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Key Features

Essentials of Diagnosis

  • Disturbance of body image and intense fear of becoming fat

  • Weight loss, leading to body weight 15% below expected

  • In females, absence of three consecutive menstrual cycles

General Considerations

  • Begins in the years between adolescence and young adulthood

  • Cause not known, probably of primary psychiatric origin

  • Must exclude medical or psychiatric illnesses that can account for anorexia, weight loss

Demographics

  • Occurs most commonly in females (90%), predominantly middle and upper income

  • Estimated prevalence

    • 270 cases per 100,000 population for females

    • 22 cases per 100,000 population for males

Clinical Findings

Symptoms and Signs

  • Loss of body fat with severe emaciation

  • Dry and scaly skin

  • Increased lanugo body hair

  • Parotid enlargement and edema

  • In severe cases, bradycardia, hypotension, and hypothermia

  • Cold intolerance

  • Constipation

  • Amenorrhea

Differential Diagnosis

  • Endocrine and metabolic disorders

    • Panhypopituitarism

    • Addison disease

    • Hyperthyroidism

    • Diabetes mellitus

  • Gastrointestinal disorders

    • Malabsorption

    • Pancreatic insufficiency

    • Crohn disease

    • Gluten enteropathy

  • Chronic infections, eg, tuberculosis

  • Cancer, eg, lymphoma

  • Rare CNS disorders, eg, hypothalamic tumor

  • Severe malnutrition

  • Depression

  • Obsessive-compulsive disorder

  • Body dysmorphic disorder

  • Malignancy

  • AIDS

  • Substance abuse

Diagnosis

Laboratory Tests

  • Check for anemia, leukopenia, electrolyte abnormalities, and elevations of blood urea nitrogen and serum creatinine

  • Serum cholesterol level often increased

  • Luteinizing hormone level depressed and impaired response to luteinizing hormone-releasing hormone

Treatment

Medications

  • Tricyclic antidepressants, selective serotonin reuptake inhibitors, and lithium carbonate are effective in some cases

Therapeutic Procedures

  • Treatment goal: restoration of normal body weight and resolution of psychological difficulties

  • Supportive care

  • Structured behavioral therapy

  • Intensive psychotherapy

  • Family therapy

  • Hospitalization may be necessary

  • Treatment by experienced teams successful in about two-thirds of cases

Outcome

Complications

  • Poor dentition

  • Pharyngitis

  • Esophagitis

  • Aspiration

  • Gastric dilatation

  • Pancreatitis

  • Constipation

  • Hemorrhoids

  • Dehydration

  • Electrolyte abnormalities

Prognosis

  • 50% of patients continue to experience difficulties with eating behavior and psychiatric problems

  • 2–6% of patients die of the complications of the disorder or from suicide

When to Refer

  • Adolescents and young adults with otherwise unexplained weight loss should be evaluated by a psychiatrist

  • All patients with diagnosed anorexia nervosa should be co-managed with a psychiatrist

When to Admit

  • Signs of hypovolemia, major electrolyte disorders, and severe protein-energy malnutrition

  • Failure to improve with outpatient management

References

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Crow  S. Eating disorders and risk of death. Am J Psychiatry. 2013 Aug 1; 170(8):824–5.
[PubMed: 23903330]  
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Dalle Grave  R,  et al. Cognitive behavioral therapy for anorexia nervosa: an update. Curr Psychiatry ...

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