Support Group For Eating Disorders

http://www.nationaleatingdisorders.org/
http://www.eda.org.au/home.htm
http://www.myhealth.gov.my/myhealth/eng/kesihatan_mental_content.jsp?lang=mental&storyid=1209370102195&storymaster=1209370102195
http://www.thebutterflyfoundation.org.au/

COMPLICATIONS OF ANOREXIA NERVOSA

Endocrine/Reproductive Complications

MENSES

To meet the criteria for diagnosis with anorexia nervosa, women must have at least three consecutive months of amenorrhea,

The amenorrhea of anorexia is marked by

• low circulating luteinizing hormone (LH) and follicles stimulating
  

hormone (FSH) despite low estrogen, may affect follicular development

• a pre-pubertal pattern of release of LH and FSH,
  
• diminished response to luteinizing hormone–releasing hormone,
  
• the absence of withdrawal bleeding after a progesterone challenge.
  

This hormone disturbance is mainly an effect of starvation and malnutrition rather than just low weight, as amenorrhea can precede weight loss in up to 1/3 of patients, and menstruation does not always correlate with weight gain.

OVARIES

The pre-pubertal hormonal state in anorexia is associated with smaller

ovaries. With severe malnourishment and low body mass index (BMI), ovaries appear small or undetectable, and have no follicles.

With resumption of eating and weight gain, ovaries can grow and develop multiple follicles until finally one follicle becomes dominant and ovulation and menstruation resume.

Pelvic ultrasound is useful to determine ovarian size.

FERTILITY

Studies report that a high number of women presenting to infertility

clinics had an undiagnosed eating disorder. In one study, five out of 14

women getting ovulation induction had an eating disorder.

PREGNANCY

Anorexia is associated with worse outcomes in pregnancy.

• There is a higher rate of cesarean-section,
  
• a 40% rate of low birth weight (LBW) infants,
  
• 2X increased rate of premature delivery.
  

These outcomes are surprisingly also the same for women with remitted anorexia.

Babies born small for gestational age were more likely to have mothers with

• lower pre pregnancy weight,
  
• lower desired weight in pregnancy,
  
• lower weight gain during pregnancy,
  
• greater than average concern about overeating,
  
• and who smoked.
  

Other endocrinal disturbances.

• Reproductive hormones, including estrogen and dehydroepiandrosterone (DHEA), are lower. Estrogen is important for healthy hearts and bones. DHEA, a weak male hormone, may also be important for bone health and for other functions.
  
• Thyroid hormones are lower. Signs of Sick Euthyroid Syndrome, probably resulting from chronic malnutrition. Labs show low T3, low or normal T4, and normal TSH. This finding can act as a marker of the systemic effects of the restricted eating, but it does not require treatment. Anorexia can also affect the hypothalamic-pituitary-adrenal axis (HPA or HTPA axis), s a complex set of direct influences and feedback interactions among the hypothalamus , the pituitary gland , and the adrenal glands .The interactions among these organs controls reactions to stress and regulates many body processes, including digestion, the immune system, mood and emotions, sexuality, and energy storage and expenditure.
  
• Stress hormones (cortisol, norepinephrine) are higher.
  
• Growth hormones are lower. Children and adolescents with anorexia may experience retarded growth.
  

  
  

  Skeletal Complications
  

  Almost 90% of women with anorexia experience osteopenia and up to 50% of patients with anorexia suffer from osteoporosis.
  

  Development of osteoporosis are dependant on the length of amenorrhea and estrogen deficiency.
  

  Factors that correlate with the presence of osteoporosis are:
  

  • Low BMI (body mass index)
    
  • Past weight history, including minimum weight,
    

  Other factors that contribute to increased risk for osteoporosis include
  

  • smoking and alcohol consumption,
    
  • low calcium,
    
  • low oestrogen levels
    
  • high cortisol (stress hormone),
    
  • DHEA and low testosterone level boys
    
  • and a family history.
    

  The long-term risk for bone fractures is 2.9 times that of controls, and occurs especially in vertebrae, wrist, hip, humerus, and tibia.
  

  
  

  Up to two-thirds of children and adolescent girls with anorexia fail to develop strong bones during their critical growing period. Boys with anorexia also suffer from stunted growth.
  

