Anorexia Nervosa

Anorexia Nervosa is an eating disorder related to mental health of the patient. It is most common in younger girls of the age group 15-21 years old. In this disorder, the patient feels intense fear of gaining weight or becoming fat, even though the patient is underweight. The patient estimate him/her obese and stop eating according to normal diet. That fear of becoming obese cause the patient’s body weight to decrease drastically below normal body weight.

Forms of Anorexia Nervosa

Two forms of Anorexia Nervosa are there

The first form is restricting type in which the patients do not engage in binge eating or purging.

The second form is purging type in which classic anorexia nervosa is combined with binge eating or purging behavior or both.

Both these forms are important because they carry different implications for treatment and diagnosis.

Cause of Anorexia Nervosa

Anorexia Nervosa is a mental disorder majorly caused due to disturbance in mental health.

Symptoms and Signs of Anorexia Nervosa

• Reduction in dietary fat
• Changes in body image
• Amenorrhea occurs that is the absence of at least three menstrual cycles. (A woman having amenorrhea have periods only with hormonal administration e.g. estrogen administration.
• Physical symptoms include drastic weight loss that is proportional to degree of malnutrition.
• The body goes to hibernation and functionally become hypothyroid (euthyroid sick) to save energy.
• Body temperature decreases below normal body temperature i.e. 37oC.
• Especially in supine position, the patient feels Bradycardia (heart rate 40 beats/min)
• Dizziness
• Lightheadeness
• Impaired cardiac function.
• Orthstasis and hypotension.
• Decreased left ventricular mass.
• Stoke volume is compromised.
• Peripheral resistance is increased.
• Dysfuction of left ventricular systole.
• Development of long QTc syndrome
• Increased QT dispersion that increases the risk of cardiac arrhythmias.
• Peripheral circulation is reduced.
• Hands and feet become blue and cool.
• Hair becomes thin.
• Nails become brittle.
• Dryness of skin.
• Affected gastrointestinal track.
• Inability to take normal quantities of food and gastrointestinal reflux that results in the body to reduced intake.

Laboratory Findings for Anorexia Nervosa

• Blood urea nitrogen is increased.
• Increased creatinine level secondary to renal insufficiency.
• Reduction in white blood cells count, platelets, and less commonly red blood cells.
• Hematocrit level decreases.
• Fat atrophy of the bone marrow occurs.
• AST and ALT increases secondary to malnutrition.
• Cholesterol level increases.
• Alkaline phosphatase level decreases secondary to zinc deficiency.
• Decreased level of FSH (follicle-stimulating hormone), LH (luteinizing hormone), estradiol and testosterone.
• Abnormal level of electrolytes.
• Phosphorus level decreases.
• Insulin-like growth factor decreases.
• Cortisol level decreases.
• Urine specific gravity in case of intentional water intoxication decreases.

Differential diagnosis for Anorexia Nervosa

If the patient has lost a significant amount of weight and there is no distortion of body image then the clinician consider the differential diagnosis. Differential diagnosis includes inflammatory bowel disease, diabetes, hyperthyroidism, malignancy, and depression. Clinicians can also diagnose the patient by adrenal insufficiency and malabsorption syndrome such as celiac disease. The laboratory reports and radiologic evaluation can also be helpful in the diagnosis of anorexia nervosa.

Complications of Anorexia Nervosa

Short-Term Complications

1. Early Satiety- Patients feel difficulty after having meal with modest calories. As the gastric emptying is poor, pancreatic and biliary secretion is diminished, so the patient feels greater difficulty after having larger meals.
2. Superior mesenteric artery syndrome- The fat pad between the superior mesenteric artery and the duodenum gets shrink, compressing the transverse duodenum and causes vomiting. There is intolerance of solid oral intake. So the best treatment involves liquid diet intake and nasoduodenal feedings until the restoration of fat pad.
3. Constipation- Patients with anorexia nervosa may face severe constipation often having no bowel movements for several weeks. Loss of gastrocolic reflex and loss of colonic muscle tone are the two main mechanisms that contribute to constipation. The colon has decreased peristaltic amplitude so typical soft sweeteners are not much effective. The best treatment includes the use of bisacodyl as well as osmotic agents that induce peristalsis. The common example of these agents includes glycol-electrolye solution (MiraLax). Patients may have constipation that persists for 6-8 weeks that requires enemas.

Long-Term Complications

1. Osteoporosis- It is a diseased condition in which bone mass is reduced at one or more sites. About 50% of females with anorexia nervosa have osteoporosis. The two hormones essential for the bone development are estrogen and testosterone. Patients with amenorrhea have estrogen deficiency and hypothalamic amenorrhea is correlated with osteoporosis. Increase of cortisol levels and reduction in insulin-like growth factor also contribute to osteoporosis. The only treatment for patients with anorexia nervosa is to regain sufficient weight for the normal menstrual cycle more specifically in females.
2. Brain Changes- Patients with anorexia nervosa have malnutrition that affects brain tissues. Both grey and white matter is affected and there is increase in cerebrospinal fluid in sulci and ventricles. There is a decrease in cognitive ability and decrease in cerebral blood flow in every malnourished patient.

Mortility rate of Anorexia Nervosa

Patients with eating disorders such as anorexia nervosa and bulimia nervosa are at higher risk of death than the general population. In such patients, the risk of dying is 5.9%. The risk of dying with such eating disorders is 0.56% per year. In anorexic patients the death is majorly due to suicide, abnormal electrolytes, and cardiac arrhythmias.

Treatment of Anorexia Nervosa

The main treatment of anorexia nervosa is therapy to the patient. Patient’s parents should be educated about the dangers of malnutrition and are instructed to supervise each meal of the patient. 20 weekly sessions are prescribed that educate the patient to take proper meal for living a normal life.