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Mental Health > Eating Disorders - Physiology and Treatments > Flashcards

Eating Disorders - Physiology and Treatments Flashcards

1
Q

Anorexia diagnostic criteria as per the DSM-5 includes…

3 Primary criteria

A
  1. Intense fear of gaining weight or becoming fat
  2. Significantly low body weight in relation to age, sex, development; with denial of seriousness of low body weight
  3. Disturbance in the way one’s body weight/shape is experienced

Amenorrhea used to be in criteria but excluded males

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2
Q

Severity of anorexia is determined by…

A

BMI ranges

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3
Q

Bulimia diagnostic criteria based on the DSM-5 includes…

A

Recurrent episodes of binge eating and compensatory behaviour to prevent weight gain, at least 1x/week for 3 months
Self-evaluation disproportionately influenced by body shape and weight

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4
Q

Severity of bulimia is based upon…

A

Frequency of inappropriate compensatory behaviours

DOES NOT INCLUDE A SPECIFIC BMI; people with BN are commonly normal to slightly overweight

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5
Q

Binge eating disorder criteria includes…

A

Recurrent episodes of binge eating without compensatory behaviour to prevent weight gain; usually an amount of food much larger than most people would eat
1x/weekly for 3 months

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6
Q

People with binge eating disorder often have lack of control over eating during their episode. This may include…

A

Eating rapidly
Eating until uncomfortably full
Eating large amounts when not hungry
Eating alone from embarassment
Feeling disgusted, depressed, guilty, or distressed after eating

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7
Q

Etiology of anorexia/bulimia involves 3 realms:

A

Genetic predisposition
Physiologic state (imbalance of NT’s)
Environmental factors, complex bio-psychosocial

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8
Q

Neurobiological dysfunction from AN/BN includes…

A

Increased release of cortisol from adrenal glands from stress, starvation, or exercise.

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9
Q

The increased release of cortisol with AN/BN results in suppression of…

A

HPA, HPT, and HPG axes.

HPT = hypothalamic pituitary thyroid
HPG = hypothalamic pituitary gonadal

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10
Q

Suppression of HPG axis may result in…

A

Decrease in estradiol, progesterone, and LH production - leading to amenorrhea and decreased libido

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11
Q

HPT axis suppression may result in…

A

Reduced T4 to T3 - reduced resting metabolic rate

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12
Q

Neurotransmitters that may be dysfunctional in AN/BN include…

A

5HT, DA, NE

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13
Q

5HT is affected in eating disorders via…

A

Decreased intake in AN - regulates postprandial satiety, anxiety, sleep, mood, etc… so would result in other mood disturbances and obsessions

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14
Q

DA is affected in eating disorders via…

A

Deficiency - lower energy, anhedonia, decreased feelings of reward

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15
Q

NE is affected in eating disorders via…

A

Deficiency from starvation - leading to hypotension, bradycardia

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16
Q

Regarding epidemiology of eating disorders, the rate of females to male is…

A

Higher

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17
Q

Peak onset for eating disorders is usually around…

A

Adolesence/early adulthood

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18
Q

Eating disorders are important to address due to…

A

High morbidity and high mortality rates, especially with AN

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19
Q

BN has been associated an increase in ____ risk, which may be due to…

A

Cardiovascular risk, due to changes in lipids or endocrine abnormalities (low estrogen)

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20
Q

Onset of eating disorders is usually related to…

A

Stressful events

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21
Q

The course and outcome of AN is highly variable, referring to how…

A

There is no recovery after the 1st episode - fluctuating pattern of weight gain + loss, but will deteriorate without good supports

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22
Q

Course of BN can be ____ or ____, with periods of ____ and ____

A

Chronic or intermittent, with periods of remission and reoccurrence

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23
Q

AN co-morbid psych conditions involve…

A

Anxiety - OCD
Mood disorders
Personality disorders
Substance use disorders

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24
Q

BN co-morbid psych conditions inclue…

A

Personality disorders
Mood disorders
Substance use
Anxiety disorders
Impulse control disorders

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25
Q

The general principles of treatment with BN include…

A

Emphasis on both helping with normalization of eating behaviours/symptoms, and attention to underlying psychological + social issues

Consider eating abnormality to be a coping mechanism
Identify stressors that predispose individual to eating disorder

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26
Q

Amenorrhea with AN increases risk of…

Lack of estrogen + normal menstrual cycles

A

Osteoporosis/osteopenia
Decreased growth velocity
Lack of sexual desire
Unexpected pregnancies

Last point- ovulation occurs prior to menstruation

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27
Q

Eating disorders during pregnancy carries high risks, such as…

A

Micronutrient deficency
Hyperemesis
Poor weight gain
Higher rates of miscarriage or low birth weight

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28
Q

Periods usually return after amenorrhea within…

A

6 months of achieving a body weight of about ~90% average for age and weight.

Not related to amount of body fat, but with amount of serum estrogen levels

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29
Q

In a review of systems in a patient with AN, vitals will likely be impacted by…

A

Hypothermia, cold intolerance

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30
Q

In a review of systems in a patient with AN, electrolytes will likely be impacted by…

A

Lack of all electrolytes - dehydration

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31
Q

In a review of systems in a patient with AN, HEENT will likely be impacted by…

A

Loss of tooth enamel
Perioral dermatitis
Enlarged parotid glands

From continuous vomiting

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32
Q

In a review of systems in a patient with AN, neurology will likely be impacted by…

A

Seizures (large fluid shifts, electrolytes)
Brain atrophy on CT
Lethargy

Other organs can be used for energy

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33
Q

In a review of systems in a patient with AN, psych will likely be impacted by…

This one is BIG

A

Mood disorders, anxiety, insomnia, OCD features
Substance abuse/dependence
Suicidal ideation
Eating behaviours, or fear of gaining weight
Cognitive impairment, decreased attention and concentration

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34
Q

In a review of systems in a patient with AN, pulmonary will likely be impacted by…

A

Atrophied vasculature

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35
Q

Cardiac complications of AN may include…

A

ECG changes - heart rate, QTc, arrythmias
Orthostatic hypotension, dizziness, lightheadednesss
Peripheral edema (cessation of laxative + diuretic abuse)

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36
Q

Prolonged QT associated with ED’s are important because…

A

Predicts cardiac arrythmia and possible sudden death; QTc > 470 ms increases risk of Torsades and cardiac death

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37
Q

Cardiac atrophy from starvation causes cardiac complications such as QTc and ECG arrythmias because…

A

Changes in blood flow, muscle, and collagen fibers alter conduction and ventricular repolarization

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38
Q

Prolonged starvation leads to wasted cardiac muscle, which would then lead to…

A

Myofibrillar atrophy and destruction, secondary to malnutrition due to decreased preload

Decreased myocardial mass
Decreased ventricular cavity size
MV prolapse
Decreased contracile forces and cardiac output

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39
Q

Sinus bradycardia in AN may be due to…

A

Vagal hyperactivity to decrease energy utilization
Decreased level of T3

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40
Q

Cardiac arrythmias in AN may be caused by ____, due to…

A

Hypokalemia; due to malnutrition and diuretic abuse

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41
Q

A decrease in heart rate variability in AN may