Death in anorexia nervosa

Behavioral Treatment of Anexoria Nervosa

A 16-year-old adolescent male was treated with systematic desensitization and cognitive restructuring for anorexia nervosa over a five-year period. Results were evaluated by means of a single-subject design. Introduction and withdrawal of systematic desensitization had a clear and systematic effect upon weight gain. Introduction of cognitive restructuring also had a clear effect on weight gain. Moreover, when cognitive restructuring treatment was withdrawn, weight gain was maintained. Results were discussed in terms of clinical and experimental control of behavior and the need for extended follow-up studies.

QT interval in anorexia nervosa

OBJECTIVES

To determine the incidence of a long QT interval as a marker for sudden death in patients with anorexia nervosa and to assess the effect of refeeding. To define a long QT interval by linear regression analysis and estimation of the upper limit of the confidence interval (95% CI) and to compare this with the commonly used Bazett rate correction formula.

DESIGN

Prospective case control study.

SETTING

Tertiary referral unit for eating disorders.

SUBJECTS

41 consecutive patients with anorexia nervosa admitted over an 18 month period. 28 age and sex matched normal controls.

MAIN OUTCOME MEASURES

maximum QT interval measured on 12 lead electrocardiograms.

RESULTS

43.6% of the variability in the QT interval was explained by heart rate alone (p < 0.00001) and group analysis contributed a further 5.9% (p = 0.004). In 6 (15%) patients the QT interval was above the upper limit of the 95% CI for the prediction based on the control equation (NS). Two patients died suddenly; both had a QT interval at or above the upper limit of the 95% CI. In patients who reached their target weights the QT interval was significantly shorter (median 9.8 ms; p = 0.04) relative to the upper limit of the 60% CI of the control regression line, which best discriminated between patients and controls. The median Bazett rate corrected QT interval (QTc) in patients and controls was 435 v 405 ms.s-1/2 (p = 0.0004), and before and after refeeding it was 435 v 432 ms.s1/2 (NS). In 14(34%) patients and three (11%) controls the QTc was > 440 ms.s-1/2 (p = 0.053).

CONCLUSIONS

The QT interval was longer in patients with anorexia nervosa than in age and sex matched controls, and there was a significant tendency to reversion to normal after refeeding. The Bazett rate correction formula overestimated the number of patients with QT prolongation and also did not show an improvement with refeeding.

Hypoglycaemia associated with anorexia nervosa

A 41 year old woman with severe emaciation due to longstanding anorexia nervosa presented with recurrent hypoglycaemia. During an episode of hypoglycaemia, serum insulin and C peptide were undetectable and plasma beta hydroxybutyrate, free fatty acids and lactate were inappropriately low. Response to intravenous glucagon was poor. Muscle enzymes were grossly elevated until she gained weight. Hypoglycaemia was abolished by weight gain.

Anorexia nervosa. Hospitalization on adolescent medicine units and third-party payments

To determine the appropriateness of hospitalization for patients with anorexia nervosa on an adolescent medicine unit, major and minor criteria justifying admission were developed. Hospitalization was considered necessary when one major and three minor, or six minor, criteria were met. A retrospective review of 20 patient records was conducted and all met the criteria. Eighteen patients were discharged with objective findings of improvement. Two were transferred to a psychiatric unit for prolonged care. A review of the financial records disclosed that four hospitalizations had been contested (partially or in total) by the patients' insurance company. Thus, in 20% of the records meeting the criteria for admission third parties refused to pay. Because insurance company denial may seriously undermine therapy and adversely influence outcome, it is proposed that a category of "Malnutrition Secondary to Anorexia Nervosa" be accepted as reimbursable under medical coverage for acute care treatment in qualified adolescent medicine units.

Hypoglycaemic coma associated with anorexia nervosa

Profound hypoglycaemia is a rare event which has been described in seven cases of anorexia nervosa. A further case is reported here and the literature regarding this complication is reviewed. The major risk factors identified are body weight below 30 kg, a period of fasting and intercurrent infection. Excessive exercise may also play a role. The precise pathogenesis has not been elucidated but several mechanisms, including depletion of liver glycogen, defective gluconeogenesis or failure of glucagon secretion have been proposed. Although hypoglycaemic coma frequently results in death, prompt treatment may result in full recovery as occurred in the case described here.

Severe hypoglycaemia and sudden death in anorexia nervosa

Two patients with severe anorexia nervosa developed hypoglycaemic coma which was fatal in one case. Physical exertion may have contributed to this complication.

A prospective study of 133 patients with anorexia nervosa treatment and outcome

One hundred and thirty-three patients with anorexia nervosa have been treated in a prospective study from 1958 to 1976. The doctor and the patient alone formed the therapeutic team, the doctor playing the role as an instructor in the pathophysiology of hunger without discussing social or psychological problems. At follow-up 58% of the patients were grouped as 'good', and 28% as 'intermediate', figures which are in accordance with those obtained from other authors. Fourteen per cent of the patients were grouped as 'poor'. None of the patients died. That therapists with different attitudes to treatment may obtain fairly similar results strengthens our view of a strong tendency to spontaneous recovery in anorexia nervosa. The outlook for patients with a short history of anorexia nervosa seems good.

Function and dimensions of the circulatory system in anorexia nervosa

The functional and dimensional components of the oxygen transporting system was studied in 17 female and 11 male patients suffering from anorexia nervosa. Both groups were 14.9 years old, on average, and had lost about 25% of their weight. Measurements at rest included blood and heart volume, heart rate, blood pressure, oxygen uptake (VO2), RQ, blood lactate (LA) and in 6 of the patients cardiac output. During bicycle ergometry the determinations of heart rate, blood pressure, LA, VO2 and cardiac output were repeated and maximal aerobic power was determined. A low metabolic rate with bradycardia and hypotension was apparent at rest. Blood and heart volume was decreased proportionally to the weight loss. On a given work load VO2 was lowered to the same extent as the resting metabolic rate. At maximal effort VO2 was reduced out of proportion to the circulatory dimensions and maximal heart rate was low. During exercise cardiac output was normally related to VO2 and stroke volume was maintained, indicating a normokinetic circulation and an unimpaired myocardial function. The main cause of the low maximal aerobic power seems to be the reduced muscle mass.