Anorexia Nervosa: Adjustments in Food, Mood and Attitude
by Kari Kassir, M.D.
Anorexia nervosa is a medical condition with both physiologic and psychological components affecting people of all ages from all walks of life. It is, however, most common in adolescent and young adult females. According to the DSM-IV-TR, its essential features include refusal to maintain a minimally normal body weight (less than 85 percent of ideal body weight), intense fear of gaining weight, significant disturbance in perception of body shape or size and loss of periods in young women who have already started to menstruate. Not all patients with anorexia nervosa meet these stringent criteria, yet the dangers to their physical and mental health are the same, making it necessary to apply the same standards of care.
Medical complications may arise from starvation, purging (vomiting, laxative use) or over-exercising, and involve virtually all organ systems. Morbidity generally results from cardiac abnormalities (rhythm disturbances, low heart rate, blood pressure problems, fainting), endocrine abnormalities (absent periods, abnormal stress hormone levels, low blood sugar), musculoskeletal problems (osteopenia and osteoporosis), metabolic derangements (low potassium level, low sodium level), and complications from refeeding (low phosphate level with associated swelling, neurologic problems, and abnormal heart rhythms). Co-existing psychiatric conditions such as depression, anxiety disorder, obsessive-compulsive disorder, and substance abuse can complicate the picture, but must be addressed alongside the medical issues. The mortality rate is at least 5 percent, with most deaths resulting from medical complications or suicide.
As both psychological and medical concerns are part of this disorder, a multidisciplinary approach should be taken involving the physician, dietician, and mental health professional. Outpatient treatment includes a comprehensive history and physical examination, with laboratory assessment (complete blood count, chemistries, urinalysis including pregnancy test, and thyroid function). A baseline electrocardiogram is also essential. Refeeding involves an initial daily caloric intake of 1200-1500 calories, with weekly increases of 500 calories a day, to achieve weight gain of one to two pounds per week. Close follow-up and education are extremely important to recovery. While no psychotherapeutic technique has distinguished itself as most efficacious in anorexia nervosa, studies show that any form of psychotherapy facilitates improvement. Family therapy has also been shown to be invaluable, particularly with younger children.
For those with more serious symptoms, hospitalization may be required. General criteria for admission include:
- low heart rate (less than 50 beats a minute)
- heart rate or blood pressure changes upon standing (orthostasis)
- blood pressure less than 80/50, low potassium or low phosphate
- weight less than 75 percent below normal weight or rapid weight loss
- low blood sugar, lack of improvement despite outpatient therapy
- suicidal ideas or co-existing psychiatric illness, or
- antitherapeutic or abusive family environment.
Hospital re-feeding must proceed slowly, using the same plan as for outpatients, one or two pounds per week. More rapid weight gain can put undue stress on the heart. Discharge can occur when a healthy weight has been achieved, and both patient and family are able to assume responsibility for continued weight gain.
To achieve full recovery and prevent relapse, care must continue after weight regain. Some specialists advocate the use of psychotropic medications (selective serotonin reuptake inhibitors, atypical antipsychotics, antiepileptics) under specific circumstances (for example, binge eating, purging, recalcitrant anorexia nervosa, concurrent psychiatric illness), but widespread use is not indicated.
Anorexia nervosa is a complex condition that requires a multidisciplinary approach and diligence to achieve full recovery and prevent complications.
Insurance coverage can be a tricky issue with anorexia nervosa. Nutritional deficiencies and medical problems can be billed under major medical coverage, while the psychological issues fall under mental health benefits. Day treatment programs and practitioners who specialize in the treatment of eating disorders can be invaluable resources for insurance information. Pediatricians can also be strong advocates for patients to secure appropriate coverage.
For further reading:
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. American Psychiatric Association, Washington, DC, 2000.
J Yager, AE Andersen. Anorexia nervosa. NEJM 2005; 353(14):1481-1488.
M Fisher. Treatment of eating disorders in children, adolescents, and young adults. Pediatrics in Review 2006; 27(1):5-15.
Committee on Adolescence. Identifying and treating eating disorders. Pediatrics 2003; 111:204-211.
K McCallum, O Bermudez, C Ohlemeyer, E Tyson, M Portilla, B Ferdman. How should the clinician evaluate and manage the cardiovascular complications of anorexia nervosa. Eating Disorders 2006; 14:73-80.