Anorexia Nervosa

Def.

symptoms

Prevalence & Mortality

Below 85% of Ideal body weight

intensely fearful of gaining weight, preoccupation w/ body image

(absence of 3 menstrual cycles)

Symptoms:

Depression

Apathy

Irritability

Irrationality

Obsessionality

Food Preoccupations Cognitive impairments

(many of the same features of starvation syndrome)

Prevalence: 0.5-1%, about 70-30 female/male

10-15% mortality---deadliest disorder in all of psychiatry

Anorexia Nervosa progression/outcomes

A quarter will develop binge eating in the first 5 years, almost 40% will develop bulimia

Almost a quarter will eventually die

about half have a good outcome, a third have an intermediate outcome, and 20% have a poor/chronic outcome

• Puberty
• perfectionist personality
• Family hx of SAD, OCD, or Anxiety disorder
• Impaired family interactions (tough to tell if interactions cause the anorexia, or if the anorexia itself tears the family apart)
• stressful life events

• Early age of onset
• higher weight at initial treatment
• Shorter duration of illness
• lack of binge-purge
• no laxative use

Cancer

IBD

TB

Addison's disease

HIV

thyroid disease

diabetes

Bulimia

Prevalence & Prognosis

Co-morbidities are common/uncommon?

Prevalence of 1-5% (much more than AN), but mortality is lower

Rule of 1/3's:  1/3 do well, 1/3 still affected w/ symptoms, 1/3 will still do poorly after 5 years

Co-morbidity is very common:

anxiety disorders

chemical dependency

bipolar disorder

personality disorder

Bulimia risk factors

favorable prognostic indicators (3)

Puberty

Dieting

anorexia

impulsivity

anxiety

Favorable prognostic indicators:

younger age at onset

higher social class

family history of alcohol abuse (interesting)

Schizophrenia - strange thoughts about food, paranoia

MDD

OCD - ritualistic eating behaviors

Medical disorders:  Kleine-Levin or Kluver-Bucy syndromes = binge eating-associated neurological disorders, differenbt from bulimia

Anorexia

1. Restricting

2. Binge/Purge type (prone to substance abuse)

Bulimia

1. Purging (vomiting, laxatives)

2. Non-purging (fasting/excessive exercise)

A: denies abnormal eating behavior

B. recognizes abnormal eating behavior

A: introverted

B. extroverted

A. turns away food in order to cope

B. turns TO food in order to cope

A. preoccupation w/ losing more and more weight

B. preoccupation w/ attaining their 'ideal' but often unrealistic weight

Eating Disorders NOS (Not Otherwise Specified)

What are cases that give this designation

• All criteria for AN but still menstruating
• All criteria for BN but less than 2x/week or for less than 3 months
• Frequent purging after NORMAL meals
• Chewing and spitting of food
• Binge eating disorder (BED)

Binge eating at least 2 days a week for 6 months

Not associated w/ any of the regular compensatory behaviors (purging, fasting, exercise) of AN or BN

Role of the hypothalamus --> increase in Corticotropin Releasing Factor CRF  in the CSF of anorexic patients

in some AN cases, amenorrhea occurs before weight loss (another indication of an issue w/ the HPA axis)

Central NT sytem dysregulation --> strongest evidence for reduced NE activity

Vomiting causes an increas in DA levels, reinforces/rewards the behavior

Theories of serotonergic hyperfunctioning in AN and serotonergic hypofunctioning in BN

6-10% of female relatives of an anorexic suffer from the condition themselves

MZ twins show 55-65% concordance (much weaker for fraternal)

Fatigue

excessive cold

dizziness/fainting

constipation

fullness/bloating

headaches

dry skin and hair

loss of menstruation

Food/lactose intolerance

Physical Findings for anorexia nervosa

Vitals?

Vitals - bradycardia, resting hypotension, orthostasis

Lanugo

Thinning hair/dry skin

Edema in extremities w/ accompanying Acrocyanosis (blueness of hands/extremities)

Signs of vomiting - loss of tooth enamel, salivary gland enlargement, Russel's sign (lesions on the knuckles)

Medical Complications of Bulimia

HypO-calcemia, -chloremia, -kalemia

Metabolic alkalosis (if vomiting) or acidosis (if using laxatives)

Electrolyte disturbances

Serum transaminases elevated

Parotid gland enlargement, elevated amylase

esophageal tears (rare but serious)

Anorexia treatment

specifically treating the bone loss?

Food!

antidepressants don't work, previous theories rejected

Dealing with not only an estrogen deficiency, but aslo a nutritional deficiency and hypercortisolism (so supplemental hormones do not have huge benefit)

- Calcium and Vitamin D supplements help