eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder: Anorexia: Follow-up

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Contributor Information and Disclosures

Updated: Mar 31, 2008

Follow-up

Further Inpatient Care

  • Inpatient management should be approached in such a way as not to seem like punishment to the patient in order to preserve self-esteem and to prevent suicidality and hopelessness.
  • The goals of inpatient therapy should be fully discussed with the family and the patient.
  • The discussion elements should include development of a healthy meal plan, addressing underlying conflicts (low self-esteem, planning new coping strategies), and enhancing communication skills.
  • Randomized controlled trials show that cognitive behavior therapy is very effective, especially in the setting of tube feeding.34
  • In a study by McIntosh et al that compared 3 psychotherapies, interpersonal psychotherapy and family therapy were also reported to be effective when the expressed emotion was not negative.35
    • Some patients who received nonspecific management appeared to have as good or better an outcome as those who received the other therapies
    • Interpersonal psychotherapy was the least effective.
    • Cognitive behavior therapy outcomes were not as effective because of the large amount of psychoeducational material, large skills acquisition, and "the inability to generate alternatives to fixed cognition stemming from the cognitive rigidity of anorexia nervosa patients."35
    • Nonspecific management may be more successful because the therapy is provided by experienced clinicians, is practiced according to a detailed treatment manual, and institutes psychoeducation with a strong focus on normalizing eating with approaches such as smart food selection and quantities needed to gain weight. The rest of the sessions were based on issues presented by the patient. Key features of this type of therapy may include the nonspecific factor of empathy and therapeutic alliance. Because this is the first time this nonspecific management was studied, a replication of this study may be necessary
  • Family involvement is a vital part of the process in the treatment of anorexia nervosa. Family group psychotherapy has been shown to be more cost-effective than family therapy and equally useful (weight gain measurements).36
  • Robin et al studied the effect of family relations on behavioral family systems therapy (BFST) versus ego-oriented individual therapy (EOIT) as treatment modalities for adolescents with anorexia nervosa.37 Although the difference was not statistically disparate, the results demonstrated a greater improvement in BMI in the BFST group. In addition, in this group, the mothers showed a decrease in negative communication and an increase in positive communication, whereas the mothers in the other group did not.
  • Indications for hospital admission include the following:
    • Physiologic decompensation
      • Temperature less than 36°C
      • Pulse less than 45 beats per minute
      • Orthostatic differential greater than 30/min
      • Altered mental status, fainting, or other signs of significant malnutrition
      • Rapid or excessive weight loss that cannot be curtailed as an outpatient
    • Complications of weight control habits
      • Inability to break the cycle of disordered eating as outpatient
      • Inability to initiate effective outpatient psychotherapy17

Further Outpatient Care

  • Patients with anorexia nervosa may respond best to family therapy. Psychodynamic psychotherapy in combination with behavioral strategies is indispensable. Remember that anorexia nervosa is associated with suicide.
  • For patients with the mild stage of anorexia nervosa, reevaluate in 1-2 months to check that the weight is not decreasing, that health is maintained, and that the patients have not developed bad eating habits. Surveillance is required to ensure that the patient has not progressed to the moderate stage.

