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eating disorders Flashcards

1
Q

what is body image

A
  • perception that a person has of their physical self
  • thoughts and feelings as a result of that perception
  • Influenced by individual and environmental factors
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2
Q

How we see ourselves
what is this called?

A

Perceptual

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3
Q

How we feel about how we look
what is this called?

A

affective
Can be positive, negative, or both

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4
Q

Our thoughts and beliefs about our body
what is this called?

A

cognitive
ex: “I will feel better about myself if I tone up”
“I won’t lose weight no matter how much I exercise”

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5
Q

What we do in relation to how we look
what is this called

A

behavioral
Destructive behaviors
Self-isolation
Wearing revealing / “bodycon” clothing

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6
Q

Developed countries tend to place a very heavy emphasis on what type of image on women and men that causes body dissatisfaction

A

thin body types for females
lean/muscular body types for men

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7
Q

where is body dissatisfaction more common?

A

Post-industrialized, high-income countries such as:
- USA
- European countries (especially Western Europe)
- Australia and New Zealand
- Japan and South Korea

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8
Q

implication of body dissatisfaction

A

If we achieve this body type, love, success and happiness will result

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9
Q

What makes body dissatisfaction different from an eating disorder?

A

“Morbid fear of weight gain”
The idea that “one cannot be too thin” overrides all other interests and affairs

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10
Q

general risk factors for body dissatisfaction

A
  1. Age - late childhood/adolescence
  2. Gender - female
  3. Low self esteem
  4. Personality - perfectionism, high achievers, anxiety, “black and white” world views
  5. Appearance teasing
  6. Activities - with emphasis on “thinness” - ballet, modeling, athletics
  7. Friends/Family - frequent dieting for weight loss or high body image concerns expressed around patient
  8. Larger body size
  9. Homosexuality - in males
  10. Acculturation into Western society - from a developing country
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11
Q

what is the biological link for body dissatisfaction

A

Possible genetic link
1. Mothers/sisters of anorexic pts - 8x as likely to also have
2. Twin studies
- 50-90% will have anorexia if their twin does
- 35-50% will have bulimia if their twin does
- More common in identical (monozygotic) twins
3. Anorexia - disturbances in serotonin, dopamine, norepinephrine
4. Bulimia - disturbances in serotonin (deficient)
5. Possible difficulty with recognizing hunger and satiety states

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12
Q

what are the commonly associated psychological problems with body dissatisfaction

A

Obsessive-compulsive
Anxiety
Depression
Low self-esteem
Social anxiety disorder
Phobias
Body dissatisfaction
Body dysmorphic disorder

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13
Q

what are the familial risk factors for body dissatisfaction

A
  1. Enmeshed parenting
  2. Conflict-avoidant families
    - Inflexibility
  3. Push for very high levels of success
  4. Family members with body dissatisfaction or poor eating habits/eating disorders
    - Patients may have childhood memories of being “made” to eat more or less food than they desired or go on diets
  5. Anorexic families - rigid, controlling, organized
  6. Bulimic/BED families - chaotic, critical, conflicted
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14
Q

sociocultural risk factors for body satisfaction

A
  1. Western society’s ideals
  2. People elicit different reactions in social situations based in part on physical and psychological traits
    - Physical - body build, degree of “attractiveness”, clothing, hygiene, grooming, etc.
    - Psychological - temperament, behavioral style, social skills
  3. Social feedback then shapes positive or negative adjustment of our self-image
  4. Related to effectiveness or ineffectiveness of parents
    - Ineffective parents don’t respond appropriately to child’s needs
    — Feeding at times of anxiety instead of hunger
    — Comfort at times of hunger rather than times of anxiety
  5. Interferes with self-ability to accurately identify hunger versus emotions and feeling helpless as a result
    - Parents of pts tend to define the pt’s needs for them
    - Pts display alexithymia and dependency
  6. Eventually causes abnormal eating habits as pt attempts to regain control over their own bodies
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15
Q

cognitive risk factors for body dissatisfaction

A
  1. Pts with eating disorders often feel that their body size is the only important part of their self-image
    - If they are not exceedingly thin, they feel it “proves” they are weak, lazy, inferior, unlovable, incompetent
  2. Mistrust for comparisons of their appearance
  3. Often ignore or have difficulty accepting objective evidence of their body’s state
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16
Q

what % of the population has had tried dieting

A

80%
40% of 9-year-old girls have dieted

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17
Q

How do we tell the difference between normative vs abnormal dieting

A

Patient’s weight
Health status
Body perception
Healthful or harmful?

