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Anorexia nervosa — Clinical Guidelines

Overview

Anorexia nervosa is a severe, often chronic psychiatric disorder characterized by an intense fear of gaining weight, distorted body image, and significant caloric restriction leading to malnutrition and physical health complications 1 7.

Diagnosis

Key Criteria: Intense fear of gaining weight, significant weight loss, and disturbance in how body weight or shape is experienced 1 35.

Recommended Tests: Comprehensive metabolic panel, complete blood count, thyroid function tests, bone density scan, and psychological evaluation 1 7 11.

Grading: DSM-5 criteria for anorexia nervosa (restricting subtype or binge-purge subtype) 35.

Management

First-Line Treatments: Nutritional rehabilitation under medical supervision, cognitive-behavioral therapy (CBT), and family-based therapy (FBT) for adolescents 1 3 7.

Adjunctive Treatments: Psychotropic medications (e.g., SSRIs) for comorbid depression or anxiety, and hormonal support if indicated (e.g., growth hormone deficiency) 1 11 22.

Refeeding Protocol: Careful refeeding to prevent refeeding syndrome, monitoring electrolytes and fluid balance 13.

Special Populations

Pregnancy: Management is complex; close monitoring of both maternal and fetal health is essential 23.

Elderly: Geriatric anorexia nervosa is underdiagnosed but associated with significant morbidity; tailored nutritional and psychological support needed 6 9.

Comorbidities: Attention to complications like gastroesophageal varices, renal failure, and cardiovascular abnormalities 4 21 31.

Key Recommendations

Comprehensive Medical Evaluation: Regular monitoring of metabolic parameters, hematological status, and bone health to address multisystem involvement (Evidence: Strong 1 7 11).

Integrated Psychological and Nutritional Support: Combining CBT or FBT with nutritional rehabilitation for optimal outcomes (Evidence: Strong 1 3).

Palliative Care Approach for Severe Cases: Implementing palliative care models for patients with severe, enduring anorexia nervosa to improve quality of life (Evidence: Moderate 3 10).

Refeeding with Close Medical Supervision: Prevent refeeding syndrome through meticulous monitoring of electrolytes and fluid balance during nutritional rehabilitation (Evidence: Moderate 13).

Consideration of Comorbid Conditions: Address specific complications such as renal dysfunction, gastrointestinal issues, and cardiovascular abnormalities (Evidence: Moderate 4 21 31).

