Eating Disorders Flashcards
1
Q
What are the 3 diagnostic criteria (DSM-5) for anorexia nervosa (AN)?
A
- Intense fear of gaining weight or becoming fat
- Significantly low body weight (less than what is ideally expected) in relation to age, sex, development, and physical health
- Disturbance in the way one’s body weight or shape is experienced and denial of the seriousness of the current low body weight.
2
Q
What are the 4 diagnostic criteria (DSM-5) for bulimia nervosa (BN)?
A
- Recurrent episodes of binge eating
- Large amounts of food consumed in a short period of time
- Lack of control of eating during this episode - Recurrent compensatory behaviour to prevent weight gain
- Laxatives, vomiting, diuretics, diet, drugs, exercise - Binge eating and compensation 1x/week x 3 months
- Self-evaluation is disproportionately influenced by body shape and weight
3
Q
True or False? Diagnosis of bulimia requires a specific BMI
A
False - no specific BMI required (pts are commonly normal to slightly overweight)
4
Q
What is binge eating disorder (BED)? (6 criteria - don’t really need to memorize, but should read it and know it in general)
A
- Recurrent episodes of binge eating without compensatory behaviour to prevent weight gain
- Eating, in a discrete period of time, an amount of food much larger than most people would eat during the same period of time
- Lack of control over eating during the episode
- > 3 of the following:
- Eating rapidly
- Eating until uncomfortably full
- Eating large amounts when not hungry
- Eating alone from embarrassment
- Feeling disgusted, depressed or guilty after eating - Binge eating 1x/weekly for 3 months
- Causes marked distress
5
Q
What is the genetic predisposition for AN and BN?
A
- AN 22-76% heritability
- Gene defects resulting in a “drive for thinness” and obsessional thinking - BN ~30% heritability
6
Q
What environmental factors can potentially be a cause of AN or BN? (4)
A
- Trauma and stress
- Participation in athletics with high focus on weight/thinness
- Societal pressures
- Family dynamics
- Enmeshment, enstrangement, high parental expectations on achievement and appearance, families with difficulties managing conflict, divorce, devaluation of mother
7
Q
What is neurobiological dysfunction (AN/BN pathophysiology)? (3)
A
- Starvation, chronic stress, excessive exercise lead to increase release of cortisol from adrenal glands causing suppression of HPA, hypothalamic pituitary thyroid (HPT), and hypothalamic pituitary gonadal (HPG) axes
- Stress is the most common trigger for binge eating leading to HPA dysfunction - HPG: ↓ in estradiol, progesterone, LH production = amenorrhea and ↓ libido
- TSH inhibition reduces T4 –> T3 = reduced resting metabolic rate
8
Q
What is neurotransmitter dysfunction (AN/BN pathophysiology)? (3)
A
- 5HT is synthesized from tryptophan (from diet) and regulates postprandial satiety, anxiety, sleep, mood, impulse control, OCD
- ↓ intake in AN - DA deficiencies lead to ↓ energy, anhedonia, ↓ feelings of reward
- NE deficiencies from starvation lead to hypotension, bradycardia
9
Q
Males vs. females. Which is AN, BN, and BED most common in?
A
All female
10
Q
True or False? Anorexia is the deadliest psychiatric illness?
