Refeeding Program for Patients With Extreme Anorexia Nervosa
Refeeding Program for Patients With Extreme Anorexia Nervosa
Anorexia nervosa (AN) is associated with one of the highest mortality rates in psychiatry. For example, a Swedish register study comparing observed with expected death rates reported that people hospitalized for AN had a standardized mortality rate of 6.2, and a follow-up study of 51 patients hospitalized for AN found that only half were symptom-free after 18 years. Although the incidence of AN has been reported to have increased in the last few decades, others have reported that this perception is incorrect, with apparent increases being due to complex interrelations among age, observational period, and cohort effects. However, an epidemiological study in adolescents found symptoms of eating disorders in 24% of girls and 16% of boys.
Epidemiological assessments of morbidity and mortality have shown that AN is one of the most serious disorders in psychiatry. Its psychiatric and somatic co-morbidities indicate that AN is complex and difficult to treat. Many co-morbid psychiatric disorders have been detected in patients with eating disorders. For example, the lifetime prevalence rates of mood disorders were estimated to be as high as 75% in patients with eating disorders, and the co-morbidity rates of obsessive-compulsive disorder, anxiety disorders and substance abuse to be 40%, 11–20%, and 40%, respectively. Adolescents with an affective disorder were reported to be at higher risk of developing an eating disorder. Personality traits often found in patients with AN include perfectionism, impulsivity and obsessive-compulsive characteristics. Obsessive-compulsive personality disorder is the most common personality disorder in patients with restrictive AN (ANR), whereas borderline personality disorder is the most prominent in patients with the binging and purging subtype of AN (ANBP).
Malnutrition and long-time starvation affect almost every organ in the body. Cardiac complications are observed in about 80% of these patients; one of the most threatening consequences is atrophy of the heart, leading to alterations in cardiac electrical activity, structure and hemodynamics. Atrophy may result in secondary prolongation of the QT-interval and cardiac arrhythmia, complications predictive of sudden cardiac death. Reduced concentrations of sodium and potassium contribute not only to cardiac arrhythmia, but may lead to myelinolysis of the pons. Serum concentrations of phosphate and magnesium are often diminished during enforced refeeding, which may contribute to the development of a 'refeeding syndrome'. The most frequent endocrine dysfunction associated with AN is amenorrhea, although chronic starvation may induce type 1 diabetes mellitus.
Due to the potentially lethal impact of AN on physical health, and studies showing that weight restoration significantly ameliorated several neuropsychological aspects of AN and reduced EEG abnormalities, the first goal of AN treatment should be restoration of weight. A detailed program for compulsory re-feeding of patients with severe AN has therefore been established over the last decade at the Department of Psychiatry, University Hospital of Munich. This report describes the demographic characteristics and short term outcomes of the first 68 AN patients enrolled in this program.
Background
Anorexia nervosa (AN) is associated with one of the highest mortality rates in psychiatry. For example, a Swedish register study comparing observed with expected death rates reported that people hospitalized for AN had a standardized mortality rate of 6.2, and a follow-up study of 51 patients hospitalized for AN found that only half were symptom-free after 18 years. Although the incidence of AN has been reported to have increased in the last few decades, others have reported that this perception is incorrect, with apparent increases being due to complex interrelations among age, observational period, and cohort effects. However, an epidemiological study in adolescents found symptoms of eating disorders in 24% of girls and 16% of boys.
Epidemiological assessments of morbidity and mortality have shown that AN is one of the most serious disorders in psychiatry. Its psychiatric and somatic co-morbidities indicate that AN is complex and difficult to treat. Many co-morbid psychiatric disorders have been detected in patients with eating disorders. For example, the lifetime prevalence rates of mood disorders were estimated to be as high as 75% in patients with eating disorders, and the co-morbidity rates of obsessive-compulsive disorder, anxiety disorders and substance abuse to be 40%, 11–20%, and 40%, respectively. Adolescents with an affective disorder were reported to be at higher risk of developing an eating disorder. Personality traits often found in patients with AN include perfectionism, impulsivity and obsessive-compulsive characteristics. Obsessive-compulsive personality disorder is the most common personality disorder in patients with restrictive AN (ANR), whereas borderline personality disorder is the most prominent in patients with the binging and purging subtype of AN (ANBP).
Malnutrition and long-time starvation affect almost every organ in the body. Cardiac complications are observed in about 80% of these patients; one of the most threatening consequences is atrophy of the heart, leading to alterations in cardiac electrical activity, structure and hemodynamics. Atrophy may result in secondary prolongation of the QT-interval and cardiac arrhythmia, complications predictive of sudden cardiac death. Reduced concentrations of sodium and potassium contribute not only to cardiac arrhythmia, but may lead to myelinolysis of the pons. Serum concentrations of phosphate and magnesium are often diminished during enforced refeeding, which may contribute to the development of a 'refeeding syndrome'. The most frequent endocrine dysfunction associated with AN is amenorrhea, although chronic starvation may induce type 1 diabetes mellitus.
Due to the potentially lethal impact of AN on physical health, and studies showing that weight restoration significantly ameliorated several neuropsychological aspects of AN and reduced EEG abnormalities, the first goal of AN treatment should be restoration of weight. A detailed program for compulsory re-feeding of patients with severe AN has therefore been established over the last decade at the Department of Psychiatry, University Hospital of Munich. This report describes the demographic characteristics and short term outcomes of the first 68 AN patients enrolled in this program.
