Anorexia nervosa and the risk of sudden death

Parent-Focused Psychotherapy for the Preventive Management of Chronicity in Anorexia Nervosa: A Case Series

Background: Anorexia nervosa (AN) is a complex eating disorder where involvement of family plays a central role in first line treatment in adolescents, but which is not so for adults where poor response to treatment is frequent. Given the reluctance of some patients to receive treatment, we set out to explore the hypothesis that certain family dynamics may be involved in the maintenance of the disorder. Methods: We aimed to understand what is underlying in the cases of patients who present clinical improvement with their parents, but not the ones who received a parent-focused psychotherapeutic intervention. We conducted a mixed methods study. On the one hand we performed a case series of 14 patients who dropped out of treatment while their parents actively attended the intervention, and on the other hand, we followed the evolution of the parents of those patients reluctant to continue treatment, through non-participant observation. Results: We present preliminary evidence where we found the parent-focused psychotherapeutic intervention was able to elicit a reflective function of the parents. We also observed that the intervention modified certain family dynamics that could be related to maintaining factors of the disorder. In patients, we found that in parallel to the assistance of their parents to psychotherapeutic treatment, and even when they were receiving no intervention, they showed significant clinical improvement of symptomatology and global functioning; we observed 9 of 14 of them who voluntarily decided to return to pharmacological treatment. Conclusions: This parent-focused intervention elicited changes in reflective functioning of participant parents; the intervention produced favorable changes in family dynamics, which we believe is probably related to improvement of global functioning, symptomatology, and insight of patients.

[A young woman with anorexia, hypokalemia and convulsion]

A woman in her twenties, who had vomited daily for a year, developed serious anorexia (BMI 14) and hypokalemia. She was admitted to a local hospital because of listlessness and palpitations. Blood tests showed pH 7.62 (7.35-7.45), pCO2: 5.51 kPa (4.70-6.00), and potassium 2.3 mmol/l (3.5-5.0), later 1.7 mmol/l. She developed tonic-clonic seizures (caused by ventricular tachycardia) and needed assisted ventilation. Upon arrival at the secondary hospital (by air ambulance), she had frequent episodes of ventricular tachycardia, pH was 7.84 (7.37-7.45), pCO2: 3.46 kPa (4.3-5.7) and QT-time was 775 ms. After onset of assisted ventilation (set to 100 % oxygen and about 20 % of normal minute volume) pH decreased, potassium increased and ventricular arrythmias gradually disappeared. She was extubated seven hours after admission without neurological sequelae. We believe the vomiting was the main cause of hypokalemia and metabolic alkalosis. Hypokalemia prolongs the QT-interval and is a risk factor for Torsades de pointes ventricular tachycardia.

INTERPRETATION

The rapid increase of potassium levels in blood upon lowering of pH (approximately 0.5 mmol per 0.1 decline in pH) can be exploited therapeutically as in our case. An anorectic patient developing hypokalemia should be treated in hospital.

Tako-tsubo cardiomyopathy complicated by recurrent torsade de pointes in a patient with anorexia nervosa

We report the case of a 57-year-old woman with anorexia nervosa showing evidence of "tako-tsubo" cardiomyopathy complicated by several syncopes due to recurrent episodes of torsades de pointes. Prolongation of QT interval and QT dispersion have been reported both in the "tako-tsubo" cardiomyopathy and in anorexia nervosa. The QT prolongation and the QT dispersion has been linked as risk indicators for sudden cardiac death. The combination of "tako-tsubo" cardiomyopathy with a condition associated with the prolongation of QT and/or with an increase of QT dispersion, such as anorexia nervosa, makes the acute and subacute prognosis of this disease much more severe than usual.

Heart failure in anorexia nervosa: case report and review of the literature

OBJECTIVE

To report the presentation and causes of heart failure complicating anorexia nervosa (AN).

METHOD

Report of a case of heart failure occurring in a patient with AN and a review of the literature.

RESULTS

A 56 year old woman with a 25 year history of AN binge-purge subtype experienced increasing shortness of breath on exertion, orthopnea, and swelling of the ankles. Investigations revealed a reduced left ventricular ejection fraction. A diagnosis of heart failure caused by severe prolonged protein-calorie malnutrition was made. She was treated with a diuretic, a beta adrenergic blocker and an angiotension enzyme inhibitor. Her cardiac function returned to normal after a year of refeeding. Protein-calorie malnutrition, ipecac toxicity, and deficiencies of thiamine, phosphorus, magnesium, and selenium have been reported to cause heart failure in patients with AN.

DISCUSSION

If shortness of breath occurs in AN it may be a symptom of heart failure. The diagnosis is further suggested by increased jugular venous pressure, increasing shortness of breath on exertion, and pulmonary crepitations at the bases of the lungs on physical examination. The chest x-ray usually shows pulmonary venous redistribution, the electrocardiogram may be normal, and the echocardiogram should document a reduced left ventricular ejection fraction. Standard medical therapy for heart failure should be started. In addition, a history of ipecac use should be taken, deficiencies should be corrected, and weight restoration can reverse cardiac abnormalities.

Complicações clínicas da anorexia nervosa e bulimia nervosa

Os transtornos alimentares estão associados a diversas complicações clínicas graves. Distúrbios hidroeletrolíticos e metabólicos assim como várias alterações endócrinas podem estar presentes, muitas dessas decorrentes da perda de peso e dos métodos compensatórios utilizados pelos pacientes. São importantes a identificação precoce e o manuseio adequado dessas complicações para a redução dos riscos relacionados. O objetivo desse artigo é discutir as complicações clínicas associadas com a anorexia nervosa e a bulimia nervosa.