  Only achieving regular menstruation as soon as possible can protect against permanent bone loss. The longer the eating disorder persists the more likely the bone loss will be permanent.
  

  
  

  Cardiovascular
  

  Complications
  

  Approximately half of deaths in anorexic patients are due to cardiovascular complications. Over 80% of
  

  patients have electrocardiogram (EKG) changes, especially bradycardia,
  

  Other cardiac complications of anorexia include:
  

  • decreased oxygen uptake,
    
  • and decreased exercise capacity
    

  
  

  HEART DISEASE
  

  Heart disease is the most common medical cause of death in people with severe anorexia. The effects of anorexia on the heart are:
  

• Dangerous heart rhythms, including slow rhythms known as bradycardia, may develop. Such abnormalities can show up even in teenagers with anorexia.
  
  

  Bradycardia is a slowness of the heartbeat, usually at a rate under 60 beats per minute (normal resting rate is 60 - 100 beats per minute).
  

• Heart rates decrease and blood pressure falls as an adaptive response to starvation. Patient may have orthostatic changes. May cause cardiac collapse if patient exerts himself.
  
• Blood flow is reduced.
  
• The heart muscles starve, losing size ie. reduced left ventricular mass, thinning of the left ventricular wall.
  

  
  

  
  

  A primary danger to the heart is from abnormalities in the balance of minerals, such as potassium, calcium, magnesium, and phosphate, which are normally dissolved in the body's fluid. The dehydration and starvation that occurs with anorexia can reduce fluid and mineral levels and produce a condition known as electrolyte imbalance. Electrolytes (calcium and potassium) are critical for maintaining the electric currents necessary for a normal heartbeat. An imbalance in these electrolytes can be very serious and even life threatening unless fluids and minerals are replaced.
  

  
  

  
  

  
  

  GASTROINTESTINAL SYSTEM
  

  The effects of anorexia on the gastrointestinal (GI) system are important both psychologically and physiologically.
  

  
  

  Psychologically
  

  • Anorexics have an exaggerated sense of the size of their stomach in terms of
    
    • Outward appearance
      
    • How they imagine their stomach appears inside their body.
      
  • When they eat, they picture their stomach ballooning out.
    
  • They have prolonged sense of fullness after a meal due to delayed gastric emptying after a period of restricted eating.
    
  • In their minds, the feeling of being "full" becomes equated with being "fat," which reinforces their fear of eating regular meals.
    

  
  

  Physiologically
  

  • Constipation, due mostly to drastically reduced calorie intake, invariably accompanies weight loss in anorexia nervosa.
    
  • Most anorexics have a period (about 2 weeks) when they begin eating regular amounts of food where they have stomach pain, nausea, gastric bloating, cramps, and diarrhea before the GI system starts to readjust.
    
  • Not only the stomach, but the whole GI tract can suffer from decreased motility. Constipation is common.
    
  • Starvation can also cause a nutritional hepatitis with decreased total protein, elevated transaminases, and increased bilirubin. It usually does not lead to severe liver disease unless the person also abuses alcohol.
    
  • Anorexics cannot be given too large a glucose or carbohydrate load as a large amount of phosphate will be rapidly consumed as it is used to metabolize glucose, and phosphate levels can fall dangerously low. The low phosphate can cause cell breakdown and milder symptoms of muscle weakness, fatigue, nausea, and vomiting.
    
  • In more severe cases, it can cause life threatening epilepsy, cardiomyopathy, hemolytic anemia, respiratory failure, coma, and even death.
    
  • Pancreatitis can also occur during refeeding, and starvation-induced hepatitis may also worsen initially during re-feeding.
    

  
  

  COMPLICATIONS IN ADOLESCENTS WITH TYPE 1 DIABETES
  

  A study of over 2,000 women found that bulimia, or a combination of bulimia and anorexia, was more common among women with type 1 diabetes.
  

  The complications of eating disorders that affect all patients are even more dangerous in this group of patients. Low blood sugar, for example, is a danger for anyone with anorexia, but it is a particularly dangerous risk for those with diabetes.
  

