Bulimia Nervosa and Anorexia Nervosa Flashcards
Inappropriate ways of controlling weight seen in bulimia nervosa
- Fasting
- Excessive exercising
- Misuse of laxatives, diuretics, or enemas
- Postprandial vomiting
Patients with bulimia are usually ___in weight
Patients with bulimia are usually average or near-average in weight
Nonpurging type bulimia
Bulimia where fasting or excessive exercising are utilized without frequent purging
Purging
Self-induced vomiting and/or missuse of laxatives, diuretics, or enemas for the purpose of preventing weight gain
Risk of relapse following treatment for bulimia
About ~33%
Physical exam and laboratory features of bulimia nervosa
-
Physical Exam:
- Parotid gland enlargement
- Tooth erosion
- Gastric dilation
- Possible Mallory-Weiss or Boerhave syndrome
- Signs of ipecac intoxication or related cardiomyopathy
-
Laboratory:
- Elevated serum amylase
- Hypokalemia
- Hypomagnesemia
- Hypochloremic contraction alkalosis
Ipecac
Rapidly acting emetic
Signs of toxicity: Pericardial pain, dyspnea, generalized muscle weakness, hypotension, tachycardia, EEG abnormalities. Chronically may cause cardiomyopathy.
(Basically, acute tachy EKG abnormalities with chest pain, chronic cardiomyopathy)
What types of person tend to get anorexia or bulimia?
- High achievers
- FHx depression
- Respond to social pressures to be thin
Hallmarks of bulimia
Binge eating
Purging behavior
Diagnostic criteria for Bulimia Nervosa
- Recurrent episodes (at least once/week for 3 months) of binge eating and inappropriate compensatory behavior (purging, fasting, excessive exercise)
- Self-evaluation is largely (and unduly) based on body shape and weight
- Behavior does not occur only during an episode of anorexia nervosa
Anorexia nervosa, binge-eating / purging type
Main DDx for Bulimia nervosa
The binge-eating/purging behavior is seen in both. However, anorexia is distinguished by the requirement of being:
- Underweight
- Amenorrheic
In contrast, patients with bulimia can be of near-average, average weight, or overweight
Is binge-eating/purging behavior sufficient to diagnose bulimia?
NO
Anorexia is still on the Ddx, and conditions of chronicity and physical sequellae must be met.
Short-lived episodes of binge-eating/purging behavior
Not necessarily bulimia, as they may be short-lived, infrequent, and unassociated with physical sequellae
These behaviors are often learned from peers, performed infrequently, and self-resolve. Bulimia is when they do not self resolve and become habit.
Bulimia behavior in CNS syndromes
Can be seen in certain CNS tumor syndromes or rare infarcts, particularly Kluver-Bucy syndrome and Klein-Levin syndrome.
Thus, a full history and physical exam should be performed with attention to neurologic deficits, excessive sleepiness, hallucinations, and B symptoms.
Treatment of Bulimia nervosa
Should have a three-pronged treatment:
- CBT* (often family based or 12-step styple group therapy)
- Nutritional rehabilitation
- Treatment with an SSRI **
*For patients who are overweight, appetite-awareness training and a structured behavioral weight-loss program are preferable to group CBT. Otherwise, this population tends to discontinue therapy prematurely.
** Fluoxetine is the standard, sertraline is second-line. Should be continued for 9-12 months after symptoms remit.
Patients with bulimia may not have any symptoms until ___, while symptoms in anorexia typically present in ___.
Patients with bulimia may not have any symptoms until early adulthood, while symptoms in anorexia typically present in adolescence.
This makse sense. If you don’t eat at all, you will see the symptoms sooner than the gradual tooth erosion and parotid hypertrophy in bulimia.
Anorectic abnormal body weight
Body weight lower than the 15% percentile for the patient’s age that is produced by conscious weight-loss efforts
Lanugo
Fine body hair present on prepubertal children and commonly seen in patients with anorexia
May also occur in other etiologies of malnutrition
__ should always be a prominent part of the assessment for anorexia nervosa.
A family assessment should always be a prominent part of the assessment for anorexia nervosa.
There is strong evidence that family functioning plays an important role in he development of this disorder.
Patients with anorexia nervosa tend to take great interest in. . .
. . . food and its preparation, despite that they severely restrict their own calorie intake.
They are living vicariously.
A key part of anorexia is the belief that. . .
. . . they are overweight, despite being extremely low weight and even malnourished
Signs of malnutrition commonly seen in anorexia
- Cachexia
- Amenorrhea (history)
- Hypothermia
- Dependent edema (due to hypoalbuminemia)
- Bradycardia with hypotension
- Lanugo
Diagnostic criteria for anorexia nervosa
- Refusal to maintain weight at or above the normal weight for one’s age and height (<15%ile)
- Intense fear of gaining weight or becoming fat despite being underweight
- Disturbance of the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the severity of the current low body weight
Insight in anorexia and bulimia
Patients with bulimia tend to have good insight
Patients with anorexia tend to have poor insight.
Main “types” of anorexia
Restrictive type
Binge-eating/purging type
Treatment of aorexia nervosa
- Medical stabilization is the initial step. In children/adolescents, this may need to be involuntary with parental consent.
- Following medical stabilization, if the patient is still 30% below expected weight or has been unresponsive to outpatient efforts to weight restoration, they will require psychiatric hospitalization for 2-6 months
- Once an outpatient again, CBT or family therapy are employed.
- Pharmacotherapy has not been definitively proven useful, however olanzapine is sometimes used. Comorbid psychiatric disorders should be treated appropriately.
Patients with anorexia nervosa are at high risk of ___ upon initiation of treatment
Patients with anorexia nervosa are at high risk of refeeding syndrome upon initiation of treatment
So, careful monitoring of electrolytes and EKG during inpatient medical stabilization is necessary.
Phases of family therapy for anorexia
- Restoring the patient’s weight
- Handing control over eating back to the patient
- Discussion of adolescent development once healthy weight is attained and maintained
Related psychiatric features sometimes observed in anorexia nervosa
Obsessions, rituals, and depression
These do not necessarily indicate another psychiatric disorder, unless diagnostic criteria per the DSM-5 are met
___ is seen in 1/3 of patients with anorexia nervosa
Mitral regurgitation is seen in 1/3 of patients with anorexia nervosa
This presents as a holosystolic murmur on exam
