Eating Disorders* Flashcards
Perception that a person has of their physical self and the thoughts and feelings as a result
Influenced by individual and environmental factors
body image
What factors make up body image?
perception “how we see ourselves”
affective “how we feel about how we look”
cognitive “our thoughts and beliefs about our body” behavioral “what we do in relation to how we look”
Chronic negative perception of one’s body is strongly tied to ____
body dissatisfaction
developed countris emphasize thin body type for females, lean/muscular types for men
Bigger issue in high-income countries: US, european countries, australia/new zealand
What makes body dissatisfaction different from an eating disorder?
Morbid fear of weight gain
Idea that one cannot be too thin that overrides all other interests and affairs
What are risk factors for body dissatisfaction (10)?
Age (late childhood/adolescence)
Female
Low self esteem
Perfectionism, high achiever, anxiety, black and white world views
Appearance teasing
Activities with emphasis on thinness (ballet, modeling, athletics)
Frequent dieting for weight loss or high body image concerns expressed around patient
Larger body size
Homosexuality in males
Acculturation in Western Society
What are biological risk factors for body dissatisfaction?
Possible genetic link
Anorexia = disturbances in serotonin, dopamine, and norepinephrine
bulimia = differences in serotonin
difficulty recognizing hunger and satiety
what are commonly associated psychological problems with body dissatisfaction (7)
obsessive-compulsive
anxiety/social anxiety disorder
depression
low self-esteem
phobias
body dissatifaction
body dysmorphic disorder
what are family factors involved in body dissatisfaction (5)?
enmeshed parenting
conflict-avoidant families
inflexibility
push for success
family members with body dissatisfaction or poor eating habits
rigid, controlling, organized family typically fits with which eating disorder
Anorexic
chaotic, critical, conflicted family fits with which disorder
bulimic/BED
what are sociocultural risk factors for body dissatisfaction?
western society ideals
Social feedback based on physical traits–> positive or negative adjustment of self-image
How are eating disorders related to parenting other than modeling?
Ineffective parents don’t respond appropriately to child’s needs ie feeding during anxiety vs hunger which interferes with self-ability to accurately identify hunger vs emotions
Eventually causes abnormal eating habits
what are cognitive risk factors for eating disorders?
- thought that only thing that matters is body image
- feelings that if not thin reflects on personal traits
- mistrust for comparisons of appearance
- often ignore or have difficulty accepting objective evidence of body state
How do you determine normal vs abnormal eating?
Patient’s weight
Health status
Body perception
Up to 80% of the population is dieting at any given time
40% of 9 year old girls have dieted
What are screening tools for eating disorders?
SCOFF questionnaire, ESP questionnaire, EAT form, PHQ form
When does avoidant/restrictive food intake disorder typically begin?
Infancy or early childhood and may persist into adulthood
Classic presentation of avoidant/restrictive food intake disorder?
Underweight child (average BMI-16)
decreased bone mineral density
comorbid anxiety (60%)
comorbid general medical disorder (50%)
What criteria must a patient have in order to be diagnosed with avoidant/restrictive food intake disorder?
Avoiding or restricting food intake
* due to lack of interest or sensory characteristics, or aversive experience
Persistent failure to meet nutritional or energy needs, as manifested by at least 1 of the following:
* clinical significant weight loss, poor growth or failure to achieve expected weight gain
* Nutritional deficiency
* oral supplements or enteral feeding required to achieve adequate nutrition
* impaired psychosocial functioning
Not due to lack of food or culturally restrictive practice, not due to general medical condition
What is epidemiology of anorexia nervosa?
Lifetime .6%
More common in women
Bimodal peak onset: early adolescence (12-15)
Late adolescence/early adulthood (17-21)
Average age at onset 18 y/o
Classic patient: adolescent white female
What are clinical findings of anorexia nervosa?
- Restricted energy intake –> low body weight
- Intense fear of weight gain, or persistent behavior preventing weight gain
- Distorted perception of weight, undue influence of weight on self-worth, or denial of the medical seriousness of low weight
- Abnormal food behaviors
- Behavioral disturbances
How is severity of anorexia nervosa designated?
what is the BMI for each category?
Mild: BMI >17
Moderate: BMI 16-16.99
Severe: 15-15.99
Extreme: <15
what are subtypes of anorexia nervosa?
Binge-eating
Restrictive
What are abnormal food behaviors in anorexia nervosa?
- reduction in total food intake
- exclusion of high caloric foods
- distaste for food or epigastric pain
- food-related obsessions
What are other common behavioral disturbances in anorexia nervosa?
- distorted perception of part or all of body weight
- may admit to being high avhiever or perfectionist
- can have limited social activities
what are observed findings with anorexia nervosa?
Psych, ____, ____, GI, Derm
- psych: depression, irritability, fatigue, weakness
bone pain - amenorrhea
- GI: constipation, abdominal pain
- derm: hair loss, brittle nails, russell’s sign
What are severe starvation findings?
- General: emaciation, hypothermia
- derm: dry and flaky skin, lanugo, petechiae on extremities, sallow complexion
- cardiovascular: significant hypotension, bradycardia, peripheral edema
- bone: dental enamel erosion, osteoporosis
What are big complications of anorexia nervosa to be aware of?
Cardiovascular complications: electrolyte abnormalities, arrhythmias
Pulmonary
Neuro
Basically body starts to shut down without nutrition it needs
Death in anorexia nervosa patients most commonly results from what?
consequences of starvation, suicide, or electrolyte imbalance
Why would you admit a anorexia nervosa patient?
signs of:
* unstable vitals or hypothermia
* end-organ complications: seizures, organ failure
* cardiac complications: low HR (<30 or <40 with hypotension or dizziness), cardiac dysrhythmias
* psych complications: suicidal ideation with high lethality plan or suicide attempt, acute food refusal, poor compliance, or acute psych emergency
* nutritional complications: weight <70% ideal body weight, marked dehydration, refeeding syndrome
what is the main goal of anorexia nervosa treatment?
