Background
Anorexia nervosa (AN) is an eating disorder characterized by a weight loss of at least 15% of expected body weight,[1] a devastating fear of weight gain, relentless dietary habits that prevent weight gain, and a disturbance in the way in which body weight and shape are experienced. This condition has potentially life-threatening physiologic effects as well as enduring psychologic disturbance.
Although anorexia nervosa is often heralded by a desire to lose an insignificant amount of weight through dieting, once the weight loss is in progress, immunologic and hormonal factors that may play a role in the downward spiraling and maintenance of anorexia nervosa include leptins (involved with signally satiety) and alpha-melanocyte–stimulating hormone.[2]
According to the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), anorexia nervosa is defined as "the refusal to maintain body weight about 85% of predicted, an intense fear of gaining weight, undue influence of body shape or weight on self-image, and missing at least 3 consecutive menstrual periods."[3] An increase in morbidity and mortality is present in anorexia nervosa compared with other psychiatric disorders.
Go to Emergent Management of Anorexia Nervosa and Bulimia Nervosa for complete information on these topics.
Pathophysiology
Anorexia nervosa is a disease that affects all organ systems, principally the cardiovascular and endocrine systems. However, complications can also involve other systems, including the gastrointestinal, renal, reproductive, neurologic, orofacial, dermatologic, and hematologic systems.
A typical case of anorexia nervosa involves a young person (teenager or young adult) who is mildly overweight or of normal weight and who begins a diet and exercise plan to lose weight. As she loses weight and receives initial positive reinforcement for this behavior (eg, compliments by peers on her appearance), the reward is high and causes an inability to stop this behavior once an ideal weight is achieved.[4]
There may be variations of the 5HTT (serotonin transporter gene) genome (eg, biallelic, triallelic) that are associated with subtypes of eating disorders and that interact with life-history factors.[5, 6, 7]
Etiology
Anorexia nervosa is a complex condition based on various biologic, psychologic, and social issues. As such, referring to anorexia nervosa as a developmental condition rather than a mental condition is preferable. Therefore, commenting about predisposing, precipitating, and perpetuating factors is more useful than commenting about actual causes.
Predisposing factors
Predisposing factors include the following factors that make a patient more vulnerable to developing an eating disorder:
- Female sex
- Family history of eating disorders[8]
- Perfectionistic personality
- Difficulty communicating negative emotions
- Difficulty resolving conflict
- Low self-esteem
Reported cases of anorexia nervosa in twins and triplets suggest the possibility of an increased genetic predisposition.[9, 10, 11] A 7% increased incidence in first-degree relatives may be related to an area on band 1p at the DF1153721 locus.[12]
Precipitating factors
Precipitating factors relate most often to developmental tasks that cause intense intrapsychic conflict and unconscious feelings of anxiety related to developing into a mature sexual person; these factors interact with physiologic and biologic factors.
In individuals aged 10-14 years, these factors are related to sexual development and menarche, which is associated with a spurt in weight gain. Societal influences intensify the fear of becoming "fat." This feeling is often intensified by a peer group that comments in a rejecting fashion. These individuals often diet and receive peer acceptance for weight loss; this emotional reinforcement combined with the physiologic response of the body to the sudden loss of weight (when >5 lb) intensifies the likelihood of continued weight loss. Sudden weight loss with loss of fat causes a decrease in body temperature, which physiologically causes a subjective feeling of chills; this discomfort is relieved by increased physical activity, which causes further weight loss. The continuous downward spiraling of weight loss then causes secondary amenorrhea and loss of secondary sexual characteristics, which further worsens weight loss.
In adolescents aged 15-16 years, precipitating factors stem from independence and autonomy struggles. They typically feel ambivalent about growing up and transition from dependence to interdependence rather than to independence.
In individuals aged 17-18 years, identity conflicts are more common. These patients do not make healthy transitions from leaving home to going to college or getting married.
Perpetuating factors, biologic issues, and psychologic factors
Perpetuating factors maintain the eating disorder. Biologic issues refer to the signs and symptoms of starvation and to the aspects involved in refeeding the malnourished patient.
