Eating Disorders and Refeeding Syndrome Flashcards
What is an indication for hospitalization in reference to suicide in eating disorders?
hospitalize when patients have specific suicide plan or intent
–> high lethality
Does bulimia nervosa or anorexia nervosa have higher suicide rates?
bulimia–> 7x higher than general population
—- 25-40% hx attempt
anorexia–> 5x higher than general population
—— 8-27% hx attempt
What should you screen for with a patient with bulimia or anorexia?
suicide ideation
Describe anorexia nervosa
restriction of energy intake–> low body weight for age, sex, and development
intense fear of gaining weight or becoming fat, despite being underweight
distorted perception of body weight and shape–> decreased self-worth, denial of medical seriousness of low body weight
What are the types of anorexia nervosa?
Restricting:
-3 months of no binging or purging via self-induced vomiting or laxatives
~~~excessive exercising, fasting, dieting
Binge eating/purging:
- 3 months of binging and purging behaviors
~~~self-induced vomiting; misuse of laxatives, diuretics and enemas
-how to distinguish from bulimia: AN has low body weight
Describe a person with anorexia nervosa
constant viewing in mirror
weight body or body parts constantly
deny starvations sx even when emaciated
weight is form of control–> self esteem centers around it
What worsens as anorexia patients lose weight?
fear of weight gain rises as they lose weight–> out of control
Medical complications of anorexia
arrhythmias, brady, hypotension, QT dispersion, mitral valve prolapse
amenorrhea and decreased libido (losing weight starts to attract others, out of control loses interest in partners and sex)
osteoporosis, hypothermia, euthyroid, hypoglycemia
gastroparesis and constipation d/t excessive laxative use
dehydration, hypokalemia, low phosphate, low magnesium (huge electrolyte disturbances)
respiratory muscle atrophy and dyspnea
anemia, leukopenia, thrombocytopenia
brain atrophy
skin issues
refeeding syndrome
Describe refeeding syndrome
result of fluid and electrolyte shifts during aggressive nutritional rehab of malnourished patients
complications are potentially fatal:
low phosphate and potassium, CHF, peripheral edema, rhabdo, seizures, hemolysis
How to avoid refeeding syndrome?
limit amount of calories and fluid in early stages of refeeding
avoid very rapid increases in daily calories
closely monitor labs and patient during first few weeks of refeeding
Comorbidities of anorexia
OCD impulse control disorders depression personality disorders perfectionism, compulsivity, narcissism
Anorexia treatment
when in doubt–> hospitalize
interdisciplinary team of mental health, dietician, IM
minimum first line of care: nutrition rehab, psychotherapy
hospitalize d/t SI, resistance to refeeding–> stay until normal weight to reduce re-hospitalization
anorexia and associated psych usually resistant to meds, only use with depression/anxiety that create barriers to care
Range for gaining weight in anorexia patients
2-3lb per week for inpatients
0.5-1lb gained per week for outpatients
initial intake of 30-40 calories more, progressively increase to match weight goals and avoid refeeding syndrome
First line therapy for anorexia
nutrition rehab AND psychotherapy (CBT, motivational interview, family therapy in adolescents)
Pharm considerations for anorexia
consider only in patients who are resistant to other therapies and are willing to take meds
low dose d/t increase side effects a/w low weight, dehydration, etc
AVOID BUPROPION d/t increased seizure risk with binge/purge subtype
AVOID TCA d/t cardiotoxicity
Olanzapine helps weight gain
Lorazepam reduces anxiety around meals
SSRI if severe anxiety/depression
–> second generation antipsychotics if not responsive
Criteria for diagnosing bulimia nervosa
recurrent episodes of binge eating (large in discrete period of time, can’t control eating during this time)
inappropriate compensatory behavior to prevent gaining weight (purging)
at least 2 times per week for 3 months
weight is normal, slightly under or over, or obese
Do bulimics focus on weight as much as anorexics?
anorexia obsessed with staying thin and not gaining weight
bulimics fearful of gaining weight but don’t need to be thin (just don’t want to be fat)
—————> feel like shit after binging
Medical complications of bulimia
same as anorexia with:
Mallory-Weiss syndrome/esophageal rupture
parotid or submandibular gland hypertrophy
abd pain/bloating/constipation
tooth enamel erosions and caries, Russel’s sign (callus on dorsum of hand from self-purging)
Comorbidities of bulimics
anxiety, mood, substance use disorders
personality disorders
impulsivity, perfectionism, compulsivity, narcissism
Treatment for bulimia
nutrition rehab
CBT (treatment of choice)–> stop binge/purge but not reducing weight
pharm (less effective if used alone)
pharm and CBT appropriate if can’t get nutrient rehab
AVOID BUPROPION d/t seizure risk
Pharm for bulimia
Fluoxetine first line
SSRIs at higher starting doses second line (sertraline or fluvoxamine)
third line: TCA, topiramate, trazadone, MAOIs
Criteria for binge eating disorder (BED)
episodes of binge eating, lack control
–> large amounts when not hungry, rapid eating, uncomfortable after eating, eating alone, guilt and depression or disgust after episode
once a week for at least 3 months
- ***** no regular use of inappropriate compensatory behaviors (purging, fasting, excessive exercise)
- -> how to differentiate between this and bulimia
Treatment for binge eating disorder
reduce binge eating, excess weight gain, comorbidities, body image concerns
psychotherapy first line treatment (CBT and IPT)
Vyvanse only med to treat
SSRIs with CBT but not more effective than CBT alone
anti-obesity drugs not recommended d/t side effects