A
True - about 1 in 10 patients will die from it
11
Q
What is the common course of AN? (2+3)
A
- Onset usually related to stressful events
- AN course and outcome is highly variable
- No recovery after 1st episode
- Fluctuating pattern of weight gain and loss
- Chronic deterioration course
12
Q
What is the common course of BN? (2)
A
- Onset usually related to stressful events
- BN is chronic or intermittent, with periods of remission and reoccurrence
13
Q
70% of AN patients have comorbid psych conditions. What are they? (4)
A
- Anxiety
- OCD (30%)
- Social phobia - Mood disorders
- MDD
- Dysthymia
- BD - Personality disorders - Cluster C spectrum
- Avoidant
- Obsessive compulsive - SUD
14
Q
What are some comorbid psych conditions typically seen in BN patients? (5)
A
- Cluster B and C Personality Disorders (30-50%)
- Borderline personality, avoidant, impulsive, narcissistic - Substance use (30%)
- Anxiety disorders
- Obsessive Compulsive
- Panic Disorder
- Social Phobia - Mood Disorders (80%)
- MDD
- Dysthymia
- BD - Impulsive Control Disorder
- Compulsive buying
- Kleptomania
- Self-mutilation
15
Q
What are the general principles of treatment of eating disorders? (4)
A
- Approaches emphasize both normalization of eating
behaviour and attention to underlying psychological and
social issues - Consider the eating abnormality to be a coping mechanism, therefore, need to develop other coping mechanisms
- Form a treatment alliance by offering help with symptoms or behaviours which are distressing to the patient
- Identify stressors that predispose to eating disorder
16
Q
What are the negatives of amenorrhea? That is, without estrogen and normal menstrual cycles, increased risk of: (4)
A
- Osteoporosis/osteopenia
- Decreased growth velocity
- Lack of sexual desire/sexual dysfunction
- Unexpected pregnancies
- Ovulation occurs prior to menstruation
17
Q
When attempting to conceive a child, what symptoms do eating disorders produce for the woman? (3)
A
- Irregular ovulation
- Inhibited sexual desire
- Substance/tobacco use
18
Q
What are the risks of eating disorders during pregnancy? (7)
A
- Micronutrient deficiency
- Hyperemesis gravidarum
- Poor weight gain
- Substance/tobacco use
- Miscarriage
- Low birth weight and/or premature infant
- C-section
19
Q
What are some of the problems that eating disorders can cause postpartum? (5)
A
- Difficulty breastfeeding
- Failure of infant bonding
- Infant feeding problems
- Relapse of ED behaviours
- Postpartum depression
20
Q
For a woman recovering from an ED, when will periods return? What is the return associated with?
A
- Usually occurs within 6 months of achieving a body weight of about 90% of the average for age and height
- Return of cycle is not related to amount of body fat, but with amount of serum estrogen levels
21
Q
Are patients with AN typically hyperthermic or hypothermic?
A
Hypothermic
22
Q
What are some electrolyte disturbances that might be seen in AN? (9)
A
- Dehydration
- Hyponatremia
- Hypokalemia
- Hypomagnesimia
- Hypocalcemia
- Hypophospatemia
- Hypozincemia (appetite changes and taste disturbances)
- Hypochloremia (if vomiting)
- Hypoglycemia
23
Q
What HEENT symptoms might be seen in an AN patient? (3)
A
- Loss of tooth enamel
- Perioral dermatitis
- Enlarged parotid glands
24
Q
What are some potential neurological signs/symptoms of AN? (3)
A
- Seizures (related to large fluid shifts and electrolyte disturbances)
- Brain atrophy on CT
- Lethargy
25
What are some cardiac complications of AN? (4)
1. Prolonged QT associated with ED
- Predicts cardiac arrhythmia and sudden death
- Controversial
2. Cardiac atrophy from starvation
- Changes in blood flow, muscle and collagen fibers
- Alters conduction and ventricular repolarization
3. QTc > 470 ms increases risk for TdP and cardiac death
4. Requires monitoring with serial ECGs
26
What is myocardial mass in AN? (2 + 4)?
