Anorexia Nervosa Past Paper PDF

# Heilpraktiker-Prüfungstrainer Psychotherapie **14.06.24, 23:13** ## Anorexia nervosa !! ### Synonym Magersucht ### Definition The Anorexia nervosa is defined as self-induced or maintained weight loss, due to a distorted body image (body schema disorder) and massive fear of a thick body. The di...

# Heilpraktiker-Prüfungstrainer Psychotherapie **14.06.24, 23:13** ## Anorexia nervosa !! ### Synonym Magersucht ### Definition The Anorexia nervosa is defined as self-induced or maintained weight loss, due to a distorted body image (body schema disorder) and massive fear of a thick body. The disorder leads to malnutrition of varying severity. **Attention:** Anorexia means "lack of appetite" in translation - this term is misleading because the patients do not lose their appetite, but are afraid of gaining weight or have a desire to lose weight. ### Häufigkeit Women and girls are about 10 times more affected than men and boys. The peak incidence is between the ages of 15 and 25, although the disorder can develop at any age. The average age of onset is 16-17 years, with peaks in the 14th and 18th year of life. Approximately 1% of all female teenagers are affected. **Note:** The incidence of Anorexia nervosa has remained fairly constant in recent decades, despite media reports to the contrary, and is relatively unaffected by the fashionable ideal of thinness. However, a shift towards younger age groups is observable. ### Ursachen As with most mental disorders, a multifactorial genesis is assumed, the following theories and factors are to be mentioned: - **Genetic Factors:** about 60% concordance in identical twins. - **Sociocultural Factors:** "Learning by example" through family, peer group, media; but also positive reactions of the environment to "successful" diets, whereby the behavior shown (diet, weight loss) is reinforced in the sense of positive reinforcement. - **Neurobiological Factors:** Disturbances in hormonal control circuits. - **Psychodynamic Factors:** Disturbances in conflict resolution, primarily unconscious dependency-autonomy conflict: the patients try to gain control and power over their own bodies, but also in the family. At the same time, there is (due to age) a dependence on the parents and a feeling of helplessness in the face of the changes to the body during puberty. - **Stressful life events as triggering factors:** e.g. loss of significant others, abuse. - **Risk factors:** low self-esteem, social withdrawal. - **Addiction-like behavior:** Successful weight loss can have euphoric and tension-reducing effects ("fasting euphoria"), which can have addictive effects. **Ursachenmodell der Anorexia nervosa:** The diagram shows different factors and their interplay. ### Körperliche Veränderungen Dangerous and sometimes permanent are the secondary physical changes due to malnutrition and the measures to avoid weight gain: - **Gastrointestinal Tract:** chronic constipation, predisposition to caries, swelling of the salivary glands (sialadenitis) - **Cardiovascular System:** low heart rate, low blood pressure, cardiac arrhythmias or even sudden cardiac death due to potassium deficiency. - **Metabolism:** insufficient carbohydrate intake (especially during physical exertion) → low blood sugar, tendency towards low body temperature (without true hypothermia) with sensitivity to cold. - **Hormonal disorders:** - **Increased cortisol levels in blood (hypercortisolism) → e.g. increased susceptibility to infection**. - **Low levels of sex hormones (hypogonadotropic hypogonadism)** with menstrual irregularities to amenorrhea (absence of menstruation) in girls or loss of libido and potency in boys, decreased bone density with risk of osteoporosis and bone fractures, delayed puberty development. - **Skin and Hair:** brittle hair, diffuse hair loss, dry, easily irritated skin, edema as a result of protein deficiency, lanugo hair. - **Blood and Immune System:** Anemia, low white blood cell count, increased susceptibility to infection. - **Nervous System:** disturbances of the peripheral nerves (polyneuropathy), pseudo-brain atrophy with cerebrospinal fluid expansion, memory problems. - **Electrolyte disturbances:** low concentrations of potassium, chloride and phosphate in the blood (hypokalemia, hypochloremia, hypophosphatemia). ### Symptome The diagram show different organs and how they are affected. ### Patientin mit Anorexia nervosa: Body weight 33 kg with a height of 166 cm (example from a book about medical history). ### Komplikationen Electrolyte disturbances can permanently damage the kidneys and/or cause life-threatening cardiac arrhythmias. Due to increased susceptibility to infection, patients are vulnerable to infections. Ultimately, patients "die intentionally", acute life-threatening risk exists with a BMI < 14.0 kg/m². A BMI < 10 kg/m² is generally not compatible with life. In addition, the suicide risk is significantly increased. ### Diagnosestellung The basis for weight assessment in eating disorders is the Body Mass Index (BMI). It is defined as: (body weight in kg)/(body height in m)². Underweight in adults is defined by a Body Mass Index (BMI) < 18.5 kg/m². Early diagnosis or initiation of therapy before the manifestation of massive physical changes improves the prognosis, which is why anorexia should be considered and at least roughly investigated in the following groups of patients: - girls and young women with low body weight and/or signs of malnutrition. - young women with menstrual irregularities. - children with delayed growth or delayed puberty development. - underweight or normal weight girls and young women with weight