  • If patients do not take their insulin, high blood sugar, which is also very dangerous, can occur. Unfortunately, patients with eating disorders may skip or reduce their daily insulin in order to decrease their intake of calories. Extremely high blood sugar levels can cause diabetic ketoacidosis, a condition in which acidic chemicals (ketones) accumulate in the body. This condition can lead to coma and death.
    

  
  

  Hematologic
  

  Complications
  

  DecreasedWBCoccurs in up to60% of patients with anorexia.8,23 Patients' BMI is correlated with leucocyte and neutrophil count.23 Anemia, which is usually normocytic,23 and thrombocytopenia occur in 30% of patients.
  

  Anemia is a common result of anorexia and starvation. A particularly serious blood problem is pernicious anemia, which can be caused by severely low levels of vitamin B12. If anorexia becomes extreme, the bone marrow dramatically reduces its production of blood cells, a life-threatening condition called pancytopenia.
  

  PSYCHOLOGICAL EFFECTS AND SUICIDE
  

  Adolescents with eating behaviors associated with anorexia (fasting, frequent exercise to lose weight, and self-induced vomiting) are at high risk for anxiety and depression in young adulthood. Alcohol and drug abuse are more common in patients with anorexia. Suicide has been estimated to account for as many as half the deaths in anorexia with studies showing up to a fifth of anorexic patients attempting suicide.
  

  
  

  Dermatological alterations
  

  • Brittle hair, eyelash and nails
    
  • Loss of hair and eyebrow
    
  • A dystrophic aspect of the skin (related to nutitional deficiencies)
    
    • Looks dry and scaling
      
    • Pale or yellowish (due to hypercarotenaemia)
      
  • Skin often covered by a fine, downy-like hair defined as lanugo, growing especially on the face, superior lip, back, arms and legs (possibly linked to hypothyroidism).
    
  • Poor wound healing
    
  • Facial dermatitis, seborrheic dermatitis and acne are occasionally observed

Neurological

• seizures
• disordered thinking
• numbness or odd nerve sensations in the hands or feet (peripheral neuropathy)
• Abnormalities in brain structure and function are seen in the early course of the ilness in adolescents.
• Enlarged ventricles with reduction in white matter
• Regional cerebral blood fllow is reduced, predominantly in the temporal lobe but also lesser extent in the parietal, and orbitofrontal lobes.
• May be only partially reversed with weight gain

Mental Status Examination Extra

Hey, here is just some extra stuff if you guys are interested in the psychiatric interview process. And you have time here is the link.

http://www.psychsign.org/psych_cards.pdf



Psychiatric Review of Systems
a. Depressive:
S: Have you had periods of feeling sad, despondent or hopeless?
I: Have you noticed a change in your interest in things you normally enjoy?
G: Have you been feeling down on yourself? Guilty about anything?
E: Have you tended to feel more tired than usual? As if all your energy is drained?
C: Have you had trouble concentrating? Making decisions?
A: Have you had any changes in your appetite? Lost or gained weight?
P: Have you felt restless or agitated? Have you been feeling slowed down?
S: have you had trouble sleeping? (initial, middle, terminal)
S: Have you ever felt that life isn’t worth living? Thought about taking your own life?


b. Anxiety:
1. Have you ever experienced a sudden attack of panic or fear in which you felt
extremely uncomfortable? Did you feel as if you were going to die or go crazy?
2. Ever been afraid of going outside, so that you tended to stay home all the time?


c. OCD
1. Are you ever bothered by persistent ideas that you can’t get out of your head,
such as being dirty or contaminated?
2. Is there anything you have to do over and over, such as washing your hands or
checking the stove?


d. Mania:
DIGFAST (distractibility, insomnia, grandiosity, flight of ideas, activity,
speech, thoughtlessness)
1. Have you ever felt extremely good or high, clearly different from your NL self?
2. Have you felt your thoughts are racing through your mind?
3. Did you need less sleep than usual to feel rested?
4. Have you done anything that caused trouble for you or your family/friends?


e. Psychosis

Delusions:
• Persecutory: have you felt that people are against you? Trying to harm you in
any way?
• Grandiose: Do you have any special powers, talents or abilities?
• Thought broadcasting: Have you heard your own thoughts out loud, as if they
were a voice outside your head? Have you felt that your thoughts were
broadcast so that other people could hear them?

