Anorexia Nervosa Nutritional Disorder/Eating Disorder

Posted: October 3rd, 2024

Anorexia Nervosa in Adolescents: Case Study Analysis of Risk Factors, Clinical Manifestations, and Treatment Approaches

Anorexia nervosa is a severe eating disorder characterized by restricted energy intake, intense fear of gaining weight, and distorted body image (Clemente-Suárez et al., 2023). It primarily affects adolescents and young adults, with a higher prevalence among females. The etiology of anorexia nervosa is complex, involving biological, psychological, and social factors.

Case Presentation
Jenny, a 16-year-old female, presented to the Eating Disorders Clinic following a fainting episode during gymnastics class. Her history revealed several risk factors and clinical manifestations consistent with anorexia nervosa.

2.1 Risk Factors

A major risk factor identified in Jenny’s case is her family environment. Her father’s alcoholism and violent behavior, coupled with her mother’s enabling attitude, create a dysfunctional family dynamic. This aligns with research indicating that adverse childhood experiences and family dysfunction contribute significantly to the development of eating disorders (Byrom et al., 2022).

2.2 Clinical Manifestations

Jenny’s review of systems revealed multiple symptoms consistent with anorexia nervosa:

Significant weight loss
Amenorrhea (last menses 6 months ago)
Feeling cold frequently
Weakness and fatigue
Decreased appetite
Occasional heart palpitations
Constipation
These symptoms correspond with the diagnostic criteria for anorexia nervosa as outlined in the DSM-5 (American Psychiatric Association, 2013).

2.3 Physical Examination Findings

Jenny’s vital signs further support the diagnosis of anorexia nervosa:

Low body temperature (95.3°F)
Bradycardia (pulse rate of 52 bpm)
Low body weight (89 lbs at 62 inches tall)
Her calculated Body Mass Index (BMI) is 16.3 kg/m², which falls below the 5th percentile for her age and gender, confirming that she is underweight (Centers for Disease Control and Prevention, 2021).

Physiological Consequences
3.1 Dehydration

Jenny’s physical examination revealed signs of dehydration:

Dry, scaling skin
Decreased skin turgor
Cool extremities
Laboratory findings further support this, showing:

Hypernatremia (Na 148 meq/L)
Elevated BUN (30 mg/dL)
Elevated hematocrit (47%)
Hypokalemia (K 2.9 meq/L)
3.2 Hematological and Immune System Effects

Jenny’s white blood cell count (3,900/mm³) is at the lower end of the normal range, potentially increasing her risk of infections. However, her hemoglobin (14.8 g/dL) and hematocrit (47%) are within normal limits, indicating no current anemia.

3.3 Endocrine Disruptions

The patient’s amenorrhea and low FSH level (0.2 mU/mL) suggest hypothalamic amenorrhea, a common consequence of severe caloric restriction (Meczekalski et al., 2014). Her TSH level (2.1 µU/mL) is within normal limits, ruling out primary hypothyroidism.

3.4 Electrolyte Imbalances

Of particular concern is Jenny’s hypokalemia (K 2.9 meq/L), which can lead to cardiac arrhythmias and muscle weakness. Her hypophosphatemia (2.3 mg/dL) and hypomagnesemia (1.7 mg/dL) are also noteworthy, as these can contribute to various complications, including cardiac abnormalities and osteoporosis (Mehler & Brown, 2015).

Treatment Approaches
Current evidence supports a multidisciplinary approach to treating anorexia nervosa, encompassing medical, nutritional, and psychological interventions (Hay et al., 2019).

4.1 Medical Management

Immediate priorities include:

Correcting electrolyte imbalances, particularly addressing hypokalemia
Gradual nutritional rehabilitation to avoid refeeding syndrome
Monitoring cardiac function due to bradycardia and electrolyte disturbances
4.2 Nutritional Rehabilitation

A structured meal plan with careful caloric progression is essential. Supplementation of vitamins and minerals, particularly phosphorus, may be necessary to prevent refeeding syndrome (Garber et al., 2016).

