Bulimia Nervosa, OSFED, Somatic Syndrome

Question 1

Bulemia Nervosa: An Overview (3)

Answer 1

1. Usually begins in adolescence or young adulthood and disturbed eating behavior persists for several years
2. Long term outcome is variable often associated with substance abuse or personality disorder traits
   * Worse prognosis if comorbid
3. Higher risk of suicide
   * Though there is a higher death rate with anorexia due to cardiac arrhythmias

Question 2

Diagnostic Criteria: Bulimia Nervosa (5)

Answer 2

1. Recurrent episode of binge eating
   - Eating in a discrete period of time, an amount of food that is definitely larger than what most individual would eat in similar period of time under similar circumstances
   - A sense of lack of control over eating during the episode
2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain
3. The binge eating and inappropriate compensatory behaviors both occurs at least once a week for 3 months
4. Self evaluation is unduly influenced by body shape and weight
5. Disturbances does not occur exclusively during episodes

Question 3

Bulimia Nervosa Partial vs. Full Remission

Answer 3

1. In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time
2. In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time

Question 4

Bulimia Nervosa Severity (Mild, Moderate, Severe, Extreme)

Answer 4

1. Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week
2. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week
3. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week
4. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week
   * Depends on number of times they are forcefully vomiting per week; need to be very specific in getting the history to classify the severity

Question 5

Bulimia Nervosa: Management (6)

Answer 5

1. Restore nutritional balance and maintain structure nutritional intake
   * Weight gain of 1-2 kg/week normalizes the cardiovascular instability
2. Counseling directed around distorted self-image, uncontrollable and excessive eating, profound guilt, and embarrassment
3. Control excessive eating
4. Use of SSRI to help the obsessive thinking and uncontrollable compulsive behaviors
   * Prozac has been shown to have an effect in many studies
5. Admission if fluid loss is extreme
6. Intermediate partial hospitalization may be needed

Question 6

Treatment Continuum for Children and Adolescents with Eating Disorders (5)

Answer 6

1. Medical and nutritional rehabilitation
2. Dietary plan
3. Menses restoration
4. Behavioral therapy
   - Inpatient
   - Outpatient basis
   - Individual, group, family therapy
5. Psychopharmacologic therapy
   * Recent use of SSRI in bulimia nervosa
   * Prozac (fluoxetine) at 60 mg a day most effective; main difference with bulimia vs. anorexia

Question 7

Medical Complications for Bulimia Nervosa (18)

Answer 7

1. Hyper or hypotension
2. Electrolyte abnormities
3. Dehydration
4. Erosion of dental enamel
5. Calluses on the dorsum of the hand: Russellʼs sign
6. Acute pancreatitis
7. Parotid enlargement
8. Acute gastric dilation or rupture
9. Mallory Weiss tear
10. Gastric and esophageal irritation or bleeding
11. GERD
12. Barrett esophagus - Lower tears of distal esophagus
13. Aspiration pneumonia
14. Diarrhea, constipation or steatorrhea
15. Emetine (epicap syrup) cardiomyopathy
16. Menstrual irregularity
17. PCOS
18. Osteopenia, osteoporosis

Question 8

Binge Eating Disorder: Diagnostic Criteria (8)

Answer 8

BING EATING IS THE MOST COMMON EATING DISORDER!

Binge eating episodes are marked by at least three of the following:

1. Eating 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 embarrassment by the amount of food consumed
5. Feeling disgusted with oneself, depressed, or guilty after overeating
6. Episodes occur, on average, at least once a week for three months
7. No regular use of inappropriate compensatory behaviors (e.g., purging, fasting, or excessive exercise) as are seen in bulimia nervosa
8. Binge eating does not occur solely during the course of bulimia nervosa or anorexia nervosa –> Minimum average frequency of binge eating required for diagnosis is once weekly over the last 3 months (identical to frequency criterion for bulimia nervosa).

Question 9

Binge Eating Severity Scores (4)

Answer 9

1. Mild – 1 to 3
2. Moderate – 4 to 7
3. Severe – 8 to 13
4. Extreme – 14 or more

Same as bulimia

Question 10

Other Specified Feeding or Eating Disorder Diagnosis

Answer 10

Does not meet the full criteria for a specific feeding and eating disorder; Clinicians record the diagnosis “other specified feeding or eating disorder,” followed by the reason that the presentation does not meet full criteria for an eating disorder.

