Kembara Xtra - Medicine - Anorexia Nervosa ( AN)

Kembara Xtra - Medicine - Anorexia Nervosa ( AN) 
An eating disorder that results in considerably low weight and a strong fear of gaining weight, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is classified into two types: - Restrictive type: no binge eating or purging in the previous three months - Regularly engaged in binge eating or purging habits (during the last three months) 
Nervous, cardiovascular, endocrine, metabolic, pulmonary, gastrointestinal, reproductive, ophthalmic, taste, and dermatologic system(s) are impacted. 
According to the DSM-5, the severity of anorexia nervosa (AN) is based on BMI: - Moderate: BMI 17 kg/m2.
BMI of 16 to 16.99 kg/m2 is considered moderate.
- Extreme: BMI of 15 kg/m2 to 15.99 kg/m2.
Extreme: BMI less than 15 kg/m2.


EPIDEMIOLOGY: Females over males (10:1 to 20:1 female-to-male ratio) Predominant age range: 15 to 24 years

Prevalence 0.1- 0.3% in men (greater in gay and bisexual men) 0.9-2.0% in women (1.1-3.0% in young females)


ETIOLOGY AND PATHOPHYSIOLOGY Complex interactions between genetic, biologic, environmental, psychological, and social elements that lead to the emergence of this condition Parenting practices that encourage high expectations may cause children to battle for control.
Neuronal systems involving serotonin, norepinephrine, and dopamine are involved.

Genetics: Evidence suggests that monozygotic twin concordance rates are higher than those of dizygotic twins; first-degree female relatives with eating disorders increase risk by a factor of 6 to 10.

On chromosome 12, there has been one major locus found across the whole genome.
 

RISK FACTORS include the following: Female gender; Adolescence; Body Dissatisfaction; Negative Self-Evaluation; Perfectionism; High Parental Expectations; Academic Pressure; Severe Life Stressors; History of Sexual or Physical Abuse; Engagement in Sports or Activities Emphasizing Leanness; Type 1 Diabetes Mellitus; Family History of Substance Abuse; Affective Disorders; or Eating Disorders.

DURATIONAL PREVENTION
Programs for prevention can lessen risk factors and the onset of eating disorders in the future.
Target girls and young women between the ages of 15 and 18.
Promote sensible approaches to weight management and positive mentality.
Encourage self-esteem.
Stop viewing thinness as the ideal.
Reduce anxiety and depressed symptoms that co-occur, and enhance stress management.

Suicide, mood and anxiety disorders, substance use disorder, and Cluster C personality disorder are frequently linked conditions.

DISEASE HISTORY
Onset could be gradual or brought on by stress.
Inability of the patient to self-identify the issue, restriction of the necessary energy intake, and consequently, severely low body weight
Reporting feeling fat despite being malnourished; obsession with body image; elaborate rituals surrounding food preparation and consumption; Other potential indicators and symptoms: - Vigorous workout
Weakness, weariness, and cognitive impairment - Amenorrhea
Growth stop and delayed puberty; a sensitivity to the cold; early satiety; bloating; and fractures
To detect individuals with eating problems, primary care clinics give a screening test for eating disorders. Are you content with the way you eat? (No is unusual.) Do you ever sneak a bite to eat? (Yes, that's unusual.)
How do you feel about yourself in relation to your weight? (Yes, that's unusual.) Have any family members ever struggled with an eating disorder? (Yes, that's unusual.) Do you now have an eating issue or have you ever had one in the past? (Yes, that's unusual.)


Abnormal vital signs include hypothermia, bradycardia, and orthostatic hypotension. Physical examination could be normal. 
Body weight 85% of predicted (person may conceal heavy objects or wear additional clothing to seem heavier on scale) Cardiac: Dysrhythmias, Mitral Valve Prolapse Midsystolic Click 
Dry skin, lanugo hair, hair loss, and peripheral edema in the skin and extremities. 
Gynecologic: amenorrhea; Neurologic and abdominal exams: to rule out other reasons of weight loss and vomiting


DIFFERENTIAL DIAGNOSIS Bulimia, body dysmorphic disorder Immunodeficiency, persistent infections Depressive, anxiety, or conversion disorders Hyperthyroidism, adrenal insufficiency IBS, malabsorption Immunodeficiency, uncontrolled diabetes 

DETECTION & INTERPRETATION OF DIAGNOSIS
Vitals: hypotension, bradycardia, hypothermia; SCOFF questionnaire; Eating Disorder Screen for Primary Care Initial Tests (lab, imaging) 
Low-serum LH, FSH; low-serum testosterone in men; low thyroid-stimulating hormone with normal T3/T4; abnormal liver enzymes in LFT; altered BUN; altered creatinine clearance; electrolyte disturbances including hyponatremia and hypokalemia; hypoglycemia; hypercholesterolemia; hypercortisolemia; hypophosphatemia; and hypomagnesemia in Chem 7; hypoglycemia; hypercortisol 
Low vitamin D and low calcium levels 
12-Lead ECG to check for a prolonged QT interval DEXA scan to check for decreased bone density if underweight for more than six months Tests in the Future & Special Considerations
Weighting is a test that can cause worry, but it's also a crucial indicator of advancement. Ask the workers to be impartial.
Try to weigh patients when they are dressed in a gown because many might be trying to hide bulky clothing or heavy objects from view.

