Differential diagnosis and pathogenesis of anorexia nervosa

Anorexia nervosa is a disease of increasing frequency with serious medical and psychological consequences. The presentation is one of significant weight loss. The initial assessment of such a patient must differentiate between an underlying systemic medical illness and an eating disorder. This paper will review the more common medical conditions causing weight loss and their distinguishing characteristics, including malignancy, inflammatory bowel disease, infections and metabolic disorders. Once an organic disease is ruled out, anorexia nervosa must then be differentiated from other eating disorders such as bulimia or other psychological diseases such as depression, schizophrenia, drug abuse, conduct disorders, and anxiety reactions. The pathogenesis of anorexia nervosa includes complex societal, family, and individual factors which require evaluation in the treatment process.     

Eating disorders in adolescent girls*

Eating disorders are common in contemporary society. New information is emerging on the pathogenesis of anorexia nervosa and bulimia nervosa and includes psychologic, biologic, family, environmental, genetic and social factors. The physician providing care to adolescents is challenged to carry out a careful evaluation and monitor the patient for complications, especially loss of bone mass. Treatment requires a multidisciplinary team.     

Perplexities and provocations of eating disorders

Background:  Etiological hypotheses of eating disorders, anorexia nervosa and bulimia nervosa have not produced informative research for predictably effective treatment.
Methods:  The rationale for applying a model of allostasis, a dysregulation of reward circuits with activation of brain and hormonal stress responses to maintain apparent stability, is developed for eating disorders.
Results:  The neurotransmitter systems involved in the allostatic state of a reward system in anorexia nervosa and bulimia nervosa may be similar to those present in drug addiction.
Conclusion:  The biological vulnerabilities underlying the unique features of eating disorders should be intensively investigated with the advancing techniques in genetics and neuroimaging. Preventing chronicity with early diagnosis and adequate treatment before age 18 is necessary.     

Behavioural eating disorders

Eating disorders are serious mental health disorders characterized by morbid preoccupation with weight and shape, manifest through distorted or chaotic eating. Planned changes to diagnostic criteria will broaden the definition of feeding and eating disorders to include presentations characterized by restricted food intake not associated with weight and shape concerns. Anorexia nervosa (AN), bulimia nervosa (BN) and partial syndromes are relatively common, and early intervention is advisable. Aetiology is multifactorial, with high heritability. Prognosis overall is good but treatment can be long and intensive, significantly impacting families. Essential aspects of management are an integrated multidisciplinary approach, working collaboratively with families and young people when possible. Psychological interventions focus on the eating disorder, supported by medical monitoring and dietetic guidance. Although working with families is the backbone of treatment for AN, young people also need opportunities for confidential discussion. The role of inpatient treatment is evolving. For BN, family or individual approaches may be equally effective. Paediatric expertise is of particular value in the assessment and management of acute malnutrition and complications secondary to disordered eating behaviours, in the early stages of re-feeding, and in the monitoring and management of long-term complications such as growth retardation, pubertal delay and osteopenia.     

Behavioural eating disorders

Eating disorders are serious mental health disorders characterized by morbid preoccupation with weight and shape, manifest through distorted or chaotic eating. Determined food avoidance in the absence of these cognitions is of uncertain nosological status. Anorexia nervosa (AN), bulimia nervosa (BN) and partial syndromes are relatively common, and early intervention is advisable. Aetiology is multifactorial, with high heritability. Prognosis overall is good but treatment can be long and intensive, significantly impacting families. Essential aspects of management are an integrated multidisciplinary approach, working collaboratively with families and young people when possible. Psychological interventions focus on the eating disorder, supported by medical monitoring and dietetic guidance. Although working with families is the backbone of treatment for AN, young people also need confidential individual appointments. The role of inpatient treatment is evolving. For BN, family or individual approaches may be equally effective. Paediatric expertise is of particular value in the assessment and management of acute malnutrition and complications secondary to disordered eating behaviours, in the early stages of re-feeding, and in the monitoring and management of long-term complications such as growth retardation, pubertal delay and osteopenia.     

Bulimia nervosa in adolescents: a disorder in evolution?

