Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr)

Anorexia is a misnomer because appetite often remains until patients become significantly cachectic. Patients are preoccupied with food:. Patients often exaggerate their food intake and conceal behavior, such as induced vomiting. The others simply restrict their food intake.

Many patients with anorexia nervosa also exercise excessively to control weight. Even patients who are cachectic tend to remain very active including pursuing vigorous exercise programs. Reports of bloating, abdominal distress, and constipation are common.

Patients usually lose interest in sex. Depression Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown Common physical findings include bradycardia, low blood pressure, hypothermia, lanugo hair or slight hirsutism, and edema.

Body fat is greatly reduced. Not recognizing the seriousness of the low body weight and restrictive eating are prominent features of anorexia nervosa. Fear of excessive weight gain or obesity stated specifically by the patient or manifested as behavior that interferes with weight gain.

In adults, low body weight is defined using the body mass index BMI. For children and adolescents, the BMI percentile for age is used; the 5th percentile is usually given as the cutoff. However, children above the 5th percentile who have not maintained their projected growth trajectory may also be considered to meet the criterion for low body weight; BMI percentile for age tables and standard growth charts are available from the Centers for Disease Control and Prevention see CDC Growth Charts.

Separate BMI calculators are available for children and adolescents. Patients may otherwise appear well and have few, if any, abnormalities in blood tests. The key to diagnosis is identifying persistent active efforts to avoid weight gain and an intense fear of fatness that is not diminished by weight loss.

Another mental disorder, such as schizophrenia Schizophrenia Schizophrenia is characterized by psychosis loss of contact with realityhallucinations false perceptionsdelusions Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr) beliefsdisorganized speech and behavior, flattened affect Mayo Clinic, Rochester, Minn. Anorexia nervosa. Arlington, Va. Accessed Nov. Hales RE, et al.

Washington, D. Klein D, et al. Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis. Mehler P. Anorexia nervosa in adults and adolescents: Medical complications and their management. Anorexia nervosa in adults: Evaluation for medical complications and criteria for hospitalization to manage these complications.

Pike K. Anorexia nervosa in adults: Cognitive behavioral therapy CBT. Walsh BT. Anorexia nervosa in adults: Pharmacotherapy. Merck Manual Professional Version. Harrington BC, et al. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa.

American Family Physician. Brockmeyer T, et al. Advances in the treatment of anorexia nervosa: A review of established and emerging interventions. In the presence of hypoglycemia, insulin levels are appropriately decreased in anorexia nervosa.

Recent studies Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr) that individuals who are older have a higher risk of hypoglycaemia [ 23 ].

Rare reports of reactive hypoglycemia during early refeeding have also been reported in anorexia nervosa [ 24 ]. Anorexia nervosa is occasionally complicated by comorbid Type 1 Diabetes Mellitus. While the exact casual association between type 1 diabetes mellitus and anorexia nervosa has not been fully elucidated, these two disorders do sometimes coexist in the same patient.

This in turn creates treatment challenges, especially during the early phases of refeeding and is associated with an increased mortality risk [ 25 ]. It is irrefutably clear that excessive hyperglycemia and poor glucose control, in all diabetic patients, are associated with premature microvascular complications such as diabetic retinopathy and nephropathy [ 26 ].

One can however logically posit that this concern is only relevant over the course of the lifetime of a patient with type 1 diabetes mellitus.

It is not likely to be of clinical significance if present for a period of just a few weeks during a structured refeeding program for the diabetic patient with severe anorexia nervosa, as long as his or her level of hyperglycemia is not excessive i. This approach should be followed during the early stages of refeeding as opposed to a weight-restored state where tight glucose control is again sought [ 27 ]. Sex hormones are affected in both male and female patients with anorexia nervosa.

These patients have low levels of hypothalamic gonadotropin releasing hormone GnRH and low levels of pituitary luteinizing LH and follicle stimulating hormone FSHestrogen and testosterone. These abnormalities affect potency, fertility and bone density. The neuroendocrine regulation of normal female reproductive functions depends on a rhythm of nerve impulses generated within the medial basal hypothalamus, which governs the pulsatile release of GnRH from nerve terminals.

Pulsatile GnRH release is the central controller of pituitary LH and FSH secretion, which determine the time onset of normal menstrual function [ 28 ].

