Anorexia Nervosa

History

Anorexia was first described by Luis Vitore marce in 1860, who however, did not name it. Later, in 1873, Charles league named the condition de l’anorexie hysterique. The name anorexia nervosa was suggested by William gull in 1874. 

Historical names in anorexia nervosa

Epidemiology

Onset

Anorexia Nervosa often has its onset during adolescence or early adulthood (i.e., between the ages of 10 and 24), typically following a stressful life event. Early onset Anorexia Nervosa (before puberty) and late-onset Anorexia Nervosa (after age 40) are relatively rare.

Incidence

Incidence, which means the number of new cases in a specified time, ranges from 0.4 for studies conducted in the united states, to 4 in Swedish studies. In developing countries like Pakistan, anorexia nervosa are exceedingly rare. But, we may expect to see more cases in future under the influence of media and western cultures. Reported incidence is increasing in recent years everywhere. The cult of thinness in westernized societies is the likeliest cause of changes in the incidence, form, and psychological content of eating disorders as they have evolved during the last decades of the 20th century. 

Prevalence 

Rare in non-western countries. The prevalence of anorexia is approximately 270 cases per 100K in females and around 22 in men. 

Gender Distribution

Previously, it was believed that anorexia nervosa is 10 times more common in females. However, according to recent community studies, male to female ratio is 4 to 1; that is, anorexia is four times more frequent in females. However, in clinical practice, only 5-to-10% of cases are male. The most likely cause is a bias on the part of the clinicians, who are more likely to miss anorexia in male patients under the false impression that it is a disorder of girls. 

Anorexia is more frequent in people of the upper social class, social class I and II in particular; however, recent evidence again suggests that people from lower classes are not at lower risk of anorexia. Occupational groups concerned with weight, like ballet dancers and gymnasts, are also at a higher risk of developing anorexia. 

Aetiology

The Minnesota Experiments

The Minnesota experiments were conducted during world war II. The aim of the study was to assess the effects of starvation. They took 36 healthy volunteers and starved them for six months. This was followed by six months of rehabilitation and 9 monitoring for a further 9 months. There were other effects of starvation, but these previously healthy men started to develop anorexia symptoms, for example, obsessions with food, hiding food and hoarding, binge eating etc. So, we might conclude that starvation itself may be one cause of the behavioural symptoms of anorexia nervosa. 

Biological Factors

Biological factors include hypothalamic dysfunction, a disordered serotonin system, and genetic factors. Patients with lesions in the hypothalamus have been shown to develop anorexia nervosa. It is also associated with an imbalance between serotonergic and dopaminergic mechanisms of the brain. These abnormalities may persist even after weight restoration. Genetic factors are also important. The rate of anorexia is 10 times in sisters of probands with anorexia nervosa, compared to its prevalence in the generation population. It has a genetic overlap with OCD and schizophrenia. 

Psychosocial Factors

Many psychosocial factors are involved in the causation of anorexia nervosa.  

Body shape misperception and body shape disparagement. The sick child plays an important role in the family’s pattern of conflict avoidance, and this role is an important source of reinforcement for his/her symptoms. Particularly AN, depression, alcoholism, psychosexual disturbances, and OCD in mothers.

Differentials  

• Restrictive food intake disorder 
• Severe depression 
• Medical conditions (cancer, Crohn's disease, ulcerative colitis, hyperthyroidism) 
• Normal behaviour 
• Atypical anorexia nervosa/ restrictive food intake disorder 
• Bulimia nervosa 
• Severe depression 
• Delusional disorder/psychosis  
• Obsessive-compulsive disorder 

Organic Manifestations

Review : (Schorr and Miller 2017) 

 Hormonal changes 

• Low T3 Syndrome (normal levels of TSH and T4)  

• Reduced levels of LH, GnRH also result in reduced testosterone and estradiol levels 

• Increased growth hormone reduced Insulin-like factor 1 (IGF1) levels (Acquired growth hormone resistance)  

• Increased levels of ACTH, Cortisol and CRH (hyper-excited HPA-Axis) 

• Reduced levels of leptin due to reduced fat stores  

• Increased levels of ADH  

Cardiovascular changes 

• Cardiac arrhythmia 

• Low blood pressure 

• Bradycardia 

Biochemical (or metabolic) changes 

• Electrolyte abnormalities 

• Hypokalemia 

• Hypophosphatemia 

• Hypoglycemia 

• Hypophosphatemia 

Prognostic Factors

---

Predictors of poor prognosis 

(Godart, Carrot and Hubert 2012) (Jagielska and Kacperska 2017) 

