Clinical Approach to Eating Disorders and Refeeding Syndromes Flashcards
What are some societal and cultural influences on eating disorders?
- Many aspects of the united states culture display on obsession with weight loss
- Women’s magazines often include stories about weight management, dieting, or how to tighten specific muscle groups
- Models and actors often display a level of thinness that is difficult to attain
What are bulimia and anorexia nervosa usually accompanied with?
- Suicidality
What are the specifics of suicide in eating disorders?
- Specific, high lethality, suicide plan or intent is an indication for hospitalization
What is Anorexia Nervosa?
- Restriction of energy intake relative to requirements, leading to a significantly low body weight for age, sex and development
- Have an intense fear of gaining weight or becoming fat despite being underweight or persistent behavior that interferes with weight gain
- Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s low body weight
What is the screening for eating disorders?
- 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 ever suffered with an eating disorder? (Yes is abnormal)
- Do you currently suffer with or have you ever suffered in the past with an eating disorder? (Yes is abnormal)
What are the different types of Anorexia Nervosa?
- Restricting Type: 3 months of no binging or purging (no self-induced vomiting or use of laxatives) –> Excessive exercising, fasting, dieting
- Binge eating/Purging type: 3 months of the binging and purging behaviors –> self-induced vomiting and misuse of laxatives, diuretics, enemas
What are some considerations with Anorexia Nervosa?
- Patients are often underweight and those with normal body weight will trend down if untreated
- Weight loss if often viewed as a form of control. Self esteem may largely revolve around weight and body image. Excessive viewing in the mirror, weighing of self or body parts are common behaviors
- Patients may still deny starvations symptoms despite acknowledgement of emaciated appearance
What are common weight loss strategies in Anorexia Nervosa?
- Excessive exercise
- Fasting
- Binging and purging
- Laxatives
- Diuretics
- Enemas
- Dietary restriction
How may patients deny, conceal, or express their disorder?
- Through related somatic or mood symptoms
- Family, friends, coworkers, employers, or teachers may not be aware of a problem until symptoms become severe
What happened in Madrid in 2006?
- Ordered that every model must have BMI of 18
- Models who were 5ft 9in must weigh a minimum of 123 lbs
- Restrictions were placed after a death of a Brazilian model who had a BMI of 13.4
What did the survey say that was conducted by Model Alliance in 2012?
- 64.1% of models said they have been asked by their agencies to lose weight
- 31.2% admitted to suffering from an eating disorder
What are some cardiac complications seen in AN?
- Bradycardia
- Hypotension
- QT dispersion
- Cardiac atrophy
- Mitral valve prolapse
What are some gynecologic complications seen in AN?
- Amenorrhea
- Decreased libido
What are some endocrine complications seen in AN?
- Osteoporosis
- Hypothermia
- Euthyroid
- Hypoglycemia
What are some GI complications seen in AN?
- Gastroparesis
- Constipation
What are some electrolyte complications seen in AN?
- Dehydration
- Hypokalemia
- Hypophosphatemia
- Hypomagnesemia
What are some pulmonary complications seen in AN?
- Respiratory muscle atrophy
- Dyspnea
What are some hematologic complications seen in AN?
- Anemia
- Leukopenia
- Thrombocytopenia
What are some neurologic complications seen in AN?
- Brain atrophy
What are some dermatologic complications seen in AN?
- Xerosis
- 1anugo
- Carotenoderma
- Acrocyanosis
- Seborrehic dermatitis
What is a note for treating refeeding syndrome?
- Do not rehydrate or feed patients beyond their current capacity.
What is refeeding syndrome?
- Clinical complications that occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients
What are some complications of refeeding syndrome?
- Hypophosphatemia
- Hypokalemia
- Congestive heart failure
- Peripheral edema
- Rhabdomyolysis
- Seizures
- Hemolysis
How do you avoid refeeding syndrome?
- Judiciously limiting the amount of calories and fluid provided in the early stages of refeeding
- Avoiding very rapid increases in the amount of daily calories ingested
- Closely monitoring the patient during the first few weeks of the refeeding process
What are some mood disorders seen with AN?
- Depression and dysthymic disorders
- Anxiety disorders: OCD and impulse control disorders
What are some personality disorders seen with AN?
- OCD
- Avoidant
- Dependent
- Narcissistic
- Paranoid
- Borderline
What are some disordered personality personality traits seen with AN?
- Perfectionism
- Compulsivity
- Narcissism
What is the treatment for AN?
- Requires interdisciplinary team
- Nutritional rehabilitation and psychotherapy are needed at minimum for first line care
- Always monitor patients for medical complications
Why is hospitalization needed in AN?
- Complications of starvation
- Resistance to refeeding
- Suicidality
- Severe psychosocial barriers to care
- Should last until normal weight is achieved to reduce relapse and re-hospitalization
What is the nutritional rehabilitation of AN?
- First line therapy supervised by a registered dietitian with a focus on proper weight gain practices
- May include supervised meals
- 2-3 lbs gained per week for inpatients
- 1-2 lbs gained per week for outpatients
What is the usual initial intake for AN patients?
- 30-40 kcal/kg and is progressively increased to match body tolerance and weight gain goals
What is the ultimate goal in the nutritional rehabilitation for AN?
