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three main features of anorexia

1. an intense pursuit of weight loss & self-induced starvation

- fear of becoming obese
- engages in dieting and excessive exercise
- paradoxically focused on food

2 a disturbance in body image: belief they are fat even though they are thin

3. medical signs/symptoms of starvation 


DSM IV version of anorexia

Weight loss to less than 85% of ideal body weight or failure to make expected weight gains in children and adolescents

Intense fear of gaining weight

Disturbance in how one perceives their body

Amenorrhea for 3 months in post-menarcheal females 


DSM 5 changes to Anorexia 

Removal of less than 85 percentile of IBW criteria -> “significantly low weight”

Intense fear of gaining weight or behaviors that interfere with weight gain

Disturbance in how one perceives their body 


Two subtypes of anorexia

• Restricting Type
• Binge-eating/purging type 


What are the different levels of severity of anorexia

• Mild: BMI >17
• Moderate: 16-16.99

• Severe: 15-15.99
• Extreme: <15 


• Eating a large amount of food in a short period of time
• Engaging in compensatory behavior to get rid of the food or weight

• Feelings of loss of control during the episode 



What vital sign changes do we see as physiological effects of starvation?

 • Hypotension

• Bradycardia

• Hypothermia 


Effect of heart, skeletal, endocrine from anorexia

• Cardiac: Bradycardia, hypotension, syncope, EKG changes, arrhythmias & sudden death

• Skeletal: Osteopenia, osteoporosis

• Endocrine:
• Hormonal changes: decreased LH, FSH & estradiol, abnormal TSH

• Cold intolerance, hypothermia
• Decreased libido, amenorrhea 


Skin/GI/Heme/Neuro changes with anorexia

• Dermatology: Dry skin, alopecia, lanugo (fine baby-like hair over the body)

• Hematologic: Pancytopenia - anemia, leucopenia

• Gastrointestinal: Delayed gastric emptying, constipation

• Neurologic: Fatigue, weakness, reduction in brain mass volume & cognitive deterioration 


Epidemiology of Anorexia nervosa

• Females > males, 1:10

• Onset is usually in the mid-teens, increasing in preadolescents

• 1% of the population, with 5% of the population showing subclinical signs

• Higher socioeconomic status and US versus other developed countries, but equalizing 


Etiology of anorexia nervosa, #1 risk factor

• Multifactorial
• Biological, psychological and social factors

• Different for almost every patient

• Dieting is the #1 Risk factor 


Steps to food disorders

Food/body acceptance--> Food/body obssessed--> disordered eating --> eating disordres: anorexia, bulimia, binge eating disorder


What genetc factors play a role in eating disorders?

• Higher rates in monozygotic twins
• Strong family history for mood disorders 


What hormonal changes are seen with disordered eating?

Hormonal, biochemical and starvation effects

associated with onset of puberty

endorphin increases

hypothalamic-pituitary-adrenal axis changes

neurotransmitter: decreased norepinephrine turnover, decreased dopamine response, serotonin increases with food 


Psychological Factors in eating disorders


Temperament: perfectionist, harm avoidant, high-achieving

Control issues: feeling helpless, not able to establish autonomy

Maturation fears: fear of becoming an adult, being shapely or sexual

Demands to increase independence: overwhelming, focuses on food versus “normal” activities

Beliefs: moral desires are greedy/unacceptable 


What social factors have a role in eating disorders?

• Media influence
• Obesity education
• Family concerns about weight
• Teasing about weight
• Dieting information
• Performance pressures in sports 


Key DDX to consider before dx with eating disorder

• Rule out
• Brain tumor or cancer
• Other psychiatric disorders: depression, somatization, schizophrenia, bulimia 


Complications of AN and how we can use Labs to support Dx

• Complicated by
• denial, secrecy
• disinterest or resistance to treatment

• No laboratory tests “diagnose” AN, but for medical assessment:

• CBC,electrolytes,magnesium,phosphorus,FSH/LH/estradiol,thyroid,LFTs,amylase,UDS, specific panels (i.e. diuretics), ECG, urine pregnancy 


is the most lethal psychiatric disorder

May require inpatient medical stabilization

Key point: Don’t ignore weight loss
in teenage patients! 

Anorexia Nervosa (AN) 


Treatment for severe AN

• Food is the best medicine!!

• May require hospitalization

• If nutritionally unstable: dehydration, electrolyte abnormalities

• Goal: reinstate nutrition, correct metabolic abnormalities, maintain structure/cooperation

• Treatment team is KEY: Primary care physician, Psychiatrist, Dietician, Psychotherapist 


What is Refeeding syndrome

• Fluid and electrolytes shift during nutritional rehabilitation

• Risk is related to: amount of weight lost during the current episode , rapidity of weight restoration

• Potentially life-threatening
Hypophosphatemia, delirium, arrhythmias and cardiac arrest 


What types of pyschotherapy are available to tx AN

• “Maudsley” Family Based Treatment:parents play an active role in restoring weight and gradually hand over control back to the patient

• Cognitive behavioral therapy (CBT): address cognitive distortions

• Dialectical behavioral therapy (DBT): address treatment interfering behaviors 

**Goal: stabilize and improve primary relationships 


What type of pharmacology is available for AN tx?

• No medications are indicated or have consistently shown benefit for the core symptoms of anorexia nervosa

• Medications are generally used to treat psychiatric comorbidities :Depression, social phobia, OCD 



Prognosis for AN

• Good to moderate in 75% of patients
• 1⁄4 have a complete recovery
• 1⁄2 have overall good function despite ongoing issues

Some continue a waxing and waning course

• Increased risk of poor prognosis and death :persisting food obsessions,  complicated by bulimia,  low albumin, very low weight

• Mortality: 7-18% 


Characteristics of Bulemina nervosa

1. episodes of overeating

2. compensatory behavior to prevent weight gain - may engage in purging or excessive exercise
- may have normal weight, be overweight or obese

3. clinical signs/symptoms 


DSM IV criteria for bulemia nervosa

Recurrent episodes of binge eating followed by inappropriate compensatory behavior in order to prevent weight gain

Episodes occur at least twice a week for 3 months

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa 


Subtypes of bulemia

• Purging type

• Nonpurging type 


 DSM 5 for bulemia nervosa

Recurrent episodes of binge eating

Recurrent inappropriate compensatory behavior in order to prevent weight gain

Episodes of A and B occur at least once a week for 3 months

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa 


What changes were made to the DSM 5 for bulemia nervosa

• Subtypes were removed
• Severity can be specified: based on number of compensatory behaviors episodes per week

• 1-3 = mild
• 4-7 = moderate
• 8-13 = severe

• 14+ = extreme