Eating Disorders

Question 1

What is the primary shared feature between anorexia nervosa and bulimia nervosa?

Answer 1

Preoccupation with own weight and excessive self-evaluation based on weight / shape

Question 2

Who is most likely to develop an eating disorder with regards to race, SES, upbringing, and sex? Has the prevalence changed?

Answer 2

Prevalence has been increasing over the past 50 years

Race - White
SES - middle / upper class
Upbringing - Sexually abused or negative feelings about body at puberty
Sex - Female

Question 3

Who is most likely to develop AN or BN:

Patient A: Family was chaotic, conflicted, and critical.
Patient B: Family was overly controlling, organized, and weight concerned.

Answer 3

A: Bulimia nervosa-> under-controlled and mood-labile patients
B: Anorexia nervosa -> anxious, inhibited, over-controlled, and OCD type patient.

Question 4

What three psychiatric comorbidities are very common with anorexia nervosa?

Answer 4

1. Depression
2. OCD - anorexia was once thought to be part of OCD spectrum
3. Personality disorders

Question 5

What personality disorders are associated with anorexia nervosa?

Answer 5

Avoidant & Obsessive-Compulsive Personality Disorder

Question 6

What personality disorders are associated with bulimia nervosa?

Answer 6

Avoidant & Borderline Personality Disorder

Question 7

What is a common, severe CNS finding in eating disorders? What drug is contraindicated because of this?

Answer 7

Seizures - bupropion

Question 8

What is the most common cause of death in eating disorders?

Answer 8

Cardiac arrythmias due to electrolyte imbalance

Question 9

What are Lanugo and Russell sign?

Answer 9

Lanugo - fine, babylike hair which typically occurs in anorexia

Russell sign - callouses on dorsal hand due to self-induced vomiting (purging-type anorexia, or bulimia)

Question 10

What is a common bone finding in anorexia?

Answer 10

Osteoporosis - can lead to metatarsal stress fractures

Question 11

What reproductive / hormonal changes occur in anorexia?

Answer 11

Low LH / FSH / TSH leads to hypothyroid symptoms as well as amenorrhea

Question 12

What are the oral manifestations of bulimia?

Answer 12

erosion of teeth enamel and decay

Question 13

What metabolic effects are seen from vomiting in bulimia and purging-type anorexia?

Answer 13

Hypokalemic, hypochloremic alkalosis

• > increased HCl excretion in vomit leads to increased bicarbonate uptake in the kidney to compensate for loss of Cl-
• > less H+ is able to be exchanged for K+, so not as much K+ can be reabsorbed

Question 14

What are the DSM general criteria for AN?

Answer 14

1. Restriction of energy intake leading to low body weight or less than minimally expected for children
2. Intense fear of gaining weight
3. Disturbed view of own weight / shape

Question 15

What are the two subtypes of AN?

Answer 15

1. Restricting type -> no binging and purging for last 3 months, just calorie restriction
2. Binge-eating / Purging type -> engage in binge-eating / purging during last 3 months

People can alternate between these two

Question 16

How does Binge-eating / purging subtype of AN differ from bulimia?

Answer 16

Bulimia is not associated with a decreased overall weight and an intense fear of weight gain

Question 17

What types of anorexia nervosa patients have the best prognosis?

Answer 17

Younger patients with prompt treatment
-> neural rewiring has not yet taken place
Close to ideal body weight upon leaving hospital

Question 18

What is the primary safety concern of anorexia?

Answer 18

High rate of suicide

Question 19

What is the initial treatment for AN and what should be avoided?

Answer 19

Gradual weight restoration -> try to return to normal weight before discharge
+
Cyroheptadine - antihistamine and anti-5HT to increase apetite

Avoid:
Refeeding syndrome - increased insulin upon introduction of carbohydrates in feeding leads to hypophosphatemia (glucose-6-phosphate formation) and cardiac arrhythmias. GO SLOWLY

SSRIs - until weight is restored

Question 20

What medications are indicated for maintenance of AN remission?

Answer 20

SSRIs
Cyproheptadine (for appetite)
Atypical antipsychotics

Question 21

What are the diagnostic criteria for bulimia nervosa?

Answer 21

1. Recurrent binge eating with lack of self control
2. Recurrent inappropriate compensatory behavior
   - > could be vomiting, but often only laxatives, enemas, diuretics, meds, or even excessive exercise
3. Behavior must average at least 1x per week for 3 months
4. Negative self-evaluation on body shape / weight gain

Question 22

What are the subtypes of BN?

Answer 22

1. Purging type -> self-induced vomiting or use of laxatives as compensatory behaviors
2. Nonpurging type -> Other inappropriate compensatory behaviors like fasting and excessive exercise are used

Question 23

How do onset and weight differ between BN and AN?

Answer 23

Onset - Anorexia is earlier

Weight - Anorexia is <85% expected for height, bulimia is normal or near-normal weight

Question 24

How is management of bulimia nervosa different than anorexia nervosa?

Answer 24

1. Most patients can be managed as outpatients rather than inpatients, with same emphasis on therapy and SSRI / antipsychotic use.
2. Bulimia patients should NOT be given cyproheptadine since their appetite is normal (vs AN)

Question 25

What is “other specified eating or feeding disorder” used for?

Answer 25

Eating conditions causing distress which do not fully meet criteria for AN or Bn

Question 26

What is binge-eating disorder?

Answer 26

Recurrent binge eating WITHOUT any compensatory behaviors

Question 27

What is purging disorder? What are they at risk for developing?

Answer 27

Recurrent purging after consuming only a SMALL amount of food in persons with normal weight and a distorted body image

At risk for developing bulimia

Question 28

Other than bupropion, what other class of medication is relatively contraindicated in eating disorders?

Answer 28

Stimulants (i.e. methylphenidate)

-> abuse potential + cause weight loss / decreased appetite