Anorexia Nervosa

神经性厌食症

Definition

说明

Anorexia nervosa is an eating disorder characterized by refusal to maintain body weight that is within the minimal range of normal. The affected individual has a distorted body image, perceiving self as globally overweight or obsessing about shape and size of particular body parts.

神经性厌食症属于进食障碍病，特点是拒绝体胖，尽管它已经是最低限度的正常体重。患者对体形看法偏执，认为自己总体超重或沉迷于身体特定部位的形状和尺寸。

There are two subtypes of anorexia nervosa. One is the restricting type, wherein the individual severely restricts food intake and compulsively exercises. The other is the binge eating and purging type marked by restricted dietary intake coupled with intermittent episodes of binge eating, followed by purging through self-induced vomiting or use of ipecac, laxatives, diuretics, or enemas.

神经性厌食症分两种。一是限制型的，患者严格限制食物摄入并强迫自己运动。另一种是狂饮狂泻型的，其特点是在限制饮食的同时又伴有间歇性暴饮，接着又通过自我诱导式呕吐或使用吐根、缓泻剂、利尿剂和灌肠剂等催泻。

Pathophysiology

病理生理学

A variety of psychologic factors are associated with the development of behaviors characteristic of anorexia nervosa. Low self-esteem often plays a significant role. Weight loss is viewed as an achievement, and self-esteem becomes dependent on body size and weight. There is also a relationship between eating disorders and mood disorders. In some cases, major depression may result from nutritional deprivation. Individuals with anorexia nervosa may lack spontaneity in social situations and may be emotionally restrained. The excess use of appetite suppressants or diet pills is seen in both types.

很 多病因素都与一些神经性厌食症特有的行为有关。缺乏自尊常常起着很重要的作用。减肥使其产生一种成就感，自尊依赖于体形和体重。饮食障碍与心境障碍也有关 系。有些病人严重抑郁，这通常是营养不足引起的，厌食症患者在社交场合缺乏自发性，在情感上会很拘束。这两类厌食症都会发生过度使用食欲抑制剂或节食丸这 种情况。

Family dynamics may play a role in development of symptoms. Parents may be controlling and overly protective. Eating behaviors may emerge in an unconscious attempt to gain control over the environment. Also contributing to this eating disorder is a societal ideal slimness that the adolescent strives to emulate. In some cases, diminished weight and loss of secondary sexual characteristics may be related to difficulty in accepting maturation into adulthood.

家族情况对症状出现也有一定影响。父母对小孩控制过严，保护过度。有意无意地想要控制环境，从而形成了不良饮食习惯。造成饮食障碍的另一个因素是社会对所谓的理想的苗条的追求，青少年努力想要效法这种苗条。在有些病例中，体重减轻，失去第二性征可能也与难以接受成年有关。

Clinical Manifestations

临床表现

Sudden, unexplained weight loss

体重突然下降，原因不明

Emaciated appearance, loss of subcutaneous fat

瘦弱，在下脂肪丢失

Changes in eating habits, unusual eating times

饮食习惯改变，饮食时间异常

Excessive exercise and physical activity

运动和体力活动过度

Amenorrhea

无月经

Dry, scaly skin

皮肤干燥、脱皮

Lanugo on extremities, back, and face

四肢、背部和脸部长出毳毛

Yellowish discoloration of skin

皮肤微黄褪色

Sleep disturbances

睡眠障碍

Chronic constipation or diarrhea, abdominal pain, bloating

长期便秘或腹泻、腹痛、胃气胀

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食管病变

Depressed mood

情结低落

Excessive focus on high achievement (becomes distressed when performance is not above average)

过度强调杰出成就，如表现一般就会感到痛苦

Excessive focus on food, eating, and body appearance

挑剔强调食物、饮食及体形

Erosion of tooth enamel and dentin on lingual surfaces (late effects)

晚期出现牙釉质和牙本质舌面病变

Diagnostic Studies

诊断检查

Electrocardiogram (ECG)

心电图

blood pressure

血压

Serum urea, electrolytes, creatinine

血清尿、电解质、肌酐

Complete blood count (CBC), platelet count

全血计数，血小板

Thyroid-stimulating hormone (TSH)

促甲状腺激素

Bone density

骨密度

Presence of hypercarotenemia

血胡萝卜素过多症

Therapeutic Management

治疗

Treatment is provided on an outpatient basis unless severe medical problems emerge. An interdisciplinary approach is needed to ensure optimal outcomes. Outpatient treatment includes medical monitoring, dietary planning to restore nutritional state, and long-term psychotherapy to work through underlying issues. Psychopharmacologic treatment may be initiated to treat symptoms of depression, anxiety, and obsessive-compulsive behaviors. Hospitalization is indicated if the adolescent weighs less than 20% of ideal body weight or is unable to adhere to the treatment program on an outpatient basis, or when neurologic deficits, hypokalemia, and cardiac arrhythmias exist.