Question 11

Atypical anorexia nervosa (part of OSFED) diagnosis (2)

Answer 11

1. All of the criteria for anorexia nervosa are met, except that body mass index is ≥18.5 kg/m2
2. Example: obese patients who demonstrate the signs and symptoms of anorexia nervosa during rapid weight loss to a normal weight; the diagnosis is “other specified feeding or eating disorder, atypical anorexia nervosa.”

Question 12

Bulimia nervosa of low frequency and/or limited duration – part of OSFED diagnosis

Answer 12

All of the criteria for bulimia nervosa are met, except that episodes of binge eating and inappropriate compensatory behavior occur, on average, less than once per week and/or less than three months.

Question 13

Binge eating disorder of low frequency and/or limited duration– part of OSFED diagnosis

Answer 13

All of the criteria for binge eating disorder are met, except that episodes of binge eating occur, on average, less than once per week and/or less than three months.

Question 14

Purging disorder– part of OSFED diagnosis

Answer 14

Recurrent episodes of purging (self-induced vomiting, or misuse of laxatives, diuretics, or enemas) to influence body weight or shape, in the absence of binge eating.

Question 15

Night eating syndrome (2)

Answer 15

1. Recurrent episodes of night eating, defined as eating after awakening from sleep or eating excessively after the evening meal.
2. The night eating is not explained by changes in the sleep-wake cycle (e.g., night shift work), medication effects, binge eating disorder, substance use disorders, or general medical disorders.

Question 16

Justification for Hospitalization in Adolescent with Eating Disorder (12)

Answer 16

1. ≤ 75% median body mass index for age and sex
2. Dehydration
3. Electrolyte disturbance
4. Physiological instability—bradycardia (< 50 beat per minute at daytime, <45 beats at night
5. Arrested growth and development
6. Failure of OPD treatment Acute food refusal
7. Uncontrollable bingeing and purging
8. Acute medical complication of malnutrition (syncope, seizures, cardiac failure, pancreatitis
9. Hypotension (90/45)
10. Hypothermia
11. Positive orthostatics
12. Comorbid psychiatric or medical condition that limits OPD treatment (Severe depression, suicidal ideation OCD, type 1 DM)

Question 17

Differential Diagnosis of Eating Disorders - GI disorders (2)

Answer 17

1. Inflammatory bowel disease

2. Celiac disease

Question 18

Differential Diagnosis of Eating Disorders - Infectious disorders (2)

Answer 18

1. Chronic infections Human immunodeficiency virus infection

2. Tuberculosis

Question 19

Differential Diagnosis of Eating Disorders - CNS

Answer 19

malignancies

Question 20

Differential Diagnosis of Eating Disorders - endocrine (3)

Answer 20

1. Hyperthyroidism (hypothyroidism)
2. Diabetes mellitus
3. Other endocrine disorders (e.g., hypopituitarism, Addison disease)

Question 21

Differential Diagnosis of Eating Disorders - psychiatric (2)

Answer 21

1. Obsessive-compulsive disorder and anxiety disorders

2. Substance abuse

Question 22

Differential Diagnosis of Eating Disorders - other (2)

Answer 22

1. Other cancers

2. Superior mesenteric artery syndrome (more commonly a consequence of severe weight loss)

Question 23

Female Athlete Triad (3)

Answer 23

1. Disordered eating
2. Menstrual Dysfunction
3. Osteoporosis
   * 40% to 60% of peak bone mass is acquired during adolescence

Question 24

Female Athletes (7)

Answer 24

1. Female Athlete Triad is seen
2. Compulsive Exercising
3. Binge eating or purging
4. Using laxatives, diet pills, or diuretics
5. Food restriction = energy depletion
6. Can be seen in all athletes that are involved in all sports
7. Particularly seen in:
   - Distance runners
   - Gymnasts
   - Swimming

Question 25

Evaluating Acute Medical Complications - Binge Eating (5)

Answer 25

1. Gastric/duodenal ulcer
2. Gastric dilatation/rupture
3. Parotid swelling (associated with high carbohydrates)
4. Pancreatitis
5. Dental caries