Complications

  • Most complications are secondary effects from starvation. Complications of anorexia nervosa include the following:
    • Orofacial - Dental caries
    • Cardiovascular38
      • Hypotension
      • Prolonged QT
      • Arrhythmias
      • Cardiomyopathy
    • GI
      • Delayed gastric emptying
      • Decreased intestinal mobility
      • Constipation
    • Endocrine and metabolic
      • Hypokalemia
      • Hyponatremia
      • Hypoglycemia
      • Hypothermia
      • Euthyroid sick syndrome
      • Hypercortisolism
      • Amenorrhea
      • Delay in puberty
      • Arrested growth
      • Osteoporosis
    • Renal - Renal calculi
    • Reproductive
      • Infertility
      • Low birth weight infant
    • Integumentary
      • Dry skin and hair
      • Hair loss
      • Lanugo body hair
    • Neurologic
      • Peripheral neuropathy
      • Ventricular enlargement
    • Hematologic
      • Anemia
      • Leukopenia
      • Thrombocytopenia
  • Cardiac complications are the most common cause of death; the mortality rate is about 10%.
    • Cardiac effects include profound bradycardia, hypotension, decreased size of cardiac silhouette, and decreased left ventricular mass associated with abnormal systolic function. Patients with anorexia report fatigue and have an attenuated blood pressure response to exercise and reduction in maximal work capacity. An increased incidence of mitral valve prolapse without significant mitral regurgitation is also observed. Low potassium-dependent QT prolongation increases risk of ventricular arrhythmia.39
    • Vital signs reflect hypotension with systolic pressures as low as 70 mm Hg and sinus bradycardia with heart rates as low as 30-40 beats per minute. These changes are a response to a decrease in basal metabolic rate. The mechanism may be due to an autonomic imbalance in heart rate regulation with increases in vagal activity and a reduction in sympathetic activity. These changes are physiologic cardiovascular responses, and treatment is unnecessary unless negative clinical sequelae are present. If ECG is performed, evidence of sinus bradycardia, ST-segment elevation, T-wave flattening, low voltage, and rightward QRS axis is apparent. All the aforementioned changes are clinically insignificant. The frequency of rhythm disturbances is most concerning, especially QT interval prolongation that may be an indication for those at risk for cardiac arrhythmias and sudden death.
    • Cardiac decompensation is greatest during the initial 2 weeks of refeeding when the myocardium cannot withstand the stress of an increased metabolic demand. If the daily weight gain is 0.2-0.4 kg, then complications are limited.
  • Foremost in the gamut of endocrinologic complications is amenorrhea, which is actually part of the diagnostic criteria of anorexia nervosa.
    • Amenorrhea results from disorders in the hypothalamic-pituitary-ovarian axis in which levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are low despite low levels of estrogen. Reversion to the prepubertal state occurs; the LH response to gonadotropin-releasing hormone (GnRH) is blunted. This blunted response is insufficient to maintain menstrual integrity, and amenorrhea results.
    • Weight loss and emotional instability play a role in amenorrhea, although persistence of amenorrhea has been observed in some patients despite a return to baseline weight.
    • Amenorrhea persists in 5-44% of patients in whom weight gain has been documented. The explanation for this wide range has not been elucidated.
  • Other changes related to endocrine function include a reduction in fertility, multiple small follicles in the ovaries, and decreased uterine volume and atrophy.
  • Thyroid function is also affected, with laboratory data revealing a decrease in T3, thyroxine (T4), and an increase in reverse T3. These changes are characteristic of the euthyroid sick syndrome. Similar to the cardiac changes, these represent an adaptive mechanism and hormonal replacement is not necessary.
  • An associated impaired release in vasopressin consistent with diabetes insipidus is present. This defect is of the neurogenic type; concentration of urine is observed after administering vasopressin. This affects 40% of those with anorexia nervosa and is reversible with weight gain.
  • Osteopenia is a serious complication. Both cortical and trabecular bone are affected, and osteopenia persists despite estrogen therapy. Low levels of progesterone (accelerates remodeling) formation and decreased insulinlike growth factor-1 (IGF-1) levels, which stimulate type 1 collagen biosynthesis, contribute to bone loss. No established treatment is available; however, 1000-1500 mg/d of dietary calcium and 400 IU of vitamin D is recommended to prevent further bone loss and to maximize peak bone mass. Although exercise and hormonal replacement therapy have some benefit in perimenopausal women, exercise may be deleterious in patients with anorexia nervosa who have amenorrhea, and hormonal replacement may induce premature closure of bone epiphysis. Treatment with bisphosphates is not indicated in adolescents.40
  • Patients with anorexia nervosa have fewer GI complications than those with bulimia. Constipation is common. In addition, they still have prolonged GI transit, alterations in antral motility, and gastric atrophy. Prokinetic agents may accelerate gastric emptying, and the relief from gastric bloating can accelerate resumption of normal eating habits.
  • Cerebral atrophy and loss of brain volume may be observed. Generalized muscle weakness is the most common neurologic symptom.
  • Patients with anorexia nervosa typically have dry scaly skin, brittle hair and nails, and increased lanugo-type body hair.
  • An increase in BUN levels, which reflects a level of dehydration and decreased glomerular filtration rate (GFR), is present. Electrolyte imbalances are secondary to vomiting, and potassium is most often affected. Other abnormalities include disturbances of calcium, magnesium, and phosphorus.

