Overview

• Anorexia Nervosa → most common cause of admissions to child and adolescent psychiatric wards.
  • Epidemiology → 90% of patients are female. Prevalence between 1 in 100 to 1 in 200.
• DSM-V Criteria:
  1. Restriction of calorie intake leading to signifcantly low body weight.
  2. Intense fear of gaining weight or becoming fat, even though underweight.
  3. Disturbance in the way in which one’s body weight or shape is experienced.

Making Diagnosis

Clinical Features

• Features → low BMI, bradycardia, hypotension, enlarged salivary glands, muscle wasting, lanugo hair (fine downy hair growth in response to the loss of body fat).
  • Failure of secondary sexual characteristics.
  • Intentional Weight Loss → restriction of food, excessive exercise, induced vomiting / laxative use.
  • Amenorrhoea.
• Physiological Abnormalities → hypokalaemia, low FSH/LH/oestrogens/testosterone, raised cortisol and growth hormone, impaired glucose tolerance, hypercholesterolaemia, hypercarotinaemia, low T3.

Investigations

• Bedside → physical examination (BMI and BP).

  • Sit-up–squat–stand (SUSS) test → assess muscle wasting. Inability to stand up from a chair without using their hands indicates failure of the squat test, which is a red-flag sign indicating severe muscle wasting.

• Bloods (exclude organic causes and monitor complications):

  • Low → FBC (Hb, platelets, WCC), electrolytes (Na, K, PO), ESR, T4, glucose.
  • High (4C’s and 2G’s) → cortisol, cholesterol, CK, carotenaemia, GH, glands (salivary).

  <aside> 💡 Most things low except 4 C’s and 2 G’s.

  </aside>

Management Plan

Screen for immediate admission (use MHA if necessary) → BMI <13, weight loss >1kg/wk, septic signs (cold peripheries), HR <40bpm, suicide risk.

• Referral Pathways:
  • Severe (BMI<15, rapid weight loss, evidence of system failure) → urgent referral to CEDS (Community Eating Disorder Services).
  • Moderate (BMI 15-17, no evidence of system failure) → routine referral to CEDS.
  • Mild (BMI>17, no additional co-morbiditiy) → monitor/advice/support for 8 weeks, ‘BEAT’ charity support.
• First GP Presentation (alongside one of the three referral pathways above):
  • Plan Going Forward → nutrition and weight restoration. Set target weight and make eating plan to gain 0.5-1kg/wk.
• General Management:
  • Social:
    • Advise on nutrition and health.
    • Signpost support (BEAT eating disorders, MIND, NHS).
    • Plan going forward (with regular follow-up and review) → nutrition and weight restoration (set target weight + make eating plan to gain 0.5-1kg/week).
  • Psycho:
    • Adult Management → first line: CBT-ED, MANTRA (Maudsley Anorexia Nervosa Treatment for Adults), SSCM (Specialist Supportive Clinical Management).
    • Children Management (≤18yo) → first line: family therapy. Second line: CBT-ED.
      • Family Therapy → this approach involves the whole family in the treatment process, recognising their role in supporting recovery. It aims to empower parents to help their child regain weight and challenge eating disorder behaviours, while also addressing any underlying issues within the family dynamic.
  • Bio:
    • Medication for physical complications, rapid weight loss, or BMI <13.5.
    • Fluoxetine if depressed/OCD with food.