• Premorbid OCD  

• Low BMI at presentation 

• Premenarchal onset 

• Requirement for hospitalization 

• Adult age 

Predictors of Good prognosis

(Errichiello et al. 2016) 

• The short duration of treatment and of the illness 

• Inpatient treatment at an early age 

• Preserved insight 

---

Specific Mental State Questions in this cas

These should include questions on the psychopathology of eating disorders, depression, and suicide. Begin with open-ended questions then follow up with more specific questions as needed.  

• Are you preoccupied with any thoughts these days? 

• Does anything specific worry you excessively? 

• Do you worry about your weight or your shape? 

• So what are your concerns (regarding the above)? 

• Have you felt that you are fat?  

• How do you feel about your body and weight in general?  

• Do you like it or dislike it? 

• How do you try or manage to control your weight? 

• What do you think can happen if you could not control your weight? 

• Do you experience any episodes during which you can not control your eating? 

• How do you feel before such incidents happen? 

• How about, after the episode? 

• Do you feel any guilt or disgust?  

• Do you have any fears about weight-gain? 

• (Clarification) Like some people fear that their weight is going out of control.  

• How is your mood, in general, these days? 

• Have you experienced any such thoughts that life is not worth living? (then follow up with more specific questions on suicide)    

• What do you think about your illness? Do you think it could be a psychiatric illness? 

Informational Care About Causes and Contributing Factors of Anorexia Nervosa

(Zipfel et al. 2015) 

• Risk in first-degree relatives is very high (almost 10 times in sisters of affected girls) 

• Estimated heritability is up to 74% 

• The findings together suggest that genetic contribution is high 

• Females are at a much higher risk than males 

• Early adverse experiences, e.g. prematurity, feeding difficulties, increase the risk  

• Certain personality and temperamental factors may interact with these factors to increase the risk e.g. perfectionism, homelessness  

• Research has also shown abnormalities in mental abilities (e.g. in task shifting and central coherence), brain structure (increased grey matter in the insular cortex and orbitofrontal cortex) and function (in regions associated with responses to food rewards)   

• Sociocultural factors like urbanization and industrialization may indirectly increase the risk by increasing exposure to social influences 

• Linking neuroimaging with neurochemistry, one theory is that the restrictive eating of anorexia nervosa is a maladaptive attempt to reduce the negative effect caused by an imbalance between the aversive (serotonergic) and reward (dopaminergic) systems of the brain.  

 A female aged 22 presented to the OPD with amenorrhoea, excessive weight loss and BMI 15. The family says that she has been in this state for the last 6 months and her aunt who is in the UK also suffers from a similar illness. Past history is insignificant for psychiatric illness. After a detailed assessment, it was decided to admit her for inpatient treatment.

1. What is your differential diagnosis? 
2. What will be the contents of an informational care session for the family about the causes, nature and contributing factors of this illness? 
3. Enumerate the poor prognostic factors in this case. 
4. What do you know about the epidemiology of various eating disorders?  
5.  What are the physical manifestations among them?  

---

Differentials  

• Anorexia nervosa 

• Restrictive food intake disorder 

• Severe depression 

• Medical conditions (cancer, Crohn's disease, ulcerative colitis, hyperthyroidism)  

---

Poor Prognostic Factors In This Case 

• Her age  

• Her requirement for hospitalization  

• Her BMI at presentation 

A 14-year-old girl was referred to you by a physician because of physical and mental exhaustion following relentless pursuits to lose 15 kg weight over a month period. 

1. Enumerate expected hormonal, cardiovascular and biochemical/metabolic abnormalities in this case. 
2. What specific questions will you ask in the mental state examination? 
3. Enumerate differential diagnoses in the order of priority that you will consider in this case? 

Differentials 

• Normal behavior 

• Anorexia nervosa  

• Atypical anorexia nervosa/ restrictive food intake disorder 

• Bulimia nervosa 

• Severe depression 

• Delusional disorder/psychosis  

• Obsessive-compulsive disorder 

---

A 22-year-old lady presents to you at the OPD. She has a dangerously lean built, yet believes she is too fat and has an overwhelming desire to be thin. Detailed history revealed amenorrhea, labile mood, lack of sexual desires, and social withdrawal. Physical examination and laboratory investigations have not been performed yet.  

