Clinical vignette A 16-year-old girl was taken by her parents to a pediatrician’s office for evaluation. She went to the consultation reluctantly and said that she had no health problems. However, her parents reported that for 5 months she had been eating a highly restrictive diet consisting primarily of vegetables and small amounts of chicken or turkey, that she did not want to increase her food intake, and that she was progressively losing weight. . At examination, his body mass index (BMI, weight in kilograms divided by the square of height in meters) was 17.5 (weight 49 kg, height 170 cm). Her blood pressure while she was sitting was 100/78 mm Hg, which decreased to 78/60 mm Hg after standing for 3 minutes. Her resting pulse was 46 beats per minute. Her skin was dry and her hair was thinning on her scalp. An examination of her oral cavity revealed extensive erosion of tooth enamel. How would she evaluate and treat this patient? |
| The clinical problem |
Anorexia nervosa is a severe psychiatric disorder characterized by hunger and malnutrition, a high incidence of coexisting psychiatric conditions, resistance to treatment, and a substantial risk of death from medical complications and suicide. The diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fifth Edition, 1 are shown in Table 1.
No absolute limit is stipulated in terms of low BMI, as several other factors deserve consideration, including the patient’s age, sex, BMI before the onset of symptoms, and rapidity of weight loss; however, low body weight (e.g., BMI ≤17.5) is typically seen in adults with anorexia nervosa.
BMI-for-age growth charts are used to assess BMI in young people. Intense fear of weight gain is a central feature; however, patients often deny this, and it must be inferred from their behavior. An extreme focus on body weight and shape is integral to the disorder, combined with complete control over everything you eat, including food preparation.2
The two designated subtypes of anorexia nervosa are the restrictive subtype , which is characterized by dietary restriction, and the binge-purge subtype , in which restriction is accompanied by binge eating, purging, or both1; The condition can progress from one subtype to another. The restrictive subtype is associated with an earlier age of onset, a better prognosis, and a greater probability of crossing over to the other subtype.3,4
The onset of anorexia nervosa usually occurs in adolescence or adulthood. In the United States, the lifetime prevalence of the condition is approximately 0.80%.5 Approximately 92% of affected individuals are women.5 It occurs less frequently among non-Hispanic black and Hispanic populations than among non-Hispanic black populations. white,5 and the global incidence is increasing, particularly in Asia and the Middle East.6,7
Co-occurring psychiatric conditions include major depression, anxiety disorders, obsessive-compulsive disorder, trauma-related disorders, and substance abuse (which is less common in patients with the restrictive subtype).8
The risk of suicide among patients with anorexia is high, with an estimated incidence that is 18 times as high as in controls.9
The long-term course is heterogeneous, with 20-year longitudinal studies suggesting complete remission in approximately 30 to 60% of patients, chronic disease in 20%, and residual symptoms in the remainder.10,11
The incidence of relapse after treatment ranges from 9 to 52%, with most studies showing an incidence of at least 25%.12,13 Anorexia nervosa is associated with high mortality, with aggregate mortality approaching 5 .6% per decade.14
Outcome studies show persistence of coexisting psychopathology,15 which correlates with the presence and severity of eating disorder symptoms.16 Recovery is often gradual; A long-term follow-up study showed recovery in approximately 31% of patients at 9 years but in almost two-thirds of patients at 22 years.12
A high incidence of familial aggregation has been reported, with twin-based heritability estimates of 50 to 60%.17 Recently, a genome-wide association study identified eight risk loci for anorexia nervosa that were also predictive of other psychiatric disorders, as well as such as low BMI and metabolic disorders.17
Other risk factors include a history of trauma and living in a society in which a high value is placed on thinness, 18,19 although anorexia nervosa develops in only a small percentage of such populations, suggesting that the behaviors of diet can trigger anorexia nervosa among vulnerable people.20
Perinatal factors that have been associated with increased risk include uterine exposure to rubella, as well as multiple births and preterm birth.20,21 Psychological risk factors include perfectionism, cognitive rigidity (e.g., dependency on rules), and mental disorders. of childhood anxiety.22
Medical complications are related to weight loss, malnutrition, and conditions attributable to purging.23 Patients who present with self-induced vomiting may have hypertrophy of the salivary glands and sometimes elevated serum amylase levels. They may have delayed gastric emptying, postprandial fullness, and bloating.
