Severe Anorexia Nervosa Research Articles

Psychotic symptoms in a woman with severe Anorexia Nervosa

With this paper we aimed to describe a case of a woman affected by Anorexia Nervosa Restricting subtype (AN-R) with delusional symptoms, visual hallucinations and severe body image distortion. We discussed the main AN diagnosis and whether delusional symptoms could be related to severity of AN describing also the use of olanzapine in such a severe clinical condition. The use of olanzapine was found to be effective to reduce both delusions and body distortions, and to improve compliance to treatments. We found a severe delusional symptomatology with mystic, omnipotence and persecution features. The psychotic structure seemed preceding the eating disorder and was also found to be worsened by emaciation. The use of antipsychotic helped reducing delusional symptoms and improving compliance to treatments. Finally, the dynamically oriented therapeutic relationship helped the patient to gain weight and to achieve a full recovery from psychotic symptoms.

Hematological abnormalities in severe anorexia nervosa

Little is known about the prevalence of hematologic abnormalities in adults with severe anorexia nervosa. We report the first major analysis of hematologic dysfunction in such patients. We retrospectively analyzed the charts of 53 men and women with severe anorexia nervosa, admitted between October 2008 and December 2010 for medical stabilization to our center, which has a national referral base. Patients were predominantly female (89%), with a median age of 28years (range 17-65), and were hospitalized for a median duration of 15days (I.Q.R. 9-29). Nadir body mass index during hospitalization was markedly low at 12.4kg/m(2) (range 8.4-15.7), and the mean discharge BMI was 13.8kg/m(2) (range 10.2-16.8). 83% of patients were anemic (hematocrit <37%), with only 3 (6%) having iron deficiency. 79% were leukopenic (WBC < 4.5k/μL), 29% were neutropenic (ANC < 1.0k/μL), 25% were thrombocytopenic (platelets < 150k/μL), and 17% of patients developed thrombocytosis (platelets > 400k/μL) during their hospitalization. Eighty-nine percent of patients had resolved their neutropenia by discharge. Marked hematologic deficiencies are often present in patients with severe anorexia nervosa, generally attributed to starvation-mediated gelatinous marrow transformation which resolves with proper nutritional rehabilitation. Improved provider awareness of this association may reduce unnecessary testing and costly treatment interventions.

Gelatinous transformation of bone marrow in a patient with severe anorexia nervosa

An 18-year-old Caucasian female was referred by her general practitioner for evaluation of chronic anaemia.

Elevation of liver function tests in severe anorexianervosa

The purpose of this article is to clarify the finding of liver function test abnormalities in anorexia nervosa (AN). Literature review and description of two representative cases of severe liver function test abnormalities from our medical stabilization unit. Abnormal elevation of liver function tests can occur during the process of refeeding patients with severe AN. The cause of this elevation is either due to excessive glucose deposition in liver cells or represents liver cell death due to the sequelae of prolonged starvation which characterizes AN before refeeding is adequately in process.

Relationship between Affective Symptoms and Malnutrition Severity in Severe Anorexia Nervosa

BackgroundVery few studies have investigated the relationship between malnutrition and psychological symptoms in Anorexia Nervosa (AN). They have used only body weight or body mass index (BMI) for the nutritional assessment and did not always report on medication, or if they did, it was not included in the analysis of results, and they did not include confounding factors such as duration of illness, AN subtype or age. The present study investigates this relationship using indicators other than BMI/weight, among which body composition and biological markers, also considering potential confounders related to depression and anxiety.Methods155 AN patients, (DSM-IV) were included consecutively upon admission to inpatient treatment. Depression, anxiety, obsessive behaviours and social functioning were measured using various scales. Nutritional status was measured using BMI, severity of weight loss, body composition, and albumin and prealbumin levels.ResultsNo correlation was found between BMI at inclusion, fat-free mass index, fat mass index, and severity of weight loss and any of the psychometric scores. Age and medication are the only factors that affect the psychological scores. None of the psychological scores were explained by the nutritional indicators with the exception of albumin levels which was negatively linked to the LSAS fear score (p = 0.024; beta = −0.225). Only the use of antidepressants explained the variability in BDI scores (p = 0.029; beta = 0.228) and anxiolytic use explained the variability in HADs depression scores (p = 0.037; beta = 0.216).ConclusionThe present study is a pioneer investigation of various nutritional markers in relation to psychological symptoms in severely malnourished AN patients. The clinical hypothesis that malnutrition partly causes depression and anxiety symptoms in AN in acute phase is not confirmed, and future studies are needed to back up our results.