Hallucinations:
• Have you heard voices no one else could hear? When no one was around
and you couldn’t account for them? Seen things?

Anorexia & The Law

Mental Health Act 1983 [Original Text]

The Mental Health Act 1983 covers the assessment, treatment and rights of people with a mental health condition. It applies to the people of England and Wales.

Treatment of Anorexia Nervosa under Mental Health Act 1983 [Original Text]

For many anorexic patients, compulsory measures will be unnecessary – the decision whether to use the Mental Health Act 1983 (MHA 1983) arises when the physical health or the survival of a patient may be seriously threatened by food- or fluid-refusal.

Anorexia Nervosa, described in the 10th revision of the International Classification of Diseases (ICD-10) under the heading of Eating Disorders:

"Anorexia nervosa is a disorder characterised by deliberate weight-loss, induced and/or sustained by the patient. The disorder occurs most commonly in adolescent girls and young women, but adolescent boys and young men may be affected more rarely, as may children approaching puberty and older women up to the menopause. Anorexia nervosa constitutes an independent syndrome in the following sense:
a) the clinical features of the syndrome are easily recognised so that diagnosis is reliable with a high level of agreement between clinicians;
b) follow-up studies have shown that, among patients who do not recover, a considerable number continue to show the main features of anorexia nervosa in a chronic form".

For a definite diagnosis, ICD-10 suggests that all these criteria should be met:

1. Body weight maintained at least 15% below expected body weight;
2. Self-induced weight-loss by:
   a. Avoidance of fattening foods;
   b. Vomiting;
   c. Purging;
   d. Excessive exercise;
   e. Use of appetite suppressants/diuretics;
3. Body image distortion with a dread of fatness;
4. Widespread endocrine disorder involving the hypothalamic/pituitary/gonadal axis;
5. If the onset is pre-pubertal, pubertal events are delayed or arrested.
   

ICD-10 also refers to:

1. The occurrence of depressive/obsessional symptoms;
2. The presence of features of a personality disorder;
3. The importance of distinguishing somatic causes of weight loss in young patients:
   a. Chronic debilitating diseases;
   b. Brain tumors;
   c. Intestinal disorders (Crohn’s Disease/malabsorption syndrome).
   

Might an anorexic be detained under MHA 1983?

Mental disorder is broadly defined in MHA 1983 – it is a matter for the clinical judgment of the medical practitioners who carry out the medical assessments whether, in the case of a particular patient, the criteria for admission are met.

Standard texts of psychiatry agree that anorexia nervosa is classifiable as a mental disorder and patients can therefore be detained in hospital under the provisions of the MHA 1983.

Detention is justified in rare cases of serious threat to health, where compulsory feeding may be necessary to combat both the physical complications and the underlying mental disorder.

The revised MHA 1983 Code of Practice advises an application for compulsory admission to be made by an Approved Mental Health Practitioner (AMHP) rather than the patient’s Nearest Relative.

An AMHP will have the same responsibilities and duties when assessing a patient with anorexia nervosa as s/he would have with a patient suffering from any other form of mental disorder – the least restrictive alternative should be used when providing compulsory treatment. However, in the case of an anorexic, this principle may be compromised by the need to treat his/her self-imposed starvation.

In what circumstances can treatment be given compulsorily for a detained anorexic patient?

Where a patient with anorexia nervosa is detained under MHA 1983, then, in accordance with Chapter 23 of the MHA 1983 Code of Practice, valid consent should always be sought for the medical treatment proposed.

Medical treatment under MHA 1983 ‘includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care…’ the purpose of which is to alleviate, or prevent a worsening of the disorder or one or more of its symptoms or manifestations – thus it covers a broad range of activities, potentially including feeding by naso-gastric tube etc.

Anorexia nervosa and the capacity to consent

Every adult is presumed to have the capacity to decide whether to accept medical treatment, even if s/he refuses treatment for reasons that seem irrational or non-existent – a person is not to be considered incapable of giving consent merely because s/he suffers from mental disorder.

The MHA 1983 Code of Practice sets out the basic principles that determine whether a patient possesses the capacity to consent.

