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Psychiatry Clerkship > Eating Disorders > Flashcards

Eating Disorders Flashcards

1
Q

DSM-5 Diagnostic Criteria - Anorexia Nervosa

A

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 less than minimally normal or less than minimally expected)
B - intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain
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 current low body weight

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2
Q

2 types of anorexia nervosa?

A
  1. Restricting type

2. Binge-eating/purging type

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3
Q

Features of anorexia nervosa - restricting type?

A

During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging. Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.

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4
Q

Features of anorexia nervosa - binge-eating/purging type?

A

During the last 3 months, the patient engaged in recurrent episodes of binge eating or purging

(Binge eating can be subjective - not actually eating a large amount of food)

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5
Q

Severity classification of anorexia nervosa?

A

Mild: BMI > 17
Moderate: BMI 16-16.99
Severe: BMI 15-15.99
Extreme: BMI <15

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6
Q

What is reverse anorexia?

A

Aka muscle dysmorphia
Subset of BDD
Concerned that they will never be muscular enough
Predominantly men

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7
Q

Prevalence of anorexia nervosa?

A

Previous estimates ~1%
Broad criteria - 4.2%
Strict criteria - 2.2%
Possible increase in prevalence in recent years

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8
Q

___% of patients with anorexia nervosa are female.

A

90-95

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9
Q

Age of onset of anorexia nervosa?

A

Puberty and menarche (13-14 and 17-18)

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10
Q

Discuss anorexia nervosa as it relates to culture.

A

-Occurs cross culturally (not considered culture bound)
-Most prevalent in industrialized societies (food plentiful, thin ideal)
-Classic pt - higher SES and Caucasian
AA - less ED behaviors
Latino - same or more severe behaviors
Asian American - unclear

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11
Q

Genetic findings of anorexia nervosa?

A

Runs in families
Appears to have a shared transmission of OCD/anxiety
Higher concordance for monozygotic compared to dizygotic
Serotonin 2A R (?)

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12
Q

Possible pathophysiology of anorexia nervosa?

A
  • Enlargement of sulci, interhemispheric fissure, and ventriles
  • Cerebral dystrophic changes
  • Deficits in dopamine function
  • Increased 5-HT1A receptors and decreased 2A
  • Hypoperfusion to frontal and parietal
  • Global hypometabolism
  • Different functioning in the cingulate cortex and insula
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13
Q

High risk populations for anorexia nervosa?

A
  • Participation in activities that require attention on weight appearance (ballet, long distance running, gymnastics, ice skating, modeling)
  • Chronically ill women (CF, DM, spina bifida, mood disorders)
  • High standards of achievement
  • Homosexual men
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14
Q

DDx - anorexia nervosa

A
  • Medical illness (GI disease, hyperthryoidism, malignancy, AIDS - none of these have fear of gaining weight)
  • MDD
  • Schizophrenia
  • SUDs
  • Social Anxiety
  • OCD
  • BDD
  • Bulimia Nervosa
  • Avoidant/Restrictive Food Intake Disorder
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15
Q

Symptoms of anorexia?

A 
Amenorrhea, infertility
Depression
Exertional Fatigue
Weakness
Headache
Dizziness
Chest Pain
Faintness
Constipation, Abdominal pain, non-focal abdominal pain, feeling full
Polyuria
Dry Skin
Cold Intolerance
Low back pain
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16
Q

Signs of anorexia?

A 
Emaciation
Hypothermia
Hyperactivity
Bradycardia
Hypotension
Hypoactive bowel sounds
Dry skin
Pressure sores
Brittle hair/nails
Hair loss
Carotenemia (orange colored skin)
Lanugo hair (very soft light hair - developed to keep in heat)
Cyanosis
Edema
Heart murmur (MVP)
Muscle wasting
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17
Q

Cardiac complications of anorexia?

A
  • Increased sudden death (unclear reason)
  • Decrease in CO and cardiac mass (below 20% IBW)
  • Progressive bradycardia, decreased HR variability
  • EKG often normal
  • MVP
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18
Q

GI complications of anorexia?

A
  • Gastroparesis
  • GERD
  • Constipation
  • Abdominal pain w/o tenderness
  • Abnormal LFTs
  • Superior mesenteric artery syndrome (so little fat that the SMA collapses onto the intenstines -> increased pain)
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19
Q

Gynecologic complications of anorexia?

A

Hypothalamic amenorrhea (should not be treated with OCPs)
Decreased levels of all sex steroids
May occur even before significant amount of weigh lost, may persist after weight regained
Infertility, pre-term birth, smaller head circumference, miscarriages, LBW

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20
Q

Endocrine complications of anorexia?