Rarely, binge eating may be associated with gastric dilation which may result in rupture; Rarely, vomiting can lead to esophageal rupture. Intermittent constipation may occur and, more rarely, diarrhea may occur.
Cardiovascular abnormalities include bradycardia (which can be severe when the heart rate decreases during sleep), hypotension (particularly orthostatic hypotension), arrhythmias, and QT prolongation.
Glomerular filtration rate may decrease over time, particularly among patients with the binge-purge subtype; Chronic volume depletion and hypokalemia are commonly implicated. In one study, end-stage renal disease developed in 5.2% of patients with anorexia over a 21-year follow-up.24
The bone marrow becomes atrophic.
The hemoglobin level and white blood cell count can be reduced (with a relative sparing of lymphocytes); rarely, the platelet count may be low.
Loss of muscle mass occurs and can lead to difficulty standing from sitting. Osteoporosis and predisposition to fractures develop in approximately one in three patients.25,26
Brain imaging studies show abnormalities (eg, sulcal widening, ventricular dilation, and cerebral atrophy) that often resolve with weight restoration but sometimes persist. Likewise, neurocognitive patterns, including cognitive rigidity, may improve or persist with weight restoration.28,29
| Strategies and evidence |
Management requires a detailed medical, psychiatric, and nutritional evaluation, physical examination (including height and weight measurement), and laboratory testing (Table 2). Information should be obtained from the patient’s caregivers as well as other medical providers to corroborate the patient’s self-report. Patient misinformation may be due to fear of forced treatment, lack of self-awareness, and the cognitive effects of malnutrition.
A collaborative approach appears to improve patient confidence.
Clinically, motivational interviewing techniques have been reported to be useful in ambivalent, fearful, or antagonistic patients.30,31 Questions can be framed as avoiding judgment (e.g., "I’m curious about you limiting your diet to one meal). a day. What does this mean to you? ” Similarly, empathic treatment and validating acceptance of the patient’s reluctance to participate in treatment appears to be helpful (e.g., “Based on what you have described to me about your previous experiences, your skepticism is understandable." ).
| Treatment |
Hospitalization, residential and day treatment
Immediate hospitalization is indicated in some patients23,24 due to profound hypotension and dehydration, severe electrolyte abnormalities, arrhythmias or severe bradycardia, and risk of suicide.
Generally, a BMI of 15 or less indicates that hospitalization is warranted.24 In rare cases, seeking involuntary treatment should be considered when the patient presents with signs and symptoms that are considered life-threatening.32
Refeeding protocols were traditionally started at 1200 kcal per day to minimize the risk of refeeding syndrome. However, recent data suggest that more aggressive refeeding protocols (with monitoring for refeeding syndrome) are safe for most patients.33
For patients for whom immediate hospitalization is not warranted (or for those who have already been hospitalized), alternatives to outpatient treatment include residential treatment and day treatment.
Decisions about treatment setting are guided by the severity and chronicity of the disease, insurance coverage, and available resources in the community. Residential treatment has become more common, with the aim of preventing relapses and chronicities; However, the available studies did not demonstrate better results with residential treatment than with day or outpatient treatment.34
Psychotherapy
Psychotherapy is the pillar of therapy.
However, data to guide choices between types of psychotherapy remain limited and controversial.
Family interventions, particularly family-based treatment, are commonly recommended in the treatment of children and adolescents.35 Such interventions are typically delivered in three phases over a period of 6 to 12 months.
The first phase emphasizes the role of the patient’s parents in promoting healthy eating behaviors and weight restoration and helps families "unite" against the eating disorder instead of assigning blame.
Caregivers often have high levels of anxiety, stress and depression, and often feel powerless to confront their child or adolescent’s restrictive eating and other problematic behaviors36 ; By providing structure and support, this approach can help reduce parental distress.