There is a consensus that some patients with anorexia nervosa – who might have the intellectual capacity to understand the nature, purpose and likely effect of treatment – may be unable to give valid consent, perhaps because their capacity to consent is compromised by fears of obesity or by denial of the consequences of their actions.

Section 63

MHA 1983, section 63 states that:

'The consent of a patient shall not be required for any medical treatment given to him for the mental disorder from which he is suffering, not being a form of treatment to which section 57, 58 or 58A above applies, if the treatment is given by or under the direction of the approved clinician in charge of the treatment.’

Treatment for many anorexic patients might include a behavioural programme designed to help them overcome the compulsion of food refusal. If so, practitioners should be aware of their own ethical and legal obligations, and of the need to avoid treatments that might be degrading or inhumane, such as the restriction of movement or natural functions.

They should also be aware that their actions must not contravene

1. Mental health or other legislation (e.g. MHA 1983, section 127, which concerns ill-treatment or wilful neglect of a patient), or;
2. The European Convention on Human Rights (particularly the Article 3 prohibition on torture or inhuman or degrading treatment, and the Article 8 right to respect for one’s private and family life).

Does such treatment include the authority to feed the patient compulsorily?

MHA clearly allows the administration of medicines in the absence of consent as a treatment for mental disorder.

The House of Lords has ruled that feeding a patient by artificial means may constitute ‘medical treatment’. It follows, and has been accepted by the Courts, that naso-gastric feeding may be a medical process, forming an integral part of the treatment for anorexia nervosa.

Riverside Health NHS Trust v Fox

The Judge observed: ‘until there is steady weight gain no other treatment can be offered for the respondent’s mental condition so I hold that forced feeding if needed will be medical treatment for the disorder’, for the debate whether feeding constitute ‘medical treatment for the mental disorder’.

The clinician in charge of the compulsory feeding must be satisfied that the food refusal which is being treated is part of the mental disorder in order to use the authority of s.63. In these circumstances further diagnostic and monitoring procedures may be necessary, including venipuncture (the process of obtaining IV access for IV therapy or obtaining a sample of venous blood), as part of the medical treatment for the mental disorder Authority for such additional procedures might be found under s.63, possibly also justifiable under the common law action that is taken in an emergency as the minimum necessary to prevent serious injury or loss of life.

Summary

In every case there will have to be:

1. Proper consideration of the alternatives;
2. A multi-disciplinary decision as to the most appropriate way of managing the patient’s overall care;
3. A mechanism for ensuring that any compulsory treatment is given under the direction of the approved clinician in charge of the treatment;
4. A way to end use of compulsory powers when they are no longer appropriate.

Laws of Malaysia: Act 615 (Mental Health Act 2001) [Original Text]

Admission of involuntary patient into psychiatric hospital
10.

1. A person who is suspected to be mentally disordered may be admitted and detained in a psychiatric hospital upon—
   a) An application made in the prescribed form to the Medical Director by a relative of the person; and
   b) The production of a recommendation in the prescribed form of a medical officer or registered medical practitioner based on a personal examination of the person made not more than five days before the admission of the person that—
   i. The person is suffering from mental disorder of a nature or degree which warrants his admission into a psychiatric hospital for the purposes of assessment or treatment; or
   ii. The person ought to be detained in the interest of his own health or safety or with a view to the protection of other persons.
   
   
2. The application and the recommendation in subsection (1) are sufficient authority for the person making the application, or a police officer or any other person authorized by the person making the application, to take the person to whom the recommendation relates to a psychiatric hospital.
   
   
3. Where a person is admitted to a psychiatric hospital under this section, the Medical Director of the psychiatric hospital shall, within twenty-four hours of the person's admission, make or cause to be made on him by a medical officer or a registered medical practitioner such examination as the Medical Director may consider necessary for determining whether or not the continued detention of the person is justified.
   
   
4. The medical officer or registered medical practitioner who makes the recommendation under paragraph (1)(b) or who admits the patient under subsection (1) shall not examine the patient under this subsection.
   
   
5. Where upon the examination of the person under subsection (3) the Medical Director—
   a) Is not satisfied that the continued detention of the person is justified, he shall discharge the person; or
   b) Is satisfied that the continued detention of the person is justified, he shall make an order in the prescribed form signed by him for the detention of the person for a period not exceeding one month.
   
