Anorexia Nervosa: Difference between revisions

No edit summary
(removed reference error)
 
(47 intermediate revisions by 3 users not shown)
Line 4: Line 4:
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}    
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}    
</div>  
</div>  
== Definition/Description ==
== Introduction ==
[[File:1287.gif|right|frameless|338x338px]]
Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted [[Body Dysmorphic Disorder|body]] image with the inability to recognize the seriousness of their significantly low body weight.<ref name=":0">Moore CA, Bokor BR. Anorexia Nervosa. [Updated 2021 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available:https://www.ncbi.nlm.nih.gov/books/NBK459148/ (accessed 9.8.2021)</ref>


{| width="40%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
The long‐term prognosis is often poor, with severe developmental, medical and [[Psychosocial considerations for individuals with SCI|psychosocial]] complications, high rates of relapse and mortality.<ref>Fisher  CA, Skocic  S, Rutherford  KA, Hetrick  SE. Family therapy approaches for anorexia nervosa. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD004780. DOI: 10.1002/14651858.CD004780.pub4. Available: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004780.pub4/full Accessed 09 August 2021.</ref>
|-
| align="right" |
{{#ev:youtube|uKUSGOB-0V8|300}}<ref>Anorexia's Childhood Roots. Available from: http://www.youtube.com/watch#!v=uKUSGOB-0V8 [last accessed 4/8/10]</ref>  


|}
== Epidemiology ==
The lifetime prevalence of anorexia nervosa is 0.66-1.9% based on geographical location, with a higher prevalence in developed countries.


<br> Anorexia nervosa is an eating disorder in which the individual exhibits severe weight loss without any indication of underlying systemic causes. Individuals with anorexia nervosa have a distorted view of their own body image and an extreme fear of gaining weight. <ref name="Bond">Bond C, Bonci L, Granger L, et al. National Athletic Trainers' Association Position Statement: Preventing, Detecting, and Managing Disordered Eating in Athletes. Journal of Athletic Training [serial online]. January 2008;43(1):80-108. Available from: Teacher Reference Center, Ipswich, MA. Accessed February 12, 2010.</ref><ref name="Mitchell">Mitchell, James E. Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians, and Physicians. Minneapolis, MN, USA: University of Minnesota Press. 2001. p 14-27.</ref><ref name="Mayo">Mayo Clinic Staff. Anorexia Nervosa. Mayo Clinic Website. 2010. Available at: http://www.mayoclinic.com/health/anorexia/DS00606. Accessed February 20, 2010.</ref><ref name="Franco">Franco, Kathleen N. Eating Disorders. Cleveland Clinic Center for Continuing Education Website. 2009. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/. Accessed February 20, 2010.</ref><ref name="Goodman">Goodman, Catherine C. and Fuller, Kenda S. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.</ref>&nbsp; Anorexia nervosa is diagnosed according to the DSM IV criteria listed below.&nbsp; <br>  
* Females are ten times more likely to be diagnosed with anorexia nervosa compared to men.
* The lifetime incidence of anorexia nervosa has increased from 0.1 to 5.4 per 100,000 over the last fifty years.  
* In females aged 15-19 years, the incidence has increased from 56.4 to 109 per 100,000 person-years.<ref name=":2">Radiopedia Anorexia Nervosa Available:https://radiopaedia.org/articles/anorexia-nervosa (accessed 9.8.2021)</ref>


<br> <br>  
== Pathophysiology ==
[[File:MediaWoman.jpg|right|frameless]]
Studies demonstrate biologic factors play a role in the development  of anorexia nervosa in addition to [[An Introduction to Environmental Physiotherapy|environmental]] factors. [[Genetic Disorders|Genetic]] correlations exist between educational attainment, neuroticism, and [[schizophrenia]]. Patients with anorexia nervosa have altered [[Brain Anatomy|brain]] function and structure there are deficits in [[neurotransmitters]] dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the [[Limbic System|corticolimbic]] system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder.<ref name=":0" />


DSM IV-TR Diagnostic Criteria of Anorexia Nervosa<br>  
The elements that contribute to the development of anorexia nervosa are complex, and involve a range of biological, psychological, and sociocultural factors. Any person, at any stage of their life, is at risk of developing an eating disorder. An eating disorder is a mental illness, not a choice that someone has made.<ref name=":1" />


#"Refusal to maintain body weight at or above a minimally normal weight for age and height: Weight loss leading to maintenance of body weight &lt;85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected." <ref name="Franco" /><br>
== Clinical Presentation ==
#"Intense fear of gaining weight or becoming fat, even though under weight."<ref name="Franco" /><br>
Patients will report symptoms such as amenorrhea, cold intolerance, constipation , extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time<ref name=":0" />[[File:Red Flags.jpg|right|frameless|394x394px]]
#"Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation,or denial of the seriousness of the current low body weight."<ref name="Franco" /><br>
The Diagnostic and Statistical Manual of mental disorders (DSM-5) recognises the following criteria for the diagnosis of anorexia nervosa
#"Amenorrhea (at least three consecutive cycles) in postmenarchial girls and women.&nbsp; Amenorrhea is defined as periods occuring only following hormone (e.g., estrogen) administration."<ref name="Franco" /><br>


<br>
* a restriction of caloric intake
* low body weight relative to age, sex and health
* unjustified fear of weight gain
* body dysmorphia


Two sub-types of anorexia nervosa have been recognized by the ''Diagnostic and Statistical Manual of Mental Disorders''.&nbsp; These sub-types include the restricting type and the binge-eating-purging type. Restricting subtype is characterized by an individual with anorexia nervosa who has not regularly taken part in binging or purging behaviors during the current episode.&nbsp; Binging and purging behaviors include the use of laxatives, diuretics, enemas, and self-induced vomiting to restrict weight gain.&nbsp; Binge-eating-purging subtype is characterized by an indivudal who has regularly taken part in binge-eating or purging behaviors in the current episode of anorexia nervosa.&nbsp; <ref name="Franco" /><ref name="Mitchell" />
Along with these, numerous signs may be observed and they include - but are not limited to - the following:


<br>  
* amenorrhoea (from suppression of the gonadal axis)
* dental caries (from purging)
* [[Orthostatic Hypotension|orthostatic hypotension]] or tachycardia
* resting [[bradycardia]]
* purpurae<ref name=":2" />


== Prevalence  ==
Two sub-types of anorexia nervosa have been recognized by the ''Diagnostic and Statistical Manual of Mental Disorders''.&nbsp;


