Clinical Approach to Eating Disorders and Refeeding Syndrome Flashcards
who is likely to develop an eating disorder?
women and adolescents
western societies
what ideology often accompanies eating disorders?
suicidality
DSM5 criteria for anorexia nervosa (AN)
restriction of energy intake relative to requirements, leading to low body weight for age, sex and development
intense fear of gaining weight or becoming fat despite being underweight
distorted perception of body weight and shape or denial of low body weight
screening questions for eating DOs
- are you satisfied with your eating patterns?
- do you ever eat in secret?
- does your weight affect the way you feel about yourself?
- have any family members suffered with an eating disorder?
- do you currently suffer with or have suffered in the past with an eating DO?
restricting type AN
3 months of no binging or purging (no vomiting or lax)
excessive exercising, fasting, dieting
binge-eating/purging type AN
3 months of binging and purging behaviors
self-induced vomiting
misuse of laxatives, diuretics, or enemas
AN cardiac complications
bradycardia hypotension QT dispersion cardiac atrophy mitral valve prolapse
AN gynecologic complications
amenorrhea
decreased libido
AN endocrine complications
osteoporosis
hypothermia
euthyroid
hypoglycemia
AN GI complications
gastroparesis
constipation
AN electrolyte complications
dehydration
hypokalemia
hypophosphatemia
hypomagnesia
AN pulmonary complications
respiratory muscle atrophy
dyspnea
AN hematologic complications
anemia
leukopenia
thrombocytopenia
AN neurologic complications
brain atrophy
AN derm complications
xerosis (dry skin) lanugo (peach fuzz) carotenoderma (orange skin) acrocyanosis (blue ext) seborrheic dermatitis
Refeeding syndrome
clinical complication that occurs as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients
complications of refeeding syndrome
hypophos hypok CHF peripheral edema rhabdomyolysis seizures hemolysis
how to avoid refeeding syndrome
limiting the amount of calories and fluid provided in early stages of refeeding
avoid rapid increases in the daily calories ingested
closely monitoring labs and the patient during the first few weeks of refeeding
AN comorbidities
OCD
depression
impulse control DO
personality DO
AN treatment
mental health clinician, registered dietitian and general medical clinician
nutritional rehab and psychotherapy
hospitalization to avoid refeeding syndrome, suicidality or starvation
hospitalization until normal weight achieved
meds may be used when depression/anxiety creating barriers to care
AN nutritional rehab
supervised meals
2-3 lbs per week for inpatient
0.5-1 lb per week for outpatient
start at 30-40 Cals/kg and progressively increase
AN psychotherapy
focus on helping patient confronting DO and change eating habits/thoughts of weight gain
cognitive behavioral therapy
specialist supportive clinical management
motivational interviewing
family therapy
AN pharmacotherapy considerations
only for patients who have been resistant to other therapies
start at low doses
AN meds
Olanzapine (anti-psych)
Lorazepam for anxiety
SSRI for anxiety or depression
DSM5 criteria for bulimia nervosa (BN)
recurrent episodes of binge eating - eating large amounts of food in a discrete period of time
recurrent compensatory behavior to prevent weight gain (vomiting, lax)
binge/purge occurs at least 2x/week for 3 months
patients self-eval is influenced by body weight and shape
disturbance does not occur exclusively during an episode of AN
BN considerations
patients vary between normal body weight, underweight or overweight
may use same weight loss tactics as AN
patients feel lack of control over binge eating but try to conceal it
dysphoria after binging
fearful of weight gain - may not want to become thin but just don’t want to become fat
BN medical complications
similar to that of AN except:
Mallory-weiss syndrome/esophageal rupture
glandular hypertrophy
abd pain, bloating and constipation
tooth enamel erosion and caries
Russel’s sign - scar and callus on dorsum of hand
BN comorbidities
anxiety
mood DO
substance abuse
personality DO
BN treatment
combination of nutritional rehab, CBT psychotherapy and pharmacotherapy
BN pharm considerations
less effective than CBT - best used in combo
avoid bupropion
BN meds
fluoxetine
SSRIs
DSM5 criteria for Binge Eating Disorder (BED)
episodes of binge eating
lack of control over eating
binge-eating marked by at least three of the following: eating large amounts when not hungry eating rapidly feels uncomfortably full after eating eating alone due to embarrassment feeling of guilt after eating
episodes occur at least 1x/week for 3 months
BED treatment
CBT and interpersonal therapy are most effective
pharmacotherapy used in combo with psychotherapy
BED pharmacotherapy
Vyvanse
SSRIs
*anti-obesity drugs NOT recommended
