APA Guidelines on Eating Disorders + Slides Flashcards
when elements are important to obtain on a history of a patient with a ?eating disorder
patients history + symptoms + behaviours
patients height + weight history
restrictive and binge eating
exercise patterns and their changes
purging and other compensatory behaviours
core attitudes regarding weight, shape and eating
associated psychiatric conditions
family hx of eating disorders or other psychiatric disorders (including etoh and SUDs)
family history of obesity
family interactiosn with regard to patients disorder
family attitudes towards eating, exercise and appearance
what should you pay particular attention to on physical exam in patients with eating disorder
vital signs
height and weight
cardiovascular and peripheral vascular function
dermatological manifestations
evidence of self injurious behaviours
calculation of BMI
who should be referred for bone density assessment
those who have been amenorrheic for more than 6 months
what element of the history is particularly important to obtain in ?eating disorders
safety assessment
in which population is family involvement in treatment essential
children and adolescent
what are the various treatment site types available for eating disorders
intensive inpatient programs
residential and partial hospitalization programs
varying levels of outpatient care
what should be considered when deciding if there needs to be a change in level of care for a patient with eating disorders
overall physical condition
psychology
behaviours
social circumstances
what physical parameters in a patient with an eating disorder should be considered when choosing a treatment setting
weight in relation to estimated individually healthy weight
rate of weight loss
cardiac function
metabolic status
at what weight does it become very difficult for someone to gain weight outside of a highly structure program
those who weigh less than approx. 85% of their individually estimated healthy weights
list factors that suggest hospitalization may be appropriate for a patient with eating disorder
rapid or persistent decline in oral intake
decline in weight despite maximally intensive outpatient or partial hospitalization interventions
presence of additional stressors that may interfere with the patient’s ability to eat
knowledge of the weight at which instability previously occurred int he patient
co occurring psychiatric conditions that merit hospitalization
degree of the patient’s denial and resistance to participate in his or her own care in less intensively supervised settings
should hospitalization for eating disorders occur before or after onset of medical instability
should occur BEFORE onset of medical instability
what % of patients with eating disorders are female
90-95%
what is the prevalence of BN in women? AN?
BN–> 3%
AN–> 1%
what % of those with eating disorders achieve recovery? partial recovery?
40-45%–recovery
30%–partial recovery
what % of those with eating disorders have a chronic course
about 25%
what is the standardized mortality rate for eating disorders? what are usually the causes of mortality in eating disorders
SMR–> 5-15%
due to malnutrition, medical complications, suicide
up to 50% of deaths in AN are due to complications of starvation
remaining 50% due to suicide or comorbid substance use
at what BMI does the APA guidelines recommend admission to a medical unit for AN
BMI of 15 at initial presentation (lectures slides indicate this is a bit of an arbitrary set point)
note that lower weight = longer weight restoration will take
below what BMI are those with an eating disorder at risk
16 and below
list the general indications for admission to medicine for AN based on the APA guideline
BMI of 15 (consider below 16)
metabolic abnormalities (low sugars, electrolyte disturbances)
–fasting blood glucose below 2.5
ECG changes–> QTc prolongation, significant ST changes, dynamic T waves
renal function changes
what lab result is associated with sudden death in AN
fasting BG below 2.5
indication of severe starvation
low sugars do not present
how does AN affect the kidneys
chronic renal failure is common
biopsies done demonstrate injury due to repetitive volume insult to the renal tubules
kidneys affected by poor intake, volume loss, excess exercise, purging, laxative use or diuretic use
what are the 5 levels of care in treating AN
outpatient
intensive outpatient
partial hospitalization/day treatment
residential treatment center
inpatient hospitalization
what types of criteria are considered when deciding what level of care to offer a patient with an eating disorder
suicidality
% of healthy body weight
motivation to recover
co-occurring disorders
ability to control exercise
purging behavours
environmental stress
geographic availability of tx
how many criteria must someone meet under a certain level of care for eating disorders (i.e under criteria for inpatient hospitaliztion) to be considered for that level of care
one or more
list the 9 criteria from a “medical status” standpoint considered for acute inpatient admission for ADULTS for eating disorders
- heart rate below 40 bpm
- BP below 90/60
- K+ less than 3 mEq/L
- electrolyte imbalance
- temp below 97 F
- dehydration
- hepatic, renal or CV compromise requiring acute treatment
- poorly controlled diabetes
list the 6 criteria considered for KIDS AND TEENS for acute inpatient admission for eating disorder
- HR near 40 bpm
- BP changes (more than 20 bpm increase in HR or more than 10mmHg to 20mmHG drop in BP)
- BP below 80/50
- hypokalemia
- hypophosphatemia
- hypomagnesemia
what weight as % of healthy body weight is considered appropriate for outpatient treatment of eating disorder
above 85%
what weight as % of healthy body weight is considered appropriate for intensive outpatient treatment of eating disorder
above 80%
what weight as % of healthy body weight is considered appropriate for partial hospitalizatio treatment of eating disorder
above 80%
what weight as % of healthy body weight is considered appropriate for residential treatment of eating disorder
