eating disorder + substance abuse Flashcards
anorexia nervosa: DSM-5 criteria
( greek for loss of appetite)
1) Persistent Restriction of Energy Intake leading to low body weight compared to what is expected for age sex, developmental trajectory, and physical health
- typically: BMI < 17.5 or less than 85% of expected body weight
2) Intense Fear of Gaining Weight/being fat or persistent behavior that interferes with weight gain
3) Disturbance in Body Image:
- distorted perception of their body weight or shape
- self-worth is excessively tied to their body size, with a disproportionate emphasis placed on weight and shape in evaluating their overall value
- lack of recognition of the seriousness of their low body weight
4) Duration: behaviors present for 3+ months
labs: anorexia
-Leukopenia
-Hypoglycemia
- hypotension
-Hypokalemic, hypochloremic metabolic alkalosis (if purging)
-EKG Changes-ST depression, T wave flattening/inversion, PROLONGED QTC, BRADYCARDIA
clinical features of anorexia: how does it manifest + starvation related medical sx
-Intense desire for thinness often despite apparent starvation
Starvation related medical sx:
-Amenorrhea
-Hypothermia
-Fatigue/weakness
-Dependent edema, cold/swollen extremities
-Cardiac arrhythmias: tachy, bradycardia
-Gastric bloating, abdominal pain, constipation
-Seizure
-Lanugo: Body knows youre losing weight - hair growth to keep you warm
-Tooth decay from purging
anorexia behavior observations
-Preoccupied with food
-Loss of appetite RARE, LATE (they just choose to starve)
-Peculiar food related behaviors
-Abuse of laxatives/diuretics
-Excessive ritualistic exercise
-Rigid, perfectionistic
-Somatic complaints
-Lack of sexual drive
bulimia nervosa: DSM-5 criteria
(greek = ravernous hunger)
Recurrent episodes of binge eating at least once a week for 3 months characterized by :
-Eating, in a discrete period of time (e.g. within any 2-hour period!!!), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
-A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating)
Recurrent compensatory behavior to prevent weight gain:
- Self-induced vomiting
- Misuse of laxatives, diuretics, or other medications
- Fasting or excessive exercise
Disturbance Does Not Occur Exclusively During Episodes of Anorexia Nervosa
Clinical Features of Bulimia Nervosa: how does it relate/compare to anorexia, what type of binge, vomiting
Premorbid History of Anorexia Nervosa:
- ~ 50% of those with Anorexia may later meet criteria for Bulimia Nervosa
- its hard to be anorexic…. often the rigid control and restricting breaks pt down and they begin the binge-purge cycle
- Malnutrition may not be as obvious in bulimics as it is in anorexia
- Bulimics have a better prognosis compared w/ anorexics
Secretive binges:
- food often consumed rapidly, sometimes without chewing
- High-calorie, sweet foods with a smooth texture are frequently chosen during binge
Vomiting: can be sticking fingers down throat but some can vomit at will
what signs for what ds
BULLEMIA sx
russell’s sign: Bruises on knuckles from upper part of your mouth from purging
tooth enamel changes from purging up gastric acid
pathology and lab examine in bulimia
-Malnutrition may not be as obvious in bulimics as it is in AN.
-Dehydration is common in patients who purge repeatedly
-Electrolyte abnormalities: decreased Mg, hypokalemia (PROLONGED QT -> SEIZURES), decreased chloride
- hypochloremic hypokalemic metabolic alkalosis: in patients who vomit, use laxatives repeatedly
-Gastric ulcers
-Gastric, esophageal tears
-Esophageal cancer
-Hypotension, bradycardia
psychological factors associated with bulimia: what are common comorbid ds
-Difficulties with impulse control: substance abuse, shoplifting, self-injurious behaviors/suicide attempts, destructive emotional relationships
-More outgoing, angry, emotionally labile
-Bulimics have a better prognosis compared w/ anorexics
comorbid ds:
- Borderline Personality Disorder
- Bipolar Disorder II
- anxiety
- impulse control ds
- substance abuse
binge eating disorder: DSM-5 criteria
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
-Eating, in a discrete period of time (e.g. within any 2-hour period!!!!), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
-A sense of lack of CONTROL over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
- episodes avg 1x/wk for 3 months
binge eating episodes are associated with 3+ sx with eating:
- RAPIDLY
-feeling UNCOMFORTABLY FULL
- large amounts of food when not feeling physically hungry
-eating ALONE because of feeling embarrassed by how much one is eating
-feeling disgusted with oneself, depressed or very guilty afterward
THERE IS NO COMPENSATORY BEHAVIORS (no vomiting/laxatives)**
Binge Eating Disorder (BED) Key Criteria
- Occurs on average, at least once a week for three months.
- Not associated with inappropriate compensatory behaviors (e.g., self-induced vomiting) as seen in Bulimia Nervosa.
- Does not occur exclusively during Bulimia Nervosa or Anorexia Nervosa.
- Binge Eating Disorder (BED) involves subjective distress about eating behaviors and often co-occurs with other psychological problems.
- BED is less common but more severe than overeating
treatment of eating disorders: hospitalization
Hospitalize when the risk of death is likely:
- malnutrition
- dehydration
- electrolyte imbalance
- BW 20% less than expected norm
- BW 30% less than expected norm usually requires long term care
- suicidal ideation
note:
- Expect resistance from anorexics!!!
