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19. Feeding+Eating, Elimination Disorders > Anorexia Nervosa > Flashcards

Anorexia Nervosa Flashcards

1
Q

how many criteria are there for AN

A

3

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2
Q

criterion A for AN

A

restriction of energy intake relative to requirements, leading to a singificantly LOW BODY WEIGHT in the context of age, sex, developmental trajectory and physical health

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3
Q

how do you define “significantly low weight” in AN

A

a weight that is less than minimally normal or, for kids and teens, less than minimally expected

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4
Q

criterion B for AN

A

INTENSE FEAR of gaining weight or of becoming fat or persistent behaviour that interferes with weight gain, even though at significantly low weight

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5
Q

criterion C for AN

A

disturbance in the way in which ones 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 low body weight

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6
Q

what are the subtypes of AN that should be specified (using DSM specifiers)

A
  1. restricting type

2. binge eating/purging type

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7
Q

what is the definition of AN, restricting type

A

during the last THREE MONTHS, the individual has NOT engaged in recurrent episodes of binge eating or purging behaviour (i.e self induced vomiting or misuse of laxatives, diuretics or enemas)

–> this subtype describes presentations in which weight loss is accomplisged primarily through DIETING, FASTING, and/or EXCESSIVE EXERCISE

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8
Q

what is the time criterion for AN

A

three months

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9
Q

what is the definition of AN, binge/purge subtype

A

during the last THREE MONTHS, the individual HAS engaged in recurrent episodes of binge eating or purging behaviour

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10
Q

what is purging behaviour

A

self induced vomiting

misuse of laxatives, diuretics, enemas

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11
Q

what is the definition of AN, in partial remission

A

after full criteria for AN were PREVIOUSLY met, criterion A (low body weight) has NOT been met for a sustained period

BUT, either criterion B or C is still met

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12
Q

what is the definition of AN, in full remission

A

after the full criteria were previously met, none of the three criteria have been met for a sustained period of time

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13
Q

what measure does the DSM use to rate the severity of AN

A 
BMI (adults)
BMI percentile (kids/teens)
  • derived from WHO categories for thinness in adults
  • the level of severity may be increased to reflect clinical symptoms, the degree of functional disability and the need for supervision
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14
Q

define mild AN

A

BMI above to equal to 17

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15
Q

define moderate AN

A

BMI 16-16.99

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16
Q

define severe AN

A

BMI 15-15.99

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17
Q

define extreme AN

A

BMI less than 15

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18
Q

what is the unit of measurement for BMI

A

kg/m2

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19
Q

do those with the binge/purge subtype with AN always display both binging and purging

A

no

most with this subtype who binge eat ALSO purge

but there are some people who purge but do not binge eat

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20
Q

is there crossover between AN subtypes?

A

yes, this is common

thus, subtypes should be sued to describe current symptoms rather than longitudinal course

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21
Q

what are the 3 essential features of AN

A
  1. persistent energy intake restriction
  2. intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain
  3. a disturbance in self perceived weight or shape
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22
Q

what does BMI describe

A

the relationship between someones weight and height

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23
Q

what is the lower limit of normal for normal body weight

A

BMI of 18.5 kg/m2

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24
Q

do you have to be underweight to be dx with AN?

A

yes–> criterion A

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25
Q

are there situations in which someone with a BMI from 17-18.5 (or even above 18.5) would be considered to have significantly low weight?

A

yes, if clinical history or other physiological information supports this judgment

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26
Q

what is the standard lower limit of normal for children (when using BMI-for-age percentile)

A

BMI-for-age percentile BELOW the 5th percentile –> suggests the child is underweight

*however, kids/teens above this benchmark may be considered underweight in light of failure to maintain expected growth trajectory

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27
Q

what should the clinician consider when deciding if a patient is significant underweight?

A
  1. available numerical guidelines (i.e BMI or BMI-for-age percentile)
  2. individuals body build, weight history, physiological disturbances
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28
Q

is the intense fear of becoming fat seen in AN alleviated by weight loss?