Prognosis

  • As described in Mortality/Morbidity, outcome depends on various prognostic factors, including age at onset, weight loss at presentation, duration of symptoms, duration of inpatient care, and state of family relationships.
  • Metacognition plays a role in predicting adverse outcomes or suicide, as does alexithymia.41
  • The mortality rate in anorexia nervosa is 10-20%. Overall, 50% of patients recover completely. Another 20% remain emaciated, 25% are thin, and 5-10% remain overweight or die of starvation.10
  • Joint family therapy is not as effective as separated family therapy when levels of maternal criticism are raised.23

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Maintain safety is important; therefore, hospitalization should not be shunned because anorexia nervosa is a complex chronic disorder associated with high comorbidity and significant mortality and complications.42 It is difficult to treat due to the shame, denial, and lack of insight concomitant with the disorder.
  • Restoring normal eating patterns is crucial because otherwise the restoration of health cannot occur.43

Special Concerns

A history of previous attempts, physical pain, drug use, and laxative use may correlate with a higher likelihood of suicide attempts.14,44,15

 
Acknowledgments

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



More on Eating Disorder: Anorexia

Overview: Eating Disorder: Anorexia
Differential Diagnoses & Workup: Eating Disorder: Anorexia
Treatment & Medication: Eating Disorder: Anorexia
Follow-up: Eating Disorder: Anorexia
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Slupik RI. Managing adolescents with eating disorders. Int J Fertil Womens Med. May-Jun 1999;44(3):125-30. [Medline].

  2. Fetissov SO, Harro J, Jaanisk M, et al. Autoantibodies against neuropeptides are associated with psychological traits in eating disorders. Proc Natl Acad Sci U S A. Oct 11 2005;102(41):14865-70. [Medline].

  3. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: APA; 1994.

  4. Feldman MB, Meyer IH. Childhood abuse and eating disorders in gay and bisexual men. Int J Eat Disord. Jul 2007;40(5):418-23. [Medline].

  5. National Institute of Mental Health. National Comorbidity Survey (NCS) and National Comorbidity Survey Replication (NCS-R). Collaborative Psychiatric Epidemiology Surveys. Available at http://www.icpsr.umich.edu/CPES/. Accessed October 30, 2007.

  6. Button E, Aldridge S. Season of birth and eating disorders: patterns across diagnoses in a specialized eating disorders service. Int J Eat Disord. Jul 2007;40(5):468-71. [Medline].

  7. Grice DE, Halmi KA, Fichter MM, et al. Evidence for a susceptibility gene for anorexia nervosa on chromosome 1. Am J Hum Genet. Mar 2002;70(3):787-92. [Medline].

  8. Mehler PS, Gray MC, Schulte M. Medical complications of anorexia nervosa. J Womens Health. Oct 1997;6(5):533-41. [Medline].

  9. Rooney B, McClelland L, Crisp AH, Sedgwick PM. The incidence and prevalence of anorexia nervosa in three suburban health districts in south west London, U.K. Int J Eat Disord. Dec 1995;18(4):299-307. [Medline].

  10. Speranza M, Loas G, Wallier J, Corcos M. Predictive value of alexithymia in patients with eating disorders: A 3-year prospective study. J Psychosom Res. Oct 2007;63(4):365-71. [Medline].

  11. Bryant-Waugh R, Knibbs J, Fosson A, Kaminski Z, Lask B. Long term follow up of patients with early onset anorexia nervosa. Arch Dis Child. Jan 1988;63(1):5-9. [Medline].

  12. Jordan J, Joyce PR, Carter FA, et al. Specific and nonspecific comorbidity in anorexia nervosa. Int J Eat Disord. Jan 2008;41(1):47-56. [Medline].

  13. Lesinskiene S, Barkus A, Ranceva N, Dembinskas A. A meta-analysis of heart rate and QT interval alteration in anorexia nervosa. World J Biol Psychiatry. Apr 5 2007;1-6. [Medline].

