● Brittle hair and nails ● Lanugo (growth of fine hair all over the body, a natural response to insulate the body for those persons who are malnourished) ● Atrophy (muscle wasting) ● Muscle weakness ● Anemia
Some of the clinical features of social anxiety disorder (social phobia), obsessive-compulsive disorder (OCD), and body dysmorphic disorder overlap with those of anorexia nervosa as seen in these examples (American Psychiatric Association, 2013; Gersch et al., 2016): ● Persons with social anxiety disorder are often embarrassed or even humiliated to be seen eating in public. Persons with anorexia nervosa who have social fears that are not related to eating may also have coexisting social anxiety disorder. ● Persons with OCD may have obsessions and compulsions related to food. If persons suffering from anorexia nervosa have obsessions and compulsions that are not related to food, an additional diagnosis of OCD may be necessary. ● Body dysmorphic disorder is an imagined flaw in appearance; for example, ears are too big. An additional diagnosis of body dysmorphic disorder is warranted only if the imagined flaw is not related to body shape and size. General Signs and Symptoms Before proceeding to manifestations of physical pathophysiology, it is helpful to review generalized signs and symptoms of anorexia nervosa (American Psychiatric Association, 2013; Gersch et al., 2016): ● Extreme thinness/weight loss to the point of emaciation ● Intense fear of gaining weight and being fat ● Ongoing, unremitting pursuit of weight loss and thinness ● Belief that a person is fat and must continue to lose weight ● Distorted body image ● Refusal to eat ● Amenorrhea ● Osteopenia (loss of bone density) ● Osteoporosis (brittle, fragile bones caused by failure of the body to keep up the manufacture of new bone mass) Pathophysiology Anorexia nervosa can lead to a state of near starvation. As a result, the body struggles to find sources of nourishment to maintain homeostasis; consequently, fat stores are exhausted, adipose tissue is depleted, and muscle mass is lost. Lack of body fat can lead to a decrease in body temperature and intolerance to cold (American Psychiatric Association, 2013; Gersch et al., 2016; Videbeck, 2017). Alterations in body temperature and cold intolerance are also manifestations of metabolic changes caused by the disease process (Gersch et al., 2016; Videbeck, 2017). Here is a summary of the clinical manifestations of metabolic changes. Hypothyroidism Hypothyroidism exists when the thyroid gland fails to produce adequate amounts of certain hormones. Here are the signs and symptoms of hypothyroidism in clients with anorexia nervosa (Mayo Clinic, 2018b; Videbeck, 2017): ● Fatigue ● Cold intolerance ● Dry skin ● Muscle weakness and muscle aches ● Pain, swelling, and stiffness of the joints ● Thinning hair ● Bradycardia ● Memory problems ● Depression ● Chest pain/angina A number of potential complications related to hypothyroidism are possible (Mayo Clinic, 2018b; Videbeck, 2017): ● Cardiac problems: Effects of hypothyroidism on the cardiac system include slowing the heart rate (bradycardia), which may cause chest pain/angina, heart enlargement, heart failure, impaired pumping ability of the heart, and elevated LDL (bad) cholesterol.
● Constipation (can be severe) ● Drop in body temperature ● Cold intolerance ● Fatigue ● Hypotension ● Bradycardia ● Infertility ● Loss of libido ● Atrophy of breast tissue ● Sleep disturbances ● Loss of scalp hair
If the client with anorexia nervosa is also purging, calluses on the knuckles and abrasions and scars on the backs of the hands could be evidence of tooth injury that occurred during self- induced vomiting. Additional evidence of self-induced vomiting is dental caries and oral or pharyngeal abrasions (American Psychiatric Association, 2013; Gersch et al., 2016). Healthcare consideration : The gravity of the clinical picture depends on the severity and extent of the disorder. These signs and symptoms reflect the pathophysiology of the disease. Healthcare professionals must correlate signs and symptoms with disease pathology to facilitate treatment and promote wellness (Gersch et al., 2016). ● Mental health problems: Depression can develop early in the course of hypothyroidism and become worse over time. Hypothyroidism can also cause a decrease in mental functioning. ● Peripheral neuropathy: If hypothyroidism is not controlled or treated over a long period, peripheral nerve damage can occur. Signs of peripheral nerve damage include numbness and tingling of affected extremities. ● Infertility: Inadequate levels of thyroid hormone interfere with ovulation and impair fertility. Experts note that the thyroid abnormalities in clients with anorexia nervosa are similar to those of euthyroid sick syndrome, which is characterized by low total thyroxine (T4) and triiodothyronine (T3). However, in euthyroid sick syndrome, thyroid-stimulating hormone (TSH) usually remains in the normal range. Levels of T3 generally decrease in proportion to the degree of weight loss. T4 levels are low because T4 is converted to a biologically inactive reverse T3 (Mehler, 2017a). Cardiac Problems Anorexia nervosa can adversely affect the cardiovascular system. Clients may exhibit any of the following problems (American Psychiatric Association, 2013; Gersch et al., 2016): ● Bradycardia ● Hypotension. ● Loss of cardiac muscle mass ● Arrhythmias ● Cardiac arrest Electrocardiogram (ECG) provides evidence of cardiac compromise by showing bradycardia, arrhythmias, and, in some cases, a significantly prolonged QT interval. The potential for prolonged QT interval is of particular concern because it can lead to torsade de pointes, which is a life-threatening ventricular arrhythmia that can lead to ventricular fibrillation (Sachs, Mehler, & Krantz, 2017).
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