Eating Disorders Flashcards
What is a purge?
Use of vomiting, laxatives, diuretics or enemas to eliminate calories
What is a binge?
Definition of a Binge:
• Eating a large amount within a discrete period (i.e. an amount “definitely larger than most people would eat under a similar circumstance”)
• Eating is out of control during the episode
What are the types of eating disorders?
- Anorexia nervosa
- Bulimia nervosa
- Binge-eating disorder
- Unspecified eating disorder
These disorders are under the “Feeding & Eating Disorders” category of DSM-5
What are the Anorexia nervosa diagnostic criteria?
Diagnostic Criteria:
1. Restriction of food that leads to a person being significantly underweight.
• Underweight is defined as having a body mass index (BMI) < 18.5 kg/m2.
- Intense fear of gaining weight (evidenced by extreme preoccupation, frequent assessment, behaviors that interfere with weight gain etc.)
- Body image disturbance (e.g. belief of being overweight, denying seriousness of low weight)
What is a normal BMI ?
(Normal BMI range: 18.5 – 24.9 kg/m2)
What are the classifications of Anorexia Nervosa?
Mild- 17 – 18.49 (grey zone, use clinical judgement
Moderate- 16 – 16.99 (“clearly” below normal)
Severe- 15 – 15.99
Extreme- less than 15
What are the subtypes of Anorexia Nervosa?
Based on recent behavior over the last 3 months
- Binge-eating/purging Type:
• If the person recurrently binges AND/OR purges - Restricting Type:
• The person does NOT recurrently binge or purge
• Weight loss is maintained through dieting, fasting +/- over exercising
What are the epidemiology of the Anorexia Nervosa?
Over 90% of affected persons are females however, the prevalence data for males is scarce.
- Onset: Bimodal (average: 17 years)
- First peak (12-15 years) and
- Second peak (15-21 years)
Interests/Occupations: • Modeling, beauty competitions • Gymnastics • Ballet dancing • Wrestling
What are the contributing factors?
Psychological and Social Factors
• Cultural pressures to be thin
• Difficulty establishing autonomy from parents during adolescence ( a “control”
issue)
• Perfectionist trait
• Low self-esteem
• Weight loss is reinforced (internally & externally)
Biological Factors
• Genetic susceptibility to anorexia
• A person may inherit biochemical alterations that leads to obsessiveness.
• Cultural pressures may direct the obsessiveness to body image.
Whaat are the associated features Anorexia Nervosa?
Symptoms: • Amenorrhea • Decreased sex drive • Constipation • Hair loss
- PhysicalExamination:
- LowBMI
- Hypothermia,bradycardia,hypotension
- Lanugo(soft,finebaby-likehair)
- Dry skin, brittle nails
- Investigations:
- Anemia, leukopenia, low bone mineral density, hypercholesterolemia
What are the main physical features of Anorexia Nervosa?
Indicators of excessive vomiting (Binge eating/purging subtype):
- Calloused knuckles → Russell’s sign
- Dental enamel erosion
- Salivary gland inflammation
a) Parotid gland hypertrophy
b) Chipmunk cheeks - Subconjunctival hemorrhage
- Hypochloremia, hypokalemia
How is Anorexia Nervosa treated?
Typically, a patient is not self-referred, since anorexia tends not to distress the patient.
• Treatment is typically family initiated.
➢ In-patient Hospitalization:
• Weight gain is the immediate goal for in-patient care.
• Combined with behavioral principles (e.g., operant conditioning) to encourage
weight gain.
• An attendant often supervises the patient to thwart attempts to lose weight
How can therapy lead to Anorexia Nervosa?
➢ Cognitive-Behavioral Therapy
• In-patient or out-patient
• It is an essential component of treatment
• Used to change the patient’s attitude about food and weight and learn how to
break destructive eating habits.
➢ Pharmacological Therapy
• No FDA approved drug for treating anorexia
• Limited to treatment of medical complications and comorbid psychiatric conditions
What are the outcomes of Anorexia Nervosa?
- In a controlled environment such as in-patient care, there is good short-term prognosis.
- However, long-term prognosis tends to be poor after patients are released home.
• Outcome is variable: some may fully recover, have relapses, or progressively
deteriorate.
• Many medical complications can result, ranging from minor to major (hormone deficiency, organ failure, brain changes, suicide) with approximately 20% mortality rate
Describe the diagnostic criteria of the Bullimia Nervosa
1.Recurrent binge eating
- Recurrent inappropriate compensatory behavior for binge
• Purging (e.g. vomiting, laxatives, diuretics, enemas)
• Non-purging (fasting and/or excessive exercise) - The binge/inappropriate compensatory behaviors must occur
≥ once a week for 3 months - Self-evaluation is unduly influenced by body shape and weight
What are the features of Bullimia Nervosa?
