Snapshot A 17-year-old female presents to your office for an annual sports physical. She is the star of her high school track team. She has not menstruated for 5 months. Her BMI is 15 kg/m2. On physical exam you note calluses on the back of her hands and fine hair on her arms. She states that she only eats vegetables but has been trying to cut back as she thinks she is holding excess body fat. Introduction Clinical definition excessive dieting with or without purging due to distorted body image characterized by intense fear of weight gain frequent weight checks denial of emaciated state two types binging/purging laxatives/diuretics abuse excessive exercise restricting Epidemiology more common in females presents typically in adolescence (14 - 18 years) Associated conditions depression bulimia nervosa Presentation Symptoms amenorrhea (no longer mandatory for diagnosis per DSM-V) anemia Physical exam weight < 85% of ideal body weight hypotension bradycardia dental cavities lanugo very fine bodily hair Evaluation Serology CBC, BMP, and endocrine levels ECG arrhythmias present if potassium deficient Psychiatric evaluation Treatment Hospitalization if weight is < 75% expected body weight Psychotherapy behavioral therapy Pharmacologic SSRIs have added benefit of causing weight gain have not been proven to be effective in anorexia nervosa have some efficacy in bulimia nervosa Prognosis, Prevention, Complications Prognosis high mortality death most commonly from cardiac arrhythmia suicide in > 10% Complications osteoporosis metatarsal stress fractures electrolyte imbalances can lead to cardiac abnormalities refeeding syndrome use caution in feeding severely malnourished patients may cause death most commonly to hypophosphatemia avoid bupropion associated with lowered seizure threshold pregnancy complications breastfeeding issues post and peripartum depression prematurity intrauterine growth retardation