concerns. ### Diagnostische Kriterien nach ICD-10: - body weight ≥ 15% below expected weight or BMI ≤ 17.5 kg/m² (in adults). - weight loss is self-induced through dieting or avoidance of high-calorie foods and one or more of the following measures: - excessive activity/sports. - self-induced laxative use. - self-induced vomiting. - use of appetite suppressants and/or diuretics. - body schema disorder (excessive fear of becoming overweight), which leads the patients to set a very low weight threshold for themselves. - lack of sex hormones (in girls/women: amenorrhea, in men: loss of libido and potency). - if onset before puberty: delayed or inhibited progression of physical development (e.g. growth retardation). ### Differenzialdiagnosen Organic causes for weight loss must be ruled out, especially malignant diseases (e.g. leukemia), infections (e.g. tuberculosis), hormonal and metabolic disorders (e.g. hyperthyroidism, diabetes mellitus) and gastrointestinal diseases (e.g. Crohn's disease, celiac disease). ### Wichtige psychological Differential diagnoses: - **Mood disorders (e.g. loss of appetite in severe depressive episode, physical hyperactivity in manic episode): mood symptoms in the foreground, generally no significant complaints about weight problems.** - **Psychoses or schizophreniform disorders (e.g. with poisoning mania): additional psychotic symptoms (e.g. hallucinations, delusions that are not consistent with reality).** - **Obsessive-compulsive disorder with eating-related obsessive symptoms:** pronounced control compulsions can affect eating behavior and lead to strictly controlled dieting, for example. - **Substance use or substance dependence (e.g. opioid dependence, dependence on cocaine or amphetamines):** thorough anamnesis, if necessary blood and/or urine tests. - **Somatoform disorder:** The main symptom is various physical complaints for which no organic correlate can be found. Significant weight loss, e.g. due to gastrointestinal complaints, is possible, but body schema disorder and fear of weight gain are not present. - **Distinction from Bulimia nervosa:** These patients also show an intensive preoccupation with food, a fear of weight gain and a body schema disorder. However, patients with bulimia nervosa are more likely to be of normal weight (although overweight and mild underweight are also possible). However, there are mixed forms of bulimia and anorexia. ### Therapie Often, the course of the disease is lengthy. A problem is the lack of illness insight of the patients, which is why they are often referred to therapy by their families. Often, outpatient therapy at the patient's place of residence is combined with periods of inpatient therapy. Therapy includes the following key areas: - **Controlled normalization of body weight (weight gain of 500-1000 g/week):** It makes sense to make a treatment contract with the patients in which the treatment conditions such as target weight, meal plan, minimum weight gain per week and rewards for weight gain or penalties for non-compliance with the contract (operant conditioning) are recorded. - **Treatment of the consequences of malnutrition.** - **Psychosocial therapy:** Especially in inpatient, specialized facilities, psychosocial recovery, including improvement of the body image disorder, can be achieved. Potential interventions include behavioral therapy with operant reinforcers (changing behavior through pleasant or unpleasant consequences) in group and individual settings, relaxation techniques, food diaries, psychoeducation, social skills training, systemic family therapy and family counseling, psychodynamically-oriented therapy or psychoanalytic treatments as well as body-oriented therapies. - **Antidepressants have no proven positive effect on anorexia, but can be used in cases of concomitant depression.** Outpatient treatment can be attempted with a BMI > 16 kg/m², good treatment motivation and illness insight. Inpatient treatment is required at the latest with a BMI < 16.0 kg/m² (intervention weight) or life-threatening risk. If there is no illness insight and acute life-threatening risk, compulsory treatment (according to BGB § 1906) with forced feeding may be necessary. This situation should always be avoided if possible. **Attention:** If normal food intake is increased too quickly after prolonged starvation, a life-threatening refeeding syndrome can result. The daily amount of food and calories should therefore be increased cautiously and under laboratory monitoring. ### Prognose Anorexia nervosa has the highest mortality of all mental illnesses (10-20%), causes of death are primarily infections (approx. 40% of deaths), cardiac arrhythmias (approx. 25% of deaths) and suicide (approx. 17% of deaths). In general, the "rule of thirds" applies: About 1/3 of patients recover fully. In 1/3 of patients, the symptoms improve, but some remain, and relapses are possible. In 1/3 of patients, the course of the disease is primarily very severe and/or becomes chronic. Other mental disorders are very common concurrently or during the course: v.a. major depression (approx. 30-90% of patients) and dysthymia, but also substance abuse, anxiety disorders (approx. 60%, v.a. social phobia), personality disorders (v.a. avoidant PD, obsessive-compulsive PD and dependent PD) and obsessive-compulsive disorder (up to 30% of patients). Therefore, after treatment of the anorectic symptoms, one must be prepared for further decompensation in the further course of life with a syndrome shift (e.g. depressive episodes). The disorder can also lead to Bulimia nervosa or a binge-eating disorder. **©2009-2024 Georg Thieme Verlag KG**