1. Prolonged starvation leads to wasted cardiac muscle
2. Myofibrillar atrophy and destruction secondary to malnutrition +/- due to decreased preload
- Decreased myocardial mass
- Decreased ventricular cavity size
- MV prolapse
- Decreased contractile forces and CO
27
What are some other, less common AN cardiac complications? (4)
1. Sinus bradycardia
- Due to vagal hyperactivity to decrease energy utilization
- Decreased level of T3 may contribute
2. Cardiac arrythmias
- Hypokalemia due to malnutrition and diuretic abuse
3. Decreased heart rate variability
- Due to abnormal autonomic NS function
- Predictor of sudden cardiac death
4. Hypotension
- Chronic volume depletion
- Decreased cardiac output
28
What are the AN cardiac outcomes? (4)
1. Most CV abnormalities normalize with weight restoration
2. QTc returns to baseline
3. Persistent MV prolapse
- Little clinical significance
4. Irreversible myocarditis with emetine toxicity
- Seen with chronic ipecac ingestion
29
What is the pharmacist's role in caring for cardiac complications of AN? (5)
1. ECG monitoring for arrhythmias, heart rate variability, and prolonged QTc
2. Avoid medications that prolong the QT interval
3. Monitor for electrolyte abnormalities
4. Monitor for orthostatic hypotension
5. To avoid refeeding induced CV complications:
- Refeed slowly
- Phosphorus supplementation
- Clinical surveillance in hospital
30
What are some potential GI symptoms in AN? (8)
1. Hypertrophy of salivary glands
2. Hypoactive bowel sounds
3. Hypomotility
4. Gastritis
5. Abdominal pain
6. Abdominal distension
7. Bloating
8. Constipation
31
What are some potential GU symptoms in AN? (4)
1. Amenorrhea
2. Infertility
3. Low estrogen levels (low test in males)
4. Low FSH/LH
32
What is the medical treatment for gastroparesis?
Domperidone
33
How does domperidone work in the treatment of gastroparesis? (5)
1. Dopamine antagonist (peripheral)
2. Does NOT cross the BBB
3. For delayed gastric emptying
4. To reduce abdominal distension, pain, and bloating
5. Increases esophageal peristalsis and GI motility
34
What are the risks of domperidone? (2)
1. QT prolongation
2. Limit use to short term due to ADEs
35
If a patient is being treated for gastroparesis, what medication should be avoided?
Metoclopromide, as can cause EPS (crosses BBB)
36
What is the medical treatment for constipation in a person with an eating disorder? (3)
1. Bowel Retraining
- PEG Lyte 250mL TID-QID
- PEG 17g po daily
- Milk of Magnesia 15-30mL HS
2. Bowel Taper
- Sennosides or cascara as needed
3. Individualize regimen based on individual patient*
37
What are some potential signs and symptoms of AN affecting the liver? (3)
1. Hypoalbuminemia
2. Increase in INR (1.5) and other LFTs
- Petechiae, purpura
3. Increase in GGT if alcohol abuse
38
What are 2 signs and symptoms of AN renally?
1. Elevation in BUN (dehydrated)
2. Decreased GFR
39
What are some endocrine signs and symptoms of AN? (4)
1. Reduction in T3 and T4
2. Increase in cortisol
3. Metabolic alkalosis (if vomiting)
4. Metabolic acidosis (if laxative abuse)
40
What are some musculoskeletal signs and symptoms of AN? (3)
1. Osteoporosis, osteopenia
2. Muscle weakness and leg cramps
3. Delayed linear growth
41
How does an eating disorder contribute to osteoporosis? (5)
1. ↓ Nutrition (especially in adolescence) --> ↓ peak bone mass
2. ↓ Body weight --> amenorrhea --> ↓ estrogen levels
3. ↓ Serum androgen levels
- androgens contribute to bone formation
4. ↓ Levels of IGF-1 (insulin-like growth factor)
- Nutrition dependant growth factor
5. ↑ Cortisol levels
42
What are some *possible* treatments to prevent worsening/improve bone mass in eating disorders? (4)
1. Estrogen Replacement?
2. Calcium and Vitamin D Supplementation?
3. Bisphosphonates (eg. Alendronate (Fosamax®), Risedronate (Actonel®))?
4. Weight Recovery?
43
What are the results of estrogen replacement as a way to help with BMD in eating disorders?