below 85%
what weight as % of healthy body weight is considered appropriate for outpatient treatment of eating disorder
below 85%
acute decline with food refusal even if not below 85% of healthy body weight
what level of motivation is required for a patient to be felt to be appropriate for outpatient management of AN
fair to good
what factors are considered in “motivation to recover” from AN
cooperativeness
insight
ability to control obsessive thoughts
with regard to motivation to recover, what factors would prompt inpatient admission for stabilization of AN
very poor to poor motivation to recover
patient reoccupied with intrusive repetitive thoughts
patient uncooperative with treatment or cooperative only in highly structure environment
with regard to motivation to recover, what factors would prompt residential treatment admission for stabilization of AN
poor to fair motivation
preoccupied with intrusive thoughts 4-6 hours per day
cooperative in highly structured environment
with regard to motivation to recover, what factors would prompt partial hospitalization/day treatment for stabilization of AN
partial motivation
preoccupied with intrusive thoughts above 3 hours per day
with regard to motivation to recover, what factors would prompt intensive outpatient referral for stabilization of AN
fair motivation
with regard to structure needed for eating/gaining weight, what level of care required would prompt admission to acute inpatient medical unit for stabilization of AN
needs supervision during and after all meals or NG/special feeding modality required
what type of patient, with regard to the following factors, would be appropriate for outpatient treatment for AN/eating disorder:
- medical status
- suicidality
- weight as percentage of body weight
- motivation to recover
- co occuring disorders
- structure needed to gain weight
- ability to control compulsive exercising
- purging behaviour
- environmental stress
- geographic availability of treatment program
- medically stable to the extent that more extensive medical monitoring (as defined by levels 4 and 5 of level of care–see other cards–is not required)
- depends on level of suicide risk on assessment; if felt to be low risk, outpatient may be appropriate
- above 85% healthy body weight
- fair to good motivation
- comorbid conditions do not require inpatient treatment independently
- self sufficient for eating/gaining weight, does not require significant support
- can manage compulsive exercise through self control
- can greatly reduce incidents of purging in an unstructured setting; no significant medical complications from purging like ECG changes
- others are able to provide adequate emotional and practical support and structure
- patient lives near treatment setting
what type of patient, with regard to the following factors, would be appropriate for inpatient hospitalization treatment for AN/eating disorder:
- medical status
- suicidality
- weight as percentage of body weight
- motivation to recover
- co occuring disorders
- structure needed to gain weight
- ability to control compulsive exercising
- purging behaviour
- environmental stress
- geographic availability of treatment program
- heart rate below 40; BP below 90/60; glucose below 600 mg/dL; K+ below 3; electrolyte imbalance; temp below 97 F; dehydration; hepatic, renal or CV organ compromise; poorly controlled diabetes (for adults–see other card for kids/teens medical status criteria for admission)
- specific plan with high lethality or intent; possibly also after SA or aborted attempt depending on other RFs
- below 85% of healthy body weight or if acute weight decline with food refusal
- very poor to poor motivation to recover; uncooperative with treatment; preoccupied with intrusive thoughts
- any existing psych disorder that would itself require inpatient treatment
- needs supervision during and after all meals or NG/speciality feeding
- some degree of external structure beyond self control required to prevennt compulsive exercising; rarely a sole indication for increasing the level of care
- needs supervision during and after all meals and in bathrooms; unable to control MULTIPLE DAILY episodes of purging that are SEVERE, persistent and disabling, despite appropriate trials of outpatient care, even if routine lab results reveal no obvious metabolic abnormalities
- severe family conflict or problems or absence of family so patient is unable to receive structured treatment in home; or patient lives alone without adequate support system
- treatment program is too distant from patient
what factors with regard to purging specifically may suggest need for inpatient admission for stabilization for AN/eating disorder
needs supervision during and after all meals and in bathrooms; unable to control MULTIPLE DAILY episodes of purging that are SEVERE, persistent and disabling, despite appropriate trials of outpatient care, even if routine lab results reveal no obvious metabolic abnormalities
what are the 3 dimensions of the STATED model of care used in BC for AN/eating disorders
- medical acuity–> refers to patients immediate medical risk due to ED and/or other psych disorders; often primary and sometimes only factor to consider in decision making
- symptom severity/life interference
- engagement with treatment
what are usually some of the goals of acute admissions for eating disorders
- stop weight loss
- prevent re-feeding syndrome
- interruption of disordered behaviours
- anticipate behavioural challenges
- initiate treatment plan for community, care plan development
- Dx review
- assess and treat psych comorbidities
what is the role of psychiatric medications in acute inpatient admission for eating disorders
use to treat acute psych symptoms like anxiety and agitation
help to decrease energy expenditure
treat psych comorbidities
is NG feeding covered under certification for eating disorders
yes
can anyone accurately predict when a starved individual will due? why or why not?
