Hallmark of anorexia nervosa are a relentless pursuit of thinness, the morbid fear of obesity, a disturbed body image and restriction of food intake in relation to the needs, resulting in a significantly lower body weight. The diagnosis is made clinically. Most treatments are working with a form of psychotherapy. Olanzapine can support a weight gain.
Anorexia nervosa occurs predominantly in girls and young women. The disorder usually begins in adolescence and rarely later than the age of the 40th
Hallmark of anorexia nervosa are a relentless pursuit of thinness, the morbid fear of obesity, a disturbed body image and restriction of food intake in relation to the needs, resulting in a significantly lower body weight. The diagnosis is made clinically. Most treatments are working with a form of psychotherapy. Olanzapine can support a weight gain. Anorexia nervosa occurs predominantly in girls and young women. The disorder usually begins in adolescence and rarely later than the age of 40. The etiology is unknown. In addition to the female sex few risk factors have been identified so far. In Western cultures, obesity is considered unattractive and unhealthy, and the desire for slimness is omnipresent, even in children. Over 50% of prepubertal girls go on a diet or take other measures to weight control. The excessive preoccupation with body weight and dietary measures in the past seem to indicate an increased risk, and probably also exists a genetic predisposition. Studies with identical twins showed concordance rates of <50%; the concordance is lower in fraternal twins. Family and social factors probably play a role. Many patients belong to the middle or upper class, are pedantic and obsessive, have an average intelligence and have very high performance and success standards. Two types of anorexia nervosa are recognized: Restrictive type: Patients restrict food intake, but not regularly have binge eating or purging behavior, make patients operate excessively sport. Binge eating- / Purging Type: Patients who regularly binge eating, then induce vomiting and / or abusing laxatives, diuretics or enemas. Binge eating is defined as eating a much larger amount of food than most people would eat in a similar period under similar circumstances, with loss of control, d. h. to resist the perceived inability or stop eating. Pathophysiology Endocrine abnormalities are common; These include low levels of sex hormones (LH, decreased secretion), slightly reduced levels of thyroxine (T4) and triiodothyronine (T3) and increased cortisol secretion. Menstruation stops i. Gen. , but the cessation of menses is no longer a criterion for diagnosis. The bone mass decreases. every major organ system can be affected virtually severely malnourished patients. Susceptibility to Infektionenist typically not increased. There may be dehydration, metabolic alkalosis and decreased serum potassium and / or sodium In; All these changes are amplified by induced vomiting and Laxanzien- or diuretics abuse. Heart muscle mass, and -kammergröße -auswurfleistung decrease; often a mitral valve prolapse is detected. Some patients have (even after correction pulse) a prolonged QT interval, which may predispose by electrolyte imbalance for tachyarrhythmias along with the risks. Sudden deaths, mostly due to ventricular tachyarrhythmias may occur. Clinical Calculator: QT interval correction (ECG) symptoms and signs anorexia nervosa can also take a mild and temporary, but serious and long course. Most patients are slim, but are concerned that they might be overweight, or that certain parts of the body (eg. As thighs, buttocks) are too thick. They strive to continue to lose weight, despite assurances and warnings from friends and family members that they are thin or even significantly underweight to lose, and they see any weight gain as an unacceptable failure of their self-control. They deal almost exclusively with their weight and are afraid of gaining weight, even if they are already severely emaciated. Actually, the term "anorexia" is wrong because the appetite to the stage of significant cachexia remains unchanged. Patients are busy dwelling on the subject of food: They study diets and count calories. They hoard and hide food and throw it away. They collect recipes. Prepare elaborate meals for others. Patients often exaggerate their food intake and conceal behaviors such. As induced vomiting. 30-50% of patients show binge eating- / purging behavior. The other limit only one their food intake. Many patients with anorexia nervosa also exercise excessively with the aim to control their weight. Even cachexia appearing patients are usually still very active (and hold on to their extreme training programs fixed). Symptoms such as bloating, abdominal pain and constipation are common. In general, patients lose interest in sexual activity. Often depression occurs. Common physical findings include bradycardia, hypotension, hypothermia, lanugo or discrete hirsutism and edema. The body fat content is very greatly reduced. Patients who vomit frequently, eroded tooth enamel, a painless salivary gland enlargement and / or an inflamed esophagus may have. Diagnosis Clinical criteria That the seriousness of low body weight and restrictive diets are not recognized, are prominent features of anorexia nervosa, and patients resist any evaluation and treatment. Usually, the patients seek only to pressure their relatives or because of other diseases to a doctor. Clinical Calculator: Body Mass Index percentiles for girls (2-20 years) clinical calculator: body mass index percentile for boys (2-20 years) Clinical criteria for diagnosis are: restriction of food intake, resulting in a significantly lower body weight Fear before being overweight (especially indicated by the patient or manifested as behavior that interferes with