Estrogen replacement has not been found to be helpful for increasing BMD in eating disorders
44
What are the results of calcium and vitamin D supplements to help with BMD in eating disorders?
There are no studies of calcium + vitamin D increasing BMD in people with eating disorders, it is believed it may be helpful since it has been shown to decrease fractures in post menopausal women
45
How is calcium absorption and clearance affected in people with eating disorders? (2)
1. Less calcium is absorbed from food and supplements
2. Calcium is cleared out of the body faster
46
What is the daily recommended intake (including food and supplements) of calcium and vitamin D
1. Ca = 1200-1500mg
2. Vit D = 1000 IU/day
47
What are the results of using bisphosphonates in women with anorexia?
No good quality studies with alendronate and risedronate. Mixed results
48
What are the results of weight recovery and BMD in patients with eating disorders? (3)
1. Best way to prevent more bone breakdown and recover bone mineral density
- May relate more to increased fat mass vs. increased BMI
2. Can take as long as 1-2 years with sustained weight recovery to see increase in BMD
3. Although weight recovery improves BMD, some people still have permanent deficits
- Very important! Act now to prevent worsening!
49
What are some skin/hair signs and symptoms of eating disorders? (4)
1. Dry, scaling skin
2. Calluses on back of hand (from hand-induced vomiting)
3. Hair loss
4. Lanugo hair (fine hair growing on the skin)
50
What are the goals of therapy for AN? (6)
1. Stabilize medical and nutritional status
2. Restore and maintain a healthy body weight
3. Re-establish healthy eating patterns
4. Reduce distorted body image concerns
5. Identify and tx underlying psychiatric conditions
6. Prevent relapse
51
What is the (first) AN non-pharm treatment?
Nutritional Rehabilitation to restore weight gradually and prevent re-feeding syndrome
52
Describe how nutritional rehabilitation works (2)
1. Caloric intake levels usually start at 30-40kcal/kg/day
(~1000-1600kcal/day) may advance to 70-100kcal/kg/day
2. Nasogastric feeding preferred over IV when life-preserving
nutrition must be provided to a patient who refuses to eat
53
What should be monitored when doing nutritional rehabilitation? (2)
1. PO4, Mg, K, Na, Ca daily for first 5 days of refeeding then every other day for several weeks. Provide electrolyte replacements prn.
2. ECGs as needed
54
What is refeeding syndrome? (6)
1. Occurs when malnourished patients are fed high carbohydrate loads
2. Intolerance in gut may cause nausea and diarrhea
3. Rapid uptake of phosphates, magnesium, and potassium into cells
4. Body retains fluid and extracellular space expands
5. Reduction in serum electrolytes and fluid retention increases cardiac workload
6. May precipitate cardiac changes and heart failure
55
What are the symptoms of refeeding syndrome? (3)
1. Gastric bloating
2. Nausea
3. Edema
56
What is the risk of refeeding syndrome? (3)
1. Cardiac decompensation risk highest in initial phases of reintroduction of nutrition
2. Higher risk in hospitalized patients
3. Insulin causes shift of extracellular phosphate to intracellular space
57
What is happening in refeeding syndrome when shifting from a catabolic to an anabolic state? (3)
How can it be prevented? (2)
1. PO4 incorporation into tissue
2. PO4/ATP depletion
3. Depleted cardiac muscle
4. Prevention
- Initiate refeeding slowly
- Supplemental phosphorus
58
How is CBT done in eating disorder patients? (5)
1. Structured, time-limited therapy
2. Addresses the relations among thoughts, affect, and behavior
3. Restructures thought process
4. Improve problem solving skills
5. Improvement in coping with life stressors
59
True or False? Adjunctive pharmacotherapy is not effective in malnourished, underweight patients
TRUE
60
What are some options for adjunctive pharmacotherapy in eating disorder pts? (3)
1. Zinc
2. Antipsychotics
3. Antidepressants
61
What are the results of using zinc in patient with AN? (3)
1. Mixed results for weight/BMI restoration
- 1/3 trials = benefit
2. May benefit mood/anxiety
3. Remains controversial
62
What is the only antipsychotic that might be used in AN patient? Why "might?"