A

typically no

–> in fact, concern about weight gain may INCREASE even as weight falls

(adolescents and some adults may not recognize, or may not acknowledge, a fear of weight gain)

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29
Q

how might body image be distorted in those with AN

A

some feel globally overweight

others recognize they are thin but have persistent concern about certain body parts being “too fat” i.e buttocks, thighs, abdomen

might employ multiple techniques to measure and evaluate body shape/size

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30
Q

how might weight loss vs weight gain be perceived by those with AN

A

weight loss viewed as impressive achievement, sign of extraordinary self discipline

weight gain perceived as unacceptable failure of self control

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31
Q

how do those with AN typically get brought to clinical attention

A

brought by family members after marked weight loss or failure to achieve expected weight gains
–> those with AN, even if they recognize they are thin, usually do not recognize the serious medical implications of their malnourished state

32
Q

in what situations might those with AN seek help on their own

A

usually because of distress over the somatic and psychological sequelae of starvation

it is rare for someone with AN to complain of weight loss per se–> in fact frequently have lack of insight into, or deny the problem outright

33
Q

are the impacts of malnutrition reversible?

A

most are, with nutritional rehabilitation

some, like LOSS OF BONE MINERAL DENSITY, are often not completely reversible

34
Q

list some psychological impacts of starvation/malnutrition

A

depressed mood

irritability

insomnia

depressed sex drive

*many people with AN present with depressive signs and symptoms–> must determine if secondary to starvation or worth a separate dx of MDD

35
Q

are OCD features, often prominent in AN, always related to food?

A

no–> both related and unrelated to food

most individuals with AN are preoccupied with thoughts of food

when display obsessions and compulsions unrelated to food, dx of OCD may be warranted

36
Q

how does undernutrition/starvation affect obsessive and compulsive symptoms i.e in AN?

A

obsessions and compulsions related to food may be EXACERBATED by undernutrition

*these behaviours have been observed associated with other forms of starvation, not just AN

37
Q

list some features that are sometimes associated with AN

A

concerns about eating in public

feelings of ineffectiveness

strong desire to control one’s environment

inflexible thinking

limited social spontaneity

overly restrained emotional expression

38
Q

what features are more likely to be found in those with AN binge/purge type compared to those with restricting type?

A

in binge/purge type:

higher rates of impulsivity

more likely to abuse alcohol and other drugs

39
Q

what is the 12 month prevalence of AN

A

among young females–> 0.4%

less known about prevalence among young males

40
Q

what is the gender ratio in presentations of AN

A

much less common in men

clinical population generally has 10:1 female:male ratio

41
Q

what is typical age of onset for AN

A

typically begins during adolescence or young adulthood

rarely begins before puberty or after age 40 (though it can on rare occasions)

42
Q

what psychosocial features/events are often associated with onset of AN

A

onset often associated with a stressful life event i.e leaving home for college

43
Q

what is the natural course of AN

A

highly variable

some recover fully after single episode

some exhibit fluctuating pattern of weight gain followed by relapse

others experience chronic course over many years

44
Q

should you exclude AN from the ddx based on older age?

A

no

45
Q

how might presentation differ based on age at presentation for AN

A

younger individuals may have more atypical features, like denying “fear of fat”

older individuals more likely to have a longer duration of illness and may have more signs and symptoms of a longer standing disorder

46
Q

most individuals with AN experience remission within what time period

A

within 5 years of presentation

*among those admitted to hospital, overall remission rates may be lower

47
Q

what is the crude mortality rate (CMR) for AN

A

5% per decade

48
Q

what are the most common causes of death in AN

A

most commonly from medical complications from the disorder itself or from suicide

49
Q

list temperamental risk factors for AN

A

those who develop anxiety disorders or display obsessional traits in childhood are at higher risk of AN

50
Q

list environmental risk factors for AN

A

cultures and settings in which thinness is valued increase risk of AN
–> this is supported by fact that historical and cross cultural variability in prevalence of AN is marked

occupations and avocations that encourage thinness increase risk (modeling, elite athletics)

51
Q

list genetic and physiologic risk factors for AN

A
  1. increased risk of AN and BN among first degree biological relatives of those with the disorder
  2. higher concordance rates among mono vs dizygotic twins
  3. unclear if there are brain abnormalities associated w AN vs whether these abnormalities are due to AN course (seen on fMRI, PET)
52
Q

having a first degree biological relative with AN increases risk of what other psychiatric disorder?