no, no one can accurately predict this
because it is not always low weight related
hypoglycemia can be asymptomatic until very low (i.e below 1.5)
many case reports and case series document assoc. of hypoglycemia with mortality in AN (glucose less than 2.5)
how do you treat hypoglycemia + low weight AN
indication for refeeding on a medical ward
treat with IV glucose and THIAMINE
watch amount of glucose you give while waiting for medical team
what is “refeeding syndrome”
electrolytes shifting–> K, PO4, Mg
what is the maximum feed rate for low weight AN with high risk of refeeding
5kcal/kg/day
what is one of the first signs of refeeding syndrome
tachycardia –> this is an indication to DECREASE feeding
what are the most common complications seen in the re-feeding period (time zero to 10 days)
CHF
seizures
–> mechanism is due to electrolyte and fluid shifting causing LV failure and cerebral edema
what is a medical complication of eating disorders that is fairly unique to children/teens and what are the implications of this
low bone mineral density, decreased bone mineral accrual in AN
bone LOSS (about 2.5% per year) as opposed to increase
adults with adolescent-onset AN have lower bone mineral density than adult-onset AN–> LIFELONG increased BONE FRACTURE RISK
high proportion of youth admitted to BCCH have low BMD
what is one of the challenges of using “actively losing weight” as a criteria for assessing eating disorders in kids
due to growth of children, kids may not be actively losing weight but are still suffering from an ED
what is a questionnaire that can screen for/assess core symptoms of anorexia and bulimia and has been used with adolescents
SCOFF questionnaire
–do you make yourself Sick because you feel uncomfortably full
–do you worry that you have lost Control over how much you eat
–have you recently lost more than One stone (14 pounds) in a 3 month period
–do you think you are too Fat, even though others say you are too thin
–would you say that Food dominates your life
5 item/brief measure
scoring is dichotomous –> score of 1 (symptoms endorsed on at least one item) has been recommended as positive screen
what ED specific questions should be asked on assessment
food/fluid intake on average day (when, what)
specifics of intake (i.e a sandwich can be many things)
self induced or spontaneous vomiting–how, when, frequency
binges –size, content, frequency
over the counter or naturopathic meds, supplements, laxatives, enemas, diuretics (teas)
food rituals, phobias, rules
chewing and spitting
excercise (walking, aerobics, weights)–duration and frequency
history of weight over time (highest, lowest, ideal)
how often weighing self, impact on wellbeing
desire to lose weight
body image
how much time spent thinking about food/weight/shape
what AAP is often used in the treatment of eating disorders
olanzapine
when might olanzapine be used in the treatment of eating disorders
increased agitation
re-feeding process stalling
caregivers not coping with dysregulation
why is olanzapine used in the treatment of eating disorders
helps to decrease OBSESSIONAL thinking about food
aids in coping with fear of food
also potentiates fluoxetine if this is a medication also used
better QTc profile than other AAPs
how would you start olanzapine in the treatment of eating disorders
start with 2.5 mg po HS
work up to 5mg HS
monitor metabolic and ECG if using long term
when might you use quetiapine in the treatment of eating disorders
if olanzapine failed or something is needed throughout the day; also sleep aid
why might you use quetiapine in the treatment of eating disorders
calming effects
less dopaminergic
more Qtc prolonging however
(12.5mg-50mg either PRN or throughout the day or larger dose at night)
at what % of body weight would you consider starting SSRIS in kids/teens
once weight restored to at LEAST above 85-90% body weight
are SSRIs helpful in AN alone?