Intelligence quotient and cognitive functions in severe restricting-type anorexia nervosa before and after weight gain

ObjectiveRestricting-type anorexia nervosa (AN-R), characterized by severe emaciation with long-term food restriction, is often difficult to treat. The present study investigated the overall intelligence quotient (IQ) scores and cognitive functions of patients with AN-R. MethodsFourteen female inpatients with AN-R (body mass index 12.84 ± 0.41 kg/m2) and 10 healthy female participants participated in this study from 2007 through 2010. The Wechsler Adult Intelligence Scale, Third Edition and the Eating Disorder Inventory–II were administered. This research was performed at Kagoshima University Hospital. ResultsIn the AN-R group, overall IQ scores showed borderline intelligence (e.g., full-scale IQ 75.86 ± 1.79, P < 0.01); the scores were significantly lower than those in the comparison group. There were negative correlations between lower IQs and higher Eating Disorder Inventory–II scores. After the weight restoration, the IQ scores of subjects with AN-R with regard to the visuospatial scales were significantly higher than before (P < 0.01); however, the auditory cognitive scores were unchanged. ConclusionThese lower IQ scores could be connected to the psychological and behavioral traits in patients with AN-R. These problems should be considered by medical staff members who seek to treat patients with AN-R successfully.

Dysphagia in Severe Anorexia Nervosa and Potential Therapeutic Intervention: A Case Series

In severe anorexia nervosa, there are a litany of medical complications that affect virtually every body system, and severe weakness is a typical characteristic. To our knowledge, aspiration risk, dysphagia recognition, and dysphagia management and intervention have not been well described in the literature in regard to severe anorexia nervosa. The purpose of this case series is to increase awareness among clinicians of possible oropharyngeal dysphagia symptoms that may present in patients with severe anorexia nervosa. We describe the cases of 3 patients with severe anorexia nervosa who presented with symptoms of dysphagia. The speech-language pathology team administered dysphagia therapy to the 3 patients utilizing neuromuscular electrical stimulation (NMES) in conjunction with swallowing therapy tasks that included strengthening exercises and compensatory strategies. After the course of dysphagia treatment intervention, the 3 patients were able to tolerate an oral diet with improved swallowing function and no ongoing aspiration. The use of NMES in conjunction with traditional swallowing exercises in the treatment of dysphagia in patients with anorexia nervosa may reduce the need for enteral feeding and prolonged hospitalization. In regard to dysphagia intervention and management within this population and across other populations, rigorous randomized controlled studies are necessary for determining the efficacy of NMES and traditional swallowing therapy implementation.

Severe anorexia nervosa (AN) during adolescence: 54 months outcome predictive factors

Severe anorexia nervosa (AN) during adolescence: 54 months outcome predictive factors

Acute Liver Damage and Anorexia Nervosa: A Case Report and Review of the Literature

We treated a patient suffering from severe anorexia nervosa [body mass index (BMI), 10.5 kg/m2] complicated with hepatic insufficiency. The treatment consisted of rehydration and the correction of her malnutrition, using adapted protocols to avoid the development of the refeeding syndrome. In view of her successful progress she was discharged from the hospital on day 50. Although we do not perform a hepatic biopsy, the mechanism seems to be related to autophagy more than hypoperfusion because of the extremely low BMI. This observation also highlights the need of following a multidisciplinary approach in these difficult cases (BMI < 13 kg/m2), involving intensive care unit doctors, gastroenterologists, endocrinologists and psychiatrists. Abbreviations: BMI: Body mass index; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; CT: Computed tomography.

A long-term prognosis of girls with severe anorexia nervosa treated by the Keio method child psychiatrist – Paediatrician team

A long-term prognosis of girls with severe anorexia nervosa treated by the Keio method child psychiatrist – Paediatrician team

Depression, anxiety and obsessive–compulsive symptoms in relation to nutritional status and outcome in severe anorexia nervosa