There are no subtypes of bulimia nervosa
• Persons typically have a BMI in the normal range or are slightly overweight (normal BMI = 18.5 – 24.99 kg/m2).
- Compare this to AN where the BMI is low
Describe Bullimia Nervosa Epidemiology
• More than 90% of persons with bulimia nervosa are women.
- Onset:
- Average age of onset: 18 – 20 years
- Women often have a history of both anorexia nervosa and bulimia nervosa, but at different times
- Occupations:
- Modeling, beauty competitions
- Gymnastics
- Ballet dancing
- Wrestling
What are the contributing factors of the Bullimia Nervosa?
Psychological and Social Factors
• Societal pressures to be thin +/- a means to improve self-esteem
• Strict dieting results in a broken diet and impulsivity, “all or none” eating (i.e.
binging)
• Fear of weight gain after binge leads to inappropriate compensatory behavior
Biological Factors
• A person may inherit biochemical changes (low serotonin) that leads to impulse control problems.
What are the associated features of Bullimia Nervosa?
• Indicators of excessive vomiting
• Seen in both bulimia and anorexia (subtype: binge-eating/purging
type)
- Physical Consequences:
- Electrolyte imbalance - ↓K, ↓Cl
- Consequences of excessive vomiting
- Enamel erosion
- Parotid gland enlargement - more likely in BN
- Knuckle calluses
What is the treatment for Bullimia Nervosa?
A patient typically initiates treatment (after several years of symptoms)→the disorder is distressful to the patient.
- Treatment tends to be out-patient based.
- CBT is essential
- Fluoxetine is the only FDA-approved medication for bulimia
- With greater motivation to change, prognosis is better for bulimia nervosa than anorexia nervosa
What is the prognosis of Bulimia Nervosa?
• Intervention soon after diagnosis has better prognosis
• Outcome: half recover fully with treatment; others have a chronic course
with relapsing symptoms.
- Having associated problems with depression or substance use has poorer prognosis
- Medical complications tend to be fewer and less severe than in anorexia, but morbidity and mortality may still result (e.g. from hypokalemia, suicide)
What’s the diagnostic criteria of the binge-eating disorder?
- Binge eating (as per bulimia criteria)
- Bingeing is associated with features such as:
A. Rapid eating
B. Eating until uncomfortably full
C. Eating when not physically hungry
D. Eating alone due to shame about quantity
E. Feeling disgusted/guilty/depressed after binge - No inappropriate compensatory behavior
- The binge behavior must occur more than once a week for 3 months
Describe onset of binge eating disorder
- Epidemiology:
- Approximately 2% with a less skewed female bias
- Onset & Course:
- Symptoms often start in adolescence
- Cross-over to other eating disorders is uncommon
- Etiology:
- Unknown but distinct from bulimia nervosa
- In binge-eating disorder, dysfunctional dieting tends not to precede bingeing
What are the features of Binge Eating Disorders?
Associated with obesity (BMI ≥ 30 kg/m2)
• High BMI is not required for a diagnosis
- Obesity without bingeing is a distinct condition:
- Not all obese people binge eat.
- There is greater distress/functional impairment in binge-eating disorder than in non-bingeing obesity
- Health consequences of binge-eating disorder are similar to those of obesity •
How is binge eating treated?
Treatment:
• Cognitive-behavioural therapy, antidepressant drugs and the stimulant drug, lisdexamfetamine
What is an unspecified eating disorder?
Many patients do not meet the criteria for either Anorexia Nervosa, Bulimia Nervosa or Binge-eating disorder but have subclinical eating problems.
The diagnosis would be “unspecified eating disorder”
- A woman with a BMI = 22 kg/m2 who frequently purges but does not binge eat • Purges→AN(binge-eating/purgingsubtype)orBN
• Does not binge eat→not BN, not BED
• Normal BMI→not AN - A woman with a BMI 25 kg/m2 binges and purges but only once a month
• Binge and purge→AN (binge eating/purging subtype) or BN
• Criteria for duration and frequency: >1 / week for 3 months
How do we screen for eating disorders?
SCOFF Questions
SCOFF Questions
❑Sick→Do you make yourself sick because you feel uncomfortably full? ❑Control→Do you worry you have lost control over how much you eat?
❑One→Have you recently lost more than one stone (14 lb.) in a 3-month period? ❑Fat→Do you believe yourself to be fat when others say you are too thin? ❑Food→Would you say that food dominates your life?
A score of ≥ 2 indicates a likely eating disorder.