Individuals with anorexia nervosa typically are young girls or women a part of the middle to upper-class families.&nbsp; Males also suffer from anorexia nervosa, but the prevalence is much lower, 5-10% of cases. <ref name="Mitchell" />&nbsp; The female to male ratios range from 6:1 to 10:1 in the United States. However, the characteristics and behaviors of males and females with anorexia nervosa are similar.&nbsp;  
# Restricting subtype is characterized by an individual with anorexia nervosa who has not regularly taken part in bingeing or purging behaviors during the current episode.&nbsp;
 
# Bingeing and purging behaviors include the use of laxatives, diuretics, enemas, and self-induced vomiting to restrict weight gain.&nbsp; Binge-eating-purging subtype is characterized by an individual who has regularly taken part in binge-eating or purging behaviors in the current episode of anorexia nervosa.&nbsp; <ref name="Franco">Franco, Kathleen N. Eating Disorders. Cleveland Clinic Center for Continuing Education Website. 2009. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/. Accessed February 20, 2010.</ref><ref name="Mitchell">Mitchell, James E. Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians, and Physicians. Minneapolis, MN, USA: University of Minnesota Press. 2001. p 14-27.</ref>
The most common age for onset of anorexia nervosa is in the mid teens and the disorder is most common in industrialized cultures such as United States, Canada, Europe, Australia, New Zealand, and South Africa.&nbsp; Anorexia nervosa is present in approximately 4% of young adolescents and adults in the United States. <ref name="Franco" />
 
When a closer look at individuals with anorexia nervosa is taken, a correlation can be seen between the number of diagnosed cases and athletes of specific sports.&nbsp; Anorexia nervosa is more commonly seen in athletes who partake in sports that exist with the view point that a leaner appearance enhances performance.&nbsp; Such sports include gymnastics, ballet, running, body building, and wrestling. <ref name="Franco" />  
 
== Characteristics/Clinical Presentation<br>  ==
 
Anorexia nervosa typically develops in adolescence around the onset of puberty.&nbsp; This is believed to develop due to the increased deposition of fat that commonly coincides with puberty.&nbsp; Adolescents are more likely to succumb to peer pressure and societal pressures to be thin at this age.&nbsp; An increased awareness of body shape and size is also present at this age period.&nbsp; Early recognition of anorexia nervosa is very important in order to prevent the devastating physical and emotional symptoms caused by starvation, malnutrition, and purging. <ref name="Mitchell" /><ref name="Bond" />
 
The following characteristics can be present in individuals with anorexia nervosa, however not all signs and symptoms may be present at the same time in one individual.&nbsp; <br>
 
*Restriction of food eaten or calories eaten
*Excessive exercise to the point of exhaustion
*Use of laxatives, enemas, or diuretics to restrict weight gain
*Elaborate preparation of meals with refusal to eat <ref name="Bond" />
*Increased preoccupation with food
*Excessive gum chewing
*Self isolation or decreased interest in social activities
*Decreased motivation
*Decreased sexual interest
*Mood changes especially depression, irritability,anxiety, or apathy<ref name="Mitchell" />
 
<br>
 
{| width="40%" cellspacing="1" cellpadding="1" border="0" align="right" class="FCK__ShowTableBorders"
|-
| align="right" |
{{#ev:youtube|ZmzJt5G9ud8|300}}<ref>Five News Ali,18. Available from: http://www.youtube.com/watch?v=ZmzJt5G9ud8 [last accessed 4/8/10]</ref>
 
|}
 
The following physical symptoms may be present in individuals with anorexia nervosa:
 
*Severe weight loss
*Abnormal blood counts<ref name="Mayo" />
*Increased fatigue, insomnia, or dizziness
*Brittle hair and nails
*Amenorrhea
*Irregular heart rhythms
*Low blood pressure
*Edema in the distal extremities or face<ref name="Mayo" />
*Osteoporosis
*Enlarged ventricles and sulci as seen by CT scans<ref name="Franco" />  
*Sore throat
*Chest pain
*Calluses on dorsum of the hand (Russell's Sign) <ref name="Mitchell" />  
*Dental erosion from gastric acids
*Electrolyte imbalances (Potassium, Sodium, Hydrogen Chloride, and Magnesium)<ref name="Bond" />
*Proximal muscle weakness with use of ipecac<ref name="Goodman" />
*Abnormal muscle biopsy and electromyograph<ref name="Goodman" />
*Gait disturbances<ref name="Goodman" />
*Muscle tetany
*Peripheral paresthesia
*Obsessive-compulsive behaviors<ref name="Franco" />


*
== Associated Co-morbidities  ==
== Associated Co-morbidities  ==


Death is the most devastating co-morbidity present with this eating disorder and most commonly occurs due to symptoms of starvation or suicide.&nbsp; Medical conditions typically causing death consist of abnormal heart rhythms and imbalances of electrolytes.&nbsp; Mortality rates are as high as 5.9% in anorexia nervosa diagnoses.  
Death is the most devastating co-morbidity present with this eating disorder and most commonly occurs due to symptoms of starvation or suicide.&nbsp; Medical conditions typically causing death consist of abnormal heart rhythms and imbalances of electrolytes.&nbsp; Mortality rates are as high as 5.9% in anorexia nervosa diagnoses.  


Co-morbid conditions present in individuals with anorexia nervosa may also include "major depressive disorder (50-75% of cases), sexual abuse (20-50% of cases), obsessive compulsive disorder (25% of cases), substance abuse (12-18% of cases), and bipolar disorder (4-13% of cases)". <ref name="Franco" /> <br>  
* Co-morbid conditions present in individuals with anorexia nervosa may also include "major depressive disorder (50-75% of cases), sexual abuse (20-50% of cases), obsessive compulsive disorder (25% of cases), substance abuse (12-18% of cases), and bipolar disorder (4-13% of cases)". <ref name="Franco" /> <br>
 
* Anemia, mitral valve prolapse, osteoporosis, and stress fractures are examples of co-morbidities that may be present with any eating disorders.&nbsp; Many individuals with anorexia nervosa often develop other types of eating disorders as well.&nbsp; Up to 50% of individuals with anorexia nervosa develop characteristics of bulimia nervosa over the span of their lifetime.<ref name="Franco" />
Anemia, mitral valve prolapse, osteoporosis, and stress fractures are examples of co-morbidities that may be present with any eating disorders.&nbsp; Many individuals with anorexia nervosa often develop other types of eating disorders as well.&nbsp; Up to 50% of individuals with anorexia nervosa develop characteristics of bulimia nervosa over the span of their lifetime.  
 
