Eating Disorders General and Anorexia Nervosa Flashcards
Overview of eating disorders (7)
- Complex illness with profound psychosocial and physical consequences
- Third most common chronic illness after asthma and obesity
- Peak age of onset is 14 to 18 years
* But can occur at much younger and older ages - Deep dissatisfaction with the patient’s own body and shape—fear of fatness
- Increase in prevalence of anorexia
- 10% of general population suffers from it but only a minority seek treatment
- Increasing recognized in the minority
DSM V Classifications of eating disorders (6)
- Anorexia nervosa
- Bulimia nervosa
- Binge eating disorder
- Avoidant/restrictive food intake disorder (ARFID)
- Rumination disorder
- Pica
Eating Disorder Risk Factors (8)
- : Female gender, particularly adolescent or young adult females.
- Certain ethnic groups such as Asians, Native Americans, and African Americans appear less likely to have eating disorders than other ethnic groups.
- Weight and Shape: Higher body mass index, concerns about weight, and a history of dieting.
- History of psychiatric problems: Depression, anxiety, or substance use
- Childhood eating difficulties or sexual abuse.
- Genetics
* Behavioral genetic studies using twin designs → substantial genetic effect for the liability for each of these disorders. - Psychobiology: Serotonin may be abnormal in eating disordered individuals. Seen more commonly in white, middle/ upper class females
- Job or profession that demands thinness
* Models
* Actors
* Entertainers - Overeaters
* Nursing
Predisposing and Precipitating Risk Factors (6)
- Self-objectification and body dissatisfaction
- Depression and negative affect
- Impulsivity and distress tolerance
- Self-critical perfectionism
- Response to internal body signals
- Family functions
Characteristics of Patient with Eating Disorders (10)
- Difficulty resolving conflict
- Low self esteem
- Ambivalence about growing up
- History of sexual abuse
- Over involved family
- Lack of conflict resolution
- Poor communication
- Chronic illness
- Poor indicators for resolution in AN
a. Disturbed parent child relationship
b. Long duration of illness or later onset
c. Concomitant personality disorder
d. Presence of vomiting - Poor indicator of resolution of BN
a. Presence of significant depression
b. Comorbidity with substance abuse
c. Coexisting personality disorder
d. History of sexual abuse
Evaluation of the Patient with a Possible Eating Disorder (4)
- Screening: Making a diagnosis
- Assessing nutritional and psychosocial status
- Determine the degree of malnutrition
- Evaluating the acute medical complications
Reproductive health history questions with eating disorders (male and female)
Male: Ask about libido? Morning erections? Changes?
Females: First period? Regular? Last period and how much did you weigh then
SCOFF Questionnaire (5)
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost >1 stone (6.3 kg or 14 lb.) in a 3-mo period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
Questionnaire (EDE-Q) - Interview and Questionnaire
EDE Interview
- Developed in 1987
- Gold standard in eating disorder diagnosis
- 16th edition
- Semi-structured clinical interview that takes 30 to 60 min to complete.
EDE questionnaire
- 36-item questionnaire derived from the EDE interview 11th edition
- Acceptable internal consistency and test-retest reliability
- Validated in the adult population but has not been validated in the adolescent or female athlete population
Female Athlete Screening Tool (FAST) (5)
- 33-item questionnaire
- Developed specifically for female athletes (24).
- 15 min to complete
- Validated in a collegiate population with subjects from both Division I and Division III National Collegiate Athletic Association schools.
- Compared using the EDE-Q, Bulimia Test-Revised (BULIT-R), EDI-2, and FAST. Reliability analysis demonstrated high internal consistency (Cronbach > = 0.87)
Eating Attitudes Test (Eat-26) (5)
- Widely used standardized self-report measure of symptoms and concerns characteristic of eating disorders
- Original EAT-40 that was first published in 1979 and refined
- Many different languages
- Reliability 0.9 (high)
- Validity 0.6 to 0.93
Eating Disorder Inventory-3 (7)
- Reliability 0.83-0.93
- Validity 0.43 to 0.68
- Use with females ages 13–53 years.
- 91 items divided into twelve subscales rated on a 0-4 point scoring system.
