Clinical Approach to Eating Disorder and Refeeding Syndrome Flashcards
what are the three eating disorder types?
- Anorexia Nervosa
- Bulimia Nervosa
- Binge Eating Disorder
Anorexia Nervosa is more common in what sex?
females: 3 times greater than males
Do adults or adolescents have a higher percentage of anorexia nervosa?
Adults- 0.6%
adolescents- 0.3%
bulimia nervosa lifetime prevalence
varies from 1-3 percent
Bulimia and Anorexia Nervosa are often accompanied by?
suicidality
what is an indication for hospitalization regarding suicide?
specific suicide plan or intent
for bulimia nervosa suicide rate is _ times higher than the general population
7
for anorexia nervosa suicide rate is _ times higher than the general population
5
DSM 5 diagnostic criteria for Anorexia Nervosa
restriction in energy/caloric intake far below their requirement leading to significantly reduced body weight
intense fear of gaining weight or becoming fat (even through they are obviously underweight)
Distorted perception of body weight and shape
what are the two types of Anorexia Nervosa
Restricting type and Binge-eating/purging type
what is the DSM5 criteria for Anorexia Nervosa - restrictive type
3 months of no binging or purging (vomiting), excessive exercising, fasting, and dieting
what is the DSM5 criteria for Anoerxia Nervosa- Binge-eating/purging type?
3 months of binging and purging behaviors
what is purging
self induced vomiting or tissues of laxatives, diuretics or enemas
DSM subtypes Anorexia Nervosa into restricting and binge-eating/purging based on weight loss strategies. However _ is common
cross over
Severity of Anorexia Nervosa is based on current _
Body Mass Index (BMI)
Mild Anorexia BMI
greater than 17 kg/m2
moderate anorexia BMI
16-16.99 kg/m2
Severe Anorexia BMI
15-15.99 kg/m2
extreme Anorexia BMI
<15 kg/m2
rituals associated with eating disorders share characteristics with _ which is especially common in anorexia nervosa
OCD
what other disorders arise in childhood and predate the development of eating disorders in most cases
OCD and anxiety disorders
in someone with anorexia nervosa_ is often viewed as a form of control
weight loss
in someone with anorexia nervosa self esteem may largely revolve around _ and _ image
weight and body image
excessive viewing in the mirror and weight measurements are common in what eating disorder
anorexia nervosa
fear of weight gain and other psychological comorbidities tend to _ (get better/worsen) as patient lose more weight
worsen
in what eating disorder will patients deny starvation despite acknowledgement of emaciated appearance
anorexia nervosa
why is screening for eating disorders important
eating disorders are often undetected and untreated
give a few examples of when you would do an eating disorder primary screen in a patient
-if there was adversity during childhood
-young adult
-female
-transgender ppl
-athletes
-signs of eating disorder
-anxiety/depression
-perfectionism
Eating disorder screen for primary care:
Are you satisfied with your eating patterns (no is abnormal)
Do you ever eat in secret (yes is abnormal)
does your weight affect the way you feel about yourself ( yes is abnormal)
have any members of your family suffered with an eating disorder ( yes it abnormal)
do you currently suffer with , or have you ever suffered in the past with an eating disorder (yes is abnormal)
What questionnaire is the most commonly used instrument and is recommended by the United States preventive services task force (screening for eating disorders)
SCOFF
what is the scoff questionnaire
do you ever make yourself SICK because you feel uncomfortably full?
do you worry you have lost CONTROL over how much you eat?
have you recently lost more than ONE stone (14 pounds) in a three month period?
do you believe yourself to be FAT when others say you are too thin ?
would you say that FOOD dominates your life ?
the most commonly used instrument and is recommended by the United States preventive services task force (screening for eating disorders)
**yes to the two or more questions is generally regarded as a positive screen and should prompt further assessment to establish or rule out a diagnosis
what are some psychosocial factors that contribute to eating disorders?
americas obsession with weight loss
magazines/models
computer programs/photoshop
preoccupation to lose weight and bring self esteem to a thin body extends into maturing adolescents
pathogenesis and neurobiology of eating disorders
aggregation of anorexia and nervosa in families suggests there are genetic factors
locus on chromosome 12
medical complications of Anorexia Nervosa
Cardiac: bradycardia, hypotension, QT dispersion, cardiac atrophy, and MVP
gynecology: amenorrhea and decreased sex drive
endocrine: osteoporosis, hypothermia, euthyroid, HYPOglycemia
electrolyte:dehydration, HYPOkalemia, HYPOphophatemia, HYPOmagnesemia
pulmonary: respiratory muscle atrophy and dyspnea
hematologic: anemia, leukopenia, thrombocytopenia
dermatologic: Xerosis, carotenoderma, acrocyanosis, seborrheic dermatitis
why should we not rehydrate or feed patients behind their current capacity in people with Anorexia Nervosa
due to Refeeding Syndrome complication
what is refeeding syndrome?
A clinical complication that occurs as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients
-complications are potentially fatal when not detected or treated early
what are some of the complications of referring syndrome ?