Depression, anxiety and obsessive–compulsive disorder are frequently reported to co-occur with anorexia nervosa (AN). There is clinical consensus that depressive symptoms and anxiety may in part be sequelae of malnutrition in AN. However, evidence-based data are still very rare. The present study among severe AN patients investigates links between these psychological variants and nutritional status at admission and subsequent to nutritional rehabilitation. Twenty-four women with AN diagnosed according to the Diagnostic and Statistical Manual IV (DSM-IV) were included prospectively and consecutively at hospitalisation. Nutritional status was assessed by body mass index (BMI). Several psychological aspects were assessed using various scales for depression, anxiety, social phobia, obsessive and eating behaviour symptoms. Follow-up weights and heights at 4–12 years after hospital discharge were measured in 18 patients. BMI and all the scores except the Yale-Brown obsessive–compulsive scale (Y-BOCS) showed significant improvement between admission and discharge. This study highlights the fact that some of the depressive and anxiety symptoms at least partially decrease with nutrition rehabilitation. The improvement in the scores on the psychometric scales between admission and discharge was not correlated with BMI improvement. Psychometric scores at admission and at discharge were not correlated with BMI at follow-up. BMI at follow-up was correlated with minimum lifetime BMI (r=0.486, P=0.04). Future studies should use a better indicator for nutritional status than BMI alone, and should also consider the initial degree of weight loss and the rate at which weight was lost.

Transnasal esophagogastroduodenoscopy for placement of nasoenteric feeding tubes in patients with severe upper gastrointestinal diseases

To evaluate the feasibility and efficacy of small-caliber transnasal esophagogastroduodenoscopy for the placement of nasoenteric feeding tubes (NET) in patients with severe upper gastrointestinal (GI) diseases. Between January 2007 and March 2010, 51 patients underwent transnasal endoscopy for the placement of NET in Peking University Third Hospital. Indications for NET included esophageal stricture or gastric outlet obstruction because of corrosive esophagitis or gastritis, partial obstruction due to malignancy, stenosis in stoma or efferent loop, gastroparesis, metallic stent in upper GI tract, tracheoesophageal fistula, severe acute pancreatitis, anorexia nervosa and intensive care patients. The tubes were endoscopically placed using the guidewire technique. The position of the tube was confirmed by the immediate second endoscopy or abdominal X-ray. If the initiate placement was not correct, an adjustment or a second placement was conducted immediately. Initial post-pyloric placement of NET was achieved in 43 of 51 patients (84.3%), but the total success rate reached 98.0% (50/51) after the second placement. The time required for the procedure ranged from 10 to 35 min, with a median time of 20.4 min. Epistaxis occurred in 2 patients. There were no complications of hemorrhage, perforation or aspiration. The transnasal endoscopic placement of NET was feasible in patients with upper GI diseases, especially in those with changed anatomy.

Ophthalmic changes in severe anorexia nervosa: A case series

We describe the diagnosis and management of lagophthalmos, or failure of eyelid closure, in five patients with severe anorexia nervosa (AN) who complained of dry, irritated eyes and photophobia. Five patients with these findings are described retrospectively. Examination revealed lagopthalmos in the setting of ptosis and enophthalmos, with multiple other starvation-mediated medical complications. These eye findings, as complications of AN, have not been described in the literature. With careful protective measures, initiation of nutritional rehabilitation, and intensively monitored early refeeding, these patients' ocular abnormalities and associated symptoms resolved completely. Recognition of this pathology and appropriate management can prevent long-term morbidity in the form of permanent loss of visual acuity due to corneal abrasions and improve the outcomes for these patients with severe AN.

Severe anorexia nervosa in men: Comparison with severe AN in women and analysis of mortality

To compare clinical characteristics of men and women with severe AN and to analyze mortality in men. One thousand and nine patients including 23 anorectic males were hospitalized in St. Anne Hospital in Paris between 1988 and 2004. Data were collected during hospitalization. Fatal outcome was assessed in 2008. Men presented significantly later age of onset, were more likely to have a history of premorbid overweight than women and less likely to have attempted suicide. Mortality in men was high (standardized mortality ratio: 8.08; 95% CI: 1.62-23.62). Several predictive factors for mortality in men were identified: lower admission body mass index (BMI), later age at admission, and AN-R subtype. All the three deceased patients had dropped out from the inpatient unit. The 10-year survival did not differ between men and women, but men died sooner after hospitalization. Male inpatients should receive close follow-up after their discharge, especially if they have a restrictive form of AN, present low BMI, or are older at admission.

