Eating Disorders Flashcards
three main features of anorexia
- 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
- medical signs/symptoms of starvation
DSM IV version of anorexia
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
DSM 5 changes to Anorexia
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
Two subtypes of anorexia
- Restricting Type
- Binge-eating/purging type
What are the different levels of severity of anorexia
- Mild: BMI >17
- Moderate: 16-16.99
- Severe: 15-15.99
- Extreme: <15
- 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
Binge/Purge
What vital sign changes do we see as physiological effects of starvation?
- Hypotension
- Bradycardia
- Hypothermia
Effect of heart, skeletal, endocrine from anorexia
- 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
Skin/GI/Heme/Neuro changes with anorexia
- 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
Epidemiology of Anorexia nervosa
- 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
Etiology of anorexia nervosa, #1 risk factor
- Multifactorial
- Biological, psychological and social factors
- Different for almost every patient
- Dieting is the #1 Risk factor
Steps to food disorders
Food/body acceptance–> Food/body obssessed–> disordered eating –> eating disordres: anorexia, bulimia, binge eating disorder
What genetc factors play a role in eating disorders?
Genetic:
• Higher rates in monozygotic twins
• Strong family history for mood disorders
What hormonal changes are seen with disordered eating?
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
Psychological Factors in eating disorders
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
What social factors have a role in eating disorders?
- Media influence
- Obesity education
- Family concerns about weight
- Teasing about weight
- Dieting information
- Performance pressures in sports
Key DDX to consider before dx with eating disorder
- Rule out
- Brain tumor or cancer
- Other psychiatric disorders: depression, somatization, schizophrenia, bulimia
Complications of AN and how we can use Labs to support Dx
- 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
is the most lethal psychiatric disorder
May require inpatient medical stabilization
Key point: Don’t ignore weight loss
in teenage patients!
Anorexia Nervosa (AN)
Treatment for severe AN
- 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
What is Refeeding syndrome
- 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
What types of pyschotherapy are available to tx AN
- “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
What type of pharmacology is available for AN tx?
- 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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Prognosis for AN
- 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%
Characteristics of Bulemina nervosa
- episodes of overeating
- compensatory behavior to prevent weight gain - may engage in purging or excessive exercise
- may have normal weight, be overweight or obese - clinical signs/symptoms
DSM IV criteria for bulemia nervosa
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
Subtypes of bulemia
Subtypes
• Purging type
• Nonpurging type
DSM 5 for bulemia nervosa
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
What changes were made to the DSM 5 for bulemia nervosa
- 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
What are some compensatory behaviors seen in bulemia?
- Purging
- Misuse of laxatives, diuretics, enemas
• Vomiting
- Other
- Excessive exercise • Restrictive dieting • Skipping meals
What are some observational signs of bulemia nervosa?
- 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”
What physiologic changes do we see from bulemia nervosa?
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
• Metabolic alkalosis: low potassium, low sodium, high bicarb
• Hypochloremia
• Associated with vomiting and diuretic use:
• Hyperchloremic metabolic acidosis: low potassium, high chloride, low bicarb
Associated with laxative abuse:
How does bulemia lead to Hypokalemia?
Hypokalemia
- Excessive vomiting leads to loss of potassium–>potentially lethal arrhythmias
- If purging more than 3 times/day refer for **inpatient evaluation **
Epidemiology of Bulemia Nervosa
- 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
Genetic and biochemical factors of Bulemia Nervosa
• 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)
Common temperments seen in Bulemia Nervosa
- overachiever, competitive
- secretive, ego dystonic, self-critical • outgoing, angry, impulsive
What types of pysch disorders is Bulemia Nervosa associated with?
Associated with depression, alcohol and other substance use disorders, impulse control disorders, personality disorders, emotional lability, anxiety, dissociative disorders, history of abuse
Social and famliy factors that affect Bulemia Nervosa
• Media influence: Anti-obesity education , Weight teasing/bullying
- Family conflict
- less close, more confrontational • control issues• neglectful/rejecting
Key to consider when Dx bulemia
- 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)
Most effective tx for bulemia nervosa
• 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)
Pharm tx for bulemia nervosa
• 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
Prognosis of bulemia compared to AN
- Higher potential for full recovery
- If untreated, remains chronic
- If complicated by substance use issues, poor prognosis
How is binge eatig disorder simular to bulemina nervosa?
- 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
What are distinguishing features of binge eating compared to bulemia nervosa
- Not associated with recurrent use of inappropriate compensatory behavior
- Not exclusively during BN or AN
How is Avoidant/Restrictive Food Intake Disorder have Similar features to AN
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
What distinguishes Avoidant disorder from AN
Not associated with a disturbance in the way one’s body weight/shape is experienced
Not part of AN or BN
What is the definition of Obesity
- Obesity:
- weighing >20% ideal body weight (IBW) or having a body mass index (BMI) of 30+
- Overweight: BMI 25-29.9
Epidemiology of obesity in children and adults
• 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
Etiology of obesity
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
Genetic, biological and pyschosocial factors of obesity
- 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
Risks associated with obesity
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
Treatment options for obesity
• 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
pancreatic lipase inhibitor limits breakdown of dietary fats
5-10lb weight loss in first 6 months, maintained at 24mo
• Orlistat (Xenical and Alli)
• symapthomimetic amine that decreases appetite
• Phentermine (lonamin)
gold Standard for weight loss
Obesity: Gold Standard
Sensible diet and exercise: calorie intake < calories burned =
most effective way to maintain long-term weight loss
REasonable weight loss in adults
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
Weight loss for children and teens
- 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
What are reasonable changes we can make to lose weight
- 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
Reasonalbe physical activity for weight loss
- 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