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18
Q

classic presentation of Avoidant / Restrictive Food Intake Disorder

A

underweight child (average BMI - 16)
- Decreased bone mineral density
- 60% have comorbid anxiety
- 50% have a comorbid general medical disorder

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19
Q

criteria for Avoidant / Restrictive Food Intake Disorder

A
  1. Avoiding or restricting food intake:
    - May be due to lack of interest in food, sensory characteristics of food, or conditioned negative response following an aversive experience
  2. Avoiding/restricting food intake leads to a persistent failure to meet nutritional or energy needs, as manifested by at least 1 of the following:
    - Clinically 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
  3. Not due to lack of available food or associated with a culturally sanctioned practice
  4. Not due to a general medical condition or another mental disorder

Must have each of the following

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20
Q

epidemiology of Anorexia Nervosa

A
  1. Lifetime prevalence - 0.6%
  2. 3x more common in women
    - In women - 0.9%; in men - 0.3%
    - Gender gap appears to be decreasing
  3. Bimodal peak onset
    - Early adolescence - 12-15 yrs
    - Late adolescence/early adulthood - 17-21 years
    - Average age at onset - 18 years
  4. Classic patient - adolescent white female
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21
Q

characterization/clinical findings of anorexia nervosa

A
  1. Restricted energy intake → low body weight
  2. Intense fear of weight gain, or persistent behavior preventing weight gain
  3. Distorted perception of weight, undue influence of weight on self-worth, or denial of the medical seriousness of low weight
  4. Abnormal Food Behaviors
    - Reduction in total food intake
    - Exclusion of highly caloric foods
    - May claim distaste for food or epigastric pain
    - May have food-related obsessions
  5. Other Common Behavioral Disturbances
    - Distorted perception of part or all of body weight
    - May admit to being high achiever or perfectionist
    - Can have limited social activities
  6. Psych
    - Depression, irritability
    - Fatigue and weakness
  7. Bone pain
  8. Amenorrhea
  9. GI
    - Constipation
    - Abdominal pain
  10. Derm
    - Hair loss, brittle nails
    - Russell’s sign
22
Q

severity classification for anorexia nervosa

A
  1. Mild - BMI ≥17
  2. Moderate - BMI 16 - 16.99
  3. Severe - BMI 15 - 15.99
  4. Extreme - BMI <15
23
Q

subtypes of anorexia nervosa

A
  1. Binge-Eating - engage in “purging” behaviors (laxatives,
    vomiting, enemas)
    - Usually smaller binges and less frequent purges than bulimia
  2. Restrictive - no purging behaviors
24
Q

what are the severe signs of starvation

A
  1. General
    - Emaciation
    - Hypothermia
  2. Cardiovascular
    - Significant hypotension
    - Bradycardia
    - Peripheral edema
  3. Derm
    - Dry and flaky skin
    - Lanugo
    - Petechiae on extremities
    - Sallow complexion
  4. Bone
    - Dental enamel erosion
    - Osteoporosis
25
Q

MC result from AN from consequences of starvation, suicide, or electrolyte imbalance

A

Death

26
Q

labs/workup for AN

A
  1. ECG for cardiac dysrhythmias
  2. UA for specific gravity
  3. Serum labs:
    - CMP - lytes, kidney and liver function, protein, glucose
    - phosphorus
    - magnesium
    - INR
    - CBC with diff
27
Q

what signs mean that the pt needs to be admitted for AN

A
  1. Unstable vitals or Hypothermia (<35 C or 95 F)
  2. End-organ complications - seizures, failure (heart, kidneys, liver, etc.)
  3. Cardiac complications
    - HR <30 bpm or <40 bpm w/hypotension or dizziness
    - Cardiac dysrhythmia (other than bradycardia)
  4. Psych complications
    - Suicidal ideation with high lethality plan or suicide attempt
    - Acute food refusal, very poor compliance or other acute psych emergency
  5. Nutrition complications
    - Weight <70% ideal body weight
    - Marked dehydration
    - Refeeding syndrome
28
Q

Main goals of treatment for AN

A
  1. Medical stability and management of complications
  2. Weight stabilization and eventual return to healthy weight
  3. Adoption of healthy nutrition and eating patterns
  4. Treating underlying disordered psychopathology
  5. Preventing relapse
29
Q

tx for AN

A
  1. Multimodal approach is essential!
    - Nutritional rehabilitation, psychotherapy, medical management
  2. Psych meds are not first line treatment
    - 2nd gen antipsychotic (olanzapine), anxiolytic (lorazepam) may help with patients not gaining weight with above
    - SSRI may help if comorbid anxiety/depression
30
Q

what medication at higher doses can prevent relapse once weight is restored?

A

fluoxetine (Prozac)

31
Q

prognosis for AN

A
  1. 50% - good outcomes
  2. 25% - intermediate outcomes
  3. 25% - poor outcomes
    - Later age at onset, longer duration, lower minimal weight, lower body fat after weight restoration, psych comorbidities
  4. 35-55% eventually relapse
  5. All-cause mortality - 6x higher risk of death
    - Medical complications - 50% of deaths
    - Suicide - 25% of deaths
32
Q

epidemiology of BN

A
  1. Lifetime prevalence - 1.0%
    - In women - 1.5%; in men - 0.5%
  2. 3x more common in women
  3. Median age of onset - 18-20 years
  4. Classic patient - adolescent white female
33
Q

criteria for BN

A

Recurrent binge eating and inappropriate compensatory behaviors at least once a week for three months
Self-evaluation is unduly influenced by body weight

34
Q

MC compensation for BN

A

vomiting (80-90%)
Laxative use in ⅓
Less common - Enemas, diuretics, fasting

35
Q

subtypes for BN

A
  1. Purging - engage in self-induced vomiting or misuse of laxatives, diuretics, enemas
  2. Nonpurging - engages in other inappropriate compensatory behaviors such as fasting, excessive exercise
36
Q

Typical pattern of behavior of BN

A
  1. Caloric restriction
  2. Binge - Consumption of large quantities of foods
    - Often in in secret
  3. Compensatory mechanism
    - Often with guilt and depression

Slightly more control over timing of behaviors - arrange around work, school, etc.