== Medications  ==
 
Currently the best evidence shows that selective serotonin reuptake inhibitors (SSRIs) demonstrate the most statistically and clinically significant positive effects in the treatment of anorexia nervosa. This medication has shown to improve mood, reduce obsessive behaviors, and satisfy hunger. <ref name="Goodman" /><ref name="Mitchell" /><ref name="Bond" /><ref name="Franco" />&nbsp; Little research has been done on the use and efficacy of other medications in the treatment of anorexia nervosa.&nbsp; The following medications have been researched in treatment for signs and symptoms of anorexia nervosa:<br>
 
*Antipsychotic drug chlorpromazine: Current standards do not consider this medication adequate for treatment. <ref name="Mitchell" />
*Antipsychotic drugs pimozide and sulpiride: Evidenced negative outcomes in RCTs and solely used in rare cases in the treatment of resistant clients. <ref name="Mitchell" />
*Lithium Carbonate: Rarely used in this population due to increased risk of cardiovascular events and fluid/electrolyte imbalance. <ref name="Mitchell" />
*Antidepressant drug clomipramine: Evidenced negative results in RCTs. <ref name="Mitchell" />
*Antidepressant drug amitriptyline: Evidenced positive results when used at 175mg in RCTs.<ref name="Mitchell" />
 
For further information on these medications, visit the following website: [http://www.drugs.com/ www.drugs.com/]
 
== Screening/Diagnostic Tests/Lab Tests  ==
 
Commonly used screening tools include:
 
*Standardized self-reporting questionnaires
*Observations
*Individual interviews
*Pre-participation physical examinations
*Physiological measurements
*Standardized questionnaires: Eating Disorders Inventory (EDI), Eating Disorder Examination (EDE-Q), and Eating Attitudes Test (EAT) <ref name="Bond" />
*Medical examination (Most Sensitive examination): diet, nutrition, body mass index, weight fluctuations, exercise habits, and menstrual history. Physical examination of the patient's height, weight, vitals, skin and nail observation, auscultation of heart and lung sounds, and abdominal palpation must be completed routinely throughout treatment.
*Body Mass Index (BMI): A BMI less than 18.5 kg/m<sup>2</sup> for individuals over 18 years old is considered underweight.&nbsp; For individuals under 18 years old, a body weight less than the 5th percentile for the age and gender is considered underweight. <ref name="Bond" />
*Body Fat Composition: skinfold thickness, air displacement plethysmography (BOD POD), bioelectrical impedence, and hydrostatic weighing<br>
*Lab Tests to determine if visceral dysfunction is present include: a complete blood count (CBC), basic metabolic profile (BMP), BUN, and urinalysis<br>
*Radiological Tests: X-Ray, Electrocardiogram (ECG), and bone density (DEXA) scan.&nbsp; <ref name="Mayo" />
 
<br>
 
Listed below are common red flags Mayo Clinic suggests to screen for during the examination. <ref name="Mayo" />
 
[[Image:Red Flags.jpg|frame|center]]
 
<br>
 
== Cause / Risk Factors  ==
 
*Biological: Young women and men are at an increased risk to develop anorexia nervosa if the idividual has a biological sibling or mother with anorexia nervosa.&nbsp; According to current research, children of patients with anorexia nervosa have a tenfold increased risk for developing the eating disorder. <ref name="Mayo" /><ref name="Franco" />&nbsp; An area on chromosone one has also been associated with increased risk for development of anorexia nervosa. <ref name="Mayo" /> Varying amounts of the chemical serotonin have shown evidence in playing a role in anorexia nervosa.&nbsp; All of the above show a definite genetic involvement in patients with anorexia nervosa.&nbsp; <br>
*Psychological: Individuals with anorexia nervosa often portray low self-esteem, low self-confidence, extreme perfectionist qualities, and obsessive-compulsive behaviors. Higher rates of eating disorders are also found in individuals who were teased about their weight at a younger age.&nbsp; Strict weight control can be used as a means to combat feelings of inadequacy or identity confusion. <br>
*Sociocultural: A correlation between prevalence rates of anorexia nervosa and modern westen cultures have been evidenced in research today.&nbsp; Modern western cultures are theorized to emphasize importance of thin appearance and associate power or wealth with thinness.&nbsp; <ref name="Franco" /><ref name="Mayo" /> Adolescents who feel pressure from families or peers to appear unrealistically thin are at an increased risk for developing anorexia nervosa.&nbsp;
*Familial: Families who struggle with resolving internal conflicts, consistantly overprotect their children, limit the autonomy of their children, or expect extraordinarily high achievements place the children at a higher risk for developing anorexia nervosa as shown in research trends. <ref name="Mitchell" />
*Athletics: Individuals who participate in any sport that emphasizes a thin build or has weight classifications is more likely to develop an eating disorder.&nbsp; Again those sports that show higher rates of anorexia nervosa include ballet, gymnastics, long-distance running, figure skating, wresting, body building, and diving.&nbsp;<ref name="Goodman" />


== Systemic Involvement  ==
== Treatment ==
[[File:Hospitalization.jpg|right|frameless|460x460px]]
Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Patients who need inpatient treatment have the following characteristics:


Individuals with anorexia nervosa may exhibit but are not limited to the systemic complications listed below:<br>
* Existing psychiatric disorders requiring hospitalization
* High risk for suicide (intent with highly lethal plan or failed attempt)
* Lack of support system (severe family conflict or homelessness)
* Limited access (lives too far away to participate in a daily treatment program)
* Medically unstable (bradycardia, dehydration, hypoglycemia or poorly controlled diabetes, hypokalemia or other electrolyte imbalances indicative of refeeding syndrome, hypothermia, hypotension,, organ compromise requiring acute treatment)
* Poorly motivated to recover (uncooperative, preoccupied with intrusive thoughts)
* Purging behaviors that are persistent, severe, and occur multiple times a day
* Severe anorexia nervosa (less than 70% of ideal body weight or acute weight loss with food refusal)
* Supervised feeding and/or specialized feeding (nasogastric tube) required
* Unable to stop compulsively exercising (not a sole indication for hospitalization).
Outpatient treatment includes intensive therapy (2 to 3 hours per weekday) and partial hospitalization (6 hours per day). Pediatric patients benefit from family-based psychotherapy to explore underlying dynamics and restructure the home environment.


