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Psychiatry > Eating Disorders > Flashcards

Eating Disorders Flashcards

1
Q

three main features of anorexia

A
  1. an intense pursuit of weight loss & self-induced starvation
  • fear of becoming obese
  • engages in dieting and excessive exercise
  • paradoxically focused on food

2 a disturbance in body image: belief they are fat even though they are thin

  1. medical signs/symptoms of starvation
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2
Q

DSM IV version of anorexia

A

Weight loss to less than 85% of ideal body weight or failure to make expected weight gains in children and adolescents

Intense fear of gaining weight

Disturbance in how one perceives their body

Amenorrhea for 3 months in post-menarcheal females

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3
Q

DSM 5 changes to Anorexia

A

Removal of less than 85 percentile of IBW criteria -> “significantly low weight”

Intense fear of gaining weight or behaviors that interfere with weight gain

Disturbance in how one perceives their body

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4
Q

Two subtypes of anorexia

A
  • Restricting Type
  • Binge-eating/purging type
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5
Q

What are the different levels of severity of anorexia

A
  • Mild: BMI >17
  • Moderate: 16-16.99
  • Severe: 15-15.99
  • Extreme: <15
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6
Q
  • Eating a large amount of food in a short period of time
  • Engaging in compensatory behavior to get rid of the food or weight

• Feelings of loss of control during the episode

A

Binge/Purge

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7
Q

What vital sign changes do we see as physiological effects of starvation?

A
  • Hypotension
  • Bradycardia
  • Hypothermia
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8
Q

Effect of heart, skeletal, endocrine from anorexia

A
  • Cardiac: Bradycardia, hypotension, syncope, EKG changes, arrhythmias & sudden death
  • Skeletal: Osteopenia, osteoporosis
  • Endocrine:
  • Hormonal changes: decreased LH, FSH & estradiol, abnormal TSH
  • Cold intolerance, hypothermia
  • Decreased libido, amenorrhea
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9
Q

Skin/GI/Heme/Neuro changes with anorexia

A
  • Dermatology: Dry skin, alopecia, lanugo (fine baby-like hair over the body)
  • Hematologic: Pancytopenia - anemia, leucopenia
  • Gastrointestinal: Delayed gastric emptying, constipation
  • Neurologic: Fatigue, weakness, reduction in brain mass volume & cognitive deterioration
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10
Q

Epidemiology of Anorexia nervosa

A
  • Females > males, 1:10
  • Onset is usually in the mid-teens, increasing in preadolescents
  • 1% of the population, with 5% of the population showing subclinical signs
  • Higher socioeconomic status and US versus other developed countries, but equalizing
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11
Q

Etiology of anorexia nervosa, #1 risk factor

A
  • Multifactorial
  • Biological, psychological and social factors
  • Different for almost every patient
  • Dieting is the #1 Risk factor
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12
Q

Steps to food disorders

A

Food/body acceptance–> Food/body obssessed–> disordered eating –> eating disordres: anorexia, bulimia, binge eating disorder

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13
Q

What genetc factors play a role in eating disorders?

A

Genetic:
• Higher rates in monozygotic twins
• Strong family history for mood disorders

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14
Q

What hormonal changes are seen with disordered eating?

A

Hormonal, biochemical and starvation effects

associated with onset of puberty

endorphin increases

hypothalamic-pituitary-adrenal axis changes

neurotransmitter: decreased norepinephrine turnover, decreased dopamine response, serotonin increases with food

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15
Q

Psychological Factors in eating disorders

A

Temperament: perfectionist, harm avoidant, high-achieving

Control issues: feeling helpless, not able to establish autonomy

Maturation fears: fear of becoming an adult, being shapely or sexual

Demands to increase independence: overwhelming, focuses on food versus “normal” activities

Beliefs: moral desires are greedy/unacceptable

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16
Q

What social factors have a role in eating disorders?