not really–use to treat comorbidities
are SSRIs helpful in BN
if CBTE not progressing, or if patient continues to have symptoms despite psychotherapeutic intervention
there is some evidence in symptom reduction–> combiation of CBT + fluoxetine has some evidence for increased efficacy
titrate to 60mg
what medication should be avoided in BN
wellbutrin–> due to seizure risk
does the following class of medications have weak, moderate or strong evidence in the treatment of AN:
SSRIs
weak
does the following class of medications have weak, moderate or strong evidence in the treatment of AN:
TCAs
weak
does the following class of medications have weak, moderate or strong evidence in the treatment of AN:
olanzapine
weak
does the following class of medications have weak, moderate or strong evidence in the treatment of AN:
zinc
weak
does the following treatment have weak, moderate or strong evidence in the treatment of AN:
CBT
weak
does the following treatment have weak, moderate or strong evidence in the treatment of AN:
family based therapy
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of AN:
IPT, psychodynamic, behavioural therapies
weak
does the following class of treatment have weak, moderate or strong evidence in the treatment of AN:
nutritional counselling alone
weak
what treatment has the best evidence for efficacy in AN
family based therapy
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
SSRIS
strong
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
TCAs
weak
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
topiramate
weak
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
CBT
strong
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
IPT
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
DBT
weak
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
psychodynamic
weak
does the following treatment have weak, moderate or strong evidence in the treatment of BN:
behavioural therapies
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
family based therapy
weak
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
SSRIs
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
TCAs
weak
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
topiramate
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
sibutamine
moderate
(appetite suppressor)
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
CBT
moderate
does the following treatment have weak, moderate or strong evidence in the treatment of binge eating disorder:
ipT
weak
what are the 4 Cs of meal support
confident
calm
compassionate
consistent
in which patients should bone mineral densities be obtained
those who have been amenorrheic x 6 months or more
which patients w BN may require inpatient admission
Most patients with uncomplicated bulimia nervosa do not require hospitalization
indications for the hospitalization of such patients include severe disabling symptoms that have notresponded to adequate trials of outpatient treatment, serious concurrent general medical problems (e.g., metabolic abnormalities, hematemesis, vital sign changes, uncontrolled vomiting),
suicidality, psychiatric disturbances that would warrant the patient’s hospitalization independent of the eating disorder diagnosis, or severe concurrent alcohol or drug dependence or abuse
good outcomes from partial hospitalization programs are correlated with what factor
treatment intensity
the more successful partial hospitalization programs have patients in treatment how often/long
at least 5 days/week for 8hours/day
what are the goals of nutritional rehabilitation for underweight patients
restore weight
normalize eating patterns
achieve normal perceptions of hunger and satiety
correct biological and physiological sequelae of malnutrition
what are realistic targets for weight gain in hospitalized vs outpatient settings
2-3pounds/week in hospital
0.5-1 pound/week in community
when required, which is preferred: IV or NG feeds
NG
continuous is likely better tolerated by patients and less likely to result in electrolyte imbalance than bolus feeding
how often should you do K, Mg, phosphorus, calcium levels when monitoring for refeeding
daily x 5 days then every other day for up to several weeks thereafter
(+ECG as indicated)
what approach to family treatment is used for kids and teens with AN
Maudsley approach
(family treatment is the MOST EFFECTIVE intervention for kids and teens with AN)
for teens who have been ill less than 3 years, after weight is restored, family therapy is a necessary component of treatment
in which patients might AAPs (olanzapine, risperidone, quetiapine) be particularly helpful
severe, unremitting resistance to gaining weight
severe obsessional thinking
denial that assumes delusional proportions
why might pro-motility agents like metoclopramide be used in treating eating disorders
useful for bloating and abdominal pains that occur during refeeding with some patients
what supplemental vitamines are often recommended in treatment of eating disorders
calcium
vitamin D
zinc supplements (?may foster weight gain)
