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Anorexia Nervosa  厌食症 / Reading and Sharing

 

Anorexia Nervosa is an eating disorder that affects approximately 0.2-1.3% of the population; that’s about 5 to 10 cases per 100,000 people. There is a 9:1 ratio of female to males that have anorexia nervosa; it does affect males as well! About 0.5-1% of women between the ages of 15 and 30 have anorexia. Age 17 is the median age for people who suffer with this. Anorexia nervosa is a psychiatric disorder that’s characterized by abnormal eating behavior and severe self-induced weight loss. (Ferri, 2018). These patients have an intense fear of gaining weight. There are two types of anorexia which include the restricting type that restrict all fat and food intake and the binge eating/purging type that includes binge eating followed by vomiting with an abuse of laxatives. 

The exact cause of anorexia is unknown, but it is said to be multifactorial with the combination of genetic, neurochemical, and sociocultural factors. The disease is considered a mental health disorder that’s started due to genetics, society, or culture (Dunphy et al., 2015). A history of sexual abuse has been reported in as many as 50% of patients that have anorexia. These patients will often times have an incompletely developed personal identity; they can’t seem to maintain a sense of control over their environment, and they usually have low self-esteem (Ferri, 2018). Anorexia is also associated with depression in 65% of cases, social phobia in 34% of cases, and OCD in 26% of cases. Mortality rate is 20%; one in 10 patients with anorexia suddenly dies from starvation, cardiac arrest, or suicide (Dunphy et al., 2015).  

Patients with anorexia nervosa will present to the clinic with excessive weight loss, electrolyte imbalances, bradycardia, lanugo, brittle nails, amenorrhea, constipation, lethargy, hypotension, dry skin, and dull hair. The patient may present bundled in clothing due to not wanting you to know that they’ve lost weight. Skin may be yellow-tinged from carotenoderma, and female fat distribution is no longer present. The patient’s axillary and pubic hair are preserved, and peripheral edema may be evident (Ferri, 2018). 

There are many types of diagnostics that can be done. For lab work, patients should get a TSH, free T3 and T4, CMP, CBC, hormone levels, lipid panel, and sed rate. Patients with anorexia will have leukopenia, anemia, elevated BUN, elevated LFTs, hypomagnesia, hypophosphatemia, elevated TSH, and hypocholesteremia (Ferri, 2018). Along with labs, the patient should be diagnosed according to the DSM-5 criteria. These criteria include a restriction of energy intake resulting in significantly low weight, intense fear of gaining weight or becoming fat, and lack of recognition of the seriousness of the current low body weight (Dunphy et al., 2015)

Treatment is often times very difficult to initiate due to the patient not wanting to get better. For best results, a multidisciplinary approach with psychological, medical, and nutritional support is necessary. A goal weight should be set and should be monitored weekly if the patient is doing treatment as an outpatient. Weight gain should be gradual, 1-3 lbs per week to prevent gastric dilation. Diet should start at 800 to 1200 kcal in frequent small meals, then increase calories to 1500 to 3000 depending on height and age. You may need to add vitamin and mineral supplements. Electrolytes should be monitored, and mealtimes should be a social interaction and not confrontation. The patient’s access to the bathroom should be monitored to prevent purging or laxative use. 

Hospitalization should be initiated when the patient is no longer stable. This includes things like heart rate less than 45, cardiac rhythm disturbances, hypotension, hypokalemia, hypophosphatemia, hypoglycemia, dehydration, weight is less than 80% of health body weight, suicidal intent, poor motivation to recover, preoccupation with ego-syntonic thoughts, coexisting psychiatric disorders, requires supervision with meals, and failed outpatient (Ferri, 2018). A referral to a psychiatrist may be beneficial; their expertise would be greatly appreciated. The goals of treatment are to return the patient to healthy body weight, help the patient analyze motivations regarding their eating disorder, to prevent and treat complications of the illness, provide psychoeducation, enlist family support, and to prevent relapse (Anorexia Nervosa, 2018). 

References:

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D J. (2015). Primary care: The art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis Company. 

Ferri, F. F. (2018). Ferri’s clinical advisor 2018. Philadelphia, PA: Elsevier.

Anorexia Nervosa(2018). Epocrates Plus (Version 18.1) [Mobile application software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials

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