37
Q

clinical findings of BN

A
  1. Lethargy
  2. Irregular menses
  3. Cardiac
    - Hypotension
    - Tachycardia
    - Peripheral edema
  4. GI
    - Constipation, abdominal pain, bloating
    - If vomiting - eroded dental enamel and “puffy cheeks” due to parotid hypertrophy may be seen
  5. Derm
    - Hair loss
    - Russell’s sign
  6. Body weight typically within or above the normal range
38
Q

severe signs of BN

A
  1. Dehydration
  2. Hypokalemia
  3. Hypochloremia
  4. Metabolic alkalosis
39
Q

what is the major complication of BN

A

GI - salivary gland hypertrophy, loss of gag reflex, GI tract dysmotility, GERD, esophageal tears or rupture, malabsorption, diarrhea, constipation, pancreatitis

cardiac more rare than AN

40
Q

labs for BN

A
  1. UA and serum labs - BUN/Cr, electrolytes, LFTs, CBC with diff
  2. If severely ill - ECG and serum calcium, magnesium and phosphorus
41
Q

Admit if BN patient displays signs of:

A
  1. Unstable medical condition
  2. Suicidal ideation or other severe psychiatric decompensation
  3. Refusal of treatment with potential to become unstable
42
Q

tx for BN

A
  1. Nutritional rehabilitation, psychotherapy, pharmacotherapy
    - Unlike anorexia, CBT shows clear advantage
  2. Antidepressants are often helpful
    - SSRIs - fluoxetine (1st line) or other SSRI
    - TCA if no improvement on SSRIs
43
Q

what antidepressant is contraindicated for AN and BN

A

Bupropion
can cause seizures

44
Q

prognosis for BN

A
  1. 2x increase in all-cause mortality
  2. High comorbidity with anxiety, depressive disorders, personality disorders, PTSD, and substance use
    - 25-40% of bulimic patients have a positive lifetime history of suicide attempt
  3. 50-70% short-term reduction of symptoms
    - 60% recover in longer follow-up
    - 28% relapse rate
45
Q

epidemiology of BED

A
  1. Lifetime prevalence (US) - 2.6%
    - 30% prevalence in weight-control
    clinical programs
  2. More common in women
    - In women - 3.5%; in men - 2.0%
  3. Median age of onset - 23 years
  4. Less researched despite higher
    prevalence
46
Q

Recurrent binge eating without compensatory behaviors
is what disorder?

A

BED

47
Q

what is the severity classification of BED

A
  1. Severity - ranked by frequency of episodes per week
    - Mild: 1-3
    - Moderate: 4-7
    - Severe: 8-13
    - Extreme: 14+
48
Q

common reported symptoms of BED

A
  1. Food is seen as a coping or comfort mechanism
  2. Patients continue eating even after they feel full, or if they do not feel hungry to begin with
  3. Many eat large quantities of food very quickly
  4. Feelings of shame, guilt, and hopelessness frequently occur during or immediately following a binge-eating episode
  5. Patients typically try to hide part or all of their eating habits
49
Q

what comorbidties contribute to BED

A
  1. About 50% of patients are overweight or obese
    - More likely to be overweight or obese prior to BED onset
    - Less likely to seek treatment if they are of normal weight
  2. Most have at least some degree of impaired functioning
  3. Frequent comorbid psychological disorders
    - Anxiety disorders (specific phobia, social phobia)
    - ADHD
    - Depressive disorders
    - PTSD
    - Alcohol use
    - Personality disorders
    - History of abuse
50
Q

complications with BED

A
  1. General - sleep changes, higher risk of cancer
  2. MSK - muscle and joint pain, limited mobility
  3. CV - heart disease, atherosclerosis, HTN, HF, CVA
  4. Pulm - dyspnea on exertion, sleep apnea
  5. Metabolic - development or worsening of obesity, DM and/or HLD
  6. GI - abdominal pain, GI upset
  7. Psych - development or worsening of comorbid psych disorders, social difficulties, impaired functioning
51
Q

management/tx for BED

A
  1. Psychotherapy - first line treatment (especially CBT)
  2. Behavioral weight loss therapy
  3. May try using pharmacotherapy
    - SSRIs (first line)
    - Antiepileptic (topiramate, zonisamide)
    - Lisdexamfetamine (Vyvanse)
    - Antiobesity drugs not recommended due to SE, limited efficacy in BED patients

Behavioral dynamics (19 decks)

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