  14. Franko DL, Keel PK, Dorer DJ, Blais MA, Delinsky SS, Eddy KT. What predicts suicide attempts in women with eating disorders?. Psychol Med. Jul 2004;34(5):843-53. [Medline].

  15. Holm-Denoma JM, Witte TK, Gordon KH, et al. Deaths by suicide among individuals with anorexia as arbiters between competing explanations of the anorexia-suicide link. J Affect Disord. Apr 2008;107(1-3):231-6. [Medline].

  16. Lilenfeld LR, Kaye WH, Greeno CG, et al. A controlled family study of anorexia nervosa and bulimia nervosa: psychiatric disorders in first-degree relatives and effects of proband comorbidity. Arch Gen Psychiatry. Jul 1998;55(7):603-10. [Medline].

  17. Kreipe RE, Birndorf SA. Eating disorders in adolescents and young adults. Med Clin North Am. Jul 2000;84(4):1027-49, viii-ix. [Medline].

  18. Puxley F, Midtsund M, Iosif A, Lask B. PANDAS anorexia nervosa--endangered, extinct or nonexistent?. Int J Eat Disord. Jan 2008;41(1):15-21. [Medline].

  19. Roberts CM, Martin-Clavijo A, Winston AP, Dharmagunawardena B, Gach JE. Malnutrition and a rash: think zinc. Clin Exp Dermatol. Nov 2007;32(6):654-7. [Medline].

  20. Nicholls D, Viner R. Eating disorders and weight problems. BMJ. Apr 23 2005;330(7497):950-3. [Medline].

  21. Kyriacou O, Treasure J, Schmidt U. Expressed emotion in eating disorders assessed via self-report: an examination of factors associated with expressed emotion in carers of people with anorexia nervosa in comparison to control families. Int J Eat Disord. Jan 2008;41(1):37-46. [Medline].

  22. Morris J, Twaddle S. Anorexia nervosa. BMJ. Apr 28 2007;334(7599):894-8. [Medline].

  23. Eisler I, Simic M, Russell GF, Dare C. A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. J Child Psychol Psychiatry. Jun 2007;48(6):552-60. [Medline].

  24. Rosenblum J, Forman S. Evidence-based treatment of eating disorders. Curr Opin Pediatr. Aug 2002;14(4):379-83. [Medline].

  25. Rigaud D, Brondel L, Poupard AT, Talonneau I, Brun JM. A randomized trial on the efficacy of a 2-month tube feeding regimen in anorexia nervosa: A 1-year follow-up study. Clin Nutr. Aug 2007;26(4):421-9. [Medline].

  26. Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating disorders. N Engl J Med. Apr 8 1999;340(14):1092-8. [Medline].

  27. Krantz MJ, Mehler PS. Resting tachycardia, a warning sign in anorexia nervosa: case report. BMC Cardiovasc Disord. Jul 16 2004;4:10. [Medline].

  28. Jagielska G, Tomaszewicz-Libudzic EC, Brzozowska A. Pellagra: a rare complication of anorexia nervosa. Eur Child Adolesc Psychiatry. Oct 2007;16(7):417-20. [Medline].

  29. Thien V, Thomas A, Markin D, Birmingham CL. Pilot study of a graded exercise program for the treatment of anorexia nervosa. Int J Eat Disord. Jul 2000;28(1):101-6. [Medline].

  30. Gordon CM, Grace E, Emans SJ, et al. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res. Jan 1999;14(1):136-45. [Medline].

  31. Ramoz N, Versini A, Gorwood P. Eating disorders: an overview of treatment responses and the potential impact of vulnerability genes and endophenotypes. Expert Opin Pharmacother. Sep 2007;8(13):2029-44. [Medline].

  32. Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am J Psychiatry. Jan 2006;163(1):41-7. [Medline]. [Full Text].

  33. Szmukler GI, Young GP, Miller G, Lichtenstein M, Binns DS. A controlled trial of cisapride in anorexia nervosa. Int J Eat Disord. May 1995;17(4):347-57. [Medline].

  34. Bergh C, Brodin U, Lindberg G, Sodersten P. Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proc Natl Acad Sci U S A. Jul 9 2002;99(14):9486-91. [Medline].

  35. McIntosh VV, Jordan J, Carter FA, et al. Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry. Apr 2005;162(4):741-7. [Medline].