'''Cardiovascular Complications'''<ref name="Mitchell" />
'''Refeeding syndrome''' can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphor.


*Bradycardia
Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored.
*Orthostatic Hypotension
*Decreased myocardial contractility
*Delayed capillary refill
*Acrocyanosis
*Mitral valve prolapse
*Ventricular arrythmias
*Abnormal QT intervals


'''Reproductive Complications'''<ref name="Mitchell" />  
'''Pharmacotherapy''' is not used initially. For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less-preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures<ref name=":0" />


*Amenorrhea
Nutritional therapy guidelines include weight gain of .9 - 1.4 kg  per week for inpatient treatment and .22 - .45  kg per week for outpatient treatment.&nbsp; Initially daily caloric goals should reach 1000-1600 kcal in divided meals and bathroom use should be restricted for two hours following each meal.&nbsp; Once a healthy weight is maintained stretching can be reintroduced followed by aerobic exercise with supervision and counselling on proper exercise guidelines.<ref name=":1" />
*Decreased testosterone in males


'''Musculoskeletal Complications'''<ref name="Franco" /><ref name="Mayo" /><ref name="Goodman" />  
== Recovery ==
It is possible to recover from anorexia nervosa, even if a person has been living with the illness for many years. The path to recovery can be long and challenging, however, with the right team and support, recovery is possible. Some people may find that recovery brings new under standing, insights and skills.<ref name=":1">National eating disorder Association. Anorexia nervosa. Available:https://nedc.com.au/eating-disorders/eating-disorders-explained/types/anorexia-nervosa/ (accessed 10.8.21)</ref>


*Rapid bone loss
== Medication ==
*Increased risk for stress fractures
[[File:Pill banner.png|right|frameless|309x309px]]
*Proximal muscle weakness
Medication can be used to manage various aspects of the complications that come with Anorexia Nervosa. Pharmacotherapy is not used initially.
*Osteoporosis
*Linear growth retardation in adolescents


'''Neurological Complications'''<ref name="Goodman" />  
For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less-preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures<ref name=":0" />


*Cerebral atrophy
* Quetiapine is an atypical antipsychotic. Low-dose quetiapine treatment can help with both psychological and physical improvements, with minimal associated side-effects, and appears to be a promising candidate for the treatment of anorexia nervosa.<ref name=":4">Court A, Mulder C, Kerr M, Yuen HP, Boasman M, Goldstone S, Fleming J, Weigall S, Derham H, Huang C, McGorry P, Berger G. Investigating the effectiveness, safety and tolerability of quetiapine in the treatment of anorexia nervosa in young people: a pilot study. J Psychiatr Res. 2010 Nov;44(15):1027-34. doi: 10.1016/j.jpsychires.2010.03.011. Epub 2010 May 5. PMID: 20447652.Available: https://pubmed.ncbi.nlm.nih.gov/20447652/ (accessed 10.8.2021)</ref>Olanzaniness, another atypical antipsychotic can also be used to assist with weight gain and obsessive thinking in patients.<ref name=":3" />
*Seizures
* Prozac can help with depressive symptoms and potentially with healthy weight maintenance once weight restoration is achieved. Prozac is part of the SSRI family, or the selective serotonin uptake inhibitors. SSRIs assist with increased serotonin levels, that is connected to mood.<ref name=":3">Eating disorders hope. Common medications in anorexia nervosa. Available:https://www.eatingdisorderhope.com/blog/common-medication-treatments-anorexia (accessed 10.8.2021)</ref>
*Muscle Tetany
*Peripheral paresthesia


'''Biochemical Complications'''<ref name="Franco" />
== Physical Therapy Management  ==
[[File:Yoga-eat.jpg|right|frameless|350x350px]]
Physical Therapy is an integral part in rehabilitation of patients with anorexia nervosa once stretching and exercise is reintroduced.&nbsp; A health care provider who has extensive knowledge of proper exercise guidelines and how to monitor physical signs of fatigue and vitals is needed to treat these patients.&nbsp; These skills are important to help the patient learn to monitor levels of fatigue and heart rate in order to prevent them from over exercising or exercising to the point of exhaustion.&nbsp; Patients with anorexia nervosa are also more susceptible to orthostatic hypotension, bradycardia, and muscle cramping due to malnutrition and low level caloric diets. A health care provider, such as a physical therapist, is the best trained professional to monitor and respond to these medical conditions.&nbsp;


*Hypercortisolemia
A physical therapist can also be beneficial during the screening process because they are educated in their professional programs on how to recognize the signs and symptoms of this disorder. A therapist may be the first provider to notice signs and symptoms present with this disorder.&nbsp; For example, during a cervical exam the therapist may note edema in the face or salivary glands or overuse injuries like stress fractures from excessively exercising.&nbsp;
*Nonsuppression of dexamethasone
*Thyroid suppression<br>


[[Image:1287.gif|center|600px]]<ref>Effects of Anorexia Nervosa. Women's Health Zone. Available at: http://www.womenshealthzone.net/eating-disorders/anorexia-nervosa/effects/.</ref><br>
When creating exercise programs for these individuals, physical therapists must take into account bone density levels, orthostatic hypotension, cardiac status, and lab values.&nbsp; The program must be adjusted in order to protect the individual from physical harm or becoming medically unstable.&nbsp; Exercise is not recommended if the patients body mass index is less than 18 kg/m<sup>2</sup>, and therefore is not introduced until the individual can maintain a healthy weight and is medically stable. &nbsp; The ideal exercise program should include elements of stretching, light upper body weights, breathing exercises, and aerobic exercise.&nbsp; It is very important for the physical therapist to set upper limits on repetitions, sets, or minutes in order to prevent the individual from over exercising.&nbsp; Encouraging the individual to focus on the positive effects of exercise on overall health and not weight is equally important for the physical therapist.&nbsp;<ref name="Goodman">Goodman, Catherine C. and Fuller, Kenda S. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.</ref>
[[File:2000px-Body mass index chart svg.png|right|frameless]]


== Medical Management (current best evidence) ==
== Body Mass Index (BMI) related guidance ==


