Pediatric Anorexia Nervosa Clinical Presentation

  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Jan 18, 2012
 

History

Obtain the patient's history with the goal of developing a treatment plan, rather than with the objective of merely ruling out an eating disorder.

Pay careful attention to the patient's self-image and self-esteem, even if the patient identifies that she has an eating disorder. This may help to stratify the risk of mortality, which is 18 times higher when anorexia nervosa (AN) is comorbid with significant psychiatric disorders such as major depressive disorder. This interview can also help to identify an increased risk of dropping out from inpatient treatment. It is important to focus on self-image in the treatment of anorexia nervosa, as control-submission interactions between patient and therapist should be handled with care.[19, 44]

With medical assessment, focus on the medical complications of altered nutrition. Seek a careful history detailing weight changes, dietary patterns, and excessive exercise. Determine weight and height.[44] Low body mass index (BMI) often relates to preexisting body dysmorphic disorder.[45, 46]

A review of systems may reveal many positive responses. The following are symptoms commonly observed in patients with anorexia nervosa:

  • Physical health and mental health concerns (including depression[47] )
  • Amenorrhea
  • Concentration and decision-making concerns
  • Headaches
  • Irritability
  • Cold hands or feet
  • Constipation
  • Dry skin or hair loss
  • Social withdrawal
  • Fainting or dizziness
  • Obsessiveness (food)
  • Lethargy
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Physical Examination

When performing a mental health assessment, focus on making the diagnosis and identifying comorbid conditions (eg, anxiety or other mental health conditions that can help predict a response to treatment and assess motivation for changing behavior), evaluating for the risk of suicide, and exploring the psychosocial context of the symptoms.[25, 26, 48, 49, 50, 51]

Focus the physical examination on the changes commonly observed in anorexia nervosa. Vital sign changes include hypotension, bradycardia, and hypothermia. Other changes include dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, atrophy of the breasts, and swelling of the parotid and submandibular glands.

It is important to note that not all of these changes are necessary to confirm a diagnosis of anorexia nervosa. Patients who self-identify as having anorexia nervosa should be taken seriously.

The electrocardiogram (ECG) may reveal a prolonged cardiac output (QT) interval,[52] and echocardiography (ECHO) reveals a decreased ventricular mass and mitral valve prolapse (see Workup). Gastrointestinal signs include intestinal dilation from constipation and diminished intestinal motility.

Characteristic signs of inadequate energy (caloric) intake observed in patients with anorexia nervosa that are due to starvation-induced changes are summarized below.

Positive signs include the following:

  • Hypothermia
  • Acrocyanosis
  • Resting bradycardia (resting heart rate often 40-49 beats per minute)
  • Hypotension
  • Orthostatic lowered blood pressure or pulse
  • Loss of muscle mass
  • Low blood glucose (impaired insulin clearance)
  • Low parathyroid hormone levels
  • Elevated liver function
  • Low white blood cell (WBC) count

Negative signs include the following:

  • Normal fundi or visual fields
  • No organomegaly
  • No lymphadenopathy
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The SCOFF Questionnaire

The SCOFF (see below) questionnaire is a screening tool for eating disorders: 1 point is awarded for every positive reply. A score greater than 2 indicates likely anorexia nervosa or bulimia. The questionnaire is as follows[53] :

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you lost more than One stone* in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

* One stone is approximately 14 lb or 6.35 kg.

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Staging

Anorexia nervosa can be divided into an early or mild stage and an established stage, as summarized below.[13, 54]

Early or mild stage is defined by the following:

  • Mildly distorted body image
  • Weight 90% or less of average weight for height
  • No symptoms or signs of excessive weight loss
  • Use of potentially harmful weight-control methods or a strong drive to lose weight

Established or moderate stage features include the following:

  • Definitely distorted body image that has not diminished with weight loss
  • Weight goal less than 85% of average weight for height associated with a refusal to gain weight
  • Symptoms or signs of excessive weight loss associated with a denial that any problems is present
  • Unhealthy means to lose weight, such as eating fewer than 1000 calories per day, purging, or excessive exercise
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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Angelo P Giardino, MD, PhD, MPH  Associate Professor, Baylor College of Medicine; Chief Medical Officer, Texas Children's Health Plan; Chief Quality Officer, Medicine, Texas Children's Hospital

Angelo P Giardino, MD, PhD, MPH is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect

Disclosure: Bayer Honoraria Review panel membership; Pfizer Grant/research funds Independent contractor; MedImmune Honoraria Review panel membership; Teva Pharmacutical travel & honoraria Managed Care Advisory Panel; CIGNA Honoraria Physician Advisory Council

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Jennifer DA Liburd, MD, to the development and writing of the source article.

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