1.  Write down your provisional diagnosis based on the information provided.
2. List any five physical consequences of this disease (that you may find on physical examination) 
3.  List any three abnormal findings which you expect on investigations. 
4. List three therapeutic interventions recommended by current evidence-based guidelines 

---

Diagnosis 

Anorexia nervosa 

---

Physical Consequences 

• Lanugo hair on the back of forearms and chest  

• Brittle nails 

• Bradycardia, arrhythmia and low blood pressure on CVS examination 

• Extreme emaciation on GPE, and in prepubertal girls, failure of breast development and stunted growth 

• Calluses on the knuckles known as Russel sign 

• Perimyolysis 

• Swelling of salivary glands 

• Dry skin and orange discolouration of palms and soles 

---

Abnormal Findings On Investigations 

• Cardiac arrhythmia on ECG 

• Reduced T3 levels on TFTs 

• Reduced serum potassium (and other electrolytes abnormalities) 

---

Therapeutic Interventions  

 (Guidelines (NICE 2017) 

• Individual eating-disorder-focused cognitive behavioral therapy (CBT-ED) 

• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) 

• Specialist supportive clinical management (SSCM). 

Non-Pharmacological Therapies For Anorexia 

---

Adolescents 

• There is strong evidence for the first two 

• Family-based treatment (FBT)  

• Maudsley family therapy (MFT)  

• Family system therapy (FST)  

• Adolescent focused therapy (AFT)  

• Cognitive-behavioral treatment (broad; CBT-b)  

• Cognitive-behavioral treatment (enhanced; CBT-E) 

Adults 

• Cognitive-behavioral therapy (CBT)  

• Cognitive-behavioral therapy (enhanced; CBT-E)  

• Behavioral therapies (BT)  

• Interpersonal psychotherapy (IPT)  

• Psychodynamic therapy (PT)  

• Cognitive analytic therapy (CAT)  

• Focal psychodynamic psychotherapy 

• Maudsley model of anorexia nervosa treatment for adults (MANTRA) 

• Specialist supportive clinical management (SSCM) 

 

A 21-year-old woman referred from the gynaecology ward for noncompliance with medical advice. They admitted there her for the investigation of irregular menstruation for the last three years. During hospitalisation, she often refuses meals despite the insistence of attendants, but on other occasions, she takes out a lot of candies and chocolates from her bag and eats hurriedly. They also found her to have vomited, but these seem to be self-induced, as witnessed by the ward servant.  

Write three differential diagnoses.  

What biopsychosocial risk factors will you search during the assessment? 

---

Differentials 

• Anorexia nervosa 

• Factitious disorder 

• Bulimia nervosa 

• Binge eating disorder 

Risk Factors 

• Family history (genetic) 

• Family relationships (enmeshment, overprotection, rigidity, lack of conflict resolution) 

• Socioeconomic status (urban, high SES) 

• Perfectionism, low self-esteem, struggle for control 

• Cultural perception of body weight 

• Early adverse experiences (prematurity, feeding and sleeping difficulties) 

---

A 22-year-old lady presented to the psychiatric OPD with over 20% weight loss and body mass index of 17kg/m2. Her mental state examination revealed ithat she has a fear of fatness, therefore she avoids eating and shows behaviours aimed at losing weight including vomiting, purging, excessive exercise, use of appetite suppressants and diuretics. She also reports the absence of menstruation for the last few months. 

Enlist 10 specific questions that you would ask this patient for the assessment of eating disorder? 

How will you manage this case? 

Considering the above scenario, what is your provisional diagnosis?  

---

Anorexia Assessment: Eating Attitudes   

• How much do you eat routinely?  

• What level of eating-restrictions do you exercise?  

• Is there any specific pattern of your eating practices?  

• For example, a person may feel compelled to eat three times a day, one-third of bread, in 3 minutes.  

• Are there any special foods or drinks that you avoid? 

• Do you restrict fluids too? 

• How is your experience of hunger?  

• Are there any episodes during which you feel compelled to eat a huge amount of food?  

• Are these episodes planned?  

• How does it start?  

• Have you ever tried to induce vomiting?  

• Can you tell me more about how you do this?  

• Have you ever seen blood in your vomitus?  

• Have you ever used an appetite suppressant or a diuretic? 

