Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Anorexia Nervosa
ANOREXIA NERVOSA
A symptom complex of nonorganic cause resulting in extreme weight loss in the preadolescent or adolescent
I. Etiology
A. Anorexia nervosa is generally hypothesized to be due to reactivation at puberty of the separation-individuation issue: the adolescent’s attempt to maintain or initiate a sense of autonomy and separateness from the mother.
B. Starvation gives the adolescent a sense of identity and control over what is happening to one’s body.
II. Incidence
A. Affects approximately 5% of women ages 15–30.
B. 90% to 95% of anorexics are female, with the peak onset occurring at ages 14 and 18 years.
C. Most cases are from middle to upper socioeconomic families but can be of any race, gender, age, or social stratum. Patients are commonly members of the same family.
D. Generally seen in perfectionists or “model children” with poor selfimages. They are high achievers academically and are frequently engaged in strenuous physical activity, such as varsity sports or vigorous exercise programs. Parents are often overprotective, controlling, and demanding. Children feel unable to live up to parental expectations despite strict adherence to these expectations.
E. In terms of body weight, 80% of anorexics respond to therapy, although other psychosocial problems may be prolonged. Amenorrhea persists in 13% to 50% even after weight returns to normal or is stabilized at 85% to 90% of ideal weight.
F. Mortality from physiologic complications or suicide is approximately 6%.
III. Subjective data
A. Weight loss
B. Amenorrhea: Absence of three consecutive menstrual periods
C. Constipation
D. Abdominal pain
E. Cold intolerance
F. Fatigue
G. Insomnia
H. Depression, loneliness
I. Dry skin and hair
J. Headaches (“hunger headaches”)
K. Fainting or dizziness
L. Anorexia
M. Pertinent subjective data to obtain
1. Preoccupation with food and dieting
a. History of dieting
b. Denial of hunger
c. Patient finds food revolting but may spend time preparing gourmet meals for others.
d. History of food rituals
2. Morbid fear of gaining weight
3. Weight history: Highest and lowest weights achieved
4. Vomiting after meals
5. Low self-esteem, poor body-image; patient complains of being fat, when in reality, one is not.
6. Dietary history
7. Menstrual history
8. Perceived body image
9. History of impulsive behaviors: Stealing, self-mutilation
10. History of suicide gestures
11. Excessive exercising
12. Laxatives, diuretics, or other medications used to control weight
13. Recent family or social stress
14. History of unpleasant sexual encounter; patient may be using starvation to try to halt development of secondary sex characteristics.
15. History of sexual activity; condition may be unconscious attempt to abort a pregnancy.
16. History of drug or alcohol abuse
N. Note: Anorexia nervosa may be identified in its early stages by a conscientious health care provider eliciting a history during a routine health maintenance visit. Any combination of the above should create a high index of suspicion.
IV. Objective data
A. Weight loss: More than 15% below ideal body weight (IBW) or in prepubertal patients, failure to gain height and weight
B. Emaciation: Patient appears gaunt, skeletal.
C. Bradycardia
D. Orthostatic hypotension
E. Hypothermia
F. Skin: Dry and flaky, lanugo hair, loss of subcutaneous fat, jaundice
G. Hair loss: Scalp and genital area
H. Extremities: Edema, cyanosis, mottling, cold; slow capillary refill in hands and feet
I. Compulsive mannerisms (e.g., handwashing)
J. Apathy, listlessness
K. Loss of muscle mass
L. Occasionally, scratches on palate from self-induced vomiting
M. Laboratory findings
1. Usually normal until later stages of malnutrition
a. CBC: Anemia
b. UA: Monitor SG (patients may water load prior to being weighed)
2. If experiencing amenorrhea
a. HCG to rule out pregnancy
b. TFT, prolactin, FSH
3. With malnutrition
a. Leukopenia: Characteristic of starvation
b. Lymphocytosis
c. Low sedimentation rate
d. Low fibrinogen levels
e. Low serum lactic dehydrogenase estrogens
f. Low T3
g. Electrolyte imbalance if vomiting: MG, Ca, Phos
h. BUN
(1) High with dehydration
(2) Low with low protein intake
i. Cholesterol levels often dramatically elevated in starvation states.
j. LFT may be mildly elevated.
k. Blood glucose: Low or low normal
4. Cranial MRI to rule out hypothalamic tumor if neurologic symptoms present and in all males (cerebral atrophy often seen). It will demonstrate decreased gray and white matter volumes.
5. CT scan demonstrates enlarged intracranial CSF spaces in the acute phase.
6. ECG for all patients who are purging or are bradycardic
V. Assessment
A. Diagnosis is made by evaluation of the subjective and objective data. Primary among these are the adolescent’s intense or morbid fear of being fat, a poor or distorted body image, and weight 15% or more below IBW (weight at which normal menstruation is restored in a menarchal female and weight at which normal sexual and physical development is restored in a premenarchal female.)