- medical stability and management of complications
- weigth stabilization and return to healthy weight
- healthy nutrition and eating patterns
- treat psychopathology
- prevent relapse
What are considerations for medication management of AN?
not first line treamtent
2nd gen antipsychotic (olanzapine), anxiolytic may help patients not gaining weight
SSRI may help if comorbid anxiety/depression
don’t want to pick escitalopram due to cardiac side effects
venlafaxine
usually pick prozac or paxil, prozac at higher doses can prevent relapse once weight is restored
what is prognosis of anorexia nervosa?
50% good outcomes
25% intermediate outcomes
25% poor outcomes
35-55% eventually relapse
All cause mortality is 6x higher (medical complications 50% of deaths, suicide 25%)
What is the epidemiology of bulimia nervosa?
1%
More common in women
Age of onset 18-20
classic patient: adolescent white female
what are clinical findings in bulimia nervosa?
- recurrent binge eating and inappropriate compensatory behaviors at least once a week for 3 months:
commonly vomiting, can be laxatives, enemas, diuretics, fasting
self evaluation is unduly influenced by body weight
what are subtypes of bulimia nervosa?
purging and nonpurging
purging: self-induced vomiting or misuse of laxatives, diuretics, enemas
nonpurging: other inappropriate compensatory behaviors ie fasting, excessive exercise
What is the typical pattern of bulimia nervosa?
- caloric restriction
- binge: consumption of large quantities of foods often in secret
- compensatory mechanisms: often with guilt and depression
more control over timing of behaviors
What are physical clinical findings of bulimia nervosa?
- lethargy, irregular menses
- cardiac: hypotension, tachycardia, peripheral edema
- GI: constipation, abdominal pain, bloating, if vomiting eroded enamel and puffy cheeks
- derm: hair loss, russell’s sign
- body weight typically within or above the normal range
depends on type of compensatory mechanism
what are complications of bulimia nervosa?
- cardiac: rare, tachycardia, palpitations, edema, dysrhythmias
- endocrine: menstrual irregularities, infertility, osteoporosis, DM
- GI: salivary gland hypertrophy, loss of gag reflex, GI tract dysmotility, GERD, esophageal tears or rupture, malabsorption, diarrhea, constipation, pancreatitis
- renal/electrolytes: dehydration, hypokalemia, hyponatremia, hypophosphatemia
- pulmonary: aspiration pneumonitis
- derm: xerosis, hair loss
How is bulimia nervosa worked up?
- UA and serum labs: BUN/Cr, electrolytes, LFTs, CBC with diff
- If severely ill: ECG and serum calcium, magnesium and phosphorus
Why would you admit a patient with bulimia nervosa?
- unstable medical condition
- suicidal ideation or other severe psychiatric decomensation
- refusal of treatment with potential to become unstable
how is BN managed?
- Multimodal: nutritional rehab, psychotherapy, pharmacotherapy
- CBT has advantage (not true in anorexia)
- Antidepressants: SSRIs-fluoxetine 1st line
- May try TCA if no improvement on SSRIs
BUPROPION IS CONTRAINDICATED in BN and anorexia(can cause seizures)
what is the prognosis of BN?
- 2x increase in all-cause mortality
- High comorbidity with anxiety, depressive disorders, personality disorders, PTSD, and substance use
- Higher risk of suicide attempt (25-40% patients)
- 50-70% have short-term reduction of symptoms
- 60% recover
- 28% relapse
what is the epidemiology of BED?
2.6% lifetime prevalence
more common in women
median age of onset-23 years
Less researched despite higher prevalence
What are clinical findings of BED?
- recurrent binge eating without compensatory behaviors
- Severity depends on frequency per week
- Food is coping or comfort
- Continue eating after feel full
- may eat very quickly
- feelings of shame, guilt, and hopelessness
- often try to hide part or all of their eating habits
What are comorbidities with BED?
- Overweight or obese
- Impaired functioning
- frequent comorbid psychological disorders: anxiety, ADHD, depression, PTSD, alcohol use, personality disorders, history of abuse
What are complications of BED?
- general: sleep changes, higher risk of cancer
- MSK: muscle and joint pain, limited mobility
- CV: heart disease, atherosclerosis, HTN, HF, CVA
- Pulm: dyspnea on exertion, sleep apnea
- Metabolic: development or worsening of obesity, DM and/or HLD
- GI: abdoinal pain, GI upset
- Psych: development or worsening of comorbid psych disorders
Body dissatisfaction is a _____ in Western Societies
Cultural norm
What labs should be ordered for all suspected anorexia patients?
ECG for cardiac dysrhythmias
UA for specific gravity
Serum labs
* CMP-electrolytes, kidney and liver function, protein, glucose
* Phosphorus
* Magnesium
* INR
* CBC with diff
What is first line treatment for anorexia nervosa?
Multimodal approach with nutritional rehabilitation, psychotherapy, medical management
What is the most common compensation in bulimia nervosa?
Vomiting
What are severe clinical findings of bulimia nervosa?
- Dehydration
- Hypokalemia
- Hypochloremia
- Metabolic alkalosis
How is BED managed?
- Psychotherapy = first-line
- Behavioral weight loss therapy
May try pharmacotherapy
* SSRIs = first-line
* Antiepileptic (topiramate, zonisamide)
* Lisdexamfetamine
* Antiobesity drugs not recommended due to SE and limited efficacy