• Do you exercise? How much?  

• Have you experienced any changes in your menses?  

• Can you eat while others are around? 

• What is your opinion about your body build and shape? 

---

Management 

• Listen to the patient carefully, develop a therapeutic relationship.  

• Carry out an OPD-based assessment.  

• Decide whether the patient needs admission or any urgent medical treatment. Admit if needed and agreed and continue with a more comprehensive assessment while she is hospitalized. 

• Start clinical management with education and supportive counseling.  

• Educate the patient about the condition, its causes, treatments, consequences if left untreated. Let her ask questions and address their concerns.  

• Agree with a treatment plan with the patient and initiate it.  

• Multidisciplinary Supportive care, including psychoeducation and monitoring.  

• Weight restoration is a key priority 

• Start a psychological therapy (either CBT-ED, MANTRA or SSCM, as preferred by the patient) 

---

A 19-year-old female is brought to the OPD on account of persistent refusal to eat adequately. For the past year, she is on a diet plan as she thinks she is fat. Her mother is worried because she looks very thin, has frequent headaches and episodes of fainting. Recently there have been three proposals for her but were declined. On examination, she is 5 feet and 7 inches tall and has a weight of 40 kg. She has a low mood. occasional episodes of weeping and feeling of inadequacy, about herself. 

What is the most likely diagnosis? 

What hematological abnormalities would be present in this case? 

Calculate her BMI? 

How would you manage her in light of current guidelines? 

---

Diagnosis  

Anorexia nervosa 

---

Haematological abnormalities 

• Normocytic normochromic anaemia 

• Mild leucopenia with relative lymphocytosis 

• Thrombocytopenia 

---

Calculate Bmi   

Divide the patient’s weight in KG by height in meters. Then divide the answer by height in meters again.  

OR Calculate BMI by dividing weight in pounds (lbs.) by height in inches (in) squared and multiplying by a conversion factor of 703. 

1 kg=2.2 pound 

Feet in centimeters: multiply the length value by 30.5 

Inches to feet: divide the length value by 12 

Feet to inches=multiply by 12 

5—1525’1—154    

5’2—1575’3—160  

5’4—1625’5—165   

5’6—1675’7---170  

Height = 5 feet 7 inches= 

7/12 = .6 (approx.) feet 

5.6 feet x 30.5 = (5x30.5=)152.5+ (0.6x30=)18=170.5cm  

40/1.7=400/17=23.5/1.7=230/17=13.8 or 14kg/m2 

Or  

5 feet 7 inches =5x12=60+7=67 inches 

Weight= 40kg x 2.2=88 lbs. 

(67/88) x 703= 13.8  

e.g. Weight = 100 kg, Height= 1.5 meters. 

100/1.5= 66   

66/1.5= 44   

Or multiply your height then divide your weight by it.    

e.g. 1.5x1.5= 2.25   

100/2.25=44     

---

A 19-year-old young girl is brought by her mother with a history of lack of interest and avoidance of food, weight loss of 18 kg (during the last three months), fear of gaining weight, disturbed sleep, menstrual irregularities, and irritability. On examination, blood pressure is 90/60 mmHg, the pulse is 56 beats per minute, with physical emaciation. Neuropsychiatric evaluation reveals mild cognitive impairment. 

Give your differential diagnosis for this case.

What further investigation would you carry out giving justification? 

How would you manage this patient? 

---

Differentials 

• Anorexia nervosa 

• Depressive episode (ICD-10)/major depressive disorder (DSM-5) 

• Hyperthyroidism  

• Restrictive food intake disorder 

---

Investigations 

Obtain baselines investigations including CBC, Serum electrolytes and urea, Liver and renal function tests, ECG, Chest x-ray and blood glucose. A long list of other investigations may be carried out based on the findings of these investigations, examination, and history, for example: 

• Hormonal assay (TFTs, estrogen, growth hormone, etc.) 

• Lipid profile 

• Serum albumin 

• Serum carotene level 

• Calcium and phosphate  

• Echocardiography 

Psychological Investigations may include the Eating attitudes test, CGI, HADs for depression screening or HAMD for the severity of depression 

References

1. Errichiello L, Iodice D, Bruzzese D, Gherghi M, Senatore I. Prognostic factors and outcome in anorexia nervosa: a follow-up study. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2016;21(1):73-82. doi:10.1007/s40519-015-0211-2