1. Identify types of anorexia
a. Restrictive type: Adolescent restricts calories and engages in vigorous activity.
b. Binge-eating, purging type: Use of laxatives, enemas, diuretics, and self-induced vomiting are considered purging.
B. Differential diagnosis
1. Inflammatory bowel disease
2. Endocrine disorders
3. Psychiatric illnesses (e.g., schizophrenia or depressive disorder)
4. Pregnancy (starving to abort pregnancy)
VI. Plan
A. Outpatient treatment
1. Refer to psychotherapist.
2. Refer to nutritionist.
3. Weekly visit to check weight and urine (water loading will be detected by specific gravity)
4. Refer family for counseling or parents group.
5. Restrict physical activity. Helps maintain weight by decreasing energy expenditure and can motivate sports-minded teenager to eat properly to resume activity.
6. Daily structure should include three meals a day.
7. Clearly identify parameters for admission:
a. Weight less than 85% of ideal body weight or acute weight loss with food refusal.
b. Dehydration
c. Electrolyte imbalance
d. EKG abnormalities
e. Severe bradycardia (40 bpm or less), hypotension (less than 80/50 mm Hg), hypothermia, orthostatic changes
f. Failure to make progress as an outpatient in 4 weeks (less than
0.5 k a week weight gain)
g. Refusal to eat
h. Suicidal ideation
i. Severe depression
B. Hospitalization indicated with severe malnutrition or for failure to make progress as an outpatient over a 4-week trial; treatment includes the following:
1. Family therapy
2. Behavior modification
a. Operant conditioning with positive reinforcers
b. Negative reinforcers
3. Pharmacotherapy
a. selective serotonin reuptake inhibitors (SSRIs)
b. Avoid tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), bupropion
VII. Education
A. This is a chronic condition and may require medical management and counseling for as long as 2 to 3 years.
B. A consistent approach by all caretakers and family is necessary.
C. Aversion to food decreases as self-image improves.
D. Emphasis should be on weight gain, not eating.
E. Recommended weight gain is about 3 lb/wk. Too rapid weight gain may cause adolescent to begin dieting again as it reinforces perceptions of being ineffective, powerless, and worthless.
F. Weekly weights preferable to daily weights.
G. Adolescent may drink copious amounts of water or conceal weights on body prior to weigh-in.
H. Bathroom use may need to be monitored for prevention of self-induced vomiting after meals.
I. Laxative use may continue if not closely monitored.
J. Anorexics who are cured generally stabilize at 85% to 90% of normal weight.
K. Television use should be monitored. Cultural influences such as television promote a preoccupation with food. In addition, television and fashion magazines are dedicated to a “thin is in” image—an ideal figure that few can hope to achieve.
L. Hospitalization should not be perceived as a punishment, but rather as an adjunct or intensification of treatment. It is increasingly difficult with some insurance plans to secure inpatient hospitalization for treatment of anorexia. In spite of established and accepted criteria developed for each patient, in many instances, patients have not been accepted for intensified treatment unless overtly suicidal (and that does not include the “notso-subtle signs” consisting of laxative and appetite suppressant abuse).
M. Acknowledge that the adolescent feels fat, and avoid stating that he or she looks thin because that can be perceived as a compliment.
N. Clearly identify threats to health: Cold hands and feet, amenorrhea, syncope represent physiologic reaction to starvation, much like an animal in hibernation.
O. Explain that unless the anorexic is dehydrated, most laboratory values (except for cholesterol, which is almost always elevated) will be within normal limits
VIII. Follow-up
A. Schedule on an individualized basis. Many patients need to be seen on a weekly basis and sometimes biweekly, until stabilized. It is an ongoing problem, and the child may need to be followed for years.
B. Contact patient or family following all referrals to ascertain that appointments have been made and kept, and to provide support.
National Association of Anorexia Nervosa and Associated Disorders, Inc. (ANAD). Mailing Address: Box 7, Highland Park, IL 60035. Toll-free hotline: 847-831-3438. Website: http://www.anad.org
The Massachusetts Eating Disorder Association (MEDA). Telephone: 617-558-1881. Website: http://www.medainc.org. E-mail: masseating@aol.com
National Eating Disorders Association. Telephone: 800-931-2237. Website: http://www.
NationalEatingDisorders.org
The Academy for Eating Disorders. Telephone: 703-556-9222. Website: http://www.aedweb.org The American Anorexia Bulimia Association. Address: 165 W. 46th St., Suite 1108, New
York, NY, 10036. Telephone: 212-575-6200. Website: http://www.aabainc.org