Psychologic issues encompass the coping strategies engendered by the eating disorders. According to Kreipe and Birndorf, the treating clinician may threaten the homeostatic balance that has been achieved within the family system secondary to dealing with the patient with anorexia; negative emotions, such as anger and denial, may be directed at the clinician.[13] In addition, maternal psychopathology (negative expressed emotion, maternal encouragement of weight loss) can be a risk factor for anorexia nervosa, especially for childhood-onset of this disorder.[14]
Epidemiology
Anorexia nervosa is diagnosed more frequently in industrialized countries where food is abundant and an emphasis is placed on a slender body shape and an overall thin appearance. According to Mehler et al, certain groups are especially at risk for anorexia nervosa, including dancers, long-distance runners, skaters, models, actors, wrestlers, gymnasts, flight attendants, college sorority members, and others for whom thinness is emphasized and overly rewarded.[15]
The prevalence of anorexia nervosa in the United States is 1%, with a bimodal pattern of onset—ages 14 and 18 years. However, although it is more frequently observed in the adolescent age group, anorexia nervosa has no age restrictions and can affect young children and older persons alike. Onset in both of the latter groups carries a poor prognosis.
One study looked at epidemiology, predisposing factors, and comorbidity—important factors in diagnosis and prognosis of eating disorders. About 21% of individuals with childhood eating disorders had early feeding difficulties that predated the diagnosis of childhood eating disorders. Three per 100,000 youth had eating disorders in childhood and, of that group, 37% met criteria for AN, 1.4% met criteria for bulimia nervosa (BN), and 43% for eating disorder, NOS. Forty-one percent had significant comorbidity (other psychiatric diagnoses) and 44% had a family history of psychiatric disorders. Treatment was helpful, as 73% improved; however, 11% were lost to follow-up and 10% did not improve, 6% worsened, and 7% were in the hospital.[16]
A point prevalence study performed in Rochester, Minnesota, showed a prevalence of 145 and 113 cases per 100,000 people in 1988 and 1991, respectively. One study performed in suburban London reported a prevalence of only 20.2 cases per 100,000 people, a much smaller figure than that observed in the United States. In another European study, a 0.48% lifetime incidence of anorexia nervosa was reported among 21,425 respondents[10] ; the study also found that most eating disorders had an age of onset of 10-20 years.
Although anorexia nervosa is more common in women, with a female-to-male ratio of 10:1, approximately 10% of cases involve men. Treatment plans remain the same for both sexes. Gay and bisexual males are more likely to have an eating disorder than heterosexual males, but they are also more likely to have bulimia than anorexia.[17, 18]
Anorexia nervosa is diagnosed more often in the white (>95%) adolescent (>75%) populations[19, 20] of the middle and upper socioeconomic classes, although it can be observed in either sex and in people of any race, age, or social stratum. This disorder is probably underdiagnosed in black individuals and males because of a low index of suspicion.[21, 22, 23]
No influences have been found with respect to the month or season of birth.
Prognosis
The prognosis of anorexia nervosa is guarded, and poor outcomes are associated with longer duration of illness, late onset of illness, and more severe weight loss. Morbidity rates range from 10-20%; only 50% of patients completely recover. Of the remaining 50%, 20% remain emaciated, and 25% remain thin.[24] The remaining 10% become overweight or die of starvation.
Deaths due to suicide are also reported in this population.[25, 26, 27] A history of previous suicide attempts, physical pain, drug use, and laxative use may correlate with a higher likelihood of suicide attempts.[25, 26, 28] Metacognition plays a role in predicting adverse outcomes or suicide, as does alexithymia.[29]
Prognostic factors
The outcome of anorexia nervosa depends on various prognostic factors, including age at onset, body mass index (BMI), weight loss at presentation, duration of symptoms, duration of inpatient care, and state of family relationships,[30] as follows.
Onset of anorexia nervosa before adulthood carries a more favorable outcome. However, onset at an age younger than 11 years is a poor prognostic factor.[31]
Although the degree of weight loss at the clinically noted onset of the involvement of the patient's organic systems is not predictive of outcome, lower weight (less than 75% of MBW mean body weight) and longer duration (more than 19 months) of symptoms were predictors of poorer outcomes in a recent review of 11 sites of 267 adolescents with eating disorders.[32]
There was a slight benefit to family therapy with the Maudsley Model. However, all adolescent medicine-based treatments were effective in helping adolescents to gain weight. A higher weight loss at presentation was predictive of a poorer outcome.
Both a shorter duration of involvement of the patient's organic systems before admission and a short inpatient treatment period are associated with a favorable outcome in some studies.