BACKGROUND: There are few reports that describe the manifestation of bulimia nervosa (BN) among adolescents. Moreover, none make reference to the comparative clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are any reports available of how distinct partial-syndrome BN cases are from those that meet full diagnostic criteria for BN. OBJECTIVES: To describe 3 groups of adolescents, those with a full-syndrome eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare these groups along demographic, general psychopathology, and eating disorder variables. DESIGN: The study population included 120 adolescents with eating disorders who were initially seen at The University of Chicago Eating Disorders Program, Chicago, Ill, for treatment. All participants completed an assessment prior to treatment. MEASURES: Weight and height were obtained from all participants. Participants also completed a baseline demographic questionnaire (eg, menstrual status, ethnicity, family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Eating Disorder Examination. RESULTS: Partial-syndrome BN cases are clinically quite similar to their full-syndrome counterparts. Only objective binge eating episodes and purge frequency distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the other hand, were quite distinct from BN and partial-syndrome BN cases on almost all variables. CONCLUSION: Early recognition and swift treatment of eating disorders in adolescents, regardless of whether a diagnostic threshold is met, are imperative because they will lead to early intervention thereby potentially improving eating disorder recovery rates.     

Bulimia nervosa in adolescence

Although eating disorders of the bulimic type have been known for a long time, "bulimia nervosa" as a special and specific type of eating disorder was described only during the last decade. Clinical evidence has shown an increase in bulimic disturbances during the last few years. About 30% of the bulimic disturbances begin between the 14th and 18th year of age. About 50% of patients with bulimia nervosa have been anorexic before. A group of 30 patients with anorexia nervosa and a group of 11 patients with bulimia nervosa were compared by means of the dexamethasone suppression test and two depression scales at the beginning of inpatient treatment, after 8-12 weeks of inpatient treatment and at discharge. Patients with anorexia nervosa revealed significantly higher cortisol levels at the beginning of inpatient treatment as compared with the bulimic group. Cortisol levels were normalized with weight gain. Therapeutic measures in bulimia nervosa comprise medical and psychotherapeutic methods.     

Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders

BACKGROUND: Anorexia and bulimia nervosa are considered to be the most serious eating disorders in female adolescents, with a multifactorial etiology and severe medical complications. It is interesting to investigate the specific relationships of these diseases to emotional stress, coping mechanisms and biofeedback mitigation. METHODS: The study comprised 76 obese and 27 anorectic girls, as well as 35 healthy girls as a control group. Psychological assessment was performed using the Eysenck Personality Questionnaire, Emotional Profile Index, General Anxiety Scale, Minnesota Multiphasic Personality Inventory and Cornell Medical Index. The therapy was multimodal, including a biofeedback relaxation system based on electrodermal response (EDR). RESULTS: Scores obtained from psychometric instruments, in particular concerning basic anxiety, intrafamily conflicts, self-defense and depression, showed that anorexia nervosa and hyperphagia are specifically stress related. Personality characteristics and the environment, as models for habits, modified the manner of coping with stress differently for anorexia and hyperphagia. The EDR biofeedback was shown to be an effective support for mitigation of eating disorders in preadolescents, with better results for anorectic girls. The correlated difference in personality profiles suggested the use of specific animated sequences. CONCLUSIONS: The results confirmed the hypothesis that obesity and anorexia nervosa could be related to different types of emotional stress and coping mechanisms, and accordingly be differently mediated by biofeedback technique.     

Anorexia und Bulimia nervosa im Kindes- und Jugendalter

Eating disorders are among the most common chronic illnesses in female adolescents and for some patients these psychiatric disorders are potentially fatal. This article defines anorexia and bulimia nervosa and goes on to describe the epidemiology, etiology, pathogenesis, comorbidities and differential diagnosis of these disorders. Details concerning eating disorder symptoms, hyperactivity, psychiatric symptoms, such as distorted self-image and obsessive fear of gaining weight are given, as well as somatic complications. A plan of treatment of eating disorders is provided in a multimodal therapy approach consisting of somatic rehabilitation, psycho-education, individual psychotherapy, involvement of family members and medication. Finally, recommendations for pediatricians, often the first to be notified by patients and their families and therefore fulfilling an important role in the initial diagnosis and referral to other specialists, are provided.     