The degree of impairment varies among patients with anorexia nervosa, but in general, the frequency and amplitude of the LH-FSH pulses are diminished, with a reversion to a prepubertal pattern and the development of the commonly found amenorrheic state.

Thus, this functional amenorrhea seen in anorexia nervosa reflects a temporary, reversible disturbance of hypothalamic-pituitary function.

Most amenorrhea seen with anorexia nervosa is of the secondary type, meaning the patient previously had normal menstrual periods. Of patients with anorexia nervosa, 20—25 percent may experience amenorrhea before the onset of significant weight loss, and 50—75 percent will experience amenorrhea during the course of dieting and its weight loss [ 29 ].

In some patients with anorexia nervosa, amenorrhea occurs only after more marked weight loss [ 30 ]. Overall, the development of amenorrhea is most strongly correlated to loss of body weight.

As a result of the aforementioned changes in reproductive hormones, patients with anorexia nervosa have difficulty conceiving, but, importantly, patients with anorexia nervosa may ovulate and become pregnant despite their amenorrhea. Unplanned pregnancy is a risk in anorexia nervosa [ 31 ]. Overall, the incidence of infertility is increased in anorexia nervosa due to the commonly found amenorrhea and decreased libido. If pregnancy does occur, there is also a higher rate of pregnancy complications as well as neonatal complications [ 32 ].

Increased numbers of miscarriages have also been reported in anorexia nervosa [ 33 ]. The bone marrow is adversely affected by anorexia nervosa. All three cell lines, namely red blood cells, white blood cells and platelets, may be affected by anorexia nervosa. Specifically, anemia and leukopenia occur in approximately one-third of the patients and thrombocytopenia occurs in ten percent [ 34 ].

The basic pathology of the affected marrow demonstrates a hypoplastic marrow with gelatinous deposition and serous fat atrophy [ 35 ]. As disease severity worsens and BMI falls, the frequency of these abnormalities is greater with upwards of seventy-five percent of patients demonstrating cytopenias [ 36 ].

However, there is no characteristic change in red cell size with most patients having normal indices. Similarly, all white cell types are proportionately reduced to cause neutropenia and lymphopenia, but no consistent pattern emerges for anorexia nervosa. The serum international normalized ratio INR level may be mildly elevated, due to liver damage and impaired synthesis of coagulation factors; patients may thus present with petechiae and purpura [ 37 ].

Interestingly, patients with anorexia nervosa do not seem to be predisposed to more frequent infectious diseases, notwithstanding their malnourished states. However, because the usual signs of infection fever and elevated white blood cell count may not be present in anorexia nervosa, increased vigilance and a lower threshold to evaluate for an infection should be followed [ 38 ].

Recent studies have demonstrated that anorexia nervosa is associated with variable, but usually significant, brain atrophy [ 39 ].

While anorexic patients often have a surprising degree of accomplishment in school, as weight erodes they become increasingly unable to attend to, and concentrate on, written materials or sustain reasoning. Of concern is the recent demonstration that weight improvement is not immediately associated with complete restoration of normality in the MRI brain scan, especially of the gray matter. This may be correlated with the duration of illness as recent studies from adolescents with a history of anorexia nervosa, when weight restored, have not revealed global or regional gray or white matter abnormalities [ 41 ].

Work is under way with positron emission tomography PET to localize the specific brain regions most affected by starvation so as to determine their response to treatment. Of note, there are no consistent peripheral nerve findings associated with anorexia nervosa, although with more marked weight loss comes overall weakness and deconditioning.

Patients with anorexia nervosa very commonly have impaired bone structure and reduced bone strength. Various modalities exist for assessment of bone density. Dual X-ray absorptiometry DEXA is the most commonly-used modality and measures the bone mineral content for a given cross sectional area of bone. Using DEXA scan, a T-score, which reflects a young adult population, and Z-score, which reflects an age-matched population, are determined.

The World Health Organization defines osteoporosis in postmenopausal women as a BMD value at the spine, hip, or forearm of 2. Definitions for bone density loss among young, pre-menopausal women and men have not been officially defined, however, measurement of bone density remains of great utility in patients with anorexia nervosa. MRI has been used to determine marrow fat content and composition among patients with anorexia. Higher marrow fat inversely correlates with bone mineral density [ 43 ].

