© Definition: Anorexia nervosa is an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain as well as a distorted body self-perception. It typically involves excessive weight loss and is diagnosed Fle) reo dul NAa CMa Meme) CMR CUMT I RU ETL)DIAGNOSIS OF ANOREXIA NERVOSA ADSM-5 diagnosis of anorexia nervosa requires each of the following criteria : » Restriction of energy intake that leads to a low body weight, given the patient's age, sex, developmental trajectory, and physical health » elntense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s low body weightSeverity (DSM 5) » eMild — BMI 17 to 18.49 kg/m? » eModerate — BMI 16 to 16.99 kg/m? » eSevere — BMI 15 to 15.99 kg/m? » eExtreme — BMI <15 kg/m?Types of Anorexi * Purging — Weight loss achieved by vomiting, laxatives, or diuretics = Weight loss achieved by restricting calories = olong diets ating and evervising te esAssociated mental disorders Anxiety disorders » Obsessive-compulsive disorder ~ Body dysmorphic disorder Posttraumatic stress disorder Mood disorders Substance use disorders ~ Disruptive, impulse control, and conduct disordersPersonality disorders eObsessive-compulsive (15 percent of patients with anorexia nervosa) eAvoidant (14 percent) eDependent (7 percent) » eNarcissistic (6 percent) » @Paranoid (4 percent) eBorderline (3 percent)Comorbid traits ePerfectionism — pursuing unrealistically high standards despite the occurrence of adverse consequences » eCompulsivity — insisting upon order, symmetry, exactness, and control eNarcissism — craving admiration and external validation from others; excessive concern with physical appearancePsychological Factors * Low Self-esteem ¢ Feelings of inadequacy or failure * Feelings of being out of control * Response to change (puberty) * Response to stress (sports or dance) * Personal illnessCommon Medical Symptoms Oe Telit -1ale] i iter) elnfertility Se sora (earl reytie le cy Becta) » eCold intolerance » Palpitations » eDizziness » eAbdominal pain and bloating » eEarly satiety > eConstipation eSwelling of the feet Irritability is often present as well.Common physical signs » Low body mass index (<17.5 kg/m?) EI Siierorom(sere Mme MM eM LAO mer icor-g meme crcl nelereh an (6) a1) Hypothermia (core temperature <35°C or 95°F) » #Bradycardia (pulse <60 beats per minute) «Hypotension (systolic bload pressure <90 mmHg and/or a diastolic blood Peete MT ste)) » #Hypoactive bowel sounds Xerosis (dry, scaly skin) Sees Claes e)Laboratory assessment eSerum electrolytes » Blood urea nitrogen » «Serum creatinine © eSerum glucose » eSerum calcium, phosphorous, and magnesium eSerum albumin and prealbumin eLiver function tests (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase)Excluding medical disorders @Neoplasm eChronic infections (eg, tuberculosis or acquired immunodeficiency syndrome) » eUncontrolled diabetes mellitus eHyperthyroidism eMalabsorption syndromes (eg, celiac disease) elnflammatory bowel disease (eg, Crohn disease) ePregnancy ePrimary ovarian failure » ePolycystic ovary disease ePituitary prolactinomaMedical complications »Cardiovascular (structural) » Decreased cardiac mass » Decreased cardiac chamber volumes © Mitral valve prolapse (20%) Myocardial fibrosis Pericardial effusion Improve with weight gain»Cardiovascular (functional) : Bradycardia » Hypotension QT dispersion Occasionally QT prolongation Decreased heart rate variability ST,T changes AV block Vent.arrhythmiasGastrointestinal » Gastroparesis with bloating » Constipation » Severe pancreatitis Mild rise in LFTS » Superior mesentric artery syndrome (rare)Renal and electrolytes » Decreased GFR » Decreased concentration » Electrolyte abnormalities (Purging > Restrictive)Pulmonary on) e)ale\-1-| » (weakness and wasting of resp. muscles) - Pneumothorax /Pneumomediastinum (weakening of alveolar walls) » Aspiration pneumonia ©PFTS: decreased maximal inspiratory pressures (59% of predicted) expiratory pressures (35%), and increased residual volume (162%). Diffusion capacity (98.1 +/- 16.2%) and transfer coefficient (98.4 +/- 16.2%) were also normalEndocrine Hypoglycemia » Hypothalamus and pituitary: Ble feretse Rela a Increased activation of HPA axis> Raised Cortisol Increased GH and decreased IGF-1 Decreased ADH levels Abnormalities of thermoregulation » Osteoporosis: In 30% (multifactorial) (BMI< 15 and Amenorrhoea >Gmonths)Treatment Nutritional rehabilitation » Psychotherapy Nutritional rehabilitation: Supervised meals Proscribing binge eating and purging Expected weight gain: 0.9 to 1.4 kg/week (in pts) c 0.2 to 0.5kg/week (out pts) 1000 to 1600 kcal /day gradually stepped up ( 30 to 40 kcal/kg)» Psychotherapy: Cognitive Behavioural Therapy Specialist supportive clinical management Motivational interviewing Family therapy Maintenance Psychotherapy» Pharmacotherapy: Olanzapine (2.5 to 10mg/day) Lorazepam 0.5mg/day soto) aA) Deep Brain Stimulation for chronic and treatment [iy [felon mage lk) dre Maia verst- (Sub callosal singulate gyrus) DBS was associated with improvements in mood, anxiety, affective regulation, and anorexia nervosa-related obsessions and compulsions. Seems to be safePrevention » Available dietary and nutritional Support Staff should be consulted to determine the initial daily calories to be ingested Patients should be fed according to.a standard protocol that includes a limited intake of sodium and fluids. The amount of dally calories should be raised by 300 to 400 keal every three to four days. Electrolyte deficiencies that are’ present in patients with anorexia nervosa should be corrected prior to initiating the refeeding process - The goal for weight gain should be limited to one kilogram per week. «Vital Signs anid weight should be monitored Gach day ‘The daily physical examination should focus upon the cardiovascular and pulmonary systems, and upon signs of edemaManagement Reduce nutritional support Correct hypophosphatemia, hypokalemia, and hypomagnesemia. Moderately to severely ill patients with marked edema or a low serum phosphate level should be hospitalized to intravenously correct electrolyte deficiencies and for close monitoring. » Continuous telemetry may be needed to monitor cardiopulmonary physiology.Thank you