Eating Disorders Flashcards
What are the DSM 5 criteria for anorexia nervosa?
(A) Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
(B) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
(C) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
What are the coding notes and specifiers for anorexia nervosa?
- Restricting type - during the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior. This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting and/or excessive exercise.
- Binge-eating/purging type - during the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior
- In partial remission - after the full criteria for AN were previously met, criterion A is no longer met but Criterion B or Criterion C is still met for a sustained period of time
- In full remission - after the full criteria were previously met, now none of the criteria are met for a sustained period of time.
- Severity
BMI over 17 - mild
16 to 17 moderate
15 to 16 severe
Below 15 extreme
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What is are the DSM V criteria for avoidant/restrictive food intake disorder?
(A) An eating or feeding disturbance (apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
- significant nutritional deficiency
- dependence on enteral feeding or oral nutritional supplements
- marked interference with psychosocial functioning
(B) Disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice
(C) The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
(D) The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
Only specifier is whether they are in remission or not.
What is the DSM 5 criteria for bulimia nervosa?
(A) Recurrent episodes of binge eating characterized as the following:
- Eating in a discrete period of time an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
- A sense of lack of control overeating during the episode
(B) Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise.
(C) This pattern occurs at least once a week for 3 months
(D) Self-evaluation is unduly influenced by body shape and weight.
(E) The disturbance does not occur exclusively during episodes of anorexia nervosa.
What are the specifiers for bulimia nervosa?
In full remission or partial remission.
Severity Specifier:
Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week
Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
Severe: an average of 8-13 episodes
Extreme: 14 or more episodes of inappropriate compensatory behaviors per week.
What is the DSM 5 criteria for binge-eating disorder?
(A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode
(B) The binge-eating episodes are associated with three or more of the following
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed or very guilty afterwards.
(C) Marked distress regarding binge eating present
(D) The binge eating occurs on average at least once a week for 3 months
(E) The binge eating is no associated with recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
What are some of the risk factors for an eating disorder?
Individual Vulnerability:
- poor coping skills
- difficulty with communication
- low self esteem
- sense of not being in control of ones life
- dieting
- family history of eating disorder
- female
- difficult family dynamics
Environmental Factors:
- capitalism
- abundance of food
- increasing body weight
- body orientated advertising
- urbanization
- immigration
- trauma
- availability of IT
What are some of the biological complication of anorexia nervosa?
- bradycardia
- hypotension
- elevated liver enzymes
- skin thinning
- discoloration
- scalp hair loss
- osteopenia
- osteoporosis
- reduced brain volume
- multi-organ failure
What are some of the complications of bulimia nervosa?
- electrolyte imbalances - hypokalaemia associated with purging
- loss of dental enamel
- dental abscesses
- reflux gastritis
- cathartic colon associated with laxative use
- cardiac arrythmia leading to death
Describe the biopsychosocial management of AN?
- pharmacological treatment is not often used but use of Trazadone 100-150mg helped with sleep disturbance associated with anorexia nervosa
- weight restoration is an important part of treatment. Aim to increase by 1-2kg per week as an inpatient and 0.5-1kg per week as an outpatient.
- Olanzapine is the only drug suggested to have any effect on weight restoration in anorexia nervosa. Only the prolactin sparing antipsychotics should be considered - therefore avoid the use of risperidone, amisulpride and sulpiride
- multivitamin and multimineral supplements
- monitoring of electrolytes and CMP during refeeding due to risk of hypophosphatemia and other disturbances
- CUSP, HCO3, Ca P and Mg as well as ECG should be monitored during refeeding
- CBT
- psychoeducation
- good therapeutic relationship
- family support
- occupational therapy and cognitive support
Describe the biopsychosocial treatment of bulimia nervosa?
- not often recommended but high dose SSRIs such as Fluoxetine 40-60mg per day has been documented to have antibulimic effects
- stabilization of an eating regime
- CBT
- psychoeducation
- good therapeutic relationship
- family support
- occupational therapy and cognitive support
What is refeeding syndrome?
- medical complication of the refeeding process
- most often presents as abnormalities in someone’s bloodwork - drop in potassium, phosphorus, magnesium, calcium, sodium
- symptoms present before the bloodwork is done often
- symptoms: dizziness, fatigue, hypotension, bradycardia, nausea, muscle weakness, cardiac arrest
- risk factors: 1. significant recent weight loss, severe restriction in food intake over the past 7-14 days, presence of a prolonged eating disorder presenting alongside starvation syndrome, BMI less than 16, weight loss of >15% over last couple of months, history of drug or alcohol abuse
- how to prevent refeeding syndrome: 1. start low and go slow 2. seek help from eating disorder professional
What is starvation syndrome?
- physical complication of eating disorder
- can impact folks of any weight
- can impact people of any eating disorder diagnosis
- side effect of severe malnutrition
- slowed heart rate
- decreased BP
- decreased concentration
- increased irritability
- feeling emotionally blunted
- decreased performance
- social isolation
What is the pathophysiology of refeeding syndrome?
In starved state, circulating insulin levels drop low, gluconeogenesis increases. Key vitamin depletion such as Thiamine.
If you refeed someone rapidly, this causes a massive increase in the blood glucose levels leading to a dramatic insulin spike. The high level of circulating insulin causes phosphate, magnesium and potassium to be driven into the cells. Thiamine is also needed by the body cells in even greater levels.
Therefore the net overall effect in low thiamine, hypophosphatasemia, hypokalemia and hypomagnesaemia.
Clinical features:
Thiamine Deficiency Leads to Wernicke-Korsakoff Syndrome. Wernicke Encephalopathy (acute) - confusion, ophthalmoplegia, ataxia. Korsakoff Syndrome (chronic neurological condition) - psychosis, amnesia, confabulations.
Hypophosphatemia - muscle weakness, rhabdomyolysis, paresthesia, seizures, arrythmias
Hypomagnesemia - common, variety of symptoms in many different organ systems
Hypokalemia - weakness beginning in the lower limbs and progressing to the trunk and upper extremities, ECG changes - T-wave flattening and U waves
Describe the management of refeeding syndrome
Prevention:
- slow nutritional support and building up feeds slowly over 3 to 7 days.
- starting with 50% of the estimated energy requirements
- multivitamin
- thiamine
- electrolyte supplementation
- Potassium (2-4mmol/kg/day)
- Phosphate (0.3-0.6mmol/kg/day)
- Magnesium (0.2 mmol/kg/day)
Monitoring: vital signs, ECGs, HGTS, bloods