HYPOphosphatemia, HYPOkalemia, congestive heart failure , peripheral edema, rhabdomyolysis, seizures, hemolysis
How can we avoid Refeeding syndrome?
judiciously limit the amount of calories and fluid provided in the early stages of refeeding
avoid rapid increase in the amount of calories ingested
closely monitor labs during the first few weeks
in anorexia nervosa: failure to recognize and treat comorbidities can have catastrophic repercussions. What are some other disorders that can present with anorexia nervosa
anxiety, OCD, PTSD, body dysmorphic disorder, depressive disorder, substance use, personality disorders
treatment of anorexia nervosa requires a _ team that usually includes a health services clinical psychologist, a registered dietitian, and PCP
interdisciplinary
what treatment options are needed at minimum first like care in a person with AN
nutritional rehabilitation and psychotherapy
hospitalization of a person with AN should last how long?
until normal weight is achieved to reduce relapse and re-hospitalization
AN is resistant to pharmacotherapy and medications are only used for what?
to reduce depression or anxiety if they are a barrier to treatment
what is the primary treatment in AN
nutritional rehabilitation
what is nutritional rehabilitation?
this is treatment in AN supervised by a registered dietitian with a focus on proper weight gain and practices
-can include supervised meals
what is the average weight gain in nutritional rehabilitation inpatient vs outpatient
inpatient 2-3 pounds/week
outpatient 0.1-1 pounds/ week
usual initial intake in nutritional rehabilitation is?
-this is progressively increased to match tolerance and weight gain goals
30-40 kcal
how is psychotherapy helpful in AN
it focuses on helping patient confront their disorder and change their eating habits and/or thoughts about weight gain
what are the different psychotherapy options?
cognitive behavioral therapy (CBT), specialist supportive clinical management, motivational interviewing, family therapy
what medication should you avoid in AN due to a risk of seizure in the binding and purging type
Bupropion (used as antidepressant)
what medications should you avoid in AN due to cardio toxicity?
tricyclic antidepressants
what medications should you exercise cation with in AN due to risk of QT prolongation
antipsychotics
what adjunctive medication in AN is used to help with weight gain?
Olanzapine
what medication in AN is associated with confronting meals
Lorazepam
what medications can you use in AN if anxiety or depression becomes severe enough to create barriers to care
SSRI
and if unresponsive
second generation antipsychotics
DSM5 Diagnostic Criteria for Bulimia Nervosa
recurrent episodes of binge eating; large amount during a given time period
patients cannot feel like they are in control of their eating during that episode
recurrent compensatory behavior to prevent weight gain such as vomiting and misuse of laxatives/diruetics, fasting or excessive exercise
the patients sense of self worth is influences by body shape and weight
disturbances does not occur exclusively during an episode of AN
In Bulimia Nervosa patients can vary between _ and can use the same weight loss tactics to those with _
patients often feel _ after binging
patients often excessively fearful of _ gain, _. behaviors are used to counteract the weight gain from binge eating. Patients dont necessarily want to become _ they just dont want to become _
weights
ANorexia Nervosa
dysphoric
weight
purging
thin
fat
medical complications of BN
electrolyte: dehydration, hypokalemia, hypochloremia, metabolic alkalosis
cardiac: hypotension, orthostasis, sinus tachycardia*, arrythmias
GI: MALLORY-WEISS syndrome, esophageal rupture, parotid and submandibular gland hypertrophy, abdominal pain
dental: tooth enamel erosions and dental caries, scar and callus on dorm of hand (RUSSEL’S sign)
BN treatment best standard
combination of nutritional rehabilitation, CBT psychotherapy, and pharmacotherapy
what treatment for BN is alone the most appropriate treatment if the other options are no available
pharmacotherapy or psychotherapy
what is the most critical assessment in BN patient
monitor them for suicidal ideation (7 times higher suicide rate)
what is the most critical assessment in BN patient
monitor them for suicidal ideation (7 times higher suicide rate)
first line treatment pharmacotherapy for BN
fluoxetine 60 mg per day; may start at full dose or 20mg per day with 20mg increases each week until 60mg is reached
second line treatment in BN
other SSRis ar higher doses than that is used to treat major depression ( sertraline or fluvoxamine)
Third line treatment in BN
tricyclis, topiramate, trazado, MAOIs
avoid what medication in BN due to increased seizure risk with binging and purging
bupropion
Episodes of binge eating, defined as consuming a large amount of food in a discrete period of time (about 2 hrs)
Binge Eating Disorder (BED)
Binge Eating Disorder DSM 5 diagnostic criteria
binge eating large amounts of food within 2 hours
lack control over their eating behavior during the episode
episodes occur on average once a week for at least 3 months
no regular use of inappropriate compensatory behavior (purging fasting) etc.
binge eating episodes are marked by at least 3 of the following
eating large amounts of food when not hungry
eating rapidly
feeling uncomfortable after eating
eating alone due to embarrassment over amount consumed
feeling of guilt, depression, disgust after binging
treatment of binge eating disorder should focus on helping to reduce the patients…. (4)
binge eating, excessive weight gain ( if present), psychiatric comorbidities, excessive body image concerns
what is the first line treatment in binge eating disorder
psychotherapy (CBT) and interpersonal therapy (IPT)
what is the first and only medication approved to treat Binge Eating Disorder
Vyvanse (lisedexamfetamine dimesylate)
Binge eating disorder pharmacotherapy
less effective than psychotherapy but less expense and time
-combination with CBT, only topiramate may be exeception
SSRIs: CItalopram, escitalopram, fluoxetine (chosed over topiramate)
what drug is not recommended in binge eating disorder due to poor efficacy and serious adverse outcomes
anti-obesity drugs