4.3 Psychological Interventions

Evidence-based psychotherapies for adolescents with anorexia nervosa include:

Family-Based Treatment (FBT), which has shown efficacy in promoting weight gain and reducing eating disorder psychopathology (Lock et al., 2020)
Cognitive Behavioral Therapy-Enhanced (CBT-E), adapted for adolescents (Dalle Grave et al., 2019)
4.4 Addressing Comorbidities

Jenny’s reported depressive symptoms and suicidal ideation require careful assessment and management. Integrated treatment addressing both the eating disorder and mood symptoms is crucial for optimal outcomes (Himmerich & Treasure, 2018).

Conclusion
Jenny’s case illustrates the complex interplay of psychological, social, and physiological factors in anorexia nervosa. Early identification and comprehensive, multidisciplinary treatment are essential for improving outcomes in adolescents with this potentially life-threatening condition. Future research should focus on refining personalized treatment approaches and exploring novel interventions to enhance recovery rates and reduce relapse in anorexia nervosa.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Byrom, N. C., Batchelor, R., Berntsen, D., & Brown, A. (2022). Seeking support for an eating disorder: a qualitative analysis of the university student experience. Journal of Eating Disorders, 10(1), 32.

Centers for Disease Control and Prevention. (2021). BMI Percentile Calculator for Child and Teen. Retrieved from https://www.cdc.gov/healthyweight/bmi/calculator.html

Clemente-Suárez, V. J., Mielgo-Ayuso, J., Beltrán-Velasco, A. I., & Nikolaidis, P. T. (2023). The Impact of Anorexia Nervosa and the Basis for Non-pharmacological Treatment: A Narrative Review. Healthcare, 11(10), 1464.

Dalle Grave, R., Sartirana, M., & Calugi, S. (2019). Enhanced cognitive behavioral therapy for adolescents with anorexia nervosa: Outcomes and predictors of change in a real-world setting. International Journal of Eating Disorders, 52(9), 1042-1046.

Garber, A. K., Sawyer, S. M., Golden, N. H., Guarda, A. S., Katzman, D. K., Kohn, M. R., … & Redgrave, G. W. (2016). A systematic review of approaches to refeeding in patients with anorexia nervosa. International Journal of Eating Disorders, 49(3), 293-310.

Hay, P., Mitchison, D., Collado, A. E. L., González-Chica, D. A., Stocks, N., & Touyz, S. (2019). Burden and health-related quality of life of eating disorders, including Avoidant/Restrictive Food Intake Disorder (ARFID), in the Australian population. Journal of Eating Disorders, 7(1), 1-10.

Himmerich, H., & Treasure, J. (2018). Psychopharmacological advances in eating disorders. Expert Review of Clinical Pharmacology, 11(1), 95-108.

Lock, J., Couturier, J., & Agras, W. S. (2020). Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of the American Academy of Child & Adolescent Psychiatry, 59(6), 811-818.

Meczekalski, B., Podfigurna-Stopa, A., & Genazzani, A. R. (2014). Hypoestrogenism in young women and its influence on bone mass density. Gynecological Endocrinology, 30(2), 97-101.

Mehler, P. S., & Brown, C. (2015). Anorexia nervosa – medical complications. Journal of Eating Disorders, 3(1), 11.

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Anorexia Nervosa Nutritional Disorder/Eating Disorder.

Jenny is a 16-year-old girl who is in the 11th grade. This is her first visit to the Eating Disorders Clinic. Physicians at the emergency room had referred her to the clinic. She had fainted at school during gymnastics class and sustained several minor bruises on her arms and legs and a laceration on her forehead. When she was younger, Jenny was of normal weight and height and ate freely. Her father owns a construction business, spends a significant amount of time traveling, and drinks excessively when he is at home. He is also violent and quick to anger when he drinks. He shouts, uses abusive language, and has thrown plates and books at Jenny’s mother and the children. Jenny never knows what to expect from him and is terrified of him. Her mother always defends her father’s poor behavior and violent actions. “Your father works very hard and needs a few drinks to relax.”