what medication may help in relapse prevention in AN
fluoxetine up to 60mg per day MAY help prevent relapse
is there indication for the use of bisphosphonates (i.e alendronate) in the treatment of AN
no
is there evidence that hormone replacement therapy is effective for improving bone mineral density in patients with AN
no
name the only FDA medication approved for BN
fluoxetine
(sertraline is the only other SSRI that has been shown to also be effective)
when would fluoxetine be recommended as initial treatment for BN
in absence of therapists qualified to treat BN with CBT
is lithium recommended for those with BN
not–> not effective
in those with both BN and bipolar disorder, lithium more likely to be associated with TOXICITY
how long should you continue fluoxetine in BN
at least 9mo-1 year
name an adjunctive non-med therapy that can be helpful in BN
bright light therapy–seems to decrease frequency of binges
is topiramate recommended in the treatment of binge eating disorder
effective for binge reduction and weight loss
adverse effects may limit use
name two treatments for night eating syndrome
progressive muscle relaxation
sertraline
list 2 clinician-administered measures for assessing eating disorders
Eating Disorder Examination (EDE)
Yale-Brown-Cornell Eating Disorder Scale (YBC-EDS)
name four self report measures for assessing eating disorders
EDE-Questionnaire
Eating Disorders Inventory
Eating Attitudes Test
Diagnostic Survey for Eating Disorders
what signs of eating disorder may be found on physical examination
abnormal vitals (bradycardia, low BP, orthostatic hypotension)
low weight
low JVP
middiastolic clicks, murmurs from mitral valve prolapse
acrocyanosis
delayed cap refill
lanugo
salivary gland enlargement
scarring on dorsum of the hands
evidence of self injurious behaviours
muscular weakness
indications of muscular irritability from hypocalcemia
gait and eye abnormalities
poor dentition
what are the names of two signs on physical exam that reflect muscular irritability due to hypocalcemia
Chvostek’s (facial muscle twitch when tapping patients cheek)
and
Trousseau’s signs (spasm of the hand after wearing inflated BP cuff for 2-3min)
list “whole body” physical signs/symptoms of AN
weakness
lassitude
low body weight
dehydration
hypothermia
cachexia
list CV and peripheral vascular physical signs/symptoms of AN
palpitations, faintness, weakness, dizziness, SOB, chest pain, cold extremities
bradycardia, orthostatic hypotension, weak/irregular pulse, acrocyanosis
what ECG changes may be seen in AN
bradycardia
arrhythmias
QTc prolongation
QT dispersion correlated with weight loss
increased PR interval
first degree heart block
ST-T wave abnormalities
what might be seen on echicardiogram in AN
mitral valve prolapse
pericardial effusion
what might be seen in CXR in AN
small heart
list CNS physical signs/symptoms of AN
apathy, poor concentration
cognitive impairment, anxiety, depression, irritable mood, seizures, peripheral neuropathy
what might be seen in CT in AN
enlarged ventricles
what might be seen in MRI in AN
decreased gray and white matter
what might be seen on EEG in AN
non specific changes
rare seizures
list endocrine/metabolic physical signs/symptoms of AN
fatigue, cold intolerance, diuresis
low body temp
how does AN affect serum cortisol
often increased
what vitamins may be depleted in AN
folate
B12
niacin
thiamine
list GI physical signs/symptoms of AN
vomiting, abdo pain, bloating, obstipation, constipation
abdo distension with meals, abnormal bowel sounds, acute gastric distension
in purging patients: benign parotid hyperplasia, dental caries, gingivitis
if vitamin deficiencies: angular stomatitis, glossitis, diarrhea
how is serum amylase affected in purging patients
increased
how is gastric motility affected in AN/BN
delayed gastric emptying
increased whole bowel and colonic transit time
anorectal dysfunction
what might be seen on abdo XR in AN/BN
superior mesenteric artery syndrome
pancreatitis
what might be seen in renal function tests in AN/BN
increased BUN
decreased GFR
decreased serum creatinine because of low lean body mass
renal failure
greater formation of renal calculi
hypovolemia nephropathy
hypokalemic nephropathy
how does AN/BN affect hair, skin, nails
change in hair–> hair loss, dry and brittle hair
yellowing of skin
lanugo
xerosis (dry skin)
carotenoderma
acne
what effect might AN/BN have on the reproductive system
arrested development of secondary sex characteristics and psychosexual maturation
loss of libido
loss of menses or primary amenorrhea
fertility problems
higher rates of pregnancy complications and neonatal complications
deficiencies in mother can lead to deficiencies in fetus
decreased serum estrogen in females/decreased tesosterone in males
prepubertal loss of LH, FSH secretions
what serum electrolyte abnormality is seen in vomiters
hypokalemia hypochloremic alkalosis
what electrolyte abnormalities are seen in vomiters and laxative abusers
hypophosphatemia
hypomagnesemia
what SUD is common in eating disorders
AUD–> increases risk of mortality in AN