Clients with anorexia nervosa can be treated in outpatient or inpatient facilities, however the approach is similar in both instances.&nbsp;Hospitalization may be required for individuals who are not medically stable.&nbsp; A more restrictive approach may be more beneficial for individuals who continue to refuse to eat orally, decline in weight despite supplementation, electrolyte imbalance, heart arrythmias, or unresponsive to previous treatment.&nbsp;
* Below [[Body Mass Index|BMI]] 14: Exercise is not recommended because weight gain at this stage is the overriding priority.
* Between BMI 14 and 15: Following assessment it may be appropriate to recommend exercises in lying and sitting eg gentle [[Pilates]], relaxation techniques and gentle [[Stretching|stretches]].
* BMI 15 to 17: Commence a gradual progression to moderate weight bearing activities. Pilates, [[Tai Chi and the Older Person|Tai Chi]] and [[Yoga]] type exercises can be introduced. Sessions should still be carefully monitored and supervised and preferably done in a group setting.
* BMI 17 and above, towards a healthy weight: At this point patients are still on a weight-restoration programme and, therefore, any recommendations for exercise must not be allowed to compromise this. Sessions may become increasingly active eg swimming, walking, dancing. Group exercises are preferable to solitary exercising.
* At a healthy weight: Patients need to find a healthy balance between activity levels and [[Nutrition|nutritional]] intake. The physiotherapist has a special role in formulating and constantly reassessing an activity/exercise regime. Adjustments must take into account the individual’s physical health, pre- morbid exercise behaviour, occupation and recreational preferences.<ref name=":0" />


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Indications for hospitalization suggested by the Cleveland Clinic are as follows:<ref name="Franco" />
== Strategies to reduce excessive exercise ==
Although patients might find exercise helps with the weight restoration process, excessive exercise is always counter-productive to its success. Excessive exercise may be a problem for patients at any stage of recovery. Various strategies may be used to help the patient to stop or reduce the inclination to over- exercise. Below are some examples of strategies


[[Image:Hospitalization.jpg|center|Hospitalization.jpg]]
* Increasing support, through constant observation for a short period of time to prohibit over-exercising, may not only break the habit, but also appease the guilt. Patients often report that they feel a sense of relief, as they now have an excuse to give up the over-exercising which they had felt compelled to do.


The main goals for treatment of anorexia nervosa include patient's recognition of eating disorder, identification of triggers, improvement of delusional thoughts and feelings towards body image and shape, achievement and maintenance of healthy weight, and preventing relapse.&nbsp; A multi-focal approach is taken for the medical management of anorexia nervosa in order to combat all symptoms manifested within this disorder. Behavioral therapy, psychotherapy, family couseling, dietary and nutritional counseling, and exercise guidance are all recommended in combination to treat anorexia nervosa.&nbsp; <ref name="Goodman" /><ref name="Bond" /><ref name="Mitchell" /> Pharmocological treatment is another aspect that may be necessary in the treatment of the depressive sypmtoms found with anorexia nervosa (see medications listed above).
* Promoting a motivational stance is helpful  and encouraging patients to adhere to a prescribed exercise programme.
* Distraction techniques, particularly at the time of the urge to exercise, can be helpful for reducing excessive exercising behaviour. eg verbalising thoughts and feelings is appropriate, while for others engaging in a sedentary activity, such as having a painting, can be more helpful. Education and advice play a key role in helping the patient to understand the consequences of over-exercising and in raising awareness about the benefits of change to their health and may help the patient to develop healthier, more appropriate exercise behaviour.
* A [[Cognitive Behavioural Therapy|CBT]] approach can be used to guide the patient in finding, new healthier ways of thinking regarding their exercise and activity and make changes to their behaviour.<ref>cpmh Physiotherapy guidance notes for exercise and physical activity in adult patients with anorexia and bulinia Available : https://cpmh.csp.org.uk/system/files/physiotherapy_guidance_notes_for_exercise_and_physical_activity_in_adult_patients_with_anorexia_and_bulimia_nervosa.pdf (accessed 13.8.2021)</ref>


Cognitive behavioral therapy (CBT) is the most commonly used and effective psychotherapy to treat this eating disorder especially when initially supportive and directive.&nbsp; For younger individuals with anorexia nervosa, family based therapy is recommended. However, family based therapy does not show positive results in individuals whose family shows high levels of expressed emotions.&nbsp; Family based therapy focuses on resolving any internal conflicts, monitoring the patient's food intake, and preventing relapse.&nbsp; These individuals, as well as individuals over 18 years old or with a longer duration of anorexia nervosa, benefit more from individual based psychotherapy. <ref name="Mitchell" /> Twelve-step programs can also be successful with this population in preventing relapse.&nbsp;
== Differential Diagnosis  ==


Nutritional therapy guidelines include weight gain of 2-3 lbs per week for inpatient treatment and 0.5-1 lb per week for outpatient treatment.&nbsp; Initially daily caloric goals should reach 1000-1600 kcal in divided meals and bathroom use should be restricted for two hours following each meal.&nbsp; Once a healthy weight is maintained stretching can be reintroduced followed by aerobic exercise with supervision and counseling on proper exercise guidelines. <ref name="Franco" /><br>  
* [[Oncological Disorders|Cancer]]
* Chronic mesenteric ischemia
* Achalasia
* Malabsorption
* [[Hyperthyroidism]]
* [[Irritable Bowel Syndrome|Irritable bowel syndrome]]
* [[Celiac Disease (Coeliac Disease)|Celiac disease]]<ref name=":0" />


== Physical Therapy Management (current best evidence)  ==
== Resources ==
A great place to start is the following link:


Physical Therapy is an integral part in rehabilitation of patients with anorexia nervosa once stretching and exercise is reintroduced.&nbsp; A health care provider who has extensive knowledge of proper exercise guidelines and how to monitor physical signs of fatigue and vitals is needed to treat these patients.&nbsp; These skills are important to help the patient learn to monitor levels of fatigue and heart rate in order to prevent them from over exercising or exercising to the point of exhaustion.&nbsp; Patients with anorexia nervosa are also more susceptible to orthostatic hypotension, bradycardia, and muscle cramping due to malnutrition and low level caloric diets. A health care provider, such as a physical therapist, is the best trained professional to monitor and respond to these medical conditions.&nbsp;
https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders
 
A physical therapist can also be beneficial during the screening process because they are educated in their professional programs on how to recognize the signs and symptoms of this disorder. A therapist may be the first provider to notice signs and symptoms present with this disorder.&nbsp; For example, during a cervical exam the therapist may note edema in the face or salivary glands or overuse injuries like stress fractures from excessively exercising.&nbsp; <br>
 