A

bipolar disorder (and depressive disorders)

–> increased risk among those with first degree relatives with AN, especially those with binge/purge type

53
Q

in which societies/cultures is AN most prevalence

A

probably most prevalent in post-industrialized, high income countries–> USA, Europe, Australia, NZ, Japan

–> however incidence in low to middle income countries is uncertain

54
Q

in which ethnic populations in the USA is incidence of AN comparatively low

A

among latinos, african americans and asians

–> note however that mental health service utilization among individuals with an eating disorder is significantly lower in these ethnic groups and that low rates may reflect ascertainment bias

55
Q

how might concerns about weight be voiced among populations in Asia (compared to the USA)

A

absence of an expressed intense fear of weight gain (“fat phobia”) appears to be relatively more common in populations in Asia–> rationale for dietary restriction is commonly related to a more culturally sanctioned complaint such as GI discomfort

56
Q

what HEMATOLOGIC abnormalities are seen on blood work in the presence of AN

A
  1. eukopenia–> common
    - -loss of all cell types but usually with apparent lymphocytosis
  2. mild anemia
  3. thrombocytopenia (rarely bleeding problems)
57
Q

what SERUM CHEMISTRY abnormalities are seen on blood work in the presence of AN

A
  1. elevated blood urea nitrogen (BUN)–> likely due to dehydration
  2. hypercholesterolemia –> common
  3. hypomagnesemia –> occasional
  4. hypophosphatemia–> occasional
  5. hepatic enzymes may be elevated
  6. metabolic alklalosis (elevated serum bicarb)–> can be due to vomiting
  7. hypochloremia–> due to vomiting
  8. hypokalemia–> due to vomiting
58
Q

what metabolic disturbance may be caused by laxative abuse

A

mild metabolic acidosis

59
Q

how might AN affect serum phosphate and magnesium

A

low

60
Q

what ENDOCRINE abnormalities are seen on blood work in the presence of AN

A
  1. serum thyroxine (T4) usually in low-normal range
  2. T3 levels decreased
  3. women have low estrogen levels
  4. males have low serum testosterone
61
Q

how does AN affect serum estrogen? testosterone?

A

low for both

62
Q

how does AN affect serum T3 levels

A

low

63
Q

what ECG changes can be noted in AN

A

sinus bradycardia–> common

significant QTc prolongation can be noted

(rarely) arrhythmias can be noted

64
Q

what changes in bone mass are seen due to AN

A

low bone mineral density–> with specific areas of osteopenia or osteoporosis –> often seen

risk of # significantly elevated

65
Q

what might be seen on EEG in AN

A

diffuse abnormalities, reflecting metabolic encephalopathy, may result from significant fluid and electrolyte disturbances

66
Q

list physical signs and symptoms of AN that the patient may complain of

A
  1. amenorrhea–> common
    - -appears to be indicator of physiological dysfunction
  2. constipation
  3. abdominal pain
  4. cold intolerance
  5. lethargy
  6. excess energy
67
Q

list findings of AN on physical exam

A
  1. emaciation
  2. significant hypotension
  3. hypothermia
  4. bradycardia
  5. lanugo–> fine, downy body hair
    - -some people
  6. peripheral edema
    - -especially during weight restoration or cessation of laxative/diuretic abuse
  7. petechiae, ecchymoses on extremities
    - -may indicate bleeding diathesis
  8. yellowing of skin–> due to hypercarotenemia

if are purging and inducing vomiting:
9. hypertrophy of salivary glands

  1. dental enamel erosion
  2. scars, calluses on dorsal surface of hand from repeated contact with teeth while inducing vomiting
68
Q

what is the relationship between suicide risk and AN

A

suicide risk = elevated in AN

69
Q

what is the rate of suicide in AN

A

12 per 100 000 per year

70
Q

when, especially, should you consider other causes of low body weight/weight loss?

A

in atypical presentations i.e older than 40 at onset

71
Q

ddx AN

A

medical conditions

MDD

schizophrenia

substance use disorders

social anxiety disorder

OCD

body dysmorphic disorder

bulimia nervosa

ARFID

72
Q

list some medical conditions that may be associated with serious weight loss

A

GI disease

hyperthyroid

occult malignancies

AIDS

73
Q

what distinguishes AN from most conditions on the differential

A

fear of gaining weight and body image disturbance

74
Q

in which substance-using patients should you seriously consider possibility of AN

A

in those that use appetite-suppressing drugs like cocaine, stimulants and who ALSO endorse fear of gaining weight/body image disturbance–> the substance use may represent a behaviour that interferes with weight gain

75
Q

when should you consider additional dx of body dysmorphic disorder in addition to AN

A

consider only if the distortion is unrelated to body shape and size (i.e preoccupation that one’s nose is too big)

76
Q

what distinguishes BN from AN

A

those with BN MAINTAIN BODY WEIGHT at or above a minimally normal level

77
Q

which psychiatric disorders commonly co-occur with AN

A

bipolar

depressive

anxiety disorders

OCD–>moreso in those with restricting type

substance use disorders–> more common among binge/purge type

19. Feeding+Eating, Elimination Disorders (12 decks)

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