Anorexia Nervosa

ETIOLOGY:
  • Malabsorption Syndrome is most common cause 
  • SATIATION
  • DISORDERS-: cancer, depression, dementia, AIDS, chronic renal failure, altitude sickness.
  • DRUGS-: stimulants, narcotics, antidepressants (side effect), phenethylamine (decrease appetite).
  • CONGESTIVE CARDIAC FAILURE (congestion of liver with venous blood).
  • LIFESTYLE
  • PHYSIOLOGICAL FACTORS- GENES( 50%)
  • NEUROBIOLOGICALFACTORS- Serotonin is strongly related to mood, sleep, emesis, sexuality and appetite. NUTRITIONAL FACTORS- Zinc deficiency causes a decrease in appetite due to hypogeusia. Also deficiency of nutrients like tyrosine, tryptophan, and thiamine decrease appetite.
  • PSYCHOLOGICAL FACTORS
  • NEUROPSCHOLOGICAL FACTORS
DIAGNOSIS:
  • Refusal to maintain body weight at or above a minimally normal weight for age and height (at or below 75- 80% of the normal weight).
  • Intense fear of weight gain or becoming fat.
  • Increase in free fatty acids,ketone bodies & Decrease in glycogen is seen within 24 hrs of starvation with Anorexia Nervosa
  • Distortion of body image (constant feeling of being fat).
  • Widespread endocrine disorders involving hypothalamic-pituitary- gonadal axis.
  • Anorexia Nervosa with euthyroid sick syndrome shows Low T3, Low T4, increased rT3, Normal TSH
  • Amenorrhea in women and loss of sexual activity and potency in males.
  • Elevated levels of GH, raised cortisol levels, changes in peripheral metabolism of thyroid hormone and insulin secretion abnormalities.
  • Anorexia nervosa can be differentiated from bulimia by Peculiars patterns of food handing & weight
  • Laboratory tests give limited aid-
  1. Tendency towards depression of gastric acid and blood sugar.
  2. Glucose tolerant curve is flat.
  3. Laboratory markers of anorexia includes decreased FSH, LH and TSH, and increased Cortisol
  4. Eliminate all other causes of anorexial symptoms such as hypothyroidism, pituitary cachexia, Addison’s disease etc.
SIGNS & SYMPTOMS:
  • PSYCHOLOGICAL SYMPTOMS:
  1. Distorted Body Image.
  2. Poor insight.
  3. Self evaluation of shape and weight.
  4. Perfectionism.
  5. OCD.
  6. Preoccupation or obsessive thoughts about food and weight.
EMOTIONAL:
  • Low self esteem & efficacy
  • Clinical depression or chronically low mood
  • Mood swings
  • Intense fear of becoming overweight.
  • Increased commitment to work
INTERPERSONAL & SOCIAL
  1. Poor, deteriorating performance.
  2. Withdrawal from previous relations.
  3. Deterioration in relationships with the family.
BEHAVIORAL
  • Excessive exercise
  • Fainting
  • Secretive
  • Possible self harm ,
  • substance abuse or suicide attempts
  • Sensitive about body references
  • Become angry when forced to eat forbidden food. 
PHYSICAL:
  • Extreme weight loss and stunted growth.
  • Body weight < 85% of the predictedPins and needles and purple extremities.
  • BMI index is higher than normal Population
  • Endocrine disorder.
  • Scars and calluses on the back of the hand
  • Self induced vomiting
  • Dehydration
  • Emaciation
  • Decreased libido, impotence in males.
  • Starvation symptoms- reduced metabolism, bradycardia, hypotension, hypothermia, anemia, low BMR.
  • Growth of lanugo hair on the body.
  • Reduction in WBC count.
  • Reduced immunity.
  • Zinc deficiency.
  • Abnormalities of minerals and electrolyte levels in the body .
  • Body mass index less than 17.5 in adults, or 85% of expected weight in children.
  • Pallid complexion and sunken eyes.
  • Amenorrhea,milk discharge from the nipples
  • Creaking joints and bones.
  • Tooth erosion.
  • Collection of fluid in ankles during day and around eye during the night.
  • Constipation.
  • Salivary gland hypertrophy
  • Malnutrition – dry & chapped lips, headaches.
  • Thinning of hair.
  • anorexia
  • Russell's sign
  • Brittle nails.
  • Dry skin.
  • Easily bruised.
  • Nerve deterioration causing movement difficulties.
  • Bulimia (binging and purging with vomiting, laxatives, or diuretics) may be seen in 50% of patients
TREATMENT:
  • First line treatment of anorexia is restoration of 90% of the weight of the patients
  • Success of a psychotherapy is determined by the weight gain
  • Every 5-6 days 300 cals in the diet are increased in the form of proteins & vits’.Continue till the daily intake is 3400-3600 cal
  • Hypophosphatemia and cardiorespiratory failure are the dangerous adverse effect of this type of re-feeding in Anorexia Nervosa
  • Appetite stimulation:
  1. ZINC(DOSE-14mg/day),
  2. MOA- increased neurotransmission in brain including amygdala
  3. MAGESTEROL ACETATE
  4. TETRA HYDRO- CANNABINOL
  5. Herbal appetite stimulants

Exam Question
  • Amenorrhea, anorexia, weight loss and with milk discharge from the nipples are seen in Anorexia nervosa
  • Leukopenia, Amenorrhea, Self induced vomiting are seen in Anorexia nervosa
  • Increased commitment to work ,Distortion of body image,Body weight < 85% of the predicted are seen in Anorexia nervosa
  • Weight loss,Dehydration,Mood changes are commonly seen in Anorexia nervosa
  • Physical findings in anorexia nervosa are Emaciation, Hypotension, Bradycardia ,Hypothermia, Skin dryness and flakiness, Lanugo ,Peripheral edema, Petechiae on extremities ,Sallow complexion ,Salivary gland hypertrophy, Dental enamel erosion, Osteoporosis ,Russell's sign ,Scars and calluses on the back of the hand, Amenorrhea ,Mood changes
  • Increase in free fatty acids,ketone bodies & Decrease in glycogen is seen within 24 hrs of starvation in a 19-year-old patient with Anorexia Nervosa
  • Hypophosphatemia and cardiorespiratory failure are the dangerous adverse effect of this type of re-feeding in Anorexia Nervosa
  • Anorexia Nervosa with euthyroid sick syndrome shows Low T3, Low T4, increased rT3, Normal TSH
  • Anorexia nervosa can be differentiated from bulimia by Peculiars patterns of food handing
  • Main difference between anorexia nervosa and bulimia nervosa lies in Weight
  • In anorexia nervosa Bulimia may be seeen in 50% cases
  • In anorexia nervosa Decreased FSH levels is seen
  • BMI index is higher than normal Population in anorexia nervosa
  • Malabsorption Syndrome is most common cause of anorexia nervosa

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