### Date : 2024-06-19 18:00 ### Topic : Anorexia Nervosa - The Haunted Mirror #medicine #internalmedicine #psychiatry ---- ### Anorexia Nervosa Overview **Anorexia nervosa** is a serious and potentially life-threatening eating disorder characterized by self-imposed starvation, an intense fear of gaining weight, and a distorted body image. Individuals with anorexia nervosa often believe they are overweight even when they are dangerously underweight. ### Pathophysiology The exact cause of anorexia nervosa is unknown, but it is believed to result from a combination of genetic, biological, psychological, and sociocultural factors. The disorder involves a complex interplay of neurotransmitters and hormones that regulate mood, appetite, and stress response. ### Clinical Features **Physical Symptoms:** - **Significant Weight Loss:** Maintaining a body weight that is below a minimally normal level for age and height. - **Emaciation:** Noticeable thinness and loss of body fat and muscle. - **Amenorrhea:** Absence of menstruation in women of reproductive age. - **Bradycardia:** Slow heart rate. - **Hypotension:** Low blood pressure. - **Hypothermia:** Low body temperature. - **Lanugo:** Fine, soft hair growth on the body, especially in severe cases. **Psychological Symptoms:** - **Intense Fear of Gaining Weight:** Despite being underweight. - **Distorted Body Image:** Seeing oneself as overweight even when underweight. - **Denial of the Seriousness of Low Body Weight:** Refusal to acknowledge the medical risks associated with low weight. **Behavioral Symptoms:** - **Restriction of Food Intake:** Severe limitation of calorie intake and avoidance of certain foods. - **Excessive Exercise:** Compulsive physical activity to burn calories. - **Ritualistic Eating Habits:** Cutting food into tiny pieces, prolonged chewing, or avoiding meals with others. ### Diagnosis The diagnosis of anorexia nervosa is based on clinical criteria defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5): 1. **Restriction of Energy Intake:** Leading to significantly low body weight. 2. **Intense Fear of Gaining Weight:** Or becoming fat, even though underweight. 3. **Distorted Body Image:** Disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight. ### Example Case Study **Patient Profile:** - **Name:** Jee Hoon Ju - **Age:** 19 - **Occupation:** College Student **Medical History:** - **Symptoms:** Jee Hoon Ju has lost a significant amount of weight over the past six months. He restricts his food intake severely, avoids eating with family, and exercises excessively. He expresses an intense fear of gaining weight and believes he is overweight despite being visibly underweight. **Physical Examination:** - **Weight:** 45 kg (99 lbs) - **Height:** 170 cm (5'7") - **BMI:** 15.6 (underweight) - **Vitals:** Bradycardia (heart rate 50 bpm), hypotension (BP 90/60 mmHg), hypothermia (body temperature 35.8°C). **Psychological Assessment:** - **Body Image Disturbance:** Reports feeling "fat" despite being underweight. - **Denial:** Refuses to acknowledge the seriousness of his weight loss. **Laboratory Tests:** - **Electrolytes:** Imbalances, including hypokalemia. - **CBC:** Possible anemia. - **Thyroid Function:** Normal. **Diagnosis:** Based on the clinical features and diagnostic criteria, Jee Hoon Ju is diagnosed with anorexia nervosa. ### Management 1. **Nutritional Rehabilitation:** - Gradual refeeding with a structured meal plan to restore body weight. - Monitoring for refeeding syndrome, a potentially fatal condition caused by rapid refeeding. 2. **Medical Monitoring:** - Regular monitoring of vital signs, electrolytes, and overall health status. - Addressing any medical complications such as electrolyte imbalances or cardiac issues. 3. **Psychotherapy:** - **Cognitive-Behavioral Therapy (CBT):** To address distorted thoughts and behaviors related to food, weight, and body image. - **Family-Based Therapy (FBT):** Especially effective for adolescents, involving family in the treatment process. 4. **Medications:** - **Antidepressants:** Such as selective serotonin reuptake inhibitors (SSRIs) to treat co-existing depression or anxiety. - **Antipsychotics:** Such as olanzapine, in some cases, to help with weight gain and reduce obsessive thoughts about weight and food. 5. **Hospitalization:** - Indicated in severe cases where there is significant medical risk, such as extreme malnutrition, bradycardia, or suicidal ideation. ### Prognosis - The prognosis varies; early intervention and comprehensive treatment improve the likelihood of recovery. - Long-term follow-up is often necessary to prevent relapse and to manage any ongoing psychological issues. - The disorder has a high relapse rate and requires ongoing support and treatment. ### Conclusion Anorexia nervosa is a serious eating disorder requiring a multidisciplinary approach for effective treatment. Early diagnosis, nutritional rehabilitation, psychological therapy, and continuous medical monitoring are essential components of management. Addressing both the physical and psychological aspects of the disorder is crucial for improving outcomes and promoting recovery.