- 3 items are specific to eating disorders and 9 are general psychological scales that while not specific are relevant to eating disorders.
- Six composites: Eating Disorder Risk, Ineffectiveness, Interpersonal Problems, Affective Problems, Over control, General Psychological Maladjustment.
- Self-report questionnaire administered in twenty minutes
ROS with eating disorders (10)
- Dizziness
- Syncope, weakness, fatigue
- Pallor, easy bruising or bleeding?
- Cold intolerance?
- Hair loss, lanugo, dry skin?
- Vomiting, diarrhea, constipation?
- Fullness, bloating, abdominal pain, epigastric burning?
- Muscle cramps, joint paints, palpitations, chest pain?
- Menstrual irregularities?
- Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel disease?
Orthostatic Hypotension (how it is measured and 3 scenarios in which it is significant)
WILL BE ON THE EXAM!
Check the patientʼs blood pressure and pulse in a sitting position (with feet on floor), then have the patient stand for two minutes and retake BP & HR
Significant/positive if
- Increase of 20 beats per minute
- A decrease of 20 mm HG in systolic BP
- A decrease of 10 mm Hg is diastolic BP
*Important to do orthostatic for patients with suspected eating disorders
Eating disorder physical exam findings (8)
- Scaphoid abdomen
- muscle wasting
- acrocyanosis
- decreased subcutaneous fat
- lanugo hair
- ecchymosis
- diminished reflexes,
- dry skin
General PE findings (3)
- Hypothermia
- Cachexia; facial wasting
- Russel sign – cuts on top of hands or fingers from sticking fingers down throat
HEENT PE Findings (2)
- Sialadenitis (parotitis most frequently reported)
2. Angular stomatitis; palatal scratches; oral ulcerations; dental enamel erosion
Cardiac PE Findings (3)
- Sinus bradycardia; other cardiac arrhythmias
- Orthostatic changes in pulse (>20 beats per min) or blood pressure (>10 mm Hg)
- Cardiac murmur (one-third with mitral valve prolapse)
Skin PE Findings (7)
- Dull, thinning scalp hair
- Dry, sallow skin
- Lanugo/Bruising/abrasions over the spine related to excessive exercise
- Russell sign (callous on knuckles from self-induced emesis)
- Cold extremities; acrocyanosis; poor perfusion
- Carotenemia (orange discoloration of the skin, particularly palms and soles)
- Edema of the extremities
Pubertal Changes (2)
- Delayed or interrupted pubertal development
2. Atrophic breasts; atrophic vaginitis (postpubertal)
Psychiatric PE Findings
Flat or anxious affect
Assessing nutritional and psychosocial status: Lab tests (11)
- Serum electrolytes with Liver function (comprehensive metabolic profile)
- Magnesium
- Phosphorus
- Blood urine nitrogen and creatinine
- Complete blood count
- Urinalysis
- TSH, Free T4
- If amenorrhea, LH, FSH and prolactin
- If amenorrhea for more than 6 months, evaluate bone mineral density
- If obese, fasting lipid profile, insulin measurement, fasting glucose (Rome, 2016)
- Elevated CK with eating disorders
ECG Findings (7)
- Low voltage ECG is common with eating disorders
Obtain if the patient has
- Bradycardia (heart rate less than 50)
- Abnormal rhythm
- Palpitations
- Chest pain
- Electrolyte imbalance
- If athletic heart: Healthy voltage due to the large amount muscle depolarization and repolarization
Undernourished heart on ECG
Low voltage due to heart muscle loss during starvation
Laboratory studies (7)
- Hematocrit, hemoglobin, transferrin (decreased amounts)
- Serum glucose, albumin, electrolytes (decreased)
- May have hypernatremia
- Liver enzymes (elevated liver function)
- Thyroid function (low thyroxin)
- Creatinine phosphokinase (elevated)
- Electrocardiogram (ECG) (abnormalities)
Ideal Body Weight definition
Weight believed to be maximally healthful for a person, based chiefly on height but modified by factors such as gender, age, build, and degree of muscular development.
Calculation is adjusted if a patient has a lot of muscle; their ideal body weight would be higher
Ideal Body Weight calculation for males
50 kg + 2.3 kg (5.06 pounds) for each inch over 5 feet.
