Anorexia nervosa Prepared by: Anish Dhakal (Aryan)

2. Objectives To discuss about anorexia nervosa Differences with bulimia nervosa Management of anorexia nervosa

3. Eating disorders in adolescent Concerns about body image and dieting are very common in modern society females Among these dieters, 5-10% become abnormally preoccupied with dieting and slimness Low self esteem, tend to be perfectionists with obsessive compulsive traits Genetic vulnerability, temperament, psychological and environmental factors also mediate the illness ‘Genes load the gun, environment pulls the trigger’

4. Anorexia Nervosa Complex eating disorder characterized by obsessive pursuit of thinness through dieting with extreme weight loss and disturbance of body image C haracterized by voluntary restriction of food intake distorted body image fear of gaining weight

5. Epidemiology Among women, lifetime prevalence is approximately 1%. Less common in males (1:10) Prevalent where food is plentiful and thinness viewed as attractive Incidence increasing

6. Etiology Probably genetic and environmental factors including social pressure to be thin and attractive ↑ I ncidence in families with an affected member

7. Clinical Features Begins in early puberty, before menarche, but seldom begins after age 40 Severe weight loss Fear of gaining weight Use of diuretics, laxatives Excessive exercise

8. Physical Features Cardiac and skeletal systems are most affected Constipation Amenorrhea Vital signs: bradycardia , hypotension, and mild hypothermia Lanugo hair in back, forearm and cheeks Salivary gland enlargement Acrocyanosis of the digits Peripheral edema

9. Diagnosis Diagnosis based on pronounced fear of fatness despite being thin absence of alternative causes of weight loss

10. Examination & Investigations Physical exam Laboratory tests complete blood count ( CBC) electrolytes protein LFT, RFT, TFT u r inalysis Psychological evaluation thoughts , feelings and eating habits Other studies X-rays (broken bones, pneumonia) Electrocardiograms (heart irregularities) Bone density testing

11. Management Aim Ensure patient’s well-being by helping them gain weight through addressing beliefs and behaviors that maintain low weight Usually done on OPD basis Inpatient treatment if weight <75% of normal if chances of death due to complications if risk of suicide if outpatient treatment fails

12. Treatment goals Establish good and caring relationship with patient Resolve underlying psychological difficulties Restore weight between ideal and the patient concept of optimal weight Provide a balanced diet of at least 3000 kcal/day

13. Outpatient treatment Aim Cognitive behavioral or interpersonal psychotherapies Family therapy is more effective than individual psychotherapy in adolescents

14. Inpatient treatment Aim Establishing a therapeutic relationship with both the patient and her family Restoring the weight to a level between the ideal body weight and the patient’s ideal weight The provision of a balanced diet, aimed at gaining 0.5–1 kg weight per week The elimination of purgative and/or laxative use and vomiting If fails, insertion of NG tube and feeding

15. Diet Calories Start calorie intake by approximately 1200-1800 kcal/day and increase intake (3000 kcal/day at least) Ideal weight gain 0.5 - 1 kg/week Micronutrients Zinc Calcium (1500 md /day) Vitamin D (400 IU/day) Essential fatty acids  omega-3 fatty acids  docosahexaenoic acid (DHA) eicosapentaenoic acid (EPA)

16. Psychotherapy Counseling Cognitive Behavioral Therapy Family-based treatment Medications Antidepressants (SSRIs) Olanzapine

17. Body shaming: a cultural epidemic

18. Prognosis About 20% of patient have good outcomes Further 20% develop chronic intractable disorder Remaining have intermediate outcomes Mortality rate is 10-20% (complication of starvation or from suicide) Suicide has been reported in 2-5% Highest mortality and suicide rate of any psychiatry disorder

19. Indicators of a poor outcome A long initial illness Severe weight loss Older age at onset Bingeing and purging Personality difficulties Difficulties in relationships

20. Complication Anorexia nervosa starvation malnutrition protein deficiency and disruption of multiple organ systems. Cardiovascular Renal Gastrointestinal Neurological Endocrine , metabolic and reproductive Integumentary , skeletal and hematologic

21. EMR 1.Delayed puberty 2.Amenorrhoea 3.Anovulation 4.Low estrogen states 5.Increased growth hormones 6.Decreased ADH 7.Hypothermia 8.Hypokalemia, hyponatremia 9.Hyper cortisolism 10.Arrested growth and osteoporosis 11.Decreased gonadotropin levels

22. CVS 1.Cardiomyopathy 2.Mitral valve prolapse 3.Supraventricular and ventricular dysrhythmias 4.Long QT syndrome 5.Bradycardia 6.Orthostatic hypotension 7.Shock due to congestive heart failure

23. Renal 1.Decreased glomerular filtration rate (GFR) 2.Elevated BUN 3.Edema 4.Acidosis with dehydration 5.Hypokalemia 6.Hypochloremic alkalosis with vomiting 7.Hyperaldosteronism 8.Renal calculi

24. GI 1.Constipation 2.Decreased intestinal mobility 3.Delayed gastric emptying 4.Gastric dilation and rupture(from binge eating and purging) can lead to pneumothorax and pneumoperitoneum

25. Neurologic 1.Peripheral neuropathy 2.Wernicke’s encephalopathy 3.Korsakkoff syndrome 4.Ventricular enlargement

26. Integumentary 1.Dry skin and hair 2.Hair loss 3.Lanugo hair/hypertrichosis

27. Hematology 1.Anemia 2.Leukopenia 3.Thrombocytopenia

28. Reproduction 1.Infertility 2.Low-birth-weight

29. References Harrison’s Principles of Internal Medicine, 19 th ed. Murtagh’s General Practice, 5 th edition, Mc Graw Hill Davidson’s Principles and Practice of Medicine, 22 nd edition Kumar and Clark Clinical Medicine, 8 th ed.

30. THANK YOU