Anorexia nervosa in adolescence

Eating disorders are complex mental health conditions. Anorexia Nervosa (AN) represents a particular subtype of eating disorder that is significantly more common in young women than in young men and is the second most common mental health disorder in adolescent girls. It is a serious condition with the highest standardized mortality of any psychiatric condition. Optimal care of requires input from a multi-disciplinary team (MDT) providing collaborative medical, nutritional and psychological interventions, which includes the family, dieticians, consultant psychiatrists, therapists, nurses, paediatricians and general practitioners. AN is associated with a range of physical complications and symptoms including acute complications such as refeeding syndrome, electrolyte disturbance and cardiovascular effects. Outpatient family based treatment is the first line psychological intervention for children and adolescents with AN. Nutritional rehabilitation including weight stabilization and restoration are to essential elements of treatment and early dietician involvement is crucial. Current outcomes for AN are variable and a firm evidence base for many areas of treatment has yet to be established.     

Breastfeeding practice in mothers with eating disorders

The purpose of this study was to compare the prevalence of breastfeeding in women with anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorders not otherwise specified – purging subtype, with mothers with no eating disorders during the first 6 months after birth. The study is based on the Norwegian Mother and Child Cohort Study conducted at the Norwegian Institute of Public Health. Questionnaire‐based information on eating disorder diagnoses and breastfeeding in 39 355 women was used to estimate the risk of cessation of breastfeeding with Cox proportional hazards regression. Almost all women (98%) initially breastfeed their infants, with no statistically significant difference between the eating disorders subgroups and women with no eating disorders. However, the risk of early cessation before 6 months post‐partum increased for all subgroups of mothers with eating disorders, compared with mothers with no eating disorders. After adjusting for maternal body mass index, age, education, birthweight and pre‐term birth, only mothers with anorexia nervosa [hazard ratios (HR), 2.35; 95% confidence interval (CI) 1.22–4.53] and eating disorder not otherwise specified‐purging subtype (HR, 1.95; 95% CI 1.08–3.53) had increased risk for cessation of breastfeeding There were no differences in the risk of cessation of exclusive breastfeeding. These results show that some eating disorders may influence mothers' early feeding practices and indicate that additional support may be necessary to assist women with anorexia nervosa in maintaining breastfeeding.     

Dental aspects of anorexia and bulimia nervosa

Anorexia nervosa and bulimia nervosa are both psychosocial pathological eating disorders. An intense preoccupation with food, weight and a distorted body image coupled with a morbid fear of becoming obese are common elements in both syndromes. Self-starvation with extreme weight loss is associated with anorexia nervosa. Bulimia nervosa is characterized by unrestrained eating sprees followed by purging, fasting or vomiting. Approximately 50% of anorexia nervosa patients also practice bulimia. The impact of eating disorders on the oral soft and hard tissues depends upon the diet as well as the duration and frequency of binge-purge behavior. Erosion of the teeth due to frequent regurgitation of highly acidic stomach contents is a common finding. Dental caries development is less predictable and appears to be diet- and oral hygiene-dependent. Painless enlargement of the parotid salivary glands is a common sequela of chronic vomiting but the pathophysiological cause has not been firmly established. The dehydration of the oral soft tissues due to salivary gland impairment in addition to dietary deficiencies and poor oral hygiene can adversely impact the health of the periodontal tissues and oral mucosa. Initial dental care is focused on discouraging behavior that is destructive to the oral tissues. Improved oral hygiene, the use of gastric acid-neutralizing antacid rinses and the daily application of topical fluorides can be useful in reducing enamel erosion. Extensive restorative oral rehabilitation should be postponed until the underlying psychiatric components of the disorder are stabilized.     

Differences in cortisol concentrations in adolescents with eating disorders: a systematic review

Objective

To perform a systematic review of the literature for scientific evidence of possible differences in cortisol concentrations in adolescents with eating disorders.

Eating disorders in children and adolescents

Anorexia nervosa and bulimia nervosa are common disorders in the pediatric population. This article is designed to help the clinician develop a detailed understanding of these disorders as they affect children and adolescents. The etiology, diagnosis, complications, and treatment of these eating disorders are discussed. The special circumstances of diabetes mellitus, athletics, and the interface with the obese patient also are covered. The need to correctly identify a patient with the disorder, perform the appropriate testing, and organize the most appropriate treatment is required from virtually every primary care practitioner.     