Question 26

Evaluating Acute Medical Complications - Anorexia Nervosa

Answer 26

cardiac arrhythmias

Question 27

Evaluating Acute Medical Complications from vomiting (6)

Answer 27

1. Hypokalemia
2. Metabolic alkalosis
3. Dehydration
4. Hypomagnesia
5. Esophagitis
6. Aspiration pneumonia

Question 28

Refeeding Syndrome (5)

Answer 28

1. Occurs due to inability to make ATP (adenosine triphosphate); source of energy
2. Prior to refeeding, prolonged undernutrition decreased blood glucose concentrations, catabolism of fat and protein stores, depletion of electrolytes, including phosphorus
3. Phosphorus concentration is low and this process can lead to insufficient amounts within 12 to 72 hours of initiating feeding.
4. Inadequate ATP causes system failures
5. If phosphorus gets depleted, you can’t make ATP and therefore there will be system failure

Question 29

Primary Prevention – Care Providers – Families – Schools (12)

Answer 29

1. Avoid categorizing foods
2. Examine goals and expectations
3. Discuss body types
4. Be aware of media images
5. Self worth
6. Self awareness
7. Accept people no matter what their weight
8. Encourage healthy positive activity
9. Well-balanced diet
10. Food pyramid/ activity pyramid
11. Encourage:
    - Self assertiveness
    - Critical thinking
    - Self-esteem
12. Discourage perfectionism and dieting

Question 30

Prognosis with eating disorders (5)

Answer 30

1. Chronic illness
2. Severe anorexia protracted course with recovery estimates 10-15 years later from 76 to 24%.
3. 50% do well in long term
4. 20% do poorly
5. 30% show varying degrees of improvement

Question 31

Somatization (4)

Answer 31

1. Somatization is key concept
2. Subject experience of physical symptoms for which pathology or injury is lacking
3. Or when the level of distress or disability exceeds what is typically associated with the clinical findings
4. Associated with high healthcare cost and expenditure

Question 32

Four Somatoform Disorders in children and adolescents

Answer 32

1. Somatic symptom disorder
2. Other specified somatic symptom and related disorder
3. Illness anxiety disorder
   - Nurses are prone to this
4. Conversion disorder

Question 33

Somatic Symptom and Related Disorders (3)

Answer 33

1. Somatoform disorders are now referred to as somatic symptoms & related disorders in the DSM-5
2. Are reduced in number and subcategories to avoid problematic overlap.
3. Somatization disorder, hypochondrias, pain disorder, and undifferentiated somatoform disorder have been removed from DSM V.

Question 34

Somatic Symptom Disorder (3)

Answer 34

1. One or more somatic symptoms that are distressing or result in significant disruption of daily life
2. Excessive thoughts, feelings or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
   - Disproportionate and persistent thoughts about the seriousness of one’s symptoms
   - Persistent high level of anxiety about health or symptoms
   - Excessive time and energy devoted to these symptoms or health concerns
3. One somatic symptoms may not be continual present, the state of being symptomatic is persistent—typically more than one month

Question 35

Severity of somatic symptom disorder (mild, moderate, severe)

Answer 35

Mild: only one of the symptoms specified in criterion B is fulfilled

Moderate: two of the symptoms specified in criterion B is fulfilled

Severe: two or more of the symptoms specified in Criterion B is fulfilled.

Question 36

DSM 5: Somatoform Disorders (2)

Answer 36

1. They have maladaptive thoughts, feelings, and behaviors in addition to their somatic symptoms.
2. Somatization disorder and undifferentiated somatoform disorder have been merged in DSM-5 under somatic symptom disorder

Question 37

Other specified Somatic symptom and related disorder (3)

Answer 37

1. One or more somatic symptom that the youth experiences as distressing or that interferes significantly with daily life
2. Similar to somatic symptom disorder but do not meet the full diagnostic criteria
3. Duration may be less than 6 months

Question 38

Illness Anxiety Disorder:

Answer 38

Individuals previously dx w/ hypochondriasis who have high health anxiety but no somatic symptom would receive this DSM-5 dx.

Question 39

Conversion disorder (2)

Answer 39

1. Modified to emphasize the importance of the neurological exam and recognizes that relevant psychological factors may not be present at the time of dx.
2. Will see in children who have been sexually assaulted; may suddenly be unable to walk