   
6. Where a person who is detained by order issued under paragraph (5) (b) or subsection 9(5) is not sooner discharged, the Medical Director of the psychiatric hospital shall, before the expiration of the order, cause to be made on the person such examination as he may consider necessary for determining whether or not the continued detention of the person is justified.
   
   
7. The examination of the person under subsection (6) shall be done by two medical officers or registered medical practitioners, as the case may be, one of whom shall be a psychiatrist.
   
   
8. Where upon the examination of the person under subsection (6), the medical officers or registered medical practitioners, as the case may be—
   a) Are not satisfied that the continued detention of the person is justified, they shall discharge the person; or
   b) Are satisfied that the continued detention of the person is justified, they shall make an order in the prescribed form signed by them for the detention of the person for a further period not exceeding three months.

Signs and Symptoms of Eating Disorders

Warning signs of eating disorders
Many people worry about their weight, what they eat, and how they look. This is especially true for teenagers and young adults, who face extra pressure to fit in and look attractive at a time when their bodies are changing.
In the early stages, it can be challenging to tell the difference between an eating disorder and normal self-consciousness, weight concerns, or dieting. As eating disorders progress, the red flags become easier to spot. But a person with an eating disorder will often go to great lengths to hide the problem, so it’s important to know the warning signs.
Restricting food or dieting
The most obvious warning signs of eating disorders involve restrictive eating behaviors. A friend or family member with an eating disorder may frequently skip meals or make excuses to avoid eating—he or she had a big meal earlier, isn’t hungry, or has an upset stomach. The person may also claim to be disgusted by foods that used to be favorites.
When your loved one does eat, he or she may take tiny servings, eat only specific low-calorie foods, or obsessively count calories, read food labels, and weigh portions. In an effort to curb appetite, your friend or family member may also take diet pills, prescription stimulants like Adderall or Ritalin, or even illegal drugs such as speed.
Bingeing
Some people with eating disorders eat normally around others, only to binge in secret—usually late at night or in a private spot where they won’t be discovered or disturbed. Warning signs of bingeing include piles of empty food packages and wrappers, cupboards and refrigerators that have been cleaned out, and hidden stashes of high-calorie foods such as desserts and junk food.
Purging
People with eating disorders often go to extreme measures to work off calories from a binge or even a normal snack or meal. They may purge by throwing up, fasting, exercising vigorously, or using diuretics and laxatives.
Common warning signs of purging include disappearing right after a meal or making frequent trips to the bathroom. If your friend or family member is vomiting, he or she may run the water to muffle the sound and use mouthwash, breath mints, or perfume to disguise the smell.
Distorted body image and altered appearance
A loved one’s appearance can also offer clues to an underlying problem. Significant weight loss, rapid weight gain, and constantly fluctuating weight are all possible warning signs. A person with an eating disorder may also wear baggy clothes or multiple layers in an attempt to hide dramatic weight loss.
Other warning signs include a distorted self-image or an obsessive preoccupation with weight. A relative complains about being fat despite a dramatically shrinking frame, for example, or a friend spends hours in front of the mirror, inspecting and criticizing her body.
Common eating disorder warning signs
§ Preoccupation with body or weight
§ Obsession with calories, food, or nutrition
§ Constant dieting, even when thin
§ Rapid, unexplained weight loss or weight gain
§ Taking laxatives or diet pills
§ Compulsive exercising
§ Making excuses to get out of eating
§ Avoiding social situations that involve food
§ Going to the bathroom right after meals
§ Eating alone, at night, or in secret
§ Hoarding high-calorie food