A

Normal cortisol with decreased clearance
Possible hyeprsecretion of CRH
Decreased IGF-1, increased or normal GH
Euthyroid sick syndrome (low/low normal T3/T4, normal TSH, increased rT3)
Fasting hypoglycemia
Increased cholesterol (due to increased HDL)
Osteoporosis

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21
Q

Discuss osteoporosis as a complication of anorexia.

A
  • DEXA z-score >-2.5 SD decrement from young bone mass
  • 40% of patients (92% have osteopenia)
  • Primary site - trabecular bone in lumbar spine and hips
  • Most treatments ineffective for patients with anorexia
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22
Q

There is no increased prevalence of anorexia in patients with DM1. However, when these occur together, how does it present?

A

Brittle diabetes, repeat symptomatic hypoglycemia
Patients may omit doses of insulin to cause an osmotic diuresis or increase dose to compensate for a binge
Increased retinopahty, nephropathy, neuropathy

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23
Q

Comorbid conditions with anorexia?

A
  • MDD
  • Dysthymia
  • Bipolar disorder
  • Anxiety disorder
  • GAD
  • Panic
  • OCD
  • Alcohol and substance use
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24
Q

Course of anorexia?

A

<50% will have a full recovery
33% will improve
20% will remain chronically ill
33% of recovered with relapse

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25
Q

What is diagnostic migration and when is the risk highest?

A

Development of bulimic symptoms after anorexia nervosa resolves; highest in the first 5 years

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26
Q

What are some reasons anorexia has the highest mortality rate of any psychiatric disorder?

A
  • High rate of suicide
  • Direct consequence of starvation or alcohol
  • Cardiac failure
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27
Q

Initial work-up for a patient with a possible eating disorder?

A
  • Complete physical exam
  • Orthostatics
  • EKG
  • CBC
  • BMP
  • Ca/Mg/Phos
  • LFTs
  • Amylase
  • BUN/Cr
  • Glucose
  • Thyroid
  • Urinalysis
  • Stool examination
  • UDS
  • Dexa scan if AN > 6 months
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28
Q

Rx - anorexia?

A
  • Little evidence for pharmacotherapy
  • Nutritional rehabilitation (mainstay)
  • Some psychiatric comorbidities improve with nutritional rehabilitation
  • Resistance to medications (fear of weight gain)
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29
Q

Discuss the pathogenesis of refeeding syndrome.

A

Chronic malnutrition/prolonged fast -> decreased insulin, increased glucagon and cortisol -> glycogenolysis, gluconeogenesis, protein catabolism -> depletion of electrolytes, proteins, fats, minerals, vitamins

Refeeding -> insulin secretion -> increased proteins and glycogen synthesis + increased glucose, phosphorus, magnesium, and potassium uptake + increased thiamine use -> hypophosphatemia, hypokalemia, hypomagnesemia, thiamine deficiency, sodium and water restriction -> convulsions, delirium, ataxia, hypotension, renal failure, arrhythmia, edema, fasciculations, rhabdomyolysis

30
Q

Steps to prevent refeeding syndrome?

A
  1. Identify patients at risk
  2. Measure electrolytes and correct before refeeding
  3. Electrolytes and phosphorus every other day for 7-10 days, then biweekly
  4. Start at 800-1000 kcal/day or 20-25 kcal/kg/day and increase caloric intake by 300-400 kcal every 3-4 days until producing 2-3 lb/week (max 3500 kcal for F, 4000 kcal for M/day)
  5. Monitor for tachycardia and edema
  6. Begin with low lactose, low fat, no added salt, gradually introduce more dairy and fats
31
Q

Criteria for tube feeding?

A
  • Persistent failure to gain weight with standard dietary procedures
  • Life-threatening weight loss
  • Worsening psychological state
32
Q

Medications to AVOID in patients with eating disorders?

A
  • Stimulants
  • Wellbutrin
  • Topiramate
  • Levothyroxine

(Can all lead to increased weight loss)

33
Q

Medications to treat anorexia?

A
  • SSRIs - meta-analysis shows no evidence in the acute phase; may be helpful in maintenance (inconsistent results)
  • Venlafaxine - no data for efficacy
  • Mirtazapine - avoid due to potential for neutropenia
  • Antipsychotics - tried due to the potential delusional nature of AN thought processes; concern for QTc prolongation and reduced seizure threshold (typicals), atypicals - weight gain, anxiolytic, anti-obsessional, need more data
  • Mood stabilizers - no evidence unless comorbid bipolar disorder
34
Q

Psychotherapy Rx for anorexia?