*Need to be able to calculate percentage below that a patient is to determine severity of eating disorder
Ideal Body Weight calculation for females
- 5 kg + 2.3 kg for each inch over 5 feet.
* Need to be able to calculate percentage below that a patient is to determine severity of eating disorder
Determine the degree of malnutrition via weight and height (4)
- Calculate the ideal body weight and proportion below ideal body weight (IBW)
- A child who is 20% below the IBW is moderate malnutrition
- A child who is 25% below the IBW represents severe malnutrition
- If the patient is not yet 20% below the IBW, then the child has mild malnutrition
Mild, moderate, and severe malnutrition based on %BMI
Mild: 80-90% of BMI
Moderate: 70% of BMI
Severe: <70% of BMI
Mild, moderate, and severe malnutrition based on BMI z score
Mild: -1 to -1.9
Moderate: -2 to -2.9
Severe: -3 or greater
Mild, moderate, and severe malnutrition based on weight loss
Mild: >10% body mass loss
Moderate: >15% body mass loss
Severe: >20% body mass loss in 1 year or >10% in 6 months
DMS 5: Diagnostic Criteria For Anorexia Nervosa (6)
- Restriction of energy intake relative to requirements
* Leads to a low body weight in terms of age, sex, and developmental level.
* BMI below the 10th percentile - Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain
- Body image disturbances with an undue influence of weight and shape or persistence lack of recognition of the seriousness of the illness
- 1,2,3 must be present then you determine if it is binging/purging
- Type is based on whether there is binging/purging or not
- The requirement for amenorrhea has been eliminated.
Anorexia Nervosa Diagnostic Criteria Specifics
Low body weight results from either strict diets and/or excess hyperactivity
*Pursued beyond the bounds of reason and with decreased in age-appropriate activities
Anorexia Nervosa Diagnostic Types: Restricting Type
Within the last three months, no engagement in recurrent episodes of binge eating or purging behavior
Weight loss is accomplished through dieting, fasting, and/or excessive exercise
Anorexia Nervosa Diagnostic Types: Binge-eating/purging type
During last three months, there has been engagement in binge eating or purging behavior (self-induced vomiting or misuse of laxative, diuretic or enemas)
Anorexia Nervosa Remission Specifics (Partial vs. Full)
- In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time
- In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time
Anorexia Nervosa Severity Levels (4)
- Mild: BMI ≥ 17 kg/m2
- Moderate: BMI 16-16.99 kg/m2
- Severe: BMI 15 – 15.99 kg/m2
- Extreme: BMI ≤ 15
Anorexia Nervosa management (15)
- Seek Information First
- Gather in a non-judgmental way
- No assumptions
- Use a non-confrontational approach
- Express compassion
- Make appropriate referrals
- PNPs must be aware of own biases and feeling towards these patients
- Establish trust
- Reestablish nutritional intake to restore physical health
- Family based treatment models with parents as central role
* Most effective part of this treatment along with multidisciplinary approach - Nutrition counseling
- Medication—antidepressants or anti-anxiety medications
- Small amounts more often if the adolescent has fasted for a long period of time
- Hospitalization -Has certain criteria
- Now a move towards more feeding rather than less feeding
Prognosis in Anorexia Nervosa Associated with Physical Hyperactivity (6)
Hyperactivity is associated with:
- More severe psychopathology
- Lower BMI
- Higher dissatisfaction with one’s own body
- Worse response to treatment
- More chronic course
- Hyperactivity is actually worse than eating restriction: poor prognosis; means more psychopathology
Medical Complications of Anorexia Nervosa (21)
- Acrocyanosis
- Dry skin
- Lanugo
- Ecchymosis
- Fatigue
- Muscle wasting
- Constipation
- Decreased deep tendon reflexes
- Orthostatic hypotension
- Atrophic breasts
- Atrophic vaginal area
- Bradycardia
- Mitral valve prolapse
- Pericardial effusion
- ECG abnormalities
- Decreased left ventricular mass and contractility
- Psychomotor retardation
- Growth delay
- Amenorrhea
- Osteopenia, osteoporosis
- Hair without shine