A good relationship between the parent and child tends toward a more favorable outcome. There may be a poorer prognosis among patients from one-parent families, from families in which parents had been married before, and from families in which several generations live together, possibly related to increased negative expressed emotion.[19, 33]
Joint family therapy is not as effective as separated family therapy if there is a high level of negative emotional expressivity (eg, high levels of maternal criticism).[34, 35]
Obsessionality and impulsivity in individuals with anorexia nervosa correlate with a lower lifetime BMI, reflecting poorer long-term outcomes, and can be measured with the Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS).[36]
Two large sample studies looked at mortality rates in eating disorders, with somewhat different results. One meta-analysis found higher mortality rates for individuals with anorexia nervosa. However, it is possible that because this study was a meta-analysis, individuals with crossover between anorexia and bulimia could not be correctly tracked, causing loss of data in this study.[37]
This meta-analysis looked at mortality rates in 36 studies of anorexia nervosa (12,189 person-years) and bulimia nervosa (32,798 person-years) between January 1, 1966 and September 30, 2010. Mortality ratios were 5.86% for anorexia nervosa, 1.93% for bulimia nervosa, and 1.92% for eating disorder not otherwise specified (ENOS). One in 5 individuals with anorexia nervosa who died had committed suicide, with a weighted annual mortality incidence of 5.10 deaths per 1000 person-years; a lower rate of suicide of 1.74 deaths per 100 person-years was noted in individuals with bulimia nervosa.
Predictors of poorer outcome, including mortality, in patients with anorexia nervosa included older age at first presentation, alcohol misuse, and low BMI at presentation. Other strong predictors of mortality involved comorbid disorders such as affective disorder, suicidal behavior or self-harm, alcohol abuse, and a history of hospitalization for such mental health problems. BMI at assessment and alcohol misuse reliably predicted mortality status, although evidence of an affective disorder almost was significant. Some studies found evidence of an association between alcohol misuse and increased mortality in anorexia nervosa. One study found that younger age and longer hospital stay at first hospitalization were associated with better outcomes, and psychiatric and somatic comorbidity worsened the outcome of patients with eating disorders.
Another study found that bulimia nervosa carried a slightly higher risk of suicidal ideation and attempts. The study measured impairment and impact of eating disorders including suicide ideation, plans, and attempts, as well as prior or current behavioral health treatment. Using nationally representative face-to-face interview surveys of 9,244 students and 879 adolescents living in households in the continental United States, the data found 12-month prevalence rates were 0.2% for anorexia nervosa (median age at onset of 12.3 y), 0.6% for bulimia nervosa (median age at onset 12.4 y), 1.6% for binge-eating disorder (BED) (median age at onset 12.6 y), 0.9% for subthreshold anorexia nervosa, and 1.1% for subthreshold binge-eating disorder (SBED) (median age at onset 12.6 y).
There was high comorbidity with other mental disorders; the majority of those with an eating disorder met criteria for at least 1 other lifetime DSM-IV disorder: anorexia nervosa (55.2% with an adjusted odds ratio of 1.5); bulimia nervosa (88% with an adjusted odds ratio of 8.6); BED (83.5% with an adjusted odds ratio of 5.9); subthreshold anorexia nervosa (69.8% with an adjusted odds ratio of 4.3); and SBED (70.1 % with an adjusted odds ratio of 2.7). Impairment was highest in anorexia nervosa, as 97.1% reported impairment and 24.2% reported severe impairment; 11.6% reported being unable to carry out normal activities for at least 1 day in the past 12 months.
Bulimia nervosa was associated with the highest rates of suicidal ideation (53% with an adjusted odds ratio of 5.93), plans (25.9% with an adjusted odds ratio of 6.46), and attempts (35.1% with an adjusted odds ratio of 6.56). However, anorexia nervosa and subacute anorexia nervosa were associated with significant and comparable levels of suicide ideation (31.4% and 30%, respectively, with an odds ratio of 6), plan (2.3-14.2% with an odds ratio of 1-5), and attempts (8.2-12.4% with an odds ratio of 5). Among adolescents with bulimia, 41.3% reported purging in their life time.
There were no sex differences in the prevalence of anorexia nervosa or SBED. Bulimia nervosa was more prevalent in the Hispanic population and girls; BED and subthreshold anorexia nervosa were more prevalent in girls. However, this study was unusual, owing to a lack of a female preponderance for eating disorders. A majority of adolescents with an eating disorder received some sort of treatment for an emotional or behavioral problem: 77.6% of those with anorexia nervosa, 88.2% of those with bulimia nervosa, 72.6% of those with BED, 70.5% of those with subthreshold anorexia nervosa, and 64.2% of those with SBED. Of youth with anorexia nervosa, 40% sought treatment from human services and 40% from school services; many of those with bulimia nervosa sought treatment from the general medical sector (49.2%) and school services (45.5%). Only a minority (3.4-27.5%) of individuals with eating disorders had actually sought treatment for their eating or weight problems.