A
  • Family based treatment - very efficacious for adolescents, little data for use in adults
  • CBT - research minimal
  • IPT - possible greater maintenance than CBT, efficacy unclear
  • Self-help/case management
  • Psychodynamic
35
Q

DSM-5 Criteria for Bulimia Nervosa?

A

A. Recurrent episodes of binge eating (eating in a discrete period of time any 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 over eating 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; excessive exercise
C. Binge eating and inappropriate compensatory behaviors both occur, on average, at least 1x/week for 3 months
D. Self-evaluation is unduly influenced by body shape and weight
E. Disturbance does not occur exclusively during episodes of AN

No undue fear of weight gain

36
Q

Compare onset of AN vs. BN.

A

BN - later onset than AN

37
Q

Prevalence of BN?

A

DSM-IV criteria - 1.5% for women, 0.5% for men

Using DSM-5 criteria - 2% for women

38
Q

Pathogenesis hypothesis of BN?

A
  • Evidence of diminished 5-HT metabolite levels
  • Altered serotonin A1 and A2 activity
  • Increased activation in anterior cingulate cortex and insula, decreased activity in other cortical structures
  • Higher concordance with identical twin
39
Q

Risk of BN with female relative with an eating disorder?

A

4.4x risk general population

40
Q

Symptoms of BN?

A 
Irregular menses
Heart palpitations
Esophageal burning
Non-focal abdominal pain
Abdominal bloating
Lethargy, fatigue
Headache
Constipation/diarrhea
Edema of hands/feet
Frequent sore throat
Teeth sensitviity
Depression
Swollen feet
41
Q

Signs of BN?

A 
Calluses on back of hand
Salivary gland hypertrophy
Erosion of dental enamel
Periodontal disease
Dental caries
Facial petechiae
Perioral irritation
Mouth ulcer
Hematemesis
Edema
Abdominal bloating
Cardiac Arrhythmia
42
Q

Lab abnormalities seen in BN (vomiting)?

A

Increased bicarbonate and pH
Decreased K and Cl
Variable Na

43
Q

Lab abnormalities seen in BN (laxatives)?

A

Decreased K
Increased or decreased Cl, bicarbonate, pH
Variable Na

Over time, becomes:
Increased bicarbonate and pH
Decreased K and Cl
Decreased or normal Na

44
Q

EKG changes seen in BN?

A

Low K - T waves flat, U waves, ST segment depression

Low Mg/Ca - prolonged QT, non-specific T wave changes

45
Q

GI complications of BN?

A 
Severe reflux
Spontaneous vomiting
Laryngitis, odynophagia, dysphagia
Barrett's esophagus
Mallory weiss tear
Esophageal rupture
Constipation
Atonic, distended colon
46
Q

Cardiac complications of BN?

A

Less likely if normal weight
If previously AN - higher ventricular arrhythmias
No consistent findings on cardiac evaluation, vitals, EKG, or echos
Arrhythmias due to electrolyte abnormalities (can be any arrhythmia with reduced K, but Vtach and Vfib most worriseome)
More likely with purging than laxative use
Ipecac use is a risk for irreversible cardiomyopathy

47
Q

Dental complications of BN?

A 
Cheliosis
Perimolysis (erosion of enamel)
Caries
Increased gingivitis
Sialadenosis
Hyperamylasemia
48
Q

Most common sign of BN?

A

Perimolysis (erosion of enamel)

49
Q

Psychiatric comorbidities of BN?

A

Mood disorders
Anxiety disorders
Substance use
Borderline personality disorder

50
Q

Course of BN?

A

Very variable longitudinal course
~50% will achieve remission at 5-12 years
33% will relapse
Minority with chronic symptoms

51
Q

Associated with a worse prognosis for BN?

A

Unsuccessful treatment attempts
Comorbid substance use
Cluster B traits

52
Q

Diagnostic migration is more common in which direction?

A

AN -> BN

53
Q

What is the binge restriction cycle?

A

Overvaluation of shape and weight -> restriction -> binging -> purging

54
Q

Initial work-up for BN?

A

CMP (very important, more likely to be abnormal in BN)
Consider hospitalization for electrolyte abnormalities (especially if K<3)
EKG if purging behavior

55
Q

Rx - BN (pharmacotherapy)?

