C h a p t e r 1 0
Disorders of Nutritional Status
237
such as amenorrhea, and low bone density,
53
does not
meet the strict DSM-5 criteria for anorexia nervosa or
bulimia nervosa, but shares many of the characteristics
and therapeutic concerns (see Chapter 44). Persons with
eating disorders may require concomitant evaluation
for psychiatric illness because eating disorders often
are accompanied by mood, anxiety, and personality
disorders.
Anorexia Nervosa
Anorexia nervosa is an eating disorder that usually
begins in adolescence and is characterized by deter-
mined dieting, often accompanied by compulsive exer-
cise and, in a subgroup of persons, purging behavior
with or without binge eating, resulting in sustained low
weight.
54
Other features include a disturbed body image,
a pervasive fear of becoming obese, and obsession with
severely restricted caloric intake.
The causes of anorexia appear to be multifactorial,
with determinants that include genetic influence, person-
ality traits of perfectionism and compulsiveness, anxi-
ety disorders, family history of depression and obesity,
and peer, familial, and cultural pressures with respect to
appearance.
54
Other psychiatric disorders often coexist
with anorexia nervosa, including major depression or
dysthymia and obsessive–compulsive disorder.
Many organ systems are affected by the malnutri-
tion that occurs in persons with anorexia nervosa. The
severity of the abnormalities tends to be related to
the degree of malnutrition and is reversed by refeeding.
The most frequent complication of anorexia is amen-
orrhea and loss of secondary sex characteristics with
decreased levels of estrogen, which can eventually lead to
osteoporosis. Bone loss can occur in young women after
as short a period of illness as 6 months.
48
Symptomatic
compression fractures and kyphosis have been reported.
Constipation, cold intolerance and failure to shiver in
cold, bradycardia, hypotension, decreased heart size,
electrocardiographic changes, blood and electrolyte
abnormalities, and skin with lanugo (i.e., increased
amounts of fine hair) are common. Abnormalities in
cognitive function may also occur. The brain loses both
white and gray matter during severe weight loss; weight
restoration results in return of white matter, but some
loss of gray matter may persist.
54
Unexpected sudden
deaths have been reported; the risk appears to increase
as weight drops to less than 35% to 40% of ideal weight.
It is believed that these deaths are caused by myocardial
degeneration and heart failure rather than arrhythmias.
The most exasperating aspect of the treatment of
anorexia is the inability of the person with anorexia
to recognize there is a problem. Because anorexia is a
form of starvation, it can lead to death if left untreated.
A multidisciplinary approach appears to be the most
effective method of treating persons with the disorder.
The goals of treatment are eating and weight gain, and
efforts to work on psychological, relationship, and emo-
tional issues. Adults whose weight is more than 25%
below the expected weight (or with less weight loss if
there are coexisting medical or psychiatric conditions,
or both) and children or adolescents who are losing
weight rapidly generally require hospitalization to
ensure an adequate food intake and to limit physical
activity.
54
Bulimia Nervosa
Bulimia nervosa is defined by recurrent binge eating
and activities including vomiting, fasting, excessive
exercise, and use of diuretics, laxatives, or enemas to
compensate for that behavior. Bulimia nervosa usually
begins during adolescence, with a peak period of onset
around 18 years of age.
55
In contrast to anorexia ner-
vosa, which is characterized by a weight that is less
than 85% of normal, most persons with bulimia ner-
vosa are of normal weight. The disorder may be asso-
ciated with other psychiatric disorders such as anxiety
disorder or depression. There is also an association
with substance abuse and risky and self-destructive
behaviors.
55
The complications of bulimia nervosa include those
resulting from overeating, self-induced vomiting, and
cathartic and diuretic abuse.
55–57
Among the compli-
cations of self-induced vomiting are dental disorders,
parotitis, and fluid and electrolyte disorders. Dental
abnormalities, such as sensitive teeth, increased den-
tal caries, and periodontal disease, occur with frequent
vomiting because the high acid content of the vomitus
causes tooth enamel to dissolve. Esophagitis, dyspha-
gia, and esophageal stricture are common. With fre-
quent vomiting, there often is reflux of gastric contents
into the lower esophagus because of relaxation of the
lower esophageal sphincter. Vomiting may lead to aspi-
ration pneumonia, especially in intoxicated or debili-
tated persons. Potassium, chloride, and hydrogen are
lost in the vomitus, and frequent vomiting predisposes
to metabolic acidosis with hypokalemia (see Chapter
8). An unexplained physical response to vomiting
is the development of benign, painless parotid gland
enlargement.
The weights of persons with bulimia nervosa may
fluctuate, although not to the dangerously low levels
seen in anorexia nervosa. Their thoughts and feelings
range from fear of not being able to stop eating to a con-
cern about gaining too much weight. They also experi-
ence feelings of sadness, anger, guilt, shame, and low
self-esteem.
Treatment strategies include psychological and
pharmacologic treatments. Cognitive-behavioral ther-
apy is the psychosocial therapy predominately used.
56
This therapy is designed to help individuals become
aware of other ways to cope with the feelings that
precipitate the desire to purge and to try and correct
maladaptive beliefs regarding their self-image. Unlike
persons with anorexia nervosa, persons with bulimia
nervosa are upset by the behaviors practiced and the
thoughts and feelings experienced, and they are more
willing to accept help. Pharmacotherapeutic agents
include the tricyclic antidepressants, the selective sero-
tonin reuptake inhibitors, and other antidepressant
medications.
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