When creating exercise programs for these individuals, physical therapists must take into account bone density levels, orthostatic hypotension, cardiac status, and lab values.&nbsp; The program must be adjusted in order to protect the individual from physical harm or becoming medically unstable.&nbsp; Exercise is not recommended if the patients body mass index is less than 18 kg/m<sup>2</sup>, and therefore is not introduced until the individual can maintain a healthy weight and is medically stable. &nbsp; The ideal exercise program should contail elements of stretching, light upper body weights, breathing exercises, and aerobic exercise.&nbsp; It is very important for the physical therapist to set upper limits on repetitions, sets, or minutes in order to prevent the individual from over exercising.&nbsp; Encouraging the individual to focus on the positive effects of exercise on overall health and not weight is equally important for the physical therapist.&nbsp;<ref name="Goodman" />
 
== Other Management (current best evidence)  ==
 
*Electroconvulsive therapy has been used in severe cases of anorexia nervosa with positive effects in weight gain and improving affect. <ref>Poutanen O., et al. Severe anorexia nervosa, co-occurring major depressive disorder and electroconvulsive therapy as maintenance treatment: a case report. Cases Journal [serial online]. 2009;2:9362. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804009/?tool=pubmed.</ref><br>
*Yoga has been proven to be effective as an adjuct to treatment for anorexia nervosa to increase self-awareness and self-reflection. <ref name="Douglass">Douglass L. Yoga as an intervention in the treatment of eating disorders: does it help. Eat Disord. 2009 Mar-Apr;17(2):126-39.</ref>
 
== Differential Diagnosis <ref name="Franco" />  ==
 
Eating Disorders:<br>
 
*[[Bulimia Nervosa|Bulimia Nervosa ]]
*Food Avoidance Emotional Disorder
*Pervasive Refusal Syndrome
*Functional Dysphagia
 
Medical Illnesses:
 
*Brain tumors or malignancies
*Gastrointestinal Disease
*Acquired Immunodeficiency Syndrome (AIDS)
 
Psychiatric Disorders:
 
*[[Depression|Depression]]
*[[Schizophrenia|Schizophrenia]]
*Somatization Disorder
 
== Case Reports<br>  ==
 
*Strategies used by physical therapists in the U.S. for treatment and prevention of the female athlete triad. [http://www.physicaltherapyinsport.com/article/S1466-853X%2808%2900116-8/abstract www.physicaltherapyinsport.com/article/S1466-853X%2808%2900116-8/abstract]<br>
*Prevalence of the Female Athlete Triad Syndrome Among High School Athletes [http://archpedi.highwire.org/cgi/content/full/160/2/137 archpedi.highwire.org/cgi/content/full/160/2/137]<br>
*Mitsuaki Tokumura, Shigeki Yoshiba, Tetsuya Tanaka, Seiichiro Nanri, Hisako Watanabe. Prescribed exercise training improves exercise capacity of convalescent children and adolescents with anorexia nervosa. European Journal of Pediatrics [serial online]. 2003;162:430-1. Available from: ProQuest Health and Medical Complete. Accessed April 8, 2010, Document ID: 1322842551.<br>
*The female athlete triad: an emerging role for physical therapy [http://www.ncbi.nlm.nih.gov/pubmed/14620789 www.ncbi.nlm.nih.gov/pubmed/14620789]<br>
*Severe Anorexia Nervosa, Co-occurring Major Depressive Disorder and Electroconvulsive Therapy as Maintenance Treatment: A Case Report [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804009/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804009/?tool=pubmed]
*Unique challenges for appropriate management of a 16-year-old girl with superior mesenteric artery syndrome as a result of anorexia nervosa: a case report [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2783065/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2783065/?tool=pubmed]<br>
*Family-Based Treatment of a 17-Year-Old Twin Presenting with Emerging Anorexia Nervosa: A Case Study Using the “Maudsley Method” [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2617742/?tool=pubmed http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2617742/?tool=pubmed]<br>
 
<br>
 
== Resources <br>  ==
 
*[http://www.anad.org/ National Association of Anorexia Nervosa and Associated Disorders]<br>
*[http://www.eatingdisorderinfo.org/ The Alliance for Eating Disorders Awareness]
*[http://www.eatingdisordersanonymous.org/ Eating Disorders Anonymous (EDA)]
*[http://www.edreferral.com/ Eating Disorder Referral and Information Center]


== References  ==
== References  ==
Line 254: Line 134:
<references />  
<references />  


[[Category:Bellarmine_Student_Project]] [[Category:Videos]]
[[Category:Bellarmine_Student_Project]]
[[Category:Conditions]]
 
[[Category:Mental Health]]
[[Category:Mental Health - Conditions]]

Latest revision as of 13:43, 8 October 2021

Original Editors - Brittney Kerchief from Bellarmine University's  Pathophysiology of Complex Patient Problems project.

Top Contributors - Brittney Kerchief, Lucinda hampton, Admin, Simisola Ajeyalemi, Laura Ritchie, Kim Jackson, Tony Lowe, Elaine Lonnemann, Vidya Acharya, Wendy Walker, George Prudden and WikiSysop  

Introduction[edit | edit source]

1287.gif

Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight.[1]

The long‐term prognosis is often poor, with severe developmental, medical and psychosocial complications, high rates of relapse and mortality.[2]

Epidemiology[edit | edit source]

The lifetime prevalence of anorexia nervosa is 0.66-1.9% based on geographical location, with a higher prevalence in developed countries.

  • Females are ten times more likely to be diagnosed with anorexia nervosa compared to men.
  • The lifetime incidence of anorexia nervosa has increased from 0.1 to 5.4 per 100,000 over the last fifty years.
  • In females aged 15-19 years, the incidence has increased from 56.4 to 109 per 100,000 person-years.[3]

Pathophysiology[edit | edit source]

MediaWoman.jpg

Studies demonstrate biologic factors play a role in the development  of anorexia nervosa in addition to environmental factors. Genetic correlations exist between educational attainment, neuroticism, and schizophrenia. Patients with anorexia nervosa have altered brain function and structure there are deficits in neurotransmitters dopamine (eating behavior and reward) and serotonin (impulse control and neuroticism), differential activation of the corticolimbic system (appetite and fear), and diminished activity among the frontostriatal circuits (habitual behaviors). Patients have co-morbid psychiatric disorders such as major depressive disorder and generalized anxiety disorder.[1]

The elements that contribute to the development of anorexia nervosa are complex, and involve a range of biological, psychological, and sociocultural factors. Any person, at any stage of their life, is at risk of developing an eating disorder. An eating disorder is a mental illness, not a choice that someone has made.[4]

Clinical Presentation[edit | edit source]

Patients will report symptoms such as amenorrhea, cold intolerance, constipation , extremity edema, fatigue, and irritability. They may describe restrictive behaviors related to food like calorie counting or portion control, and purging methods, for example, self-induced vomiting or use of diuretics or laxatives. Many exercise compulsively for extended periods of time[1]

Red Flags.jpg

The Diagnostic and Statistical Manual of mental disorders (DSM-5) recognises the following criteria for the diagnosis of anorexia nervosa

  • a restriction of caloric intake
  • low body weight relative to age, sex and health
  • unjustified fear of weight gain
  • body dysmorphia

Along with these, numerous signs may be observed and they include - but are not limited to - the following:

Two sub-types of anorexia nervosa have been recognized by the Diagnostic and Statistical Manual of Mental Disorders. 

