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Anorexia Nervosa – More Dangerous Than You Think

May 11, 2020

Written by Clay Smith

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Anorexia nervosa (AN) is a common condition, with a high mortality rate. This will help you spot signs of severe illness, when to get labs and ECG, and when to admit.

Why does this matter?
A hallmark of this illness is the person is nonchalant about it. If you don’t know the danger signs, you may miss the severity on presentation, which could be a fatal error.

More dangerous than you think
AN is a common, severe psychiatric illness. It is often present with comorbid psychiatric illnesses. There is a high mortality rate, 5.6% per decade. It is notoriously difficult to treat with psychotherapy and pharmacotherapy. Most important for us in the ED is to recognize the danger signs and indications for immediate hospitalization.


  • Ask about weight trends, eating habits, food restriction, purging, fear of weight gain, excessive exercise, menstrual history (often amenorrhea), and syncope.

  • Ask others to corroborate focus on appearance, eating habits, fear of gaining weight, dissatisfaction with body shape, preoccupation with weight, and food intake.

  • Ask about suicidal ideation or depression.


  • Vitals: Take note of a BMI <16.5. Note the trajectory of weight loss as well. A rapid downward trend in weight is worrisome. A BMI ≤15 is often an indication for immediate admission. Look for orthostatic hypotension, bradycardia, and hypothermia. Note, patients will usually not become tachycardic, even if profoundly dehydrated.

  • Look for signs of dehydration, hair loss, presence of lanugo, erosion of dental enamel or salivary gland hypertrophy to indicate purging, or evidence of self harm.


  • If any concerns about severity, obtain labs and ECG.

  • Look for hyponatremia, hypokalemia, hypochloremia, hypomagnesemia, hypophosphatemia, and hypoalbuminemia.

  • On ECG, look for bradycardia, ectopy or other arrhythmias, and long QT interval.


  • Be careful. Severity of illness is easy to overlook in these patients. They downplay most symptoms and are often not forthcoming with the severity of their own calorie restriction.

  • Some may need immediate hospitalization and refeeding. Indications may include: BMI ≤15, syncope, bradycardia, electrolyte abnormalities, concerning ECG findings, self harm, or suicidal ideation.

Anorexia Nervosa. N Engl J Med. 2020 Apr 2;382(14):1343-1351. doi: 10.1056/NEJMcp1803175.

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