Parents carefully monitor all of the patient’s meals and activities to avoid excessive exercise and purging. As treatment progresses into the second phase, feeding autonomy gradually returns to the child or adolescent. The third phase focuses on facilitating better communication and family independence.
Clinical experience and randomized trials have suggested that this form of therapy is more beneficial than other treatments, with remission rates (defined as weight restoration and improvement in cognitive function) at the end of treatment and follow-up of up to 12 months ranging from 30 to 60%, with small to medium effect sizes; Weight gain early in treatment has been shown to predict better outcomes.37,38
However, a recent review of the Cochrane database that included 25 trials showed a substantial risk of bias in many of the studies and concluded that there is limited low-quality evidence to support family therapy approaches over "treatment as usual" 39 , although this conclusion has been criticized.40
Emerging data support multifamily treatment, a variant in which parents of children with eating disorders support each other. A multicenter trial showed better results at one year with multifamily therapy than with regular family therapy.41
Cognitive behavioral therapy (CBT) approaches , which target eating and exercise behaviors as well as negative thoughts about eating, weight, and body shape, have inconsistent support as outpatient therapy in adolescents and adults. An enhanced version of CBT typically involves 40 sessions, compared to about 20 sessions for regular CBT.
Other types of psychotherapy are also used in adults and older adolescents. Maudsley Anorexia Treatment for Adults uses individually targeted behavioral, educational and motivational approaches to address the perpetuating characteristics of anorexia nervosa, including inflexible thinking and fear of making mistakes, interpersonal and emotional problems, beliefs about positive aspects of having Anorexia nervosa and the response of family members and significant others.
Specialized supportive clinical management involves the provision of support, education and encouragement to help the patient increase nutrient intake and regain weight, while allowing the patient to guide much of the content of therapy.
Focal psychodynamic therapy involves identifying foci for therapy, followed by three phases of treatment aimed at understanding how eating behaviors relate to the patient’s beliefs, self-esteem, and relationships.
A randomized trial including adults with anorexia nervosa compared the improvement outcomes of CBT, 43 the Maudsley Model of Anorexia Treatment for Adults, and specialized supportive clinical management. At 1-year follow-up, the percentages of patients who had achieved healthy body weight and remission (mean, 50% and 28%, respectively) did not differ significantly between groups; however, 40% of participants did not complete treatment.
Another randomized trial with adults comparing enhanced CBT with focal psychodynamic therapy and a form of treatment as usual similarly showed no significant difference in BMI increase at the end of treatment or at one year between treatment groups.44
Similarly, a recent network meta-analysis including 18 randomized controlled trials and 17 naturalistic studies of psychotherapies for adolescents and adults showed that the available data, although limited, did not support the superiority of any treatment over another.45
Pharmacotherapy
Most psychopharmacological agents are not effective in the treatment of anorexia nervosa.46 Randomized trials have generally shown that various antidepressant medications , when used in combination with psychotherapy, are no more effective than psychotherapy alone in increasing weight, improve depressive symptoms or reduce the incidence of relapse among patients with anorexia nervosa.47
Similarly, although some studies have suggested a modest benefit of second-generation antipsychotic drugs as a means of stimulating appetite and promoting weight gain, overall, results have been disappointing.46 Despite the lack of efficacy Of psychotropic drugs, they continue to be prescribed for patients with anorexia nervosa.48
Management of bone loss
Osteoporosis is a major concern in patients with anorexia nervosa.25,26
Weight restoration (with the goal of resumption of menstruation) to improve bone density is the primary strategy for management. Additionally, adequate calcium intake (usually 1200 to 1500 mg per day) is routinely recommended for all patients with anorexia nervosa, along with vitamin D supplementation when the blood level of this vitamin is low.
Whereas oral contraceptives do not appear to be effective in reducing bone loss in patients with anorexia nervosa (a finding attributed at least in part to suppression of insulin-like growth factor 1 [IGF-1]), 25,26 some Evidence supports the use of transdermal estrogen (which does not suppress IGF-1).