Individuals who develop anorexia during adolescence are especially of great concern as bone accrual continues normally through the mids and thus these individuals may never reach normal peak bone mass. Women who develop anorexia nervosa as adolescents, end up having lower bone mineral density than women who develop anorexia nervosa Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr) adulthood with similar duration of amenorrhea [ 46 ].

This low bone mass is due to reduced bone formation and increased bone resorption. Multiple hormonal adaptations, designed to decrease energy expenditure during periods of low energy intake, may be to blame for this phenomenon. The aforementioned elevated growth hormone GH levels may be important for mobilizing fat stores in the setting of nutritional deprivation. IGF-1 mediates the actions of GH on bone metabolism. Low IGF-1 levels may decrease energy expenditure among several physiologic processes in the body, including the maintenance of bone mass.

Also, similar to the effects of estrogen deficiency in postmenopausal women, this deficiency found in anorexia nervosa, due to the ubiquitous hypogonadotropic hypogonadism of anorexia nervosa, results in an increase in bone resorption and decreased bone mass [ 44 ]. According to one study, duration of amenorrhea in anorexia nervosa was the only factor associated with decreased lumbar spine bone mineral density and IGF-1 levels were the only significant independent predictor of decreased bone mineral density BMD of the proximal femur [ 47 ].

Males with anorexia nervosa also have osteopenia and osteoporosis as noted above. Lower BMI and longer illness duration predicted lumbar Z-scores [ 44 ].

Low testosterone levels may also correlate directly with degree of bone mineral density loss [ 48 ]. In fact, male patients with anorexia nervosa seem to have worse degrees of low bone density compared with female anorexia nervosa patients [ 49 ].

Anorexia nervosa should be considered in the differential for unexplained bradycardia in the outpatient setting [ 50 ]. In addition, resting tachycardia is highly unusual and may be indicative of a superimposed infection or other complication [ 51 ].

Heightened vagal tone has been suggested as the cause of bradycardia in the setting of anorexia nervosa [ 52 ]. Low blood pressure and heart rate universally increase to normal levels after refeeding and restoration of normal weight [ 53 ].

Structural abnormalities, including pericardial effusion and decreased left ventricular size are also commonplace in the setting of anorexia nervosa. Factors which may correlate with pericardial effusion in this patient population include low BMI, rapid weight loss, low T 3 levels, and IGF-1 levels [ 57 Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr).

Most patients show resolution of the effusion after weight restoration without further intervention necessary; however, there are case reports of cardiac tamponade and the rare need for urgent pericardiocentesis for prevention thereof [ 5859 ].

Multiple studies of patients with anorexia nervosa have revealed findings of decreased left ventricular mass, left ventricular index, cardiac output, and left ventricular diastolic and systolic dimensions [ 56 ]. To identify family interaction patterns D.

To initiate a refeeding program. Nurse Donald is planning a psychoeducational discussion for a group of adolescent clients with anorexia nervosa. Which of the following topics would Nurse Donald select to enhance understanding about central issues in this disorder?

Peer pressure and substance abuse B. Self-esteem and self-control C. Anger management D. Parental expectations. Nurse Eugenia understands that her client Michelle who is bulimic feels shame and guilt over binge eating and purging. Your healthcare provider will ask you about your medical history. He or she will give you a physical exam. Your healthcare provider may advise psychological testing.

Talking with family members and other concerned adults can also help. Treatment for anorexia can depend on your age, overall health, medical history, symptoms, and other factors. Urgent medical care may be needed for physical problems. Nutrition counseling can help you learn how to make healthy Le Patient Est Isole - Anorexia Nervosa (2) & Dornenreich - Anorexia Nervosa (CDr) choices. It can also help bring you back to a healthy weight. Therapy can help you learn how to deal with emotions.

It can also help you improve your coping skills and adopt healthy habits. Therapy can be done one-on-one, with your family, or with a group. Some medicines can also help to treat mental health problems such as depression and anxiety. Experts don't know how to prevent anorexia nervosa. It may help if family members have healthy attitudes and actions around weight, food, exercise, and appearance. Adults can help children and teens build self-esteem in various ways.

This includes academics, hobbies, and volunteer work. Focus on activities that aren't related to the way a person looks.

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