Jenny has felt totally neglected in the family during the last several years. She is the only female and her father tends to get involved more in the activities of his two sons because “they can play sports.” Jenny has taken a part-time job at the ice cream shop, has become very involved in her studies and closest friendships, and rarely comes home before 10 PM. One year ago, she decided that she needed to lose several pounds but would not say exactly how many. She began to exercise by walking 45 minutes each day during lunchtime and tried out for both the girls’ track and volleyball teams. She started reading articles in Cosmopolitan magazine about weight loss, being thin, and being beautiful like the Hollywood actresses and supermodels. She experimented with Lasix for several weeks but decided that it was not helping her lose weight as she desired. She began skipping breakfast and lunch completely. For dinner, she would have a large bowl of cereal and would feel filled up. Several months ago, she bought online and began taking Metabo-Speed XXX, advertised as the “Diet Pill of the Stars, the Appetite Killer, Metabolism Booster, and Fat Blaster.” She denies using any laxatives or ipecac. She denies any forced vomiting.

Her mother informs the eating disorders specialist that “Jenny has not been herself lately. She has been losing too much weight and has been very touchy and argumentative lately. She is always a good girl, works hard on her schoolwork and job, and always does what’s expected of her.” Jenny confides in her healthcare provider that she “has one very good friend who also comes from a dysfunctional family. We understand one another and we support one another, but we have both grown up too fast.” She admits to feeling “very sad, ignored, and worried for almost two years.” She cries frequently at night and wakes up around 4 AM unable to go back to sleep. She often lies awake at night when she goes to bed, crying and tossing and turning for hours before falling asleep. She occasionally experiences nightmares about her father chasing her with a knife. Jenny admits to having suicidal thoughts but no plan. “I probably wouldn’t be able to go through with it.” More recently, she has had thoughts that she wishes she could “just go to sleep and wake up in heaven.” She denies any history of sexual abuse.

Patient Case Question 1. Identify one major risk factor for anorexia nervosa from this patient’s history of present illness.

Past Medical History

No previous psychiatric history or major medical problems or hospitalizations
Measles as a young child
History of urinary tract infections
One episode of iron deficiency anemia last year
Menarche began at age 12
Occasional headaches
Family History Jenny is the middle child of three children. She has an older brother and a younger brother. Father and paternal grandfather are alcoholics and smokers. Mother is in good health.

Social History

Straight “A” student who would like to go to college
Enjoys reading and writing
Very active in various student activities, including track and volleyball; a member of the student council and journal club; also a class officer
Denies use of tobacco, alcohol, or illicit drugs
Review of Systems

States that overall she is doing okay
Trying to lose weight so that she will be more attractive
Doesn’t like her size and shape
Doesn’t believe that she has lost too much weight
Complains of weakness and always feeling cold
Denies chest pain, but occasionally feels “heart flutters”
No history of seizures
Reports a decrease in both appetite and energy and has felt fatigued for the last 3 weeks
Has had no abdominal pain
Usually has one bowel movement daily, but admits that she has not had one in the past 3 days
Last menses was 6 months ago
Denies nausea, vomiting, diarrhea, shortness of breath, and hemoptysis
No blood in the stool
Patient Case Question 2. Identify a minimum of seven clinical manifestations from the review of systems above that are consistent with a diagnosis of anorexia nervosa.

Medications No prescribed medications but she has been taking Metabo-Speed XXX for weight loss and used furosemide from her parents’ medicine cabinet.

Allergies No known drug allergy.

Physical Examination and Laboratory Tests

General

The patient is a cooperative, pleasant, young female in no apparent distress
She is appropriately dressed with regard to clothing size
She is extremely thin
Easily engaged in conversation
She is not guarded with her answers and makes good eye contact
Answers all questions with a soft voice
No odd or inappropriate motor behavior
Vital Signs See Patient Case Table 96.1

Patient Case Table 96.1 Vital Signs

BP 125/80*
RR 15
Ht 62 in
P 52
T 95.3°F
Wt 89 lbs *A normal blood pressure for a 15–17-year-old female is 128/82.
Patient Case Question 3. Identify three vital signs that are consistent with a diagnosis of anorexia nervosa.

