777 final eating disorder Flashcards
DSM 5 Diagnoses
Pica (307.52)
Rumination Disorder (307.53)
Avoidant/Restrictive Food Intake Disorder (307.59)
Anorexia Nervosa (307.1)
Bulimia Nervosa (307.51)
Binge-Eating Disorder (307.51)
Other Specified Feeding or Eating Disorder (307.59)
Unspecified Feeding or Eating Disorder (307.50)
Anorexia Nervosa DSM 5 Criteria
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than the minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Anorexia Nervosa DSM 5 Criteria (continued)
Coding note: The ICD 9-CM code for anorexia nervosa is 307.1, which is assigned regardless of the subtype. The ICD-10-CM code depends on the subtype.
Specify whether:
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e.. Self-induced vomiting or the misuse of laxatives, diuretics or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating, or purging behaviors (i.e., slef-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Anorexia Nervosa DSM 5 Criteria (continued)
Specify if: In partial remission In full remission Specify current severity: The minimum level of severity is based, for adults on current body mass index (BMI) or, for children and adolescents, in BMI percentile. The ranges below are derived from the WHO categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision. Mild: BMI > 17 kg/m2 Moderate: BMI 16-16.99 kg/m2 Severe: BMI 15-15.99 kg/m2 Extreme: BMI < 15 kg/m2
Epidemiology
12 month prevalence is 0.4% - 1% in adolescent girls 5% of young women with some symptoms Less common in males Gay males (norms for slimness) 10:1 ratio female to male Age of onset mid-teens - early 20’s Most common age of onset 14-18 Most frequent in developed countries Increased frequency in modeling, ballet, wrestling elite athletes
Onset associated with stressful life event
Genetic
Higher concordance rate in monozygotic twins
Sisters of patients more likely to be afflicted
Major mood disorders more common in family members
Biological Factors
Social Factors
Psychological and psychodynamic factors
Biologic Factors Influencing Anorexia Nervosa
Endongenous opioids may contribute to denial of hunger Starvation Hypercortisolemia Nonsupression by dexamethasone Suppression of thyroid function Ammenorhea hypoleptinemia CT reveals enlarged CSF spaces Studies have shown dysfunction in serotonin, dopamine, norepinephrine
Social Factors
Sociocultural influences
Family issues
Vocational/avocational influences: ballet, wrestling, gymnastics, athletes, models
Internet influences (ana website)
Psychological and Psychodynamic Factors
Reaction to independence Weight concerns Increased social and sexual functioning Lack of autonomy and self-hood Experience their body under parents’ control Unable to separate psychologically from mother Negative emotionality/affect Perfectionism Alexithymia
Psychodynamic Formulations
Multiply determined symptom
Desperate attempt to be special and unique
An attack on the false sense of self fostered by parental expectations
Assertion of a nascent true self
Attack on a hostile maternal interject
A defense against greed and desire
Effort to make others feel greedy and helpless
Defensive attempt to prevent projections from the parents from entering the patient
Escalating cry for help to shake the parents out of their self-absorption
Dissociative defense into separate self states as a way of regulating intense affect
Behaviors
Intense fear of gaining weight Secretive Refuse to eat with families or in public Often preoccupied with food Diet with restricted fat and carbohydrates Laxative and diuretic abuse Over exercising/physical hyperactivity Rigid and perfectionistic Compulsive stealing Poor sexual adjustment
Signs and Symptoms
BMI 17 or below Hypothermia Hypotension Lanugo ECG changes: T wave flattening or inversion, ST segment depression, lengthening of QT interval Dependent edema Bradycardia Amenorrhea
Differential Diagnoses
Medical conditions MDD Schizophrenia Substance use disorders Social anxiety disorder OCD Body dysmorphic disorder Bulimia nervosa Avoidant/restrictive food intake disorder
Comorbidities
MDD Bipolar disorder Substance use disorder OCD Social anxiety disorder Specific phobia BPD Obsessive compulsive personality disorder
Subtypes
Restricting type 50% of cases 300-500 calories/day Over exercising Binge-eating purging type
Assessment (continued)
BMI VS Labs: CBC, lipids, LFT’s ECG Bone density Delayed or absent menses Hypertrophy of salivary glands Dental enamel erosion/caries Scars or calluses on dorsal surface of fingers Suicide assessment
SCOFF Assessment Tool
Do you make yourselfSick because you feel uncomfortably full?
Do you worry you have lostControl over how much you eat?
Have you recently lost more thanOne stone in a 3 month period?
Do you believe yourself to beFat when others say you are too thin?
Would you say thatFood dominates your life?
