When Can Our Patient with Anorexia Go to the Psychiatry Unit?

Patient Presentation
An 18-year-old female was admitted to the general pediatric inpatient unit for continued weight loss despite intensive outpatient treatment for her anorexia nervosa. She began having problems 6 months previously when she began to restrict calories to around 500-600 calories/day and increase her running from 2 miles/day to 6 miles/day in addition to the regular sports workouts she had for soccer and basketball. In the outpatient clinic she complained of generalized fatigue and dizziness when standing and walking. She was admitted for medical stabilization prior to her going to the eating disorders unit. The past medical history shows a healthy female with mild intermittent asthma when she was school aged. The family history is negative for eating disorders but positive for anxiety and depression on both sides of the family. The social history found that she was proud to be an “all A” student who liked athletics. The review of systems had her denying purging behaviors and no temperature instability, but did have constipation and amenorrhea.

The pertinent physical exam showed her weight was <75% for ideal body weight (=body mass index of 16), heart rate of ~30 that was reactive to mid-30s, blood pressure of 86/55, and temperature of 36.8° C. She was gaunt appearing, and wore sweat clothes despite warm temperatures. HEENT – no parotid swelling or dental enamel problems noted. Her thyroid had no masses or enlargement. Lungs were clear. Heart rate was regular but bradycardic. There was a S1, S2 cardiac sounds without a murmur. Abdomen was soft without organomegaly, but generalized stool was noted. Genitourinary exam showed a Tanner Stage V female. Musculoskeletal exam found generalized weakness. She had fine lanugo hair. Neurologically she was intact including no Trousseau sign. Psychiatric examination showed her to be alert and oriented x 4, but with an increased time lag to answering questions. Emotionally she seemed restricted overall yet would be tearful or smiling depending on how distressing the discussion was to her. She stated that she wanted to be hospitalized because she wanted to be healthy. The work-up showed normal electrolytes, amylase, lipase, liver function tests, urinalysis, thyroid function tests, phosphorus, calcium, and complete blood count. Urine pregnancy test and drug screen were negative. An electrocardiogram was consistent with sinus bradycardia without heart block.

The diagnosis of severe anorexia nervosa was confirmed. The patient was placed on cardiac telemetry with exercise restriction. She was begun on a low fat, low lactose diet with 3 meals/day initially, with the goal of gaining 200-400 g/day. The plan was to increase the meals and snacks to allow for an increase in calories by 400 g every 4 days. During the initial 3 days, she was compliant with the activity restriction and was taking all calories with normal food and no purging. Her heart rate was slowly increasing to the mid-30s consistently. There was a discussion about when she would be ready to go to the eating disorders unit. The inpatient team and the cardiologists were not sure if there was a specific heart rate the patient needed to achieve before transferring. They thought the mid-40s would be appropriate assuming she was otherwise stable because this was the heart rate where patients who are otherwise hemodynamically stable do not need to have a pacemaker placed. With a further literature search and discussions with the psychiatrists, a clinical pathway was found which used a heart rate > 46 beats/minutes as its criterion for being medically compromised but not medically instable, and a clinical report used > 50 beats/minutes as defining a moderate eating disorder (not severe). The team planned to utilize these and other criteria for transfer timing.

Discussion
Patients with anorexia nervosa refuse to maintain their body weight at or above a minimally normal weight for age and height (basically less than 85% of expected). They have an intense fear of gaining weight or becoming fat, even though they are underweight. They also have a distorted view of their own body weight or shape and often deny the seriousness of being underweight. For women who are postmenarchal, amenorrhea often occurs.

Anorexia nervosa can have numerous complications which can be reviewed in the To Learn More section below. Cardiovascular problems include vascular instability with orthostasis, bradycardia and poor perfusion. Conduction abnormalities and repolarization abnormalities are potentially life-threatening requiring aggressive management. Myocardial dysfunction, pericardial effusion and functional mitral valve prolapse also occur. Congestive heart failure can also occur particularly during refeeding, and especially if there are concomitant electrolyte abnormalities also.

A discussion of common medical tests for evaluation and medical clearance of patients presenting with psychiatric problems can be found here.

Learning Point
Hospital admission criteria for anorexia nervosa cited by the American Academy of Pediatrics from the Society for Adolescent Medicine includes:

• <75% ideal body weight or ongoing weight loss despite intensive treatment
• Refusal to eat
• Body fat < 10%
• Heart rate < 50 beat per minute during the day and < 45 at night
• Systolic blood pressure of < 90 mm Hg
• Orthostatic changes in pulse (> 20 beats/minute) or blood pressure ( > 10 mg Hg)
• Temperature < 96° F
• Arrhythmia

The clinical pathway from the Lucille Packard Children’s Hospital in 1999 describes 3 stages of treatment.

• Admission/stage 1 is medical instability defined as:
  • < 75% ideal body weight
  • Dehydration
  • Abnormal electrolytes
  • Temperature < 36.3° day or evening or < 36° C at night
  • Irregular pulse or electrocardiogram QT interval of = .43
  • Pulse < 46 beats/minute
  • Orthostatic changes of systolic BP > 10 mg/Hg or pulse > 35 beats/minute
  • Urine specific gravity < 1.030 or between 1.010 and 1.020 and weight criteria not met
  • Pulse between 46 and 50 beats/minute and pulse change between 30-35 beats/minute
• Stage 2 is medical compromise with criteria of stable vital signs for 24-48 hours, no acute findings on physical exam, solid food intake initiation but may still be on liquid nutrition, and is progressing toward unobserved eating
• Stage 3 is practicing with criteria of stable vital signs for 48-72 hours, independent planning of caloric intake and eating, and 100% solid food intake.

Hospitalization discharge criteria was completion of Stage 2 program “includ[ing] weight rehabilitation to at least exercise weight and partaking of adequate nutrition with minimal support.” Patients (100%) had weight gain of 1 kg/week during the 20 months of followup.

Questions for Further Discussion
1. What are some physical examination findings in a patient with anorexia nervosa?
2. What other entities should be considered in the differential diagnosis of an eating disorder?

Related Cases

Disease: Eating Disorders

Symptom/Presentation: Eating Disorders | Weight Loss

Specialty: Adolescent Medicine| Cardiology / Cardiovascular-Thoracic Surgery | General Pediatrics | Psychiatry and Psychology

Age: Young Adult

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Eating Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Fisher M, Golden NH, Katzman DK, Kreipe RE, Rees J, Schebendach J, Sigman G, Ammerman S, Hoberman HM. Eating disorders in adolescents: a background paper. J Adolesc Health. 1995 Jun;16(6):420-37.

Lock J. How clinical pathways can be useful: an example of a clinical pathway for the treatment of anorexia nervosa in adolesents. Clin Child Psychol Psychiary. 1999;4:331-340.

Rome ES, Ammerman S, Rosen DS, Keller RJ, Lock J, Mammel KA, O’Toole J, Rees JM, Sanders MJ, Sawyer SM, Schneider M, Sigel E, Silber TJ. Children and adolescents with eating disorders: the state of the art. Pediatrics. 2003 Jan;111(1):e98-108.

Rosen DS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010 Dec;126(6):1240-53.

ACGME Competencies Highlighted by Case