Anorexia nervosa remains, despite its frequency, a disturbing disease and difficult to master.
Its prevalence is large and stable: 0.1 to 1% in Western countries.
DIAGNOSTIC:
Symptoms and examinations:
Recognize anorexia nervosa at the stage of cachexia is very easy. The mentioned earlier, even from the first weeks is more difficult.
The classic symptoms of the disease is simple and very telling: weight loss, secondary amenorrhea, considerable decrease in power should not leave, in an adolescent, no room for doubt. However, pathology is denied by the patient, and often by the family. This shows the importance of the general family physician, who knows in time the different actors of the disease, is best placed to think quickly to diagnosis.
And it is important to do so, early one and appropriate care that should result in an important element of prognosis.
The table has evolved:
– Thinness increasingly wasting contrasting with a long enough preserved intellectual and physical activity;
– Some yellowish pallor, as the development of a laguno;
– The emergence later of edema;
– The collapse of physical activity;
– Closer to death. unfortunately still sometimes seen patients arrive in such a state.
Biologically, anorexia nervosa is characterized by:
– The long respected constants, except for those who vomit or take laxatives or diuretics, which can be threatening hypokalemia;
– LH lower rate (luteinizing hormone), FSH (follicle stimulating hormone) and sex hormone;
– Normalcy in blood sugar and decreased serum albumin, in advanced forms (possible Electrolyte disturbances: attention to cardiac dysrhythmia!);
– A preserved cortisol; a slight lowering of the free T3 benefiting rT3;
– A hypercarotinémie;
– TSH normal or slightly high;
– Good markers of malnutrition that are the dosages of prealbumin (transthyretin or) and transferrin (impaired as malnutrition).
Pure restrictive form is by far the most common.
Food is increasingly restricted, sometimes initially qualitative aspects, but excluding food is increasingly complete.There is no vomiting, but the obsession with emptiness can lead to laxative and sometimes diuretics.
Forms with vomiting represent around 20% of cases. They are of course hidden, but organic stigmata we can find (alkalosis hypochlorokaliémique) but also clinics (small ulcerations of the back of the first phalanges or metacarpals).
These forms are accompanied by a conserved prandial food intake, and sometimes even important or very important, patients vomiting without food. The combination of anorexia nervosa with bulimia is real rare, but some patients may switch from one to another pathology, several years of evolution.
Anorexia nervosa in adult women is not exceptional. This may be the resurgence of a sometimes abortive form of adolescence. But the disease can really settle in adulthood.
These are forms of worse prognosis.
Male Anorexia nervosa is rare (5% of female cases in France). It reflects a more severe psychopathology. Pure restrictive forms would be less frequent. Cachexia may be there just as impressive.
Sexual activity and testosterone lower.
Differential diagnosis:
Such pictures leave little room for the differential diagnosis. It is conventional (and necessary) to eliminate other causes of weight loss:
– Cancers are rarely involved in a young person;
– TB still exists;
– Celiac disease and especially Crohn’s disease (digestive diseases) are often rough clinical translation, diarrhea may be absent or very discreet. The family context of Crohn’s disease is sometimes a little difficult. Both diseases can cause significant weight loss in adolescents, and you have to think about, especially if the standard report shows even moderate inflammatory syndrome that has no place in anorexia nervosa.
Etiologies:
Role of genetics:
The involvement of genetics is based on the following observations:
– Existence of familial cases;
– Mono or heterozygous twin studies that have found a vulnerability to disease (heritability of about 70%); gene polymorphism on 5HT (2A), which alter the phenotype and the expression of the disease.
Psychosocial component:
It is conventional to say that the pressure of society, touting since the end of World War II female thinness promotes the onset of anorexia nervosa. It may be noted that this thin dictatorship then continues as the true obesity develops in our affluent societies subject to the “law of the market.” Such an environment undoubtedly plays a role in weakening individuals also at risk.
Psychofamiliale component:
Some general features are often found in the anorexic families: the family appears pathogen.
The first patient is often this “enfantimage” aconflictuelle, whose main concern is to match the expectations of his mother.
The anorexic, chasing any roundness of her figure goes barren mother’s reproductive and caregiving daughter. Among the girls the “me” is characterized by a deep sense of helplessness against external influences.
If we can not get a grip on reality that surrounds them, patients use all their energy to their own control. This is active behaviors, volunteers, accompanied by a pride to master the spoken word. Anorexics trigger the disease most often in puberty or pubertal post.
The lack of intergenerational barrier with parents, the “symbiotic” relationship with the mother (despite the low opinion she feels), the absence of a real paternal authority are among the constituent elements of these personalities.
The adolescent crisis will be there forever agenda.
The anorexic parents probably “responsible but not guilty.”
The mother often suffered relationship with her own mother: emotional deprivation severely felt and / or humiliation.Mothers will thus see their daughter what they missed.
But they give instead of listening. Infants, future anorexics, are used from the beginning to the responses unrelatedquestions. The introduction, in the first weeks of wrong answers is a major cause of cognitive distortion which suffer the anorexic.
The father often appears in the background, but pathogenically. The anorexic fathers suffered emotional neglect from their mother, they idealize. They then choose a wife “as restorative mother figure,” able to ensure their emotional comfort, and to undertake the tasks, including education, the home. They are thus often missing or “present absentees” fathers will contribute to the imbalance of their daughter by not ensuring the construction of any “quilting point” solid, allowing a first degree of independence.
Related issues:
The personalities of anorexics have in common with that of drug addicts. The difficulty or impossibility to manage the shortage is one example. One can of course ask whether anorexia promotes addiction or if it’s the opposite. Both behaviors could be the result of the same psychological profile, the same fragility, and for at least part of the same educational context.