A
  • Media influence
  • Obesity education
  • Family concerns about weight
  • Teasing about weight
  • Dieting information
  • Performance pressures in sports
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17
Q

Key DDX to consider before dx with eating disorder

A
  • Rule out
  • Brain tumor or cancer
  • Other psychiatric disorders: depression, somatization, schizophrenia, bulimia
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18
Q

Complications of AN and how we can use Labs to support Dx

A
  • Complicated by
  • denial, secrecy
  • disinterest or resistance to treatment
  • No laboratory tests “diagnose” AN, but for medical assessment:
  • CBC,electrolytes,magnesium,phosphorus,FSH/LH/estradiol,thyroid,LFTs,amylase,UDS, specific panels (i.e. diuretics), ECG, urine pregnancy
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19
Q

is the most lethal psychiatric disorder

May require inpatient medical stabilization

Key point: Don’t ignore weight loss
in teenage patients!

A

Anorexia Nervosa (AN)

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20
Q

Treatment for severe AN

A
  • Food is the best medicine!!
  • May require hospitalization
  • If nutritionally unstable: dehydration, electrolyte abnormalities
  • Goal: reinstate nutrition, correct metabolic abnormalities, maintain structure/cooperation
  • Treatment team is KEY: Primary care physician, Psychiatrist, Dietician, Psychotherapist
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21
Q

What is Refeeding syndrome

A
  • Fluid and electrolytes shift during nutritional rehabilitation
  • Risk is related to: amount of weight lost during the current episode , rapidity of weight restoration

• Potentially life-threatening
Hypophosphatemia, delirium, arrhythmias and cardiac arrest

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22
Q

What types of pyschotherapy are available to tx AN

A
  • “Maudsley” Family Based Treatment:parents play an active role in restoring weight and gradually hand over control back to the patient
  • Cognitive behavioral therapy (CBT): address cognitive distortions
  • Dialectical behavioral therapy (DBT): address treatment interfering behaviors

**Goal: stabilize and improve primary relationships

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23
Q

What type of pharmacology is available for AN tx?

A
  • No medications are indicated or have consistently shown benefit for the core symptoms of anorexia nervosa
  • Medications are generally used to treat psychiatric comorbidities :Depression, social phobia, OCD
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24
Q

t

A
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25
Q

Prognosis for AN

A
  • Good to moderate in 75% of patients
  • 1⁄4 have a complete recovery
  • 1⁄2 have overall good function despite ongoing issues

Some continue a waxing and waning course

  • Increased risk of poor prognosis and death :persisting food obsessions, complicated by bulimia, low albumin, very low weight
  • Mortality: 7-18%
26
Q

Characteristics of Bulemina nervosa

A
  1. episodes of overeating
  2. compensatory behavior to prevent weight gain - may engage in purging or excessive exercise
    - may have normal weight, be overweight or obese
  3. clinical signs/symptoms
27
Q

DSM IV criteria for bulemia nervosa

A

Recurrent episodes of binge eating followed by inappropriate compensatory behavior in order to prevent weight gain

Episodes occur at l_east twice a week for 3 months_

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa

28
Q

Subtypes of bulemia

A

Subtypes
• Purging type

• Nonpurging type

29
Q

DSM 5 for bulemia nervosa

A

Recurrent episodes of binge eating

Recurrent inappropriate compensatory behavior in order to prevent weight gain

Episodes of A and B occur at least once a week for 3 months

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa

30
Q

What changes were made to the DSM 5 for bulemia nervosa

A
  • Subtypes were removed
  • Severity can be specified: based on number of compensatory behaviors episodes per week
  • 1-3 = mild
  • 4-7 = moderate
  • 8-13 = severe

• 14+ = extreme

31
Q

What are some compensatory behaviors seen in bulemia?

A
  • Purging
  • Misuse of laxatives, diuretics, enemas

• Vomiting

  • Other
  • Excessive exercise • Restrictive dieting • Skipping meals
32
Q

What are some observational signs of bulemia nervosa?