  36. Geist R, Heinmaa M, Stephens D, et al. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Can J Psychiatry. Mar 2000;45(2):173-8. [Medline].

  37. Robin AL, Siegel PT, Moye A. Family versus individual therapy for anorexia: impact on family conflict. Int J Eat Disord. May 1995;17(4):313-22. [Medline].

  38. Matzkin V, Slobodianik N, Pallaro A, Bello M, Geissler C. Risk factors for cardiovascular disease in patients with anorexia nervosa. Int J Psychiatr Nurs Res. Sep 2007;13(1):1531-45. [Medline].

  39. Facchini M, Sala L, Malfatto G, Bragato R, Redaelli G, Invitti C. Low-K+ dependent QT prolongation and risk for ventricular arrhythmia in anorexia nervosa. Int J Cardiol. Jan 13 2006;106(2):170-6. [Medline].

  40. Golden NH. Eating disorders in adolescence: what is the role of hormone replacement therapy?. Curr Opin Obstet Gynecol. Oct 2007;19(5):434-9. [Medline].

  41. Woolrich RA, Cooper MJ, Turner HM. Metacognition in patients with anorexia nervosa, dieting and non-dieting women: a preliminary study. Eur Eat Disord Rev. Sep 22 2007;[Medline].

  42. Gowers SG. Management of eating disorders in children and adolescents. Arch Dis Child. Apr 2008;93(4):331-4. [Medline].

  43. Muscari M. Effective management of adolescents with anorexia and bulimia. J Psychosoc Nurs Ment Health Serv. Feb 2002;40(2):22-31. [Medline].

  44. Witte TK, Merrill KA, Stellrecht NE, Bernert RA, Hollar DL, Schatschneider C. "Impulsive" youth suicide attempters are not necessarily all that impulsive. J Affect Disord. Sep 3 2007;[Medline].

  45. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. Dec 4 1999;319(7223):1467-8. [Medline].

  46. Steiner H, Lock J. Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Apr 1998;37(4):352-9. [Medline].

  47. Steinhausen HC. Outcome of anorexia nervosa in the younger patient. J Child Psychol Psychiatry. Mar 1997;38(3):271-6. [Medline].

  48. Tan JO, Hope T, Stewart A, Fitzpatrick R. Control and compulsory treatment in anorexia nervosa: the views of patients and parents. Int J Law Psychiatry. Nov-Dec 2003;26(6):627-45. [Medline].

  49. Tchanturia K, Davies H, Campbell IC. Cognitive remediation therapy for patients with anorexia nervosa: preliminary findings. Ann Gen Psychiatry. 2007;6:14. [Medline].

  50. Wade TD, Gillespie N, Martin NG. A comparison of early family life events amongst monozygotic twin women with lifetime anorexia nervosa, bulimia nervosa, or major depression. Int J Eat Disord. Sep 14 2007;40(8):679-686. [Medline].

  51. [Best Evidence] Ward L, Tricco A, Phuong P, Cranney A, Barrowman N, Gaboury I. Bisphosphonate therapy for children and adolescents with secondary osteoporosis. Cochrane Database Syst Rev. 2007;(4):CD005324. [Medline].

  52. Wildes JE, Marcus MD, Gaskill JA, Ringham R. Depressive and manic-hypomanic spectrum psychopathology in patients with anorexia nervosa. Compr Psychiatry. Sep-Oct 2007;48(5):413-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

The SCOFF questionnaire is a screening tool for eating disorders. One point is awarded for every positive reply. A score greater than 2 indicates likely anorexia nervosa or bulimia. The questionnaire is as follows: 45

  • 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?

[ CLOSE WINDOW ]

Keywords

anorexia, anorexia nervosa, eating disorders, excessive weight loss, anorexiant, anorexic, anorectic, diminished appetite, aversion to food, psychiatric disorder, fear of weight gain, dieting, amenorrhea, constipation, hypotension, bradycardia, hypothermia, dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, breast atrophy, mitral valve prolapse, hypokalemic hypochloremic metabolic alkalosis, acidosis, leukopenia, thrombocytopenia, dehydration, distorted body image, congestive heart failure, CHF, edema, psychosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
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.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.