From the Guidelines
Anorexia nervosa is characterized by severe restriction of food intake, leading to significantly low body weight, and patients typically exhibit physical signs including emaciation, lanugo, bradycardia, hypotension, and amenorrhea in females. The physical exam findings for anorexia nervosa include:
- Emaciation
- Lanugo (fine body hair)
- Bradycardia
- Hypotension
- Amenorrhea in females
- Laboratory abnormalities such as electrolyte imbalances, anemia, and leukopenia. According to the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1, the initial physical examination of a patient with a possible eating disorder should include assessment of vital signs, height, weight, and BMI, as well as physical appearance, including signs of malnutrition or purging behaviors. Treatment requires a multidisciplinary approach centered on weight restoration, nutritional rehabilitation, and psychological intervention. For severely underweight patients (BMI <16), hospitalization may be necessary. Nutritional rehabilitation typically begins with 1,200-1,500 calories daily, gradually increasing by 200-300 calories every 2-3 days until reaching 3,000-4,000 calories for weight gain of 2-3 pounds weekly. Psychotherapy, particularly cognitive behavioral therapy (CBT), family-based treatment (FBT) for adolescents, and dialectical behavior therapy (DBT) are first-line psychological treatments. Medication has limited efficacy but may include olanzapine (2.5-10mg daily) to reduce anxiety around eating and weight gain, fluoxetine (20-60mg daily) for comorbid depression or obsessive features, and sometimes cyproheptadine (4-8mg three times daily) as an appetite stimulant. Medical monitoring should include regular assessment of vital signs, electrolytes, and cardiac function, as refeeding syndrome is a serious risk during initial refeeding. Recovery is often prolonged, requiring consistent support and monitoring for relapse, with the best outcomes occurring with early intervention and comprehensive treatment.
From the Research
Physical Exam Findings for Anorexia
- Sinus bradycardia is a common physical finding in patients with anorexia nervosa, occurring in up to 95% of patients 2
- Bradycardia may be associated with sudden death, especially in the presence of other arrhythmias or EKG abnormalities, such as prolongation of the QTc interval 2
- Other cardiac abnormalities associated with anorexia nervosa include pericardial and valvular pathology, changes in left ventricular mass and function, conduction abnormalities, hypotension, and dysregulation in peripheral vascular contractility 3
- Malnutrition associated with anorexia nervosa can affect nearly every organ system in the body, with cardiac complications responsible for 50% of the deaths in anorexia nervosa 4
- Physical examination may also reveal signs of malnutrition, such as weight loss, fatigue, muscle pain, and mood changes 5
Clinical Presentation
- Anorexia nervosa is characterized by restricted energy intake, intense fear of weight gain, and body image disturbances 5
- Patients may present with a range of symptoms, including fluctuating appetite, fatigue, muscle pain, mood changes, and sleep disturbances 5
- Psychiatric findings, such as obsessive weight monitoring and self-induced vomiting, may also be present 5
Treatment Options
- Early psychiatric intervention and multidisciplinary management are crucial to address malnutrition, electrolyte imbalances, and cardiac dysfunction 5
- Treatment may involve a combination of psychotherapy, psychopharmacology, and nutritional therapy 4
- Family therapy may be more effective than individual therapy in younger patients who have been ill for less than 3 years 4
- Medications, such as fluoxetine, may help prevent relapse in weight-restored patients 4