Mental Disorder

Females outnumber males 15:1
Most common in upper social classes.
Age onset 15.5 years average (87% within 5 years of menarche) Point prevalence - 1 % girls age- 16-18 years in private schools.
1-2% of female university students may suffer.
Minor variants in community more common than severe cases.
Recent increased incidence is likely, especially in less severe form.

Clinical Features

1. Physical

Marked loss of body weight and malnutrition due to:
Purposive avoidance of ‘fattening foods’, self induced vomiting and purgation, exercise, subterfuges in disposal of food.
Nutritional myopathy (gross muscle wasting with good power).
Bradycardia
Peripheral cyanosis
Normal secondary sexual hair
Episodic bulimia.

2. Endocrine

Specific hypothalamic hypophyseal failure of gonadotrophin secretion. In female, amenorrhoea preceds or coincident with weight loss in 50%.
In males loss of sexual interest, impotence may occur.
Low oetrogen, testosterone gonadortophin. Euthyroid. Raised GH, and cortical may be present. Delayed return of cyclical gonadotrophin output from pituitary when weight returns to normal.

3. Psychological

• Marked fear of becoming fat, explicit or implicit in behaviour. Strives to be thin, believes self to be fat when thin, loss of judgement in food needed, sets weight limits.
• Non specific :

Depression 25-50%, obsessional symptoms 20-25% anxiety 40%. Highly conscientious strives to achieve.

Causes
Problems inherent in adolescence (Adoption of adult role, emancipation).
High incidence of marital difficulties in parents
Menarche
High parental expectations.

Psychodynamics
Regression (abandon the genitor sexual stage of development) Fixation at oral level. Striving toward ascetic ideals. Struggle for control of the self. Invest in thinness, seen as acerbity. Perceptual disorder of body image.

Differential Diagnosis
Malabsorption syndrome, Reticulosis, Diabetes mellitus, Thyrotoxicosis, G.I. neoplasm.
Depressive illness, Phobic anxiety state, Obsessional neurosis.

Complications
Physical
Oedema, impaired excretion water load ( especially in chromic illness). Electrolytes disturbance, e.g. hypokalemia, alkalosis when vomiting dehydration. Secondary hyperaldosteronism.

Hypercholesterolaemia, Carotenaemia Hypoglycaemia,
Hypothermia.
Moderate normocyteic anaemia Hb. 10-11 G%.
(Occasionally plastic crisis).
Follicular hyperkeratosis, Languor type hair on trunk.

Psychological
Intense family reaction (anxiety, hostility, wish to control). Aversion to food worse when weight loss severe.

Treatment
Initial
Restoration of normal nutrition (may be urgent), Admit to hospital normal average body weight or less.

Psychotherapy
Ongoing support, help to face precipitating factors.

Drug and physical
anxiolytic and antidepressants when symptomatically indicated, (High doses of chlorpromazine is recommended by some).

Long Term Outcome
Good (normal weight and menstruation) 40% , intermediate 27% Poor (constant low weight and amenorrhoea) 29%, Death 5%. Body weight has to be maintained near normal for some time before menstruation return.

Prognostic Factors
Poor outcome when illness is prolonged, onset in late teens or older, children adjustment difficulties, poor relationship with family and with other children in school.

Psychosomatic Disorders
ANOREXIA NERVOSA, Endocrine, Physical, Prognostic Factors, Psychodynamics, psychological