Management of eating disorders in children and adolescents

The eating disorders, anorexia nervosa, bulimia nervosa and their variants, typically develop in adolescence or early adulthood, mainly in females. Despite a long history, the evidence base for effective treatments is weak and existing clinical guidelines are based on consensus views rather than strong research. Effective coordinated management of physical and psychological aspects of the disorders is crucial, but outcomes remain very variable, with adverse outcomes commonly extending into adulthood. Anorexia nervosa carries a high morbidity and occasional mortality.     

Management of eating disorders in children and adolescents.

The eating disorders, anorexia nervosa, bulimia nervosa and their variants, typically develop in adolescence or early adulthood, mainly in females. Despite a long history, the evidence base for effective treatments is weak and existing clinical guidelines are based on consensus views rather than strong research. Effective coordinated management of physical and psychological aspects of the disorders is crucial, but outcomes remain very variable, with adverse outcomes commonly extending into adulthood. Anorexia nervosa carries a high morbidity and occasional mortality.     

Bulimia nervosa: an update and treatment recommendations.

Bulimia nervosa is a common eating disorder in adolescent women. Biological, psychological, and social factors are implicated in onset and important in treatment. Diagnosis of the syndrome, but not its subtypes, can be made well using the DSM-IV system. Screening tools, laboratory findings, and physical findings can be helpful in making the diagnosis. Comorbid disorders include affective disorders, addictive disorders, anxiety disorders, personality disorders, and anorexia nervosa. The etiology of bulimia nervosa is complex, with biologic, psychological, social, and family factors, which likely differ somewhat from patient to patient. Treatment, accordingly, should be comprehensive, individualized, and multifaceted. Many patients respond well to the use of an antidepressant, and cognitive-behavioral therapy is a useful approach for many patients. Combining these two treatments seems to be a good strategy. Environmental and family issues also need to be addressed. Many patients are treated insufficiently. More research on bulimia nervosa specific to adolescence is needed.     

Les crises de boulimie à l’adolescence

Binge eating, bulimia nervosa, binge eating disorder, anorexia-bulimia are terms often used without really knowing what precisely one is referring to. Otherwise, there are many articles concerning anorexia nervosa in medical literature, a disease, which can be seen and fascinates. These eating disorders are frequent in today's society; medical, psychological and social consequences are important.     

Weight and menstrual function in patients with eating disorders and cystic fibrosis

Many patients with eating disorders have menstrual dysfunction. In patients with anorexia nervosa, amenorrhea has been linked to weight loss. However, many patients with bulimia nervosa, even those of average or greater than average weight, also experience menstrual abnormalities, including amenorrhea. It was hypothesized that low weight per se is not responsible for menstrual dysfunction in patients with eating disorders. First, 16 patients with bulimia nervosa of average weight and 29 patients with cystic fibrosis of below average weight of similar menstrual age were compared. Of the patients with bulimia nervosa, 11 (73%) had had secondary amenorrhea at some time compared with 8 (28%) of the patients with cystic fibrosis (P less than .01). At the time of study, 6 (40%) of the patients with bulimia nervosa and 21 (78%) of the patients with cystic fibrosis were having regular cycles (P less than .01). Next 18 patients with anorexia nervosa were compared with 18 patients with cystic fibrosis matched for weight and menstrual age. Although 18 (100%) of the patients with anorexia nervosa had had secondary amenorrhea, only 6 (33%) of the patients with cystic fibrosis had amenorrhea. Although only 1 (6%) of the anorexia nervosa group was currently having regular cycles, 14 (78%) of the patients with cystic fibrosis were (P less than .0001). Closer approximation to ideal body weight was associated with regular menses only in the cystic fibrosis group. Exercise did not appear related to regularity of menstruation in any group. Body weight is not the major factor responsible for menstrual abnormalities in patients with eating disorders.     

Evidence-based treatment of eating disorders

Anorexia nervosa and bulimia nervosa are common problems facing adolescents and young adults. Treatment of these disorders poses a challenge to health care providers given the general paucity of clinical trials to guide management. There is evidence to support the use of CBT as well as psychopharmacotherapy to decrease binge and purge behaviors in bulimia nervosa. Significantly fewer trials have examined the efficacy of such therapies for anorexia nervosa. Short-term trials appear promising regarding potential treatments for bone loss in anorexia nervosa. The role of exercise in the management of anorexia nervosa remains controversial and begs future investigative efforts.