Test interpretation: AN may coexist with long-term medical conditions such osteoporosis and osteoopenia, pathologic fractures, sick euthyroid syndrome, dehydration, cardiac impairment, renal impairment, etc.

Treatment and general precautions
OP treatment includes: - An interdisciplinary team composed of a primary care physician, a mental health professional, and a dietician - A weekly weight gain target of 0.5 to 1.0 kg with a gradual increase in caloric intake. - CBT - Pay attention to health, not only weight growth.
- Create a therapy alliance based on trust.
- Work with the patient to determine their dietary and exercise objectives.
- Assist the patient in identifying the emotions that trigger disordered eating.
– Instead of pursuing a healthy weight in chronic instances, the objective can be to reach a safe weight.
If at all possible, admit the patient to a specialized eating disorders facility for inpatient therapy.
– Keep an eye on your weight, electrolytes, heart function, edema, and vital signs.
– Analyze the potential for refeeding syndrome.
– Initial meals under supervision can be required.
Tube feeding or TPN should only be used as a last resort. Psychotherapy (such as CBT or family therapy) should be made available. CBT has shown promise in boosting treatment compliance and reducing dropout rates among AN patients.


First Line: MEDICATION
There are no drugs that can effectively treat AN patients, however pharmacotherapy can be used in conjunction with CBTs.
Due to the increased risk of side effects, start medicines at low doses.
SSRIs may: - Assist in preventing relapse following weight gain
- Treat comorbid depression or OCD - Research on the use of atypical antipsychotics has produced conflicting results thus far. As an adjuvant therapy for underweight patients in hospital settings, olanzapine may be advantageous.

Bupropion should be avoided since it is linked to a higher frequency of seizures. Pay attention to black box warnings.
Next Line
Weight gain is the main kind of treatment for osteopenia.
- Vitamin D 800 IU/day and elemental calcium 1,200–1,500 mg/day; no evidence for bisphosphonates in AN
- Hormone replacement treatment has little scientific support.
Psyllium for diarrhea prevention

QUESTIONS FOR REFERENCE
An interdisciplinary team (primary care physician, mental health provider, nutritionist) is necessary for patients with AN.

ALTERNATIVE & COMPLEMENTARY MEDICINE
Acupuncture and relaxation training

CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING

Suggested physiologic values to admit: heart rate 40 beats/min, blood pressure 90/60 mm Hg, symptomatic hypoglycemia, temperature 97.0°F (36.1°C), dehydration, other cardiovascular abnormalities, weight 75% of expected, rapid weight loss, and lack of improvement while receiving OP therapy. Suggested psychological indications: poor motivation/insight, lack of cooperation with OP treatment, inability to eat


Child Safety Considerations
Children frequently complain of nausea, abdominal pain, feeling full, and difficulty swallowing.
Hospitalization is also indicated by heart rate greater than 50 beats per minute, orthostatic blood pressure, hypokalemia, hypophosphatemia, and rapid weight loss even if weight is not more than 75% below normal. 
Family-based therapy and treatment should be made available to kids and teenagers.

Aspects of Geriatrics

 Late-onset AN (>50 years of age) may be a chronic condition or be brought on by a loved one's death, marital strife, divorce, or despair.
Always keep other natural reasons for weight loss in mind.
When medically stable, release. Set up an appointment with the primary care physician and the mental health professional.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
Close follow-up is necessary until the patient shows improvement in the care plan. 
Individual and family treatment are crucial for long-term results.
CBT is beneficial for the treatment of AN and could help avoid relapse.
Stress the value of moderate exercise for health.


Patient Monitoring: Level of Exercise: Weigh patient once a week until stable, then once a month.
Depression and suicidal thoughts


Nutritional education initiatives, dietary consultations while the patient is hospitalized, and DIET

Patient education is available at the Mayo Clinic and the National Alliance on Mental Illness websites (www.mayoclinic.org/ diseases-conditions/ anorexia/ home/ ovc-20179508 and www.nami.org/ About-Mental-Illness/ Mental-Health-Conditions/ Eating- Disorders).

50% of patients heal, 30% improve, and 20% develop chronic illnesses.
Mortality: 5–18% (5 deaths per 1,000 person-years annually)

​ALERT
High risk of suicide (about 1 in 5 people with AN who died had killed themselves)

Refeeding syndrome, cardiac arrhythmia, cardiac arrest, cardiomyopathy, and congestive heart failure are some of the complications. Necrotizing colitis, delayed stomach emptying, seizures, Wernicke encephalopathy, peripheral neuropathy, and cognitive impairments osteoporosis and osteoopenia
During pregnancy and the postpartum period, behaviors may continue, change, or recur. There is also a higher risk of preterm labor, c-section delivery, and low birth weight babies; anemia, genitourinary infections, and labor induction should be treated as high risk. Fertility may also be affected.