A
  • Fluoxetine (decreased binge/purge, associated psychological symptoms, more data for acute phase)
  • SSRIs (especially fluvoxamine for maintenance)
  • TCAs - desipramine
  • MAOIs - brofaromine
56
Q

Non-antidepressant pharmacotherapy for BN?

A
  • Topiramate (double-edged sword - helps with cravings, can decrease appetite)
  • Ondansetron - potential use at times of urges
  • Naltrexone - mixed efficacy
  • Baclofen - reduce rewarding effects in substance abuse
  • Memantine - reduced binge eating
  • Antipsychotics - little to no data, especially in normal weight BN, potential for mood stabilization
57
Q

Psychotherapy for BN?

A
  • CBT - gold standard (acute and maintenance)
  • IPT - may be as good as CBT (better in the long-term, CBT better in short-term) - targets psychosocial issues which can lead to relapse
  • DBT - needs more research
  • Self-help, group, psychodynamic
58
Q

DSM-5 Diagnostic Criteria for Binge Eating Disorder?

A

A. Recurrent episodes of binge eating
B. Binge eating episodes are associated with 3+ of the following:
-Eating much more rapidly than usual
-Eating until feeling uncomfortably full
-Eating large amounts of food when not feeling physically hungry
-Eating alone because of feeling embarassed by how much one is eating
-Feeling disgusted with oneself, depressed, or very guilty afterward
C. Marked distress regarding binge eating
D. Occurs, on average, at least 1x per week for 3 months
E. Not associated with the recurrent use of inappropriate compensatory behavior as in BN and does not occur exclusively during BN or AN

59
Q

Prevalence of Binge Eating Disorder?

A

F - 3.5%

M - 2.0%

60
Q

Medical comorbidities of Binge Eating Disorder (chicken or egg)?

A
  • Increase in health complications and health dissatisfaction
  • Obesity
  • IBS
  • Fibromyalgia
  • DM2
  • HTN
  • OA
61
Q

Psychiatric comorbidities of Binge Eating Disorder?

A 
MDD
Bipolar disorder
Anxiety Disorder
BN
SUDs
Personality Disorders
62
Q

Course and outcome of Binge Eating Disorder?

A

Chronic condition, similar morbidity and mortality to BN
Length similar or longer than BN, much longer than AN
Treatment - some data suggest less likely to relapse
-Little to no diagnostic migration to BN or AN

63
Q

Rx - Binge Eating Disorder (pharmacotherapy)

A

SSRIs - mixed data
Sibutramine - decreased episodes/weight, possibly depression
Orlistat
Topiramate - reduces frequency of binge episodes and facilitates weight loss, does not help psychological symptoms, poorly tolerated
Zonisamide - reduced frequency of binge eating, poorly tolerated
Atomoxetine - reduced binge frequency, promotes weight loss, does not help psychological symptoms

64
Q

Nutritional treatment of Binge Eating Disorder?

A

Traditional weight loss programs - variable, some efficacy supports
Structured exercise

65
Q

Psychotherapy for Binge Eating Disorder?

A

CBT - gold-standard (over medications)

IPT, DBT, self-help, groups

66
Q

DSM-5 Diagnostic Criteria of Rumination Disorder?

A

A. Repeated regurgitation of food over a period of at least 1 month. May be re-chewed, re-swallowed or spit out
B. Repeated regurgitation not attributable to an associated GI or other medical condition
C. Does not occur exclusively during AN, BN, BED, or avoidant/restrictive food intake disorder

67
Q

Rumination disorder common in what populations?

A

Children and adolescents

individuals with intellectual disabilities

68
Q

Rx - Rumination disorder?

A

Operant conditioning - gold standard

G and J tubes may be necessary

69
Q

DSM-5 Diagnostic Criteria for Avoidant/Restrictive Food Intake Disorder?

A

A. Eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with 1+ of the following:
-Significant weight loss
-Significant nutritional deficiency
-Dependence on enteral feeding or oral nutritional supplements
-Marked interference with psychosocial functioning
B. Disturbance not better explained by lack of available food or by an associated culturally sanctioned practice
C. Does not occur exclusively during the course of AN or BN and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced
D. Not attributable to a concurrent medical condition or another mental disorder

70
Q

Atypical AN?

A

All criteria met except for significant weight loss (weight within or above normal range)

71
Q

Purging disorder?

A

Recurrent purging behavior to influence weight or shape in the absence of binge eating

72
Q

Night eating syndrome?

A

Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal

Awareness and recall of eating

Not better explained by external influences

Causes significant distress and impairment

Not better accounted for by another disorder/substance

Psychiatry Clerkship (8 decks)

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