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Anorexia nervosa Elizabeth Outten, MS, PA-C
GENERAL FEATURES • Anorexia nervosa is the most common cause of intentional weight loss in teenage girls. • The exact cause of anorexia is not known, but may be a mixture of endocrine and psychiatric causes and cultural influences. • Anorexia is commonly associated with psychiatric disorders and has a strong association with depression, anxiety, and suicidal ideation. • The first episode of anorexia can be preceded by a major life event such as the loss of a loved one or moving. • The two subtypes of anorexia are binge-purging and restricting. CLINICAL ASSESSMENT • History { Remain nonjudgmental and establish a good rapport with the patient. { Ask about diet habits, food rituals, and exercise habits. Family members and loved ones are usually very informative about this, as patients will not be forthcoming with this information. { Identify any family history of eating disorders or psychiatric illness. { Screen all patients for comorbid psychiatric disorders such as depression, substance abuse, or anxiety. Assess and question all patients about their risk for suicide. { Patients may present with vague somatic complaints of fatigue, constipation, difficulty sleeping, abdominal pain, or bloating. { Identify any recent major life events that could serve as a trigger for the patient. • Physical examination { Have patients dress in gowns, as they will often hide weight loss with layered, bulky clothing. { Common physical examination findings are hypotension, bradycardia, xerosis, and dehydration. { Some patients with severe anorexia may have amenorrhea.
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Examine patients for self-injurious behavior such as cutting or burning.
DIAGNOSIS • According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), anorexia nervosa is defined as: { Restriction of energy intake relative to caloric requirements, leading to severe weight loss (body weight less than a minimally normal weight for the patient’s age and height). { Intense fear of gaining weight or becoming fat, even though the patient is underweight. { Distorted body image or disturbance in the way in which one’s body weight or shape is experienced and denial of the seriousness of the current low body weight. • Specify the type of anorexia { Binge-purging: during the last 3 months, the person has engaged in recurrent episodes of binge eating or purging behavior. { Restricting: during the last 3 months, the patient has not engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or misuse of laxatives). • Obtain an accurate height, weight, and BMI. • Classify the severity according to BMI: { Mild: BMI ≥17 kg/m2 { Moderate: BMI 16 to 16.99 kg/m2 QUESTIONS 1. What type of anorexia is characterized by severe diet restriction that occurs for 3 or more months? a. restorative anorexia b. restricting anorexia c. binge-purging anorexia d. bulimia 2. Which of the following is a goal of treatment for a patient with anorexia?
Elizabeth Outten is an assistant professor and clinical coordinator of the PA program at Arcadia University in Newark, Del. The author has disclosed no potential conflicts of interest, financial or otherwise. Dawn Colomb-Lippa, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000459819.47779.b8 Copyright © 2015 American Academy of Physician Assistants
a. rapid weight gain b. fluid rehydration c. weight restoration d. integrate a high-intensity physical exercise program
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
43
QUICK RECERTIFICATION SERIES
TREATMENT • All patients newly diagnosed with anorexia should undergo a psychiatric evaluation. Most patients can participate in outpatient programs; some may need inpatient psychiatric care. • Patients with severe hypovolemia, electrolyte abnor-
44
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malities, and severe malnutrition should be kept as inpatients until hemodynamically stable, and may need parenteral nutrition. • Psychotherapy is the cornerstone of treatment for anorexia. In particular, cognitive behavioral therapy and family therapy have been shown to have the greatest effect on a patient’s recovery and rehabilitation. • The goal of treatment is to treat all psychiatric comorbidities and restore the patient to normal body weight.
Answers
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1. B. The restricting type of anorexia is characterized by severe diet restrictions and lack of purging via selfinduced vomiting or laxative overuse. The binge-purging type of anorexia is characterized by binge eating followed by purging via self-induced vomiting or laxative overuse. 2. C. In patients with anorexia, the goal of treatment is to identify and address underlying psychiatric comorbidities and restore the patient to a normal weight.