Anorexia nervosa occur in girls where addiction affect the boy.
The frequency of eating disorders is higher among individuals who engage in high-level sports, including dancers, gymnasts and athletes in endurance sports and antigravity.
The link between these different situations can be at the level of opioids and their receptors.
Endorphin levels are higher in anorexic. They are also in intensive physical exercise, especially in endurance or endurance sports. There is a search for some inner state through sport, addiction, fasting, able to supply a disappointing real world, judged inaccessible or misunderstood.
MANAGEMENT OF MENTAL ANOREXIA:
Early intervention:
Early diagnosis and prompt appropriate management are good prognostic factors. If the family doctor is best placed to diagnose the disease early, however it is not in a position a priori favorable curator. It is rule necessary to use an external colleague familiar with the disease, internist or interested nutritionist. It is he who will be the prime contractor for the treatment. The intervention of the psychiatrist should not be systematic outset.
If we have the chance to see the patient quickly, sometimes things can be adjusted in outpatient, in a number of consultations, often with secondary support from a psychologist or psychiatrist. The key to success for somatitien held in four words:
– Authority because patients have suffered and suffer from a lack of solid benchmarks, intergenerational barrier, which partly explains the often perverse and manipulative side that is found in many anorexics. It must, in some way, replace the failing paternal authority;
– Truth because you have to show these girls what they really are when they have or claim to have a body image quite pathological;
– Severity because we must, negotiate on anything: the objectives are and must be totally out debate;
– Confidence is essential, because we have to show that the proposed therapeutic relationship is a relationship between persons responsible, the doctor trusts prior to the patient, for it to show the evolution of the weight that can be trusted renewed.
Weight is indeed the absolute witness to the evolution of the disease, and it is possible to cheat on time with him, it is impossible to make up the over time. It is not unusual that in such conditions, we had the satisfaction of seeing regress and disappear debutante anorexia.
Regular monitoring of at least 6 months is however prudent and necessary.
Treat the patient herself does not exempt to meet the family. In favorable cases, parents are quite willing, at least outwardly, to do everything to help their daughter. However, they often have the greatest difficulty admitting that they are “responsible but not guilty.”
We must therefore try to get them to this realization, but do not delude ourselves about the possibility for adults to question their deeper personality. This family psychotherapy, conducted in principle with the aid of a “shrink” will at least limit the deleterious parental attitudes in the course of evolution.
From this phase, the use of a dietician is often highly demanded by the patient and / or family. We must keep: it is one thing an anorexic does not absolutely need is a plan. The aim is, and must remain the resumption of a normal diet.
For advanced forms: hospital:
Hospitalization is required:
– If the patient does not consult very late: it is often found before critical situations with great cachexia and sometimes life-threatening displayed;
– If the attempt to outpatient management failed: if the weight of goals at each consultation are not made, and of course if the weight continues to fall, it must be hospitalized, even if the weight is still relatively okay.
The hospital is in a service where the specialized doctor who started the treatment, or that the patient was sent to a disaster. Besides the therapist, one must find the psychiatric skills, dietary this time or in intensive care. It’s always the doctor who will remain sole master of the therapeutic conduct. The principle of authority is essential for the duration of hospitalization.
Once the necessary (but limited) somatic and hormonal assessment base is made, the stay will be based on several principles:
– Isolation of the family friendly environment must be total: no direct communication with the patient relatives (diffi cult in the era of mobile phones) and no visit
– A weight contract must be signed by the therapist and the patient: it sets the weight that will allow its release. It should be a powerful act, solemn, reflecting its commitment to the path of healing. Even when it is signed without enthusiasm, even reluctantly, merely for the patient to sign this document is a step forward;
– The somatitien the informal psychotherapy must be articulated with the psychiatrist of the team throughout the stay.Listening is a very important point, essential counterweight to contractual obligations and basic trust.
The proposed power supply is normal. The dietician helps compose calorie intake that can be set between 2000 and 3000 Kcalories (outside recharge extreme cases, to be progressive and fast enough at a time).
The evolution is usually favorable if the management of the whole team is correct. Intake of 1 to 2 kg per week will fill the weight contract in 6 to 10 weeks. It is rare to need further isolation. It may be helpful to use a zinc supplementation.Sometimes antidepressant treatment is recommended by the psychiatrist. The prognosis, except in cases of extreme outset, is good in the short term, and filled out contract is the most common.
Family support in various ways is of course necessary during hospitalization. Choosing between a family therapy, or family, or interviews at the request depends on the practices and preferences of therapists.
Duration of treatment after hospitalization:
The output of the patient obviously does not say healing. The medical and psychiatric consultation should continue, at least monthly at first, for 6 to 18 months. The need to extend the regular monitoring beyond this term is a poor prognosis.
Long-term results:
Excluding abortive forms quickly (small outbreaks parapubertaires), the results of patients who lost at least 10% of their weight are roughly divided into thirds:
– 1/3 good results;
– 1/3 of poor results, where persistent food or chronic amenorrhea disorders, witnessed a weight kept below normal;
– 1/3 of poor results with chronic anorexia nervosa tables and / or other severe somatization.
Death occurs in less than 10% of cases.
Suicide is possible but uncommon. Among the prognostic factors, besides the speed of care, the importance of the initial weight loss, that is to say the immediate severity of the disease, is the most important. The age of onset is less (greater severity in adulthood). The shapes of the boy are typically more severe, usually reflecting a true psychiatric underlying disorder and not a “mere” disturbance problem more or less strong construction of the personality.
Surprisingly, the overall survival of anorexics would not be different from that expected in a reference population; it remains to be confirmed.