1. Olanzapine
"Might" because while it has shown modest weight increases, there are no benefits for eating-disorder cognitions or obsessionality
- Overall, very limited evidence of effect with SGAs. If olanzapine used should be combined with behavioural interventions
63
What are the adverse effects of antipsychotics? (4)
1. EPS
- Akathisia
- Acute dystonia
- Parkinsonism
2. Anticholinergic toxicity
3. QTc prolongation
- Can be of increased risk in eating disorders, especially if electrolyte imbalance
4. Tardive dyskinesia
64
True or False? Patients with AN tend to be less sensitive to cardiac and movement related ADEs?
False - they tend to be MORE sensitive
65
What is the evidence for using antidepressants in AN?
(TCAs, SSRIs, and bupropion)
1. TCAs - not currently recommended - risk of OD is high
2. SSRI - studies found them to not be beneficial - may help with comorbid depression and OCD after weight restoration though
3. Bupropion - not recommended as can precipitate seizures in ED patients (lowers seizure threshold)
66
What are the complications of bulimia nervosa? (4)
1. Amenorrhea
2. Orthostatic hypotension, bradycardia, ECG changes
3. Osteoporosis/osteopenia
4. Guilt and depression after binge
67
What are the symptoms of "purging" seen in BN? (5)
1. Parotid gland enlargement
2. Callus on dorsum of hand
3. Dental caries
4. Esophageal rupture (Mallory-Weiss tear)
5. Gastric rupture
68
What are some of the consequences of abused substances (ipecac, diuretics, laxatives) in BN? (3)
1. Electrolyte imbalance
2. Serious cardiac/skeletal myopathies (& death) from ipecac
3. Irreversible submucosal nerve fiber damage from phenothalein
69
What are the goals of therapy for BN? (7)
1. Stabilize medical and nutritional status
2. Restore and maintain a healthy body weight
3. Decrease and eventually eliminate binging & purging behaviours
4. Re-establish healthy eating patterns
5. Reduce distorted body image concerns
6. Identify and treat any underlying psychiatric conditions
7. Prevent relapse
70
What is the treatment plan for BN? (3)
1. Psychotherapy
- Cognitive-behaviour therapy
2. Nutritional rehabilitation
3. Pharmacotherapy
- Moderately effective for treating BN
71
Describe how CBT is done in BN/what is the efficacy? (4)
1. Most effective psychotherapy
2. Superior in efficacy to drug therapy
- 50-60% symptom remission
3. Focuses on change of though pattern and specific behaviours
4. 20 hour long sessions over 6 months
72
How do we go about weight gain treatment in BN patient? (4)
1. Initially: 1000-1600kcal/day
2. Slowly titrating upward to 2000-3000 kcal/day
3. Goal weight: 90% of ideal or when menses start
4. Improves dysphoric mood and OC behaviour
73
What are the drugs of choice for BN patients?
Why?
SSRIs
- At high doses, SSRIs decrease binge-purge episode regardless of co-occurring depression
74
The only FDA approved SSRI for treatment of BN is?
Fluoxetine
75
How do we feel about topiramate use in BN patients?
At mean doses of 100mg/day it has demonstrated short term efficacy (10 weeks) in decreasing binge/purge episodes (3 RCTs)
- Use limited by ADEs (BRAIN FOG --> so bad that we really try to stay away from this med if possible)
76
What should be monitored in a BN patient? (8)
1. Frequency and severity of binge/purge episodes
2. Exercise patterns
3. Use of laxatives, enemas, ipecac, diuretics
4. Eating habits
5. Daily caloric intake
6. Mood and anxiety symptoms
7. Weight & BMI
- Monitor weekly
- No more than 2-3lb/week
8. Labs