Patient Case Question 4. Calculate this patient’s body mass index to confirm that the patient is technically underweight.

Skin

Cool to touch
Dry with some scaling
Negative for rashes or lesions
Skin tone normal in color
Decreased turgor
Patient Case Question 5. Identify three clinical manifestations from the skin and HEENT examinations above that suggest Jenny is dehydrated.

Patient Case Question 6. Why did the eating disorders specialist examine the patient’s teeth, a procedure that is not common in a physical examination?

Neck/Lymph Nodes

Neck supple without lymphadenopathy or thyromegaly
No jugular vein distension or carotid bruits
Breasts Normal without masses, discoloration, discharge, or dimpling.

Lungs

Clear to auscultation bilaterally
No wheezing or crackles
Cardiac

Regular rate and rhythm, slow beat
No murmurs, rubs, or gallops
S1 and S2 normal; no additional cardiac sounds
Abdomen

Soft and non-tender
Hypoactive bowel sounds
No hepatosplenomegaly
No masses or bruits
No guarding or rebound tenderness
Patient Case Question 7. Which negative abdominal clinical sign parallels a single clinical symptom reported by the patient during the review of systems?

Genitalia/Rectum Stool heme-negative.

Patient Case Question 8. What is the significance of the rectal examination?

Musculoskeletal/Extremities

Extremities are slightly cool to touch
No cyanosis or clubbing but mild-to-moderate (1 level) peripheral edema
Range of motion within normal limits
Good peripheral pulses bilaterally
Age-appropriate strength
Neurologic

Alert and oriented to time, place, and person
Cranial nerves II–XII intact
Deep tendon reflexes 2 throughout
Negative Babinski sign
No gross motor-sensory deficits present
Laboratory Blood Test Results See Patient Case Table 96.2.

Urinalysis The patient’s urine was clear in appearance, but amber in color. Complete urinalysis is pending.

Electrocardiogram Except for bradycardia, no abnormalities were observed.

Patient Case Question 9. Which four laboratory blood test results in Table 96.2 are consistent with dehydration?

Patient Case Question 10. Do any of the laboratory data in Table 96.2 support a diagnosis of anemia?

Patient Case Table 96.2 Laboratory Blood Test Results

Na 148 meq/L
Hb 14.8 g/dL
AST 30 IU/L
K 2.9 meq/L
Hct 47%
ALT 38 IU/L
Cl 111 meq/L
Plt 170,000/mm3
Alk phos 123 IU/L
HCO3 22 meq/L
WBC 3,900/mm3
T protein 4.9 g/dL
BUN 30 mg/dL
Ca 8.3 mg/dL
TSH 2.1 µU/mL
Cr 1.1 mg/dL
Mg 1.7 mg/dL
T cholesterol 190 mg/dL
Glu, fasting 60 mg/dL
Phos 2.3 mg/dL
FSH 0.2 mU/mL
Patient Case Question 11. Is this patient at risk for developing infections?

Patient Case Question 12. This patient has many clinical manifestations that are associated with hypothyroid disease. Is this patient hypothyroid?

Patient Case Question 13. Based on the patient’s laboratory blood test results, provide one reasonable explanation for the observed level 1 peripheral edema.

Patient Case Question 14. Can the patient’s recent amenorrhea be explained by any of the laboratory blood test results shown in Table 96.2?

Patient Case Question 15. Which of the following findings from the laboratory blood tests has to be of greatest concern and why: hypernatremia, hypokalemia, hypoglycemia, hypomagnesemia, hypocalcemia, or hypophosphatemia?

Patient Case Question 16. Some patients with anorexia nervosa are hypercholesterolemic. Does the patient in this case study have a markedly elevated serum cholesterol concentration?