如无急诊情况出现，一般行门诊治疗。为确保理想治疗效果，通常进行多科室诊治。门诊治疗包括医学监测、饮食计划以恢复营养、长期进行心理疗法解决潜在问题。抑郁症、焦虑症和强迫性行为可心通过精神药理手段进行治疗。如体重低于理想体重20%或门诊治疗无法保证治疗计划落实，或出现神经缺欠、低钾血及心律失常，这时就需要住院。

The following medications may be used:

使用药物：

Antidepressants--the selective serotonin reuptake inhibitors (SSRI) are also used, particularly if compulsive exercising is a component of the illness (imipramine, desipramine, fluoxetine, sertraline, paroxetine)

抗抑郁药，也可使用选择性5羟色胺再吸收抑制剂，特别是患有强迫运动时，如丙米嗪、地昔帕明、氟西汀、舍曲林、帕罗西丁等。

Estrogen replacement for amenorrhea

无月经者可补充雌激素。

Nursing Management

护理

Goals

目标

The individual's physical health status improves without symptoms with steady, reasonable weight gain (about 1lb every 4 days).

患者身体健康状况改善，无症状，体重稳定、合理增加（约每4天1磅)

The individual establishes a healthy pattern of nutritional intake.

患者确立健康的营养摄取方式

The individual establishes increased self-esteem and improvement in psychologic functioning.

患者自尊增强，心理作用改善

Nursing Diagnoses

护理诊断

Imbalanced nutrition: less than body requirements related to exercise in excess of caloric intake, refusal to eat, self-induced vomiting following eating, or laxative abuse

营养失调：低于机体需要量　与运动过多、热量摄入相对不足、拒绝进食、进食后自我诱发呕吐及滥用泻药有关

Disturbed self-concept related to inaccurate perception of self as obese

自我概念紊乱　与错误认为自己肥胖有关

Risk for deficient fluid volume related to vomiting and excessive weight loss

有体液不足的危险　与呕吐及体重丢失过多有关

Disturbed sleep pattern related to fears and anxiety concerning weight status

睡眠型态紊乱　与害怕或担心体重增加有关

Activity intolerance related to fatigue secondary to malnutrition

活动无耐力　与继发于营养不良的疲乏有关

Ineffective individual coping related to self-induced vomiting, denial of hunger, and insufficient food intake secondary to feelings of loss of control and inaccurate perceptions of body states

个人应对无效　与自我诱发性呕吐、否认饥饿、及行为失控感和对自已身体状况认识不足引起的食物摄入不足有关

Nursing Interventions

护理措施

Include family in forming dietary supplementation plan.

让家人参与制定食物补充计划。

Provide information about adequate nutritional intake and the impact inadequate intake has on energy level and psychologic well-being.

提供有关足够营养摄入的资讯，使其了解摄入不足对能量与心理健康的影响

Initiate specific plan of exercise as reinforcer for positive behavioral outcomes.

制定具体的锻炼计划，强化积极的行为结果

Establish trusting relationship that promotes disclosure of feelings and emotions.

建立信任关系，鼓励情感和情结的表达

Organize eating of meals with others, record amount of food eaten, and monitor activity for 2 hours after eating.

组织与他人共餐，纪录饮食数量，监视饭后2小时内的活动

Promote the individual's sense of responsibility and involvement in recovery and treatment.

增强患者责任感，鼓励其参与恢复及治疗活动

Participate on interdisciplinary team that uses multiple modalities such as individual and group psychotherapy, assertiveness training, music and/or art therapy, and nutritional education.

参加多种形式科室小组活动，如个人和小组精神　疗法，表达训练、音乐和/或艺术疗法及营养教育等。

Support involvement of family members who are vital to recovery.

支持重要家族成员的参与。

Patient Teaching

病人宣教

Recommend psychotherapy for treatment of distorted body image and self-concept.

建议用精神疗法治疗体像和自我概念的错误认识

Refer adolescent and family to community resources, that is, support groups and mental health professionals.

安排社区资源，如支援小组和心理健康专家。

Instruct parents to promote the patient’s activities that strengthen the patient’s self-esteem, facilitate the resocialization process and promote social acceptance among peers.

指导父母鼓励病人参加一些有益的活动，如增强病人自尊、便于重建社交及促进同伴社交接受度的活动。