Major depression, specific phobia, oppositional defiant disorder, and conduct disorder were associated with subthreshold anorexia nervosa and major depression. Specific phobia, panic disorder, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and substance abuse of or dependence on drugs and/or alcohol were associated with subthreshold bulimia nervosa.[38]
Per the National Comorbidity Replication Survey study,[38] 0.3% of youth have been affected by anorexia. According to the National Comorbidity Study-Adolescent Supplement (NCS-A), a nationally representative, face-to-face survey of more than 10,000 teens aged 13-18 years, 0.3% of youth have been affected by anorexia, 0.9% by bulimia, and 1.6% by BED.
The researchers also tracked the rate of some forms of eating disorders not otherwise specified (ED-NOS), a catch-all category for symptoms that do not meet full criteria for specific disorders but still impact a person’s life. ED-NOS is the most common eating disorder diagnosis. Overall, another 0.8% had subthreshold anorexia and another 2.5% had symptoms of SBED. Latinos reported the highest rates of bulimia, while whites reported the highest rates of anorexia.[38]
Those with an eating disorder also met criteria for at least one other psychiatric disorder, such as depression. The presence of an eating disorder was associated with higher levels of suicidal thinking compared with those who did not have an eating disorder. The prevalence of these disorders and their association with coexisting disorders, role impairment, and suicidal thinking suggest that eating disorders represent a major public health concern. In addition, the significant rates of subthreshold eating conditions support the notion that eating disorders tend to exist along a spectrum and may be better recognized by doctors if they included a broader range of symptoms. In addition, the findings clearly underscore the need for better access to treatment specifically for eating disorders.[38]
Complications
Most complications of anorexia nervosa are secondary effects from starvation and include an effect on the following systems:
- Orofacial: Dental caries
- Cardiovascular[39] : Hypotension, prolonged QT, arrhythmias, cardiomyopathy
- Endocrine and metabolic: Hypokalemia, hyponatremia, hypoglycemia, hypothermia, euthyroid sick syndrome, hypercortisolism, amenorrhea, delay in puberty, arrested growth, osteoporosis
- Reproductive: Infertility, low birth weight infant
- Gastrointestinal: Delayed gastric emptying, decreased intestinal mobility, constipation
- Neurologic: Peripheral neuropathy, ventricular enlargement
- Integumentary: Dry skin and hair, hair loss, lanugo body hair
- Renal: Renal calculi
- Hematologic: Anemia, leukopenia, thrombocytopenia
Cardiovascular complications
Cardiac complications are the most common cause of death; the mortality rate is about 10%. Cardiac effects from anorexia nervosa include profound bradycardia, hypotension, decreased size of the 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 the risk of ventricular arrhythmia.[40]
The patient's 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 the 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 electrocardiography (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; however, 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. However, if the daily weight gain is 0.2-0.4 kg, then complications are limited.
Endocrinologic and metabolic complications
Foremost in the gamut of endocrinologic complications is amenorrhea, which is actually part of the diagnostic criteria of anorexia nervosa.[41] 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 in patients with anorexia nervosa, 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 and, similar to the cardiac changes, represent an adaptive mechanism; 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 condition 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. Treatment with bisphosphonates is not routinely indicated in adolescents because of concerns about osteonecrosis of the jaw; however, if this therapy is used, close monitoring is critical.[41, 42] Supplementation with 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.[41]
Gastrointestinal complications
Patients with anorexia nervosa have fewer gastrointestinal complications than those with bulimia. Constipation is common. In addition, these patients still have prolonged gastrointestinal 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.
Neurologic, integumentary, and renal complications
Cerebral atrophy and loss of brain volume may be observed in patients with anorexia nervosa. 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 blood urea nitrogen (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.
Patient Education
According to Becker et al, for adequate weight gain, the patient or family requires some "education on nutrition, adjustment of caloric and nutritional intake, and limitations on exercise and other modifications of behavior. Enteral or parenteral nutrition is reserved for patients with severe undernutrition that has been refractory to treatment by these methods."[43]
In the moderate stage of anorexia nervosa, in addition to the above recommendations, providing structure to daily activities is necessary. This includes eating 3 meals a day. Also, parents should ensure that healthy food is available, but the patient should assume all responsibility for eating.
For patient education information, see Eating Disorders Center and Women's Health Center, as well as Anorexia Nervosa, Bulimia, and Amenorrhea.
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