Dysphagia in severe anorexia nervosa: A case report

The purpose of this case report is to increase awareness among clinicians that oropharyngeal dysphagia occurs in patients with severe anorexia nervosa, placing them at risk for aspiration and impeding nutritional rehabilitation. We describe a patient with severe anorexia nervosa who manifested symptoms of dysphagia, with resultant aspiration pneumonia, at the time of her admission for medical stabilization. The speech pathology team administered dysphagia therapy, using neuromuscular electrical stimulation (NMES) in conjunction with swallowing therapy. Following the course of dysphagia treatment intervention, the patient was able to tolerate an oral diet with improved swallowing function and no ongoing aspiration. Patients with severe anorexia nervosa should be screened for possible dysphagia. NMES in the treatment of dysphagia in patients with anorexia nervosa may reduce the need for enteral feeds and prolonged hospitalization.

A Randomized Controlled Trial of Adjunctive Family Therapy and Treatment as Usual Following Inpatient Treatment for Anorexia Nervosa Adolescents

Research on treatments in anorexia nervosa (AN) is scarce. Although most of the therapeutic programs used in ‘real world practice’ in AN treatment resort to multidisciplinary approaches, they have rarely been evaluated.ObjectiveTo compare two multidimensional post-hospitalization outpatients treatment programs for adolescents with severe AN: Treatment as Usual (TAU) versus this treatment plus family therapy (TAU+FT).MethodSixty female AN adolescents, aged 13 to 19 years, were included in a randomized parallel controlled trial conducted from 1999 to 2002 for the recruitment, and until 2004 for the 18 months follow-up. Allocation to one of the two treatment groups (30 in each arm) was randomised. The TAU program included sessions for the patient alone as well as sessions with a psychiatrist for the patient and her parents. The TAU+FT program was identical to the usual one but also included family therapy sessions targeting intra-familial dynamics, but not eating disorder symptoms. The main Outcome Measure was the Morgan and Russell outcome category (Good or Intermediate versus Poor outcome). Secondary outcome indicators included AN symptoms or their consequences (eating symptoms, body mass index, amenorrhea, number of hospitalizations in the course of follow-up, social adjustment). The evaluators, but not participants, were blind to randomization.ResultsAt 18 months follow-up, we found a significant group effect for the Morgan and Russell outcome category in favor of the program with family therapy (Intention-to-treat: TAU+FT :12/30 (40%); TAU : 5/29 (17.2%) p = 0.05; Per Protocol analysis: respectively 12/26 (46.2%); 4/27 (14.8%), p = 0.01). Similar group effects were observed in terms of achievement of a healthy weight (i.e., BMI≥10th percentile) and menstrual status.ConclusionsAdding family therapy sessions, focusing on intra-familial dynamics rather than eating symptomatology, to a multidimensional program improves treatment effectiveness in girls with severe AN.Trial RegistrationControlled-trials.com ISRCTN71142875

Functional Recovery of a Patient With Anorexia Nervosa: Physical Therapist Management in the Acute Care Hospital Setting

People with severe, long-standing anorexia nervosa (AN) often develop physical manifestations of medical starvation. Functional deficits are not well described, and little information is available to guide physical intervention. This case report describes the physical therapy clinical decision-making process and intervention provided to a patient with severe AN. The patient was a 48-year-old woman admitted to an acute care hospital with medical complications associated with AN and requiring medical stabilization. On admission, she was unable to complete basic functional activities (eg, bed mobility, transfers, ambulation). She was considered at risk for falls, with a score of 17 on the Performance-Oriented Motor Assessment (POMA) and a score of 19.27 seconds on the Timed "Up & Go" Test (TUG). Physical therapist examination and intervention focused on functional testing and training, strengthening, and postural stability training for return to independence. In 9 weeks, the patient returned to independence in basic activities of daily living, as measured by 3 items from the motor domain (bed mobility, transfers, and ambulation) of the Functional Independence Measure, with improvements from 1 ("total assistance") to 6 ("modified independence") on each item. Postural stability improved to "low risk" for falls (POMA score of 24). Her TUG score improved to 11.00 seconds. Walking speed improved from 0.35 to 0.81 m/s. Once she attained medical stability, she was discharged home with her parents with outpatient services. Physical therapist management of this severely deconditioned patient hospitalized with severe AN focused on the restoration of functional activities, with intervention intensity being guided by physiologic responses. Traditional aerobic and endurance training were de-emphasized to minimize kilocalorie expenditure and tendencies toward exercise compulsion in this patient population.