weight gain) body image disorder (miscalculation of body weight and / or appearance) or denial of illness in adults low body weight with BMI is defined. A BMI of <17 kg / m2 is considered to be significantly low; a BMI of 17 to <18.5 kg / m2 may be significantly low, depending on the starting point of the patient. In children and adolescents, the BM-percentile is applied for old age; The 5th percentile is reported as the Cuttoff value in the rule. However, children can also meet the criteria from the 5th percentile, which have not reached their targeted growth rate; BMI percentiles for age tables and standard growth charts are available from the CDC (see CDC Growth Charts). Clinical Calculator: Body Mass Index (Quetelet's index) clinical calculator: body mass index percentiles for boys (2-20 years) Patients may otherwise appear healthy. is critical to the diagnosis that their central "fear of being fat" is elicited, which is not reduced by weight loss. Clinical Calculator: body mass index percentiles for girls (2-20 years) differential diagnosis Another mental disorder such as schizophrenia or primary depression can cause weight loss and resistance to the food, but these disorders are not associated with anorexia nervosa. Rarely can lead to significant weight loss unrecognized, severe physical illness. Disorders which should be considered are malabsorption syndromes (eg. As by an inflammatory bowel disease or celiac disease), new-onset type 1 diabetes, adrenal insufficiency. Abuse of amphetamines may cause similar symptoms. Prognosis The mortality rates are high, almost 10% a decade among the affected people who come under clinical supervision; an unrecognized weak disease will likely rarely death. Half of the patients may again reach by treating their previous normal weight at least compensate for a large part of the weight loss again and thus make hormonal and other complications reversed. At about a quarter of the results are mediocre, and they may suffer relapses. The remaining quarter is poor Eregbnisse, with relapses and sustained physical or psychological complications. Children and adolescents who are being treated for anorexia nervosa, have better success. Treatment food Rehabilitation Psychotherapy (z. B. cognitive-behavioral treatment) family-based therapy for young people as a lifesaving measure may require a short-term intervention, in which the body weight is restored. With very strong or very rapid weight loss or decrease in body weight less than 75% of the recommended weight as quickly as possible a weight gain must be achieved; a hospital admission should be considered. (N. D. Talk .: In life-threatening cases, tube feeding is necessary.) When in doubt, patients should be hospitalized. Outpatient treatment may include in varying degrees support and care and often include a team of practitioners. A nutritional supplement that begins with about 30-40 kcal / kg / day can lead to weight gains of up to 1.5 kg / week in-patient treatment and 0.5 kg / week for outpatient treatment. Oral administration with solid food is best, but malnourished patients who are very reluctant, however, may need to be fed through a nasogastric tube. Elemental Ca 1200-1500 mg / day and vitamin D 600 to 800 I.E./Tag are usually prescribed for bone loss. After stabilization of the nutritional, fluid and electrolyte balance, the long-term treatment begins. Outpatient psychotherapy is the cornerstone of treatment. (Note to the German-speaking countries: Initial is a stationary psychotherapeutic treatment makes sense to support the patient in weight gain better.) Treatments should emphasize behavioral outcomes such as normalized (s) diet and weight. Treatment should be continued for a full year after the weight is restored. The results are best in young people, in which the disorder has lasted <6 months. A family-based therapy, in particular according Maudsley model is useful for young people. This model is divided into three phases: the families will learn how the young person (eg through a supervised family meal.) Can be nursed back to restore the weight (in contrast to previous approaches, this model does not work with blaming the family or young person). The control over eating is gradually returned to the young people. After the young person is able to maintain the regained weight, the focus of treatment is on to create a healthy adolescent identity. The treatment is complicated by the extreme anxiety of the patients gain weight and lack of insight. The physician should try to build a peaceful, compassionate and stable relationship, and thereby encourage the patient to take a reasonable amount of calories. Although Psychotherapy is the primary treatment, but sometimes medications are helpful. (Note to the German-speaking countries: it is allowed no medication for anorexia nervosa, there always is off-label use.) Antipsychotics 2nd generation (atypical antipsychotics, such as olanzapine to 10 mg 1.mal / day. ) can contribute to weight gain and reduce anxiety. Key points Patients with anorexia nervosa have an intense fear of gaining weight or becoming fat, which persists despite all evidence to the contrary. When restrictive type: Patients restrict food intake and sometimes exaggerate excessively sport, but do not have regular binge eating or purging behavior. When binge eating- / purging type, patients have regular eating binges and then induces vomiting and / or abusing laxatives, diuretics or enemas to rid themselves of the food in the attempt. In adults, the BMI is very low, and in adolescents, the BMI percentile low or reduced significantly. Deficiency diseases are common, and death may occur. Treatment with dietary supplements, cognitive behavioral therapy and family therapy in adolescents; 2nd generation of antipsychotics (eg. As olanzapine) may be helpful.