Severe: BMI 15 to 15.99 kg/m2 Extreme: BMI
Anorexia nervosa Elizabeth Outten, MS, PA-C
GENERAL FEATURES • Anorexia nervosa is the most common cause of intentional weight loss in teenage girls. • The exact cause of anorexia is not known, but may be a mixture of endocrine and psychiatric causes and cultural influences. • Anorexia is commonly associated with psychiatric disorders and has a strong association with depression, anxiety, and suicidal ideation. • The first episode of anorexia can be preceded by a major life event such as the loss of a loved one or moving. • The two subtypes of anorexia are binge-purging and restricting. CLINICAL ASSESSMENT • History { Remain nonjudgmental and establish a good rapport with the patient. { Ask about diet habits, food rituals, and exercise habits. Family members and loved ones are usually very informative about this, as patients will not be forthcoming with this information. { Identify any family history of eating disorders or psychiatric illness. { Screen all patients for comorbid psychiatric disorders such as depression, substance abuse, or anxiety. Assess and question all patients about their risk for suicide. { Patients may present with vague somatic complaints of fatigue, constipation, difficulty sleeping, abdominal pain, or bloating. { Identify any recent major life events that could serve as a trigger for the patient. • Physical examination { Have patients dress in gowns, as they will often hide weight loss with layered, bulky clothing. { Common physical examination findings are hypotension, bradycardia, xerosis, and dehydration. { Some patients with severe anorexia may have amenorrhea.
{
Examine patients for self-injurious behavior such as cutting or burning.
DIAGNOSIS • According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), anorexia nervosa is defined as: { Restriction of energy intake relative to caloric requirements, leading to severe weight loss (body weight less than a minimally normal weight for the patient’s age and height). { Intense fear of gaining weight or becoming fat, even though the patient is underweight. { Distorted body image or disturbance in the way in which one’s body weight or shape is experienced and denial of the seriousness of the current low body weight. • Specify the type of anorexia { Binge-purging: during the last 3 months, the person has engaged in recurrent episodes of binge eating or purging behavior. { Restricting: during the last 3 months, the patient has not engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or misuse of laxatives). • Obtain an accurate height, weight, and BMI. • Classify the severity according to BMI: { Mild: BMI ≥17 kg/m2 { Moderate: BMI 16 to 16.99 kg/m2 QUESTIONS 1. What type of anorexia is characterized by severe diet restriction that occurs for 3 or more months? a. restorative anorexia b. restricting anorexia c. binge-purging anorexia d. bulimia 2. Which of the following is a goal of treatment for a patient with anorexia?
Elizabeth Outten is an assistant professor and clinical coordinator of the PA program at Arcadia University in Newark, Del. The author has disclosed no potential conflicts of interest, financial or otherwise. Dawn Colomb-Lippa, MHS, PA-C, department editor DOI: 10.1097/01.JAA.0000459819.47779.b8 Copyright © 2015 American Academy of Physician Assistants
a. rapid weight gain b. fluid rehydration c. weight restoration d. integrate a high-intensity physical exercise program
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
43
QUICK RECERTIFICATION SERIES
TREATMENT • All patients newly diagnosed with anorexia should undergo a psychiatric evaluation. Most patients can participate in outpatient programs; some may need inpatient psychiatric care. • Patients with severe hypovolemia, electrolyte abnor-
44
www.JAAPA.com
malities, and severe malnutrition should be kept as inpatients until hemodynamically stable, and may need parenteral nutrition. • Psychotherapy is the cornerstone of treatment for anorexia. In particular, cognitive behavioral therapy and family therapy have been shown to have the greatest effect on a patient’s recovery and rehabilitation. • The goal of treatment is to treat all psychiatric comorbidities and restore the patient to normal body weight.
Answers
{
1. B. The restricting type of anorexia is characterized by severe diet restrictions and lack of purging via selfinduced vomiting or laxative overuse. The binge-purging type of anorexia is characterized by binge eating followed by purging via self-induced vomiting or laxative overuse. 2. C. In patients with anorexia, the goal of treatment is to identify and address underlying psychiatric comorbidities and restore the patient to a normal weight.
Severe: BMI 15 to 15.99 kg/m2 Extreme: BMI