Anorexia Nervosa
Dramatic weight loss in a relatively short period of time
Wearing big or baggy clothes or dressing in layers, to hide body shape and/or weight loss
Obsession with weight and complaining of being overweight
Obsession with calories and fat content of foods
Obsession with continuous exercise
Visible food restriction and self-starvation
Use or hiding use of diet pills, laxatives, ipecac syrup or enemas
Fear of eating around and/or with others
Hiding food in places like closets, cabinets or suitcases, to avoid eating it
Flushing uneaten food down the toilet
Vague or secretive eating patterns.
Keeping a "food diary"
Pre-occupied thoughts of food and weight
Visiting websites that promote unhealthy ways to lose weight
Reading books about weight loss and eating disorders
Hair loss
Pale or "grey" appearance to the skin
Dizziness and headaches
Low self-esteem
Feeling worthless
Need for acceptance and approval from others
Complaints of often feeling cold.
Low blood pressure
Loss of menstrual cycle
Constipation or incontinence
Perfectionist personality
Loss of sexual desire
Mood swings
Depression
Fatigue
Insomnia or poor sleeping habits
Bulimia
Frequent trips to the bathroom immediately after meals (at times accompanied with water running in the bathroom for a long period of time - to hide the sound of vomiting).
Visible bingeing and/or purging
Hiding food in places like closets, cabinets or suitcases, to eat it later
Maintaining a list that consists of food and/or behaviors, like purging, restricting, calories consumed, exercise, etc
Self-defeating statements after food consumption
Frequent soar throats and/or swollen glands
Abnormal bowel functioning
Damaged teeth and gums
Swollen salivary glands in the cheeks
Sores in the throat and mouth
Bloating
Dehydration
Fatigue
Dry skin
Irregular heartbeat
Sores, scars or calluses on the knuckles or hands
Menstrual irregularities or loss of menstruation (amenorrhea)
Feeling that they can't control your eating behavior
Eating until the point of discomfort or pain
Self-induced vomiting
Laxative use
Excessive exercise
Unhealthy focus on body shape and weight
Having a distorted, excessively negative body image
Depression or anxiety
Binge Eating
Fear of not being able to control eating
While eating, not being able to stop
Chronic dieting on a variety of popular diet plans
Eating much more food during a binge episode than during a normal meal or snack
Eating faster during binge episodes
Feeling that the eating behavior is out of control
Frequent dieting without weight loss
Frequently eating alone
Hoarding food
Hiding empty food containers
Feeling depressed, disgusted or upset over the amount eaten
Holding the belief that life will be better if they can lose weight
Vague or secretive eating patterns
Self-defeating statements after food consumption
Blaming weight for failure in social and professional community
Holding the belief that food is their only friend
Frequently out of breath after relatively light activities
Excessive sweating and shortness of breath
High blood pressure and/or cholesterol
Leg and joint pain
Weight gain
Decreased mobility due to weight gain
Loss of sexual desire
Poor sleeping habits

Pathophysiology of Anorexia Nervosa

Pathophysiology Of Anorexia Nervosa
Most of the medical complications of anorexia nervosa result from starvation. Few organs are spared the progressive deterioration brought about by anorexia.
Cardiovascular Changes
People who suffer from Anorexia Nervosa severely restrict the amount of calories they consume, which means the body is not getting adequate nutrients. The body then slows down all bodily processes. Eventually, it will begin to consume itself, leading to muscle and bone loss. Most of those die from heart disease, as the heart especially suffers from the effects of anorexia. The heart muscles as well act as a source of energy for the body and the muscles undergo atrophy. Muscle mass of the heart decreases until that it cannot generate enough force to pump blood adequately to other parts of the body. This results in heart failure, hypotension, fatal heart arrhythmias and heart rate could be as low as 50 beats/min (sinus bradycardia). A reduction in the work capacity of the heart is associated with severe weight loss and starvation.
Gastrointestinal Changes
Constipation is a common complication of anorexia. In fact, many cases of anorexia come to the attention of doctors when anorexics seek out treatment for constipation. Dehydration can arise with severe weight loss, starvation, and abuse of laxatives, so it is not surprising that it is such a common complaint among anorexics. As anorexia progresses and starvation complications become more pronounced, a number of gastrointestinal problems may develop, both in combination with or independent from constipation. Normal movement in intestinal tract often slows down with very restricted eating and severe weight loss. Gaining weight and some medications help to restore normal intestinal motility. Gastrointestinal mobility slows, and it takes longer for the gastric system to empty. Some anorexics also develop abnormal muscle activity in the esophagus. Gastric problems such as constipation, bloating, and a sensation of early fullness all tend to suppress the urge to eat, thus speeding up the process of weight loss and starvation.
Endocrine Abnormalities (The Glandular System)
Disturbances in the menstrual cycle are frequent and can affect not only fertility but also bone density, which is very important to a woman's health as she ages. Hormonal imbalances are found in men with anorexia as well. Continual restrictive eating can trick the thyroid into thinking that the body is starving, causing it to slow down in an attempt to preserve calories.
Amenorrhea (cessation of the menstrual cycle) is one of the hallmark symptoms of anorexia, when a menstrual period is missed for three or more months without any other underlying cause. Amenorrhea often precedes severe weight loss and continues after normal weight is restored. Reduced levels of growth hormones are sometimes found on anorexic patients and may explain growth retardation sometimes seen in anorexic patients. Normal nutrition usually restores normal growth.