A
  • Swollen cheeks: parotid gland hypertrophy or infection
  • Metacarpal-phalangeal calluses (Russel’s signs): abrasions on knuckles from scraping against teeth
  • Dental erosions and caries: from gastric acid in the mouth • Front teeth that are chipped or ragged and “moth-eaten”
33
Q

What physiologic changes do we see from bulemia nervosa?

A

Labs: fluid and electrolyte imbalance

GI: GERD, esophageal varices or rupture; melanoisis coli (laxative use)

Cardiac: arrhythmias and myopathies

Endocrine: menstrual abnormalities

Neuro: neuropathy, fatigue, cognitive slowing, seizures

34
Q

• Metabolic alkalosis: low potassium, low sodium, high bicarb

• Hypochloremia

A

• Associated with vomiting and diuretic use:

35
Q

• Hyperchloremic metabolic acidosis: low potassium, high chloride, low bicarb

A

Associated with laxative abuse:

36
Q

How does bulemia lead to Hypokalemia?

A

Hypokalemia

  • Excessive vomiting leads to loss of potassium–>potentially lethal arrhythmias
  • If purging more than 3 times/day refer for **inpatient evaluation **
37
Q

Epidemiology of Bulemia Nervosa

A
  • More common than Anorexia Nervosa 1% to > 3% of the population
  • Onset is generally later than in AN: Late adolescence/early adulthood
  • Surveys of college women found up to 20-40% report binging and purging
38
Q

Genetic and biochemical factors of Bulemia Nervosa

A

• Genetic: First degree relatives with BN or depression

  • Biochemica: Increased rate of mood disorders and impulse control disorders, More responsive to serotonin fluctuations
  • Endorphin release (reinforces vomiting)
39
Q

Common temperments seen in Bulemia Nervosa

A
  • overachiever, competitive
  • secretive, ego dystonic, self-critical • outgoing, angry, impulsive
40
Q

What types of pysch disorders is Bulemia Nervosa associated with?

A

Associated with depression, alcohol and other substance use disorders, impulse control disorders, personality disorders, emotional lability, anxiety, dissociative disorders, history of abuse

41
Q

Social and famliy factors that affect Bulemia Nervosa

A

• Media influence: Anti-obesity education , Weight teasing/bullying

  • Family conflict
  • less close, more confrontational • control issues• neglectful/rejecting
42
Q

Key to consider when Dx bulemia

A
  • Neurologic disorders: seizures, tumors, Kluver-Bucy, Klein-Levin • Other psychiatric diagnoses, comorbidities?
  • Can be complicated by: denial & secrecy but tend to seek treatment
  • No laboratory tests to diagnose, but for medical assessment (similar to AN)
43
Q

Most effective tx for bulemia nervosa

A

• Most do not require hospitalization

  • Most effective treatment is therapy • Cognitive Behavioral Therapy (CBT)
  • Dialectical Behavioral Therapy (DBT)
  • Family therapy

• Group therapy (particularly inpatient or partial hospitalization)

44
Q

Pharm tx for bulemia nervosa

A

• SSRI antidepressant medication have shown to be effective

• Fluoxetine (Prozac) is the only FDA approved agent
Bupropion (Wellbutrin) is contraindicated because of increased seizure risk

45
Q

Prognosis of bulemia compared to AN

A
  • Higher potential for full recovery
  • If untreated, remains chronic
  • If complicated by substance use issues, poor prognosis
46
Q

How is binge eatig disorder simular to bulemina nervosa?

A
  • Similar features to BN:
  • Recurrent episodes of binge eating
  • Marked distress regarding eating binge eating
  • Occurs once per week for 3 months
  • Same severity scale as bulimia nervosa
47
Q

What are distinguishing features of binge eating compared to bulemia nervosa

A
  • Not associated with recurrent use of inappropriate compensatory behavior
  • Not exclusively during BN or AN
48
Q

How is Avoidant/Restrictive Food Intake Disorder have Similar features to AN

A

Persistent failure to meet appropriate nutritional/energy needs

Not better explained by lack of food or cultural practice

Not attributable to a concurrent medical condition or other mental disorder, or beyond what one would expect for another condition/disorder