Abstract P189: Cardiac Repolarization and Resting Energy Expenditure in Patients Hospitalized With Severe Anorexia Nervosa

Background and Objectives: Anorexia nervosa (AN) carries the highest mortality among psychiatric illnesses and disproportionately impacts women. QTc prolongation is believed to underlie this risk but is a subject of controversy as ECG data among patients with advanced AN is inadequately characterized. Moreover, previous studies have utilized non-digitized ECG data and therefore have limited measurement precision. We sought to determine the prevalence of QTc prolongation and assess its relationship to body mass index (BMI) and resting energy expenditure (REE) within a national AN referral center. Methods and analysis: We identified 34 patients hospitalized with severe AN. ECGs were obtained on admission then digitized and read with high-precision calipers by a single blinded electrophysiologist. We evaluated the proportion of patients with marked QTc prolongation defined as exceeding 0.500 seconds. Descriptive statistics were used to summarize continuous normally distributed data. Categorical variables were summarized with frequencies and percentages. Pearson's and Spearman's correlation coefficients were used to determine if there was an association between QTc and admission BMI and REE calculated using the Harris Benedict equation. Findings: A total of 31 of 34 (91.2%) patients were women, and median age was 27 years. The median weight on admission was 81.4 pounds and median BMI was 13.5 kg/m 2 (interquartile range 11.8 - 14.5) Mean heart rate was 58 bpm and mean QTc calculated by the Fridericia formula was 0.421 seconds. A QTc interval exceeding 0.500 seconds was seen in only one patient (4.8%). There was no significant correlation between QTcF and either BMI (-0.20, p=0.39) REE (+0.19, p=0.40) on hospital admission. Conclusions: QTc interval prolongation occurs infrequently among patients with severe anorexia nervosa; most exhibit normal cardiac repolarization even at the height of their illness. Disease severity as assessed by admission BMI and REE is not significantly correlated with the QTc interval. Beyond the need for larger studies, these findings suggest that other markers of sudden death should be investigated within this vulnerable population.

Factors influencing QT prolongation in patients hospitalized with severe anorexia nervosa

BackgroundAnorexia nervosa (AN) carries the highest mortality of any psychiatric disorder largely attributable to sudden cardiac death and suicide. Controversy exists regarding the underlying mechanism of cardiac risk, whether QT prolongation is a consistent feature of the disorder and whether repolarization varies by disease severity. Some of the uncertainty may relate to a lack of standardized electrocardiography (ECG). To date, studies have not utilized centrally adjudicated digital ECG, and most have relied on the Bazett formula for rate-correction, which is suboptimal at the extremes of heart rate often observed in AN. MethodsWe evaluated a hospitalized cohort of medically compromised, very-low-body mass index (BMI) AN patients. The QT interval was measured with high-precision calipers by a single, blinded electrophysiologist and rate corrected (QTc) using the Fridericia formula. Anatomically corrected left ventricular (LV) mass and resting energy expenditure (REE) were calculated as proxies for disease severity. Proportions exceeding categorical thresholds for QTc prolongation and correlations between admission QTc and disease severity were performed. ResultsAmong 19 patients, mean BMI was 12.3 kg/m2, and 95% were female. The majority (68%) of patients were receiving QT-prolonging drugs. Four patients (21%) had QTc prolongation. Two of these patients (10.5%) exceeded the 500 ms threshold for marked QTc-prolongation, though each had concomitant factors contributing to delayed repolarization. The QTc interval was not significantly correlated with LV mass, LV mass index, BMI or REE. ConclusionsAlthough delayed cardiac repolarization was observed among a medically compromised cohort of patients with anorexia nervosa, the QTc interval was not a reliable correlate of disease severity despite digital ECG adjudication and optimal rate correction.

A case of anorexia nervosa with disseminated intravascular coagulation syndrome

A 36-year-old Japanese woman with anorexia nervosa (AN) was admitted to our department because of severe emaciation. Although we were thorough in her clinical management and were careful to avoid precipitating refeeding syndrome, disseminated intravascular coagulation (DIC) developed 3 weeks after hospitalization. We treated her for DIC with sepsis using anticoagulants, protease inhibitors, antithrombin, and platelet concentrate transfusion. To treat her bacterial infection, we administered antimicrobial drugs and immunoglobulin. We began probiotic and prebiotic (synbiotics) treatment for bacterial translocation. We think that the prevention of sepsis via bacterial translocation is an important aspect of care for patients with severe AN in addition to the prevention of refeeding syndrome.