A randomized trial of 110 young patients with anorexia nervosa showed significantly higher spine and hip z-scores over an 18-month period with transdermal estrogen and cyclic progesterone than with placebo27,49 in adults with anorexia nervosa who have osteoporosis, limited data support a benefit of bisphosphonates , but additional studies are lacking, and these agents are generally not used in adolescents.27
| Areas of uncertainty |
Well-conducted randomized trials of psychotherapies that include long-term follow-up are needed. Additionally, additional data are lacking from randomized trials of interventions to treat bone loss in this population.
Additional studies of approaches to preventing anorexia nervosa are also warranted. A systematic analysis of randomized trials suggested a benefit from some interventions. Among patients who were considered at higher risk, "dissonance-based interventions," which seek to introduce more realistic attitudes about issues such as weight, appeared to be most effective in reducing risk.
For patients with features of eating disorders but no established diagnosis, the CBT approach appeared to be effective.50 However, most trials had methodological limitations,51 and the cost-effectiveness of such strategies is unclear.
| Guides |
The American Psychiatric Association guidelines for the treatment of anorexia nervosa were most recently updated in 201052; those from the National Institute for Health and Clinical Excellence were updated in 2017,53 and those from the American Academy of Child and Adolescent Psychiatry were updated in 2015.54
Recently published updated guidelines from Germany are also available (2019).55 The present treatment recommendations are generally consistent with these guidelines.
| Conclusions and recommendations (clinical vignette) |
The low BMI, marked weight loss, restricted eating behavior, and physical examination in the adolescent patient described in the vignette strongly suggest the diagnosis of anorexia nervosa, most likely the binge-and-purge subtype given the extensive tooth enamel erosion. .
Although the patient initially reports no problems, we would attempt to use motivational interviewing techniques to obtain information, and we would also obtain a history from his parents (Table 2).
Testing should include measurement of levels of serum electrolytes, calcium, phosphorus, magnesium, fasting blood glucose, albumin, prealbumin, amylase, and lipids, a complete blood count and platelet count, and electrocardiography.
His low blood pressure and bradycardia are concerning; especially if you also have marked electrolyte disturbances, we would be inclined to recommend at least brief hospitalization, in an eating disorders unit if available.
During hospitalization, care should involve both a child psychiatrist and a pediatric specialist, additional patient interview with discussion of anorexia nervosa as the problem, intravenous fluid administration (and replacement of potassium and phosphorus as necessary), and the beginning of feedback.
Assuming that the patient begins to be more open in discussing his problems and behaviors and is not actively suicidal, we recommend that once his condition is medically stable, he will be discharged to begin family therapy with weekly sessions in the clinic. Although rigorous data are lacking to support any type of psychotherapy over another, family-based approaches are preferred for children and adolescents.
The initial approach would be to work collaboratively with the patient to increase his food intake, stop purging behaviors, and regain weight, with his parents taking a supervisory role, while he undergoes weekly medical and laboratory monitoring.
The long-term plan would be to increasingly emphasize their independence and establish effective family communication, with an expected reduction in the frequency of family intervention sessions after 6 months.
Although we would anticipate that she would continue to have some body image disturbance and some anxiety when consuming high-fat, high-calorie foods, goals would include eating independently, attending school, participating in extracurricular activities, socializing with peers , and achieve a weight of at least 90% of a normal weight range for your height and age.
She should continue to be monitored by her parents and periodically by a clinician for at least a year for any evidence of relapse, which would indicate the need to quickly restart therapy. Drug therapy is generally not indicated for the management of anorexia nervosa.
Table 1. Diagnostic Criteria, Subtypes and Severity of Anorexia Nervosa |
Diagnostic criteria* Restriction of energy intake relative to requirements, leading to significant low body weight for the patient’s age, sex, developmental trajectory, and physical health. Significantly underweight is defined as a weight that is less than the minimum normal weight or, in children and adolescents, less than the minimum expected weight. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though the patient is at a significantly low weight level. Disturbance in the way body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent failure to recognize the severity of current low body weight. Subtype designation Restriction Type: During the past 3 months, the patient has not engaged in recurrent episodes of binge eating or purging behaviors (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas). Weight loss is mainly achieved through diet, fasting, excessive exercise or all of these methods. Type of binge eating and purging: During the past 3 months, the patient has engaged in recurrent episodes of binge eating or purging behaviors (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas). Current severity Mildly severe underweight is defined as a BMI of ≥17. † Moderately severe underweight is defined as a BMI of 16-16.99. Severe underweight is defined as a BMI of 15-15.99. Extremely low body weight is defined as a BMI <15. |
*These three criteria, all of which are required for the diagnosis of anorexia nervosa, are from the Diagnostic and Statistical Manual of Mental Disorders , fifth edition.