  1. Restricting subtype is characterized by an individual with anorexia nervosa who has not regularly taken part in bingeing or purging behaviors during the current episode. 
  2. Bingeing and purging behaviors include the use of laxatives, diuretics, enemas, and self-induced vomiting to restrict weight gain.  Binge-eating-purging subtype is characterized by an individual who has regularly taken part in binge-eating or purging behaviors in the current episode of anorexia nervosa.  [5][6]

Associated Co-morbidities[edit | edit source]

Death is the most devastating co-morbidity present with this eating disorder and most commonly occurs due to symptoms of starvation or suicide.  Medical conditions typically causing death consist of abnormal heart rhythms and imbalances of electrolytes.  Mortality rates are as high as 5.9% in anorexia nervosa diagnoses.

  • Co-morbid conditions present in individuals with anorexia nervosa may also include "major depressive disorder (50-75% of cases), sexual abuse (20-50% of cases), obsessive compulsive disorder (25% of cases), substance abuse (12-18% of cases), and bipolar disorder (4-13% of cases)". [5]
  • Anemia, mitral valve prolapse, osteoporosis, and stress fractures are examples of co-morbidities that may be present with any eating disorders.  Many individuals with anorexia nervosa often develop other types of eating disorders as well.  Up to 50% of individuals with anorexia nervosa develop characteristics of bulimia nervosa over the span of their lifetime.[5]

Treatment[edit | edit source]

Hospitalization.jpg

Treatment for anorexia nervosa is centered on nutrition rehabilitation and psychotherapy. Patients who need inpatient treatment have the following characteristics:

  • Existing psychiatric disorders requiring hospitalization
  • High risk for suicide (intent with highly lethal plan or failed attempt)
  • Lack of support system (severe family conflict or homelessness)
  • Limited access (lives too far away to participate in a daily treatment program)
  • Medically unstable (bradycardia, dehydration, hypoglycemia or poorly controlled diabetes, hypokalemia or other electrolyte imbalances indicative of refeeding syndrome, hypothermia, hypotension,, organ compromise requiring acute treatment)
  • Poorly motivated to recover (uncooperative, preoccupied with intrusive thoughts)
  • Purging behaviors that are persistent, severe, and occur multiple times a day
  • Severe anorexia nervosa (less than 70% of ideal body weight or acute weight loss with food refusal)
  • Supervised feeding and/or specialized feeding (nasogastric tube) required
  • Unable to stop compulsively exercising (not a sole indication for hospitalization).

Outpatient treatment includes intensive therapy (2 to 3 hours per weekday) and partial hospitalization (6 hours per day). Pediatric patients benefit from family-based psychotherapy to explore underlying dynamics and restructure the home environment.

Refeeding syndrome can occur following prolonged starvation. As the body utilizes glucose to produce molecules of adenosine triphosphate (ATP), it depletes the remaining stores of phosphor.

Also, glucose entry into cells is mediated by insulin and occurs rapidly following long periods without food. Both cause electrolyte abnormalities such as hypophosphatemia and hypokalemia, triggering cardiac and respiratory compromise. Patients should be followed carefully for signs of refeeding syndrome and electrolytes closely monitored.

Pharmacotherapy is not used initially. For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less-preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures[1]

Nutritional therapy guidelines include weight gain of .9 - 1.4 kg per week for inpatient treatment and .22 - .45 kg per week for outpatient treatment.  Initially daily caloric goals should reach 1000-1600 kcal in divided meals and bathroom use should be restricted for two hours following each meal.  Once a healthy weight is maintained stretching can be reintroduced followed by aerobic exercise with supervision and counselling on proper exercise guidelines.[4]

Recovery[edit | edit source]

It is possible to recover from anorexia nervosa, even if a person has been living with the illness for many years. The path to recovery can be long and challenging, however, with the right team and support, recovery is possible. Some people may find that recovery brings new under standing, insights and skills.[4]

Medication[edit | edit source]

Pill banner.png

Medication can be used to manage various aspects of the complications that come with Anorexia Nervosa. Pharmacotherapy is not used initially.

For acutely ill patients who do not respond to initial treatment, olanzapine is a first-line medication. Other antipsychotics have not demonstrated similar effects on weight gain. For patients who are not acutely ill but have co-morbid psychiatric conditions such as generalized anxiety disorder or major depressive disorder, combination therapy with selective serotonin reuptake inhibitors (SSRIs) and therapy is best. Patients who do not respond to SSRIs may need a second-generation antipsychotic. Tricyclic antidepressants (TCAs) are less-preferred due to concerns about cardiotoxicity, especially in malnourished patients. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures[1]

  • Quetiapine is an atypical antipsychotic. Low-dose quetiapine treatment can help with both psychological and physical improvements, with minimal associated side-effects, and appears to be a promising candidate for the treatment of anorexia nervosa.[7]Olanzaniness, another atypical antipsychotic can also be used to assist with weight gain and obsessive thinking in patients.[8]
  • Prozac can help with depressive symptoms and potentially with healthy weight maintenance once weight restoration is achieved. Prozac is part of the SSRI family, or the selective serotonin uptake inhibitors. SSRIs assist with increased serotonin levels, that is connected to mood.[8]

Physical Therapy Management[edit | edit source]

Yoga-eat.jpg

Physical Therapy is an integral part in rehabilitation of patients with anorexia nervosa once stretching and exercise is reintroduced.  A health care provider who has extensive knowledge of proper exercise guidelines and how to monitor physical signs of fatigue and vitals is needed to treat these patients.  These skills are important to help the patient learn to monitor levels of fatigue and heart rate in order to prevent them from over exercising or exercising to the point of exhaustion.  Patients with anorexia nervosa are also more susceptible to orthostatic hypotension, bradycardia, and muscle cramping due to malnutrition and low level caloric diets. A health care provider, such as a physical therapist, is the best trained professional to monitor and respond to these medical conditions. 