References

1 Fricke C, Voderholzer U. Endocrinology of Underweight and Anorexia Nervosa. Nutrients 2023. link 2 Mhalhel K, Briglia M, Aragona M, Porcino C, Abbate F, Guerrera MC et al.. Nothobranchius as a model for anorexia of aging research: an evolutionary, anatomical, histological, immunohistochemical, and molecular study. Annals of anatomy = Anatomischer Anzeiger : official organ of the Anatomische Gesellschaft 2023. link 3 Treem J, Yager J, Gaudiani JL. A Life-Affirming Palliative Care Model for Severe and Enduring Anorexia Nervosa. AMA journal of ethics 2023. link 4 Takata K, Nagata T, Uchida Y, Kitaguchi T, Higashi T, Fukuda H et al.. Gastroesophageal Varices and Hyperplastic Nodules of the Liver in a Patient with Anorexia Nervosa. Internal medicine (Tokyo, Japan) 2021. link 5 Simeunovic Ostojic M, Maas J. Anorexia nervosa and uric acid beyond gout: An idea worth researching. The International journal of eating disorders 2018. link 6 Zayed M, Garry JP. Geriatric Anorexia Nervosa. Journal of the American Board of Family Medicine : JABFM 2017. link 7 Singhal V, Misra M, Klibanski A. Endocrinology of anorexia nervosa in young people: recent insights. Current opinion in endocrinology, diabetes, and obesity 2014. link 8 Holmes SR, Gudridge TA, Gaudiani JL, Mehler PS. Dysphagia in severe anorexia nervosa and potential therapeutic intervention: a case series. The Annals of otology, rhinology, and laryngology 2012. link 9 Donini LM, Dominguez LJ, Barbagallo M, Savina C, Castellaneta E, Cucinotta D et al.. Senile anorexia in different geriatric settings in Italy. The journal of nutrition, health & aging 2011. link 10 Lopez A, Yager J, Feinstein RE. Medical futility and psychiatry: palliative care and hospice care as a last resort in the treatment of refractory anorexia nervosa. The International journal of eating disorders 2010. link 11 Polli N, Scacchi M, Pecori Giraldi F, Sormani M, Zappulli D, Cavagnini F. Low insulin-like growth factor I and leukopenia in anorexia nervosa. The International journal of eating disorders 2008. link 12 Södersten P, Nergårdh R, Bergh C, Zandian M, Scheurink A. Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in neuroendocrinology 2008. link 13 Azumagawa K, Kambara Y, Kawamura N, Takenaka Y, Yamasaki T, Tanaka H et al.. Anorexia nervosa and refeeding syndrome. A case report. TheScientificWorldJournal 2007. link 14 Sundararaghavan S, Pitts TY, Suarez WA, Johnstone C. Chest pain among adolescents with anorexia nervosa. Pediatric emergency care 2005. link 15 Castro J, Deulofeu R, Gila A, Puig J, Toro J. Persistence of nutritional deficiencies after short-term weight recovery in adolescents with anorexia nervosa. The International journal of eating disorders 2004. link 16 Zenger F, Russmann S, Junker E, Wüthrich C, Bui MH, Lauterburg BH. Decreased glutathione in patients with anorexia nervosa. Risk factor for toxic liver injury?. European journal of clinical nutrition 2004. link 17 Chial HJ, McAlpine DE, Camilleri M. Anorexia nervosa: manifestations and management for the gastroenterologist. The American journal of gastroenterology 2002. link 18 Lee S, Leung CM, Wing YK, Chiu HF, Chen CN. Acne as a risk factor for anorexia nervosa in Chinese. The Australian and New Zealand journal of psychiatry 1991. link 19 Signer SF, Benson DF. Three cases of anorexia nervosa associated with temporal lobe epilepsy. The American journal of psychiatry 1990. link 20 McLoughlin IJ, Hassanyeh F. Pica in a patient with anorexia nervosa. The British journal of psychiatry : the journal of mental science 1990. link 21 Abe K, Mezaki T, Hirono N, Udaka F, Kameyama M. A case of anorexia nervosa with acute renal failure resulting from rhabdomyolysis. Acta neurologica Scandinavica 1990. link 22 Mansfield MJ, Emans SJ. Anorexia nervosa, athletics, and amenorrhea. Pediatric clinics of North America 1989. link36684-6) 23 Milner G, O'Leary MM. Anorexia nervosa occurring in pregnancy. Acta psychiatrica Scandinavica 1988. link 24 Svec H. Anorexia nervosa: a misdiagnosis of the adolescent male. Adolescence 1987. link 25 Sturmey P, Slade PD. Anorexia nervosa and dysmorphobia. A case study. The British journal of psychiatry : the journal of mental science 1986. link 26 Brotman AW, Stern TA, Brotman DL. Renal disease and dysfunction in two patients with anorexia nervosa. The Journal of clinical psychiatry 1986. link 27 Backett SA. Acute pancreatitis and gastric dilatation in a patient with anorexia nervosa. Postgraduate medical journal 1985. link 28 Silber TJ, Kass EJ. Anorexia nervosa and nephrolithiasis. Journal of adolescent health care : official publication of the Society for Adolescent Medicine 1984. link80245-4) 29 Sreenivasan U. Anorexia nervosa associated with energy-wasting disorders. Canadian Medical Association journal 1984. link 30 Szmukler GI, Tantam D. Anorexia nervosa: starvation dependence. The British journal of medical psychology 1984. link 31 Brotman AW, Stern TA. Case report of cardiovascular abnormalities in anorexia nervosa. The American journal of psychiatry 1983. link 32 Byerley B, Black DW, Grosser BI. Anorexia nervosa with hyperthyroidism: case report. The Journal of clinical psychiatry 1983. link 33 Kulig JW, Siqueira LM. Diagnosis of anorexia nervosa in the adolescent male. Journal of adolescent health care : official publication of the Society for Adolescent Medicine 1983. link80225-3) 34 Chipman JJ, Hagan RD, Edlin JC, Soll MH, Carruth BR. Excessive weight loss in the athletic adolescent. A diagnostic dilemma. Journal of adolescent health care : official publication of the Society for Adolescent Medicine 1983. link80246-0) 35 Kirstein L. Diagnostic issues in primary anorexia nervosa. International journal of psychiatry in medicine 1981. link 36 Salkind MR, Fincham J, Silverstone T. Is anorexia nervosa a phobic disorder? A psychophysiological enquiry. Biological psychiatry 1980. link 37 Abraham SF, Banks CN, Beaumont PJ. Eye signs in patients with anorexia nervosa. Australian journal of ophthalmology 1980. link 38 How J, Davidson RJ. Chlorpromazine-induced haemolytic anaemia in anorexia nervosa. Postgraduate medical journal 1977. link

Anorexia nervosa