49
Q

What distinguishes Avoidant disorder from AN

A

Not associated with a disturbance in the way one’s body weight/shape is experienced

Not part of AN or BN

50
Q

What is the definition of Obesity

A
  • Obesity:
  • weighing >20% ideal body weight (IBW) or having a body mass index (BMI) of 30+
  • Overweight: BMI 25-29.9
51
Q

Epidemiology of obesity in children and adults

A

• US Adults:

Upwards of 2/3 of US adults are considered overweight/obese

>1/3 of US adults are obese

• Children:

rates in children who are overweight/obese were increasing for many years, but arel eveling off and decreasing for very young children (<5)

25% preschool & 35% school-aged children are overweight/obese

52
Q

Etiology of obesity

A

Balance energy IN > energy OUT

  • Environmental
  • Increased availability of high calorie foods
  • Decreased requirement for physical activity
  • 78% Americans don’t meet activity level requirements; 25% are completely sedentary
53
Q

Genetic, biological and pyschosocial factors of obesity

A
  • Genetic: identical twins have the greatest risk
  • Biological: set point/satiety, development, medical issues, medications

• Psychological/Social: culture, family habits, psychiatric comorbidity (i.e. binge-eating disorder), low socioeconomic status

54
Q

Risks associated with obesity

A

Cardiovascular: diabetes type 2, hypertension, coronary artery disease, stroke, cardiovascular death**Cancer***Depression, quality of life

Reproduction and sexual function

Lung function: respiratory disease, asthma, obstructive sleep apnea

Memory/cognitive function: Alzheimer’s disease

Musculoskeletal: osteoarthritis, hip replacement, chronic back/limb pain

Other: gallstones, gout, kidney, fatty liver, mortality

55
Q

Treatment options for obesity

A

• Commercial dieting and weight loss programs: regain weight in 5 years

  • Bariatric surgery
  • including banding, gastrectomy, gastric Bypass
  • for BMI >40 or >35 with life-threatening condition
  • initially effective, but questionable regarding long-term weight loss

• Pharmacologic agents: variably efficacy and safety • Sensible diet and exercise

56
Q

pancreatic lipase inhibitor limits breakdown of dietary fats

5-10lb weight loss in first 6 months, maintained at 24mo

A

• Orlistat (Xenical and Alli)

57
Q

• symapthomimetic amine that decreases appetite

A

• Phentermine (lonamin)

58
Q

gold Standard for weight loss

A

Obesity: Gold Standard

Sensible diet and exercise: calorie intake < calories burned =

most effective way to maintain long-term weight loss

59
Q

REasonable weight loss in adults

A

5-10 % loss of initial body weight over 6 months or 1-2 pound weight loss per week

• cutting back calorie intake by 500-1000 calories/day

  • Women: total 1000-1200 calories/day
  • Men or women who exercise routine: 1200-1600

**After 10% body weight lost and kept off for 6 months, consider further weight loss if still overweight

60
Q

Weight loss for children and teens

A
  • Children and teens:
  • Initial goal: maintain weight or slow weight gain by healthy eating and physical activity

• Obesity: maintenance for 3 months, then slow weight loss

  • Slower weight loss than with adults: from 1 lb/mo
  • Half weight loss from diet, half from exercise
61
Q

What are reasonable changes we can make to lose weight

A
  • Diet: limit portion size, cut out second helpings, limit high calorie foods, high sugar, sugar additives, fast food, high fat
  • Behavioral modification (MOST SUCCESSFUL): recognize external cues, keep food diary, develop new eating patterns (i.e. eat slowly, chew food well, stay seated, etc.), use rewards/reinforcements
  • Group therapy
62
Q

Reasonalbe physical activity for weight loss

A
  • Needs/options vary
  • Example: 150 minutes of moderate-intensity aerobic activity weekly and muscle-strengthening activities 2+ days/week; or shorter duration, with more vigorous activity
  • If with a heart problem, chronic disease, or having chest pain or dizziness, seek medical advice

Psychiatry (19 decks)

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