Anorexia Nervosa/Atypical Anorexia Nervosa

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Anorexia nervosa has the highest mortality rate among all psychiatric illnesses, as it can result in significant psychopathology along with life-threatening medical complications. Atypical anorexia nervosa is a new variant described in the latest DSM edition, which has much in common with anorexia nervosa and also can result in significant morbidity and mortality. The evolution of the criteria for these illnesses is reviewed, and the two are compared and contrasted in this article. Important labs to monitor for in those with these illnesses, along with an emphasis on the monitoring of vital signs and weight, are reviewed here. The necessity for close psychiatric monitoring of safety concerns, including suicidal thoughts, is also stressed. The etiology and the treatment of these illnesses are reviewed from a biopsychosocial approach; and lastly, the prognosis of these illnesses is discussed.

Section snippets

Anorexia Nervosa

Anorexia nervosa (AN) is a diagnostic term that literally means neurotic loss of appetite. Sir William Gull first reported a case of AN in the Lancet in 1888.1 The diagnostic criteria for AN have evolved considerably over time. For example, in the DSM III, the weight loss criterion was more stringent in that a 25% weight loss was required. There was, however, no amenorrhea criterion at that time. The criteria also used to specify that the weight loss was not due to another medical illness.2 It

Etiology

While the etiology of EDs is largely unknown, it is thought that a combination of biological, psychological, and social factors contribute to the illness (Table 2). We know EDs tend to cluster in families.21 Though based on small sample sizes, we also know from twin studies that the concordance for monozygotic twins having AN is greater than for dizygotic twins.22 Genes are thought to contribute anywhere from more than 50% up to 74% of the risk to developing AN.23 Studies also show there is an

Demographics/Prevalence

In general, the incidence of AN in society is relatively low, with one study citing it as 8/100,000, with average prevalence rates being 0.3 for young females, and 0.3–1% for BN.49, 50 The lifetime prevalence of AN is between 0.5% and 2%.51 However, since EDNOS has accounted for the majority of ED diagnoses, in the past, the overall prevalence rate is felt to be 3%.50 One multi-site study looking at the ED population in 14 adolescent medicine clinics showed that 33.9% of patients met criteria

Medical Complications

The major cause for the medical complications in AN is the imbalance between energy intake and requirements, leading to a hypometabolic state. Therefore, in an effort to maintain homeostasis in the malnourished state, the body down regulates, causing many of the signs and symptoms observed in AN. Little has been reported as yet on the medical complications of atypical AN. One study of 118 individuals, 59 meeting DSM-IV criteria for AN, and another 59 with “subthreshold” AN, showed no difference

Psychiatric Comorbidities/Complications

As a general rule, AN is typically present with other psychiatric disorders, with one study examining adolescent females finding cormobidity rates as high as 73.3%.63 These comorbid disorders should always be screened for as they can further complicate treatment.64 Two of the most common psychiatric comorbidites present with AN are depression and anxiety disorders. One study showed mood disorders were the most common at around 60.4%.63 Anxiety disorders are also highly prevalent, with one study

Similarities Between Anorexia Nervosa and Atypical Anorexia Nervosa

There are many similarities between AN and atypical AN, and the criteria is almost the same, as discussed in the next section. Those with atypical AN have lost a large amount of weight by engaging in ED behaviors, including restricting and often over-exercising, and may binge/purge, vomit or abuse diet pills, laxatives or diuretics as in the AN-binge/purge subtype. Further, these patients report an intense fear of gaining weight and often deny or do not recognize the seriousness of the weight

Differences Between Anorexia Nervosa and Atypical Anorexia Nervosa

In comparing and contrasting AN with atypical AN, the similarities are more striking than the differences. In terms of differences between the two, there is essentially one main difference, the patient’s weight. Patients with AN are often significantly emaciated, which may raise concerns with parents, teachers, etc. Those with atypical AN can be of normal weight, overweight, obese or slightly underweight.

Although there is essentially no available literature comparing the two diagnoses, in

Making the Diagnosis of Anorexia Nervosa versus Atypical Anorexia Nervosa

Despite the different diagnostic criteria for AN and atypical AN found in the DSM-5, distinguishing between the two can prove challenging. For AN, the below 85% IBW cutoff was eliminated as a criterion9 which allows clinicians to exercise their discretion in determining what is a significantly low weight. While there are suggested BMI guidelines included in the severity specifiers for mild, moderate, severe and extreme AN,9 these BMI guidelines mostly apply to adults, not to adolescents, and

Evaluation/Assessment/Monitoring—Medical and Psychiatric

In terms of medical assessment, all patients with AN and atypical AN need a thorough baseline medical evaluation to check for medical stability. The examination should include patient׳s height, post-void undressed weight, BMI, BMI percentile and orthostatic vital signs (blood pressure and pulse rates), along with temperature and respiratory rates. A full physical examination should include all organ systems, looking for signs of ED behavior (calluses or parotid enlargement from purging) and to

Treatment—Biological

The primary treatment for both AN and atypical AN is for the patient to consume sufficient caloric intake and correct the underlying malnutrition. Though cliché, food is the best medicine to treat an ED. Not only will the nutritional rehabilitation correct the medical complications, but it can also help correct the psychological aspects, as typically ED thoughts, and to some extent depression and anxiety, will improve with refeeding. Despite the fact that patients with atypical AN are often

Treatment—Psychological

As mentioned above, refeeding is the first step in treatment, and is necessary to help with depressive and anxiety symptoms and is a vital precursor to more effective therapy. While limited evidence exists that therapies other than a family-based treatment (FBT) approach helps treat patients with AN, refeeding patients is often done alongside other psychotherapy approaches. Cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), interpersonal therapy (IPT), cognitive

Treatment—Social

Social treatment for both AN and atypical AN involves building up the lives of these patients outside of the ED. Adolescents with AN and atypical AN benefit greatly from self-esteem building activities, including finding areas of success, whether it be through new hobbies, excelling in an area in school, obtaining a job, feeling more independent, making new friends, etc. Given the complexity of AN and atypical AN, as well as the high acuity associated with these illnesses, multidisciplinary

Prognosis

Despite advances in psychiatry, the prognosis for AN remains guarded. It is thought that, on average, less than half recover, one third have a varied course, and 20% remain chronically ill.94 A 21-year follow-up study of 84 patients who were hospitalized for AN showed that 51% had recovered, while 10% still met full diagnostic criteria for AN and 16% had passed away from complications of the AN.95 While specific studies do not yet exist examining the prognosis of atypical AN, it can be surmised

Conclusion

Since the first case report of anorexia nervosa appeared in the literature over 125 years ago, much has been learned about eating disorders. Presently, eleven distinct eating disorders are categorized in the DSM-5, from the classic anorexia nervosa, to rumination disorder and night-eating syndrome. Research regarding causation, course, complications, and treatments fill the literature. Indeed, entire programs and careers focus solely on the care of those with eating disorders. However, in spite

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