†A patient who underwent bariatric surgery could be considered to have mildly severe body weight even with a BMI of 22 if the patient continues to “feel fat,” has symptoms of malnutrition, or persists with severely limited energy intake to achieve a greater weight loss.
| Table 2. Recommended evaluation in patients with suspected Anorexia Nervosa. | |
| Assessment | Findings in patients with Anorexia Nervosa* |
| Patient characteristics | |
| BMI | Low BMI (≤16.5) † |
| weight history | Progressive weight loss or inadequate weight gain |
| Duration of weight problems | Highly variable duration |
| Menstrual status | Irregular menstruations, amenorrhea |
| Eating patterns, avoided foods, and food rules | Reduced intake and avoidance of fats and foods with high caloric density |
| Excessive food consumption and loss of control while eating | Excessive food consumption, loss of control while eating in some patients |
| Purge behavior | Self-induced vomiting; misuse of laxatives, diuretics or enemas |
| Exercise | Excessive; Patient exercises despite injury and feels driven or obligated to exercise |
| Body Check | Frequent checking of the mirror, measuring body parts |
| Weighing | Frequent, multiple times a day |
| Dissatisfaction with the body | Severe, the patient “feels fat” (sometimes all over the body, sometimes in specific parts of the body) |
| Fear of gaining weight | Severe |
| Concern about weight and shape | Dominant thought |
| Self-esteem | Strongly influenced by body weight and shape and control over overeating behavior |
| Current or past suicidal thoughts or plans | They may be present |
| Self-injurious behavior (e.g. cutting or burning) | They may be present |
| Depression, anxiety, obsessive-compulsive disorder, trauma, post-traumatic stress disorder | Often present |
| Alcohol and drug abuse (including diet pills) | may be present |
| Current or past psychiatric treatment | may be present |
| Psychosocial history | Extensive history |
| Physical exam | |
| Blood pressure | Hypotension (particularly orthostatic) |
| Temperature | Low |
| Pulse | Bradycardia, arrhythmias |
| Fur | Dry skin, hair loss, lanugo |
| Mouth | Erosion of tooth enamel, poor teeth‡ |
| Salivary glands | Hypertrophy (especially parotid) ‡ |
| Hydration status | Evidence of dehydration (eg, dry skin, orthostatic hypotension, but usually without tachycardia) |
| Arms and legs | Muscle wasting, edema (may occur with hypoalbuminemia or refeeding) |
| Laboratory analysis | |
| Complete analysis and differential counting | Typically slightly low, with relative lymphocytosis |
| Platelet count | May be reduced |
| Serum electrolyte levels | |
| Sodium | Diminished |
| Potassium | Diminished |
| Chlorine | Diminished |
| Endocrinological tests | |
| T3 | diminished |
| T3 reverse | Increased |
| metabolic tests | |
| Calcium | Normal |
| Match | Diminished |
| Magnesium | Diminished |
| Fasting blood sugar | diminished |
| Albumin | diminished |
| Prealbumin | diminished |
| Cholesterol | Increased |
| Amylase‡ | Increased |
| Dual X-ray absorptiometry | Osteopenia, osteoporosis |
| Electrocardiography | Bradycardia, QT prolongation, arrhythmias |
* Most of the findings listed are not always present; Its occurrence depends on the associated behaviors and the severity and chronicity of the disease. † A low BMI is not required for the diagnosis of anorexia nervosa. For example, anorexia nervosa may be diagnosed in a person who has excessive weight loss after bariatric surgery, when symptoms of starvation are present and more weight is desired to be lost, but the BMI is not in a low range. ‡ These findings are suggestive of purging. | |