- Bulimics rarely require admission
pharmacotherapy of eating disorders
-Antidepressants (especially SSRI’s) have shown effectiveness
- give FLUOXETINE FOR BULIMIA NERVOSA: reduce binge-purge cycle
-Higher doses typically required compared to mood disorders
-Rate of compliance better with bulimics compared to patients with anorexia
NEVER GIVE BUPROPRION: risk of seizures
inpatient tx of AN and BN: management strategies
-Daily weight monitoring
-Monitoring input and output
-Monitoring electrolyte levels
-Small meals to prevent circulatory overload, total 500 calories over maintenance wt
-Bathroom observation
-Stool softeners for constipation-never laxatives!
-positive/negative reinforcement
-Education
-Medication
-CBT, group therapy
match column to eating ds
psychotherapy for eating disorders: cognitive behavioral therapy for AN vs BN
Bulimia Nervosa (BN): 1st line tx!!!
- Effective in over 20 clinical trials with well-maintained improvements.
- Treatment based on manual-guided CBT.
- Typical course: 18-20 sessions over 5-6 months
Anorexia nervosa: Benefits noted but no large-scale studies
- pt monitor food intake, binge/purge behaviors, feelings, and emotions.
- Cognitive restructuring challenges core beliefs.
- Develop problem-solving skills to cope with food-related and interpersonal issues, disrupting the binge/purge/dieting cycle
anorexia prognosis and positive prognostic indicators
50% significant improvement
25% recover completely
25% chronic, severe disease
Positive prognostic indicators:
- Admission of hunger
- Decreased denial
- Improved self-esteem
binge eating disorder prognosis and poor prognostic indicators
-Rates of partial and full recovery similar to bulimia nervosa
- Studies show BED does not cross over to anorexia nervosa
Twelve-Year Outcomes
- most cases remit within 5 yrs (significantly improve)
- 30-36% continue to binge eat
Poor prognosis indicators:
- Psychiatric comorbidity
- Self-injury
- Experience of sexual abuse (linked to severity)
bulimia prognosis and poor prognostic indicators
Higher rates of partial and full recovery compared to anorexia.Rates of partial and full recovery similar to binge eating ds
- treated pts fare better than untreated patients.
- 30% continue recurrent binge-purge behaviors
Poor prognostic indicators:
- Co-morbid substance abuse
- Longer duration of disease
Substance Dependence: Diagnostic Criteria
Maladaptive pattern of substance use leading to impairment, evidenced by 3+ of the following within a 12-month period:
- tolerance
- withdrawal
- Substance is taken in larger amounts or over a longer period than intended
- Persistent desire or unsuccessful attempts to cut down/control use
- Significant time spent obtaining, using, or recovering from the substance
- Important social, occupational, or recreational activities are reduced or given up
- Continued use despite knowledge of physical or psychological problems caused or worsened by the substance
alcohol dependence: DSM 5
At least two of the following within a 12-month period:
- alcohol is often taken in larger amounts or over a longer period than was intended. [Do you drink more than you mean to?]
- persistent desire or unsuccessful efforts to cut down or control alcohol use.[Do you want to stop, but can’t?]
- A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.[Is drinking taking over your life?]
-Craving, or a strong desire or urge to use alcohol. [If you can’t drink, are you thinking about drinking?]
-Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.[Is your drinking getting in the way of day-to-day activities?]
-Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. [Is drinking getting in the way of your relationships?]
- Tolerance
- withdrawal: characteristic withdraw syndrome or drinking to avoid the sx
Substance Use Disorder: Key Signs
-Taking the substance in larger amounts or for longer than you’re meant to
-Wanting to cut down or stop using the substance but not managing to
-Spending a lot of time getting, using, or recovering from use of the substance
-Cravings and urges to use the substance
-Not managing to do what you should at work, home, or school because of substance use
-Continuing to use, even when it causes problems in relationships
-Giving up important social, occupational, or recreational activities because of substance use
-Using substances again and again, even when it puts you in danger
-Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance
-Needing more of the substance to get the effect you want (tolerance)
-Development of withdrawal symptoms, which can be relieved by taking more of the substance
opiate dependence
Opioids are often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
Craving, or a strong desire or urge to use opioids.
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
Important social, occupational, or recreational activities are given up or reduced because of opioid use.
Recurrent opioid use in situations in which it is physically hazardous.
Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
Exhibits tolerance
Exhibits withdrawal
Alcohol Withdrawal Symptoms
Mild/Early:
- Tremulousness
- Minor Agitation
- Restlessness/ Insomnia
- Anxiety
Moderate = Alcohol Hallucinosis
- Occurs within 12-24 hours
- Resolves in 24-48 hours
- stable vital signs
Severe = Severe Alcohol Withdrawal Syndrome
- Seizures
- Occur within 6-48 hours
- Kindling Effect: Risk of withdrawal seizures increase with each repeated withdrawal
- MC = Generalized Tonic-Clonic Seizures
Delirium Tremens
Definition: Rapid-onset, fluctuating disturbance of attention and cognition
- Occur within 72-96 hours
- Altered sensorium: confusion, agitation, disorientation
- abnormal vital signs: Fever, Tachycardia, Hypertension, Sweats
