The clinical features of anorexia include wearing oversized layered clothing to hide appearance, fine hair on the face and trunk (lanugo-like hair), rough and scaly skin, bradycardia, hypothermia, decreased body mass index, erosion of enamel of teeth (acid from emesis), and acrocyanosis of hands and feet. Signs of hyperthyroidism should not be present (see Chapter 175). The diagnostic criteria for anorexia nervosa are listed in Table 70-2.
Treatment requires a multidisciplinary approach, including a feeding program as well as individual and family therapy. Feeding is accomplished through voluntary intake of regular foods, nutritional formula orally or by nasogastric tube. When vital signs are stable, discussion and negotiation of a detailed treatment contract with the patient and the parents
Early adolescence— Fear of growing up increased body awareness Middle adolescence— Rebelliousness increased self-awareness
Late adolescence— Anxiety and worry for the future identity
Anxious Sad Angry Down Feeling: “I’m fat” “I hate...” Rebellious Thoughts: Restrictions Binging Purging Eating disorder behaviors
Figure 70-1 The eating disorder cycle.
are essential. The first step is to restore body weight. Hospitalization may be necessary (Table 70-3). When 80% of normal weight is achieved, the patient is given freedom to gain weight at a personal pace. The prognosis includes a 3% to 5% mortality (suicide, malnutrition) rate, the development of bulimic symptoms (30% of individuals), and persistent anorexia nervosa syndrome (20% of individuals).
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Table 70-4 presents the diagnostic criteria for bulimia nervosa. The prevalence of bulimia nervosa is 5% in female college students. The female-to-male ratio is 10:1. Binge-eating episodes consist of large quantities of often forbidden foods or leftovers or both, consumed rapidly, followed by vomiting. Metabolic abnormalities result from the excessive vomiting or laxative
Risk Factors Familial Personality types Previous overweight Affective disorders (family history) Impulsive/negative (bulimia nervosa) Psychiatric disease Clinical features -Wearing oversized clothing Fine hair on the face and trunk (lanugo-like hair) Bradycardia, hypothermia Decreased body mass index Erosion of enamel of teeth (acid from emesis) Acrocyanosis of hands and feet. Susceptible individual Feeling that something is not right: With self With control (environment) Behavioral change Exercise or Eating Eating disorder cycle
Figure 70-2 The slippery slope to eating disorders.
Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to body weight <85% of ideal)*
Intense fear of gaining weight or becoming fat, even though underweight
Denial of the seriousness of the low body weight—a disturbance in the way in which one’s body weight or shape is experienced *The diagnostic criteria may be difficult to meet in a young adolescent. Allow for a wide spectrum of clinical features.
Weight loss >25% ideal body weight* Risk of suicide Bradycardia, hypothermia Dehydration, hypokalemia, dysrhythmias Outpatient treatment fails *Less weight loss accepted in young adolescent.
Recurrent episodes of binge eating, at least twice a week for 3 months, characterized by the following:
Eating in a discrete period an amount of food that is definitely larger than most people would eat during a similar period
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
Compensatory behavior to prevent weight gain (i.e., self-induced vomiting, misuse of laxatives or diuretics, excessive exercise)
Disturbance does not occur exclusively during episodes of anorexia nervosa.