Bone Changes
Persons with anorexia are at an increased risk for skeletal fractures (broken bones). When the onset of anorexic symptoms occurs before peak bone formation has been attained (usually mid to late teens), a greater risk of osteopenia (decreased bone tissue) or osteoporosis (bone loss) exists. Bone density is often found to be low in females with anorexia, and low calcium intake and absorption is common. An 18-year-old high school student can have bones as fragile as those of her 84-year-old grandmother.
Other Changes
Kidney (renal) function may appear normal. However, there are significant changes in kidney function in many people with anorexia, resulting in potassium deficiency, increased urination, or decreased urination.
Anorexics who use a large quantity of laxatives or who frequently vomit are at great risk for electrolyte imbalance, which can have life-threatening consequences.
Anemia is frequently found in anorexic patients. Suppressed immunity and a high risk for infection are suspected, but not clinically proven.
Physical Symptoms
Physical symptoms, other than the obvious loss of weight, can be seen. Anorexia can cause dry, flaky skin that takes on a yellow tinge. Fine, downy hair grows on the face, back, arms, and legs. Despite this new hair growth, loss of hair on the head is not uncommon. Nails can become brittle. Frequent vomiting can erode dental enamel and eventually lead to tooth loss.

Mental State Examination

Component	Observation	Common findings	Illness
General Appearance	Body Build Posture Clothing (Appropriateness/ Color) Grooming Hygiene Physical Stigmata(Tattoos) Facial Expression (depression, worry)	Bizarre Appearance	Mania, Schizophrenia, Personality disorder
		Unkempt	Schizophrenia, Depression
		Anxious, Apprehensive	Anxiety disorder
		Over Bright Clothing	Mania, Personality disorder
		Scarred wrist, tattoos	Personality disorder
Speech	Tempo Modulation Quality	Increased Tempo	Mania, Acute Schizophrenia
		Slowed	Depression
Mood	Persistent Emotional State: Depth Intensity Duration Fluctuation of mood	Depressed	Depression
		Anxious/irritable	Anxiety disorder, Depression
Affect	The way patient conveys emotional state: Full Blunted Restricted Inappropriate	Blunted/Restricted	Schizophrenia
Thought	Thought Form - Quantity of ideas(pressured /slow) - Flow (Fragmented, connected) - Logical Thought content - Suicidal - Delusion	Disorder of thought form	Schizophrenia
		Flight of ideas	Mania, schizophrenia
		Poverty of ideas	Schizophrenia, mania depression
		Delusions	Schizophrenia, mania, depression
Perception	Hallucination(does it have clear sensorium )	Visual Hallucination	Alcohol withdrawal, drug intoxication, acute brain syndrome, epilepsy
		Auditory Hallucination	schizophrenia
		Tactile(touch) / Gustatory (taste)	Schizophrenia, epilepsy
Cognition	Alertness/ Conciousness - Level of alertness - Fluctuating levels	clouding	delirium
	Orientation - Time - Place - Person	Disorientation	Dementia, Delirium
	Short term memory	Loss of short term memory	Dementia, Delirium
	Long term memory	Loss of long term memory	Dementia
	Concentration	Poor concentration	Delirium, acute psychosis
	General Knowledge and intelligence	Poor general knowledge	Dementia, Delirium
Judgment	Capacity to behave properly	Impaired judgment	Psychoses, dementia. Personality disorder
Insight	Awareness of own problem and level of understanding	Lack of insight	Psychoses, dementia