- Bring patient back to normal body weight and teach patient proper eating habits for long term self-care
What is first line therapy in psychotherapy for AN?
- Focus on helping patients confront their disorder and change their eating habits and/or thoughts about weight gain
How is the choice made for the psychotherapy in AN?
- Based on patient preference
- Could include CBT, specialist supportive clinical management, motivational interviewing, or Family therapy
What are some pharmacotherapy considerations for treating AN?
- Consider only for patients who have been resistant to other therapies and are willing to take medications
- Start low and increase as needed due to increased risk of side effects
- Avoid bupropion (increased seizure risk) and tricyclic antidepressants (cardiotoxicity)
- Be careful with antipsychotics and antidepressants with risk of QT prolongation
What medication can be given that has shown to help with weight gain?
- Olanzapine (adjunctive medication)
What medication can be given that has shown to help confront meals?
- Lorazepam to help reduce anxiety
What meds should be considered if anxiety or depression becomes severe enough to create barriers?
- SSRI
What is Bulimia Nervosa?
- Recurrent episodes of binge eating defined as eating an unusually large amount of food in a discrete period of time
- Patients cannot control their eating during the episode
What is considered binge eating in bulimia nervosa?
- Occurs at least two times per week for three months
What are some considerations in bulimia?
- Patients can vary between normal body weight, slightly underweight, overweight, or obese. Compare this to patients with AN who are mostly underweight
- Patients can use the same weight loss tactics as those with AN
- DSM does not divide into different categories
Do bulimia patients want to become thin?
- No, just don’t want to be fat
- Purging behaviors are used to counteract the weight gain from binge-eating
What are the electrolyte complications seen in bulimia?
- Dehydration
- Hypokalemia
- Hypochloremia
- Metabolic alkalosis
What are some cardiac complications seen in bulimia?
- Hypotension
- Orthostasis
- Sinus tachycardia
- ECG changes
- Arrhythmias
What are some GI complications seen in bulimia?
- Mallory-Weiss syndrome
- Esophageal rupture
- Parotid and submandibular gland hypertrophy
- Abdominal pain and bloating
- Constipation
What are some dental and skin complications seen in bulimia?
- Tooth enamel erosions and dental caries
- Scar and callus on dorsum of hand (Russell’s Sign)
- Xerosis
What are some comorbidities?
- Anxiety, mood, and substance use disorders
- Personality disorders: OCD, avoidant, dependent, histrionic, paranoid, and borderline
- Disordered personality traits: impulsivity, perfectionism, compulsivity, and narcissism
What is the treatment for bulimia?
- Combination of nutritional rehabilitation, CBT psychotherapy, and pharmacotherapy
- Pharmacotherapy or psychotherapy alone is appropriate treatment if other options are not available
What is nutritional rehabilitation is used for in bulimia patients?
- Helps counsel patients about proper eating habits, and to help control binging and purging
What is the treatment of choice for BN?
- CBT psychotherapy
How does CBT psychotherapy help BN?
- Shown to help reduce binging and purging. Not indicated for reducing weight
- Improves self-esteem
- Decrease emphasis upon thinness
- Eliminate dietary restraint
- Create pattern of regular eating
- Eliminate binge and purge habits
What improves the effectiveness of CBT psychotherapy?
- When combined with pharmacotherapy
What medications should be avoided in BN?
- Bupropion due to increased seizure risk with binging and purging
What is needed to be done when giving medications to BN patients?
- Counsel on side effects. Especially given to increased suicidality and weight change for this patient population
What is the first line pharmacotherapy for BN patients?
- Fluoxetine 60mg per day (either start with full dose or titer up, increases 20mg after starting at 20mg each week
What is the second line pharmacotherapy for BN patients?
- Other SSRIs at doses higher than starting dose used to treat major depression. Recommended is Sertraline or fluvoxamine
What is the third line pharmacotherapy for BN patients?
- Tricyclics, topiramate, trazodone, and MAOIs
What is binge eating disorder?
- Episodes of binge eating, defined as consuming a large amount of food in a discrete period of time (within a 2 hour window)
What do people with binge eating disorder feel like?
- Feel they lack control over eating during the episode
What are the binge-eating episodes marked by in binge eating disorder?
- Eating large amounts of food when not hungry
- Eats rapidly
- Feels uncomfortably full after eating
- Eating alone due to embarrassment over amount consumed
- Feelings of guilt, depression, disgust after binging
How is binge eating disorder different from bulimia?
- There is no regular use of inappropriate compensatory behaviors (purging, fasting, or excessive exercise) as are seen in bulimia nervosa
What is the purpose of treatment for BED?
- Focus on help reduce the patient’s:
1. Binge eating
2. Excess weight gain
3. Psychiatric comorbidities
4. Excessive body image concerns
What is the first line therapy for BED?
- Psychotherapy like CBT and interpersonal therapy
What medications are usually given for BED?
- Vyvanse for moderate to severe BED
What SSRIs are given to help with BED?
- CItalopram, Escitalopram, fluoxetine, fluvoxamine, and sertraline
- Usually chosen over topiramate or zonisamide
What kinds of medications are not given to patients with BED?
- Anti-obesity drugs
- They have poor efficacy and serious adverse effects