A physical therapist can also be beneficial during the screening process because they are educated in their professional programs on how to recognize the signs and symptoms of this disorder. A therapist may be the first provider to notice signs and symptoms present with this disorder.  For example, during a cervical exam the therapist may note edema in the face or salivary glands or overuse injuries like stress fractures from excessively exercising. 

When creating exercise programs for these individuals, physical therapists must take into account bone density levels, orthostatic hypotension, cardiac status, and lab values.  The program must be adjusted in order to protect the individual from physical harm or becoming medically unstable.  Exercise is not recommended if the patients body mass index is less than 18 kg/m2, and therefore is not introduced until the individual can maintain a healthy weight and is medically stable.   The ideal exercise program should include elements of stretching, light upper body weights, breathing exercises, and aerobic exercise.  It is very important for the physical therapist to set upper limits on repetitions, sets, or minutes in order to prevent the individual from over exercising.  Encouraging the individual to focus on the positive effects of exercise on overall health and not weight is equally important for the physical therapist. [9]

2000px-Body mass index chart svg.png

Body Mass Index (BMI) related guidance[edit | edit source]

  • Below BMI 14: Exercise is not recommended because weight gain at this stage is the overriding priority.
  • Between BMI 14 and 15: Following assessment it may be appropriate to recommend exercises in lying and sitting eg gentle Pilates, relaxation techniques and gentle stretches.
  • BMI 15 to 17: Commence a gradual progression to moderate weight bearing activities. Pilates, Tai Chi and Yoga type exercises can be introduced. Sessions should still be carefully monitored and supervised and preferably done in a group setting.
  • BMI 17 and above, towards a healthy weight: At this point patients are still on a weight-restoration programme and, therefore, any recommendations for exercise must not be allowed to compromise this. Sessions may become increasingly active eg swimming, walking, dancing. Group exercises are preferable to solitary exercising.
  • At a healthy weight: Patients need to find a healthy balance between activity levels and nutritional intake. The physiotherapist has a special role in formulating and constantly reassessing an activity/exercise regime. Adjustments must take into account the individual’s physical health, pre- morbid exercise behaviour, occupation and recreational preferences.[1]

Strategies to reduce excessive exercise[edit | edit source]

Although patients might find exercise helps with the weight restoration process, excessive exercise is always counter-productive to its success. Excessive exercise may be a problem for patients at any stage of recovery. Various strategies may be used to help the patient to stop or reduce the inclination to over- exercise. Below are some examples of strategies

  • Increasing support, through constant observation for a short period of time to prohibit over-exercising, may not only break the habit, but also appease the guilt. Patients often report that they feel a sense of relief, as they now have an excuse to give up the over-exercising which they had felt compelled to do.
  • Promoting a motivational stance is helpful and encouraging patients to adhere to a prescribed exercise programme.
  • Distraction techniques, particularly at the time of the urge to exercise, can be helpful for reducing excessive exercising behaviour. eg verbalising thoughts and feelings is appropriate, while for others engaging in a sedentary activity, such as having a painting, can be more helpful. Education and advice play a key role in helping the patient to understand the consequences of over-exercising and in raising awareness about the benefits of change to their health and may help the patient to develop healthier, more appropriate exercise behaviour.
  • A CBT approach can be used to guide the patient in finding, new healthier ways of thinking regarding their exercise and activity and make changes to their behaviour.[10]

Differential Diagnosis[edit | edit source]

Resources[edit | edit source]

A great place to start is the following link:

https://cpmh.csp.org.uk/content/physiotherapy-eating-disorders

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Moore CA, Bokor BR. Anorexia Nervosa. [Updated 2021 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available:https://www.ncbi.nlm.nih.gov/books/NBK459148/ (accessed 9.8.2021)
  2. ↑ Fisher  CA, Skocic  S, Rutherford  KA, Hetrick  SE. Family therapy approaches for anorexia nervosa. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD004780. DOI: 10.1002/14651858.CD004780.pub4. Available: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004780.pub4/full Accessed 09 August 2021.
  3. ↑ 3.0 3.1 Radiopedia Anorexia Nervosa Available:https://radiopaedia.org/articles/anorexia-nervosa (accessed 9.8.2021)
  4. ↑ 4.0 4.1 4.2 National eating disorder Association. Anorexia nervosa. Available:https://nedc.com.au/eating-disorders/eating-disorders-explained/types/anorexia-nervosa/ (accessed 10.8.21)
  5. ↑ 5.0 5.1 5.2 Franco, Kathleen N. Eating Disorders. Cleveland Clinic Center for Continuing Education Website. 2009. Available at: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/. Accessed February 20, 2010.
  6. ↑ Mitchell, James E. Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians, and Physicians. Minneapolis, MN, USA: University of Minnesota Press. 2001. p 14-27.
  7. ↑ Court A, Mulder C, Kerr M, Yuen HP, Boasman M, Goldstone S, Fleming J, Weigall S, Derham H, Huang C, McGorry P, Berger G. Investigating the effectiveness, safety and tolerability of quetiapine in the treatment of anorexia nervosa in young people: a pilot study. J Psychiatr Res. 2010 Nov;44(15):1027-34. doi: 10.1016/j.jpsychires.2010.03.011. Epub 2010 May 5. PMID: 20447652.Available: https://pubmed.ncbi.nlm.nih.gov/20447652/ (accessed 10.8.2021)
  8. ↑ 8.0 8.1 Eating disorders hope. Common medications in anorexia nervosa. Available:https://www.eatingdisorderhope.com/blog/common-medication-treatments-anorexia (accessed 10.8.2021)
  9. ↑ Goodman, Catherine C. and Fuller, Kenda S. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier; 2009.
  10. ↑ cpmh Physiotherapy guidance notes for exercise and physical activity in adult patients with anorexia and bulinia Available : https://cpmh.csp.org.uk/system/files/physiotherapy_guidance_notes_for_exercise_and_physical_activity_in_adult_patients_with_anorexia_and_bulimia_nervosa.pdf (accessed 13.8.2021)
Retrieved from "https://www.physio-pedia.com/index.php?title=Anorexia_Nervosa&oldid=283272"