*One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia
Treatment
Paucity of evidence based treatment Hospitalization Specialized ED programs Individual and group psychotherapy Pharmacotherapy Other treatments: Deep brain stimulation, Equine therapy
Goals of Treatment
1st restoration of eating for weight gain
2nd engagement in psychotherapy
Long term expressive supportive therapy
Address underlying disturbance of the self
Address distortions of internal object relations
Treatment Studies
Anorexia Nervosa Treatment of Outpatients (ANTOP)
Compared 3 treatments
80 patients received focal psychodynamic therapy
80 patients received enhanced CBT
82 optimized treatment as usual
Results
BMI increased in all treatments
Focal psychodynamic better outcomes at 12 months
Enhanced CBT more effective with respect to speed of weight gain and improvements in ED psychopathology
Meta-analysis suggested family based treatment for adolescents is superior to individual treatment (Coururier, 2013)
RCT comparing supportive clinical management with specialized CBT and ITP found supportive treatment superior (McIntosh, 2005)
Important Treatment Techniques
Avoid excessive investment in changing eating behavior
Avoid interpretations early in the treatment
Carefully monitor countertransference
Examine cognitive distortions
Hospitalization
Based on medical condition
Patients 20% below expected weight recommended for inpatient programs
30% below psychiatric hospitalization for 2-6 months
Restoration of nutritional status
Usual tx: combination of behavioral management, individual psychotherapy, family education and therapy, psychotropic medications
Hospital management:
Daily weights
Monitor serum electrolytes if necessary
Frequent small meals
Psychotherapy
Cognitive Emotional Behavioral Therapy Emotion Acceptance Behavior Therapy: goal is to enhance emotional awareness and decrease emotional avoidance Focal psychodynamic psychotherapy (FPT) Interpersonal psychotherapy Enhanced CBT (CBT-E) CBT DBT ACT Family therapy Maudsley family treatment
Pharmacotherapy
Cyproheptadine Amitriptyline Anafranil Pimozide Fluoxetine Chlorpromazine Olanzapine
Bulimia NervosaDSM Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self induce vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
Bulimia NervosaDSM Criteria (continued)
D. Self evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify if:
In partial remission
In full remission
Specify current severity:
Mild: An average of 1-3 inappropriate compensatory behaviors per week.
Moderate: An average of 4-7 inappropriate compensatory behaviors per week
Severe: An average of 8-13 inappropriate compensatory behaviors per week
Extreme An average of 14 or more inappropriate compensatory behaviors per week
Epidemiology
1-4% of young women
More common in women
20% of college women experience transient bulimic symptoms
History of obesity common
Etiology
Biologic factors Serotonin and norepinephrine Increased frequency in families Increased endorphin levels after vomiting Social factors High achievers Increased familial depression Family conflict
Psychological Factors
Difficulties with adolescent demands Impulse problems ETOH and substance abuse Shoplifting Emotional lability SIB Suicide attempts Self destructive sexual relationships Promiscuity Personality disorders
Psychodynamic Understanding
Generalized inability to delay impulse discharge
Weakened ego and lax superego
Parental problems
Sexual or physical abuse
Negative self-evaluation
Disturbance in the emotional dialogue with parents
Consistent pattern of conflict between contradictory parts of the self
Difficulty with separation in parents and patient
Absence of a transitional object
Differential Diagnoses
Epileptic seizures CNS tumor Kluver-Bucy syndrome Kleine-Levin syndrome Comorbidities: Substance abuse Impulsivity BPD Bipolar II
Treatment
Hospitalization Comorbid psychiatric issues Electrolyte and metabolic imbalance Psychotherapy CBT, CBT-E DBT Dynamic psychotherapy Group Other modalities: internet facilitated programs
Pharmacotherapy
SSRI’s Fluoxetine: 60-80mg/day Imiprimine Desimprimine Trazodone MAO-I’s CBT and meds most effective
Binge-Eating Disorder (307.51) (F50.8)DSM Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g. within any 2-hour period) an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating.)
Binge-Eating Disorder (307.51) (F50.8)DSM Criteria (continued)
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
Binge-Eating Disorder (307.51) (F50.8)DSM Criteria (continued)
D. The binge eating occurs on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
Specify if:
In partial remission
In full remission
Specify current severity:
Mild: 1-3 binge-eating episodes a week.
Moderate: 4-7 binge-eating episodes a week.
Severe: 8-13 binge-eating episodes a week.
Extreme: 14 or more binge-eating episodes a week.
Epidemiology
Most common ED
25% of patients seeking medical care for obesity
50-75% of people with severe obesity (BMI > 40)
Females 4%
Males 2%
Etiology
Unknown Impulsive and extroverted personality styles Low calorie diets Stress Alleviate anxiety Cope with depressive symptoms Insecure attachment
Treatment
CBT Self-help groups Psychopharmacotherapy Lisdexamfetamine SSRI’s high dose Desimprimine Topiramate Sibutramine
Other Specified Feeding or Eating Disorder (307.59) (F50.8)
This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The other specified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder followed by the specific reason
Unspecified Feeding or Eating Disorder
This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeling and eating disorders diagnostic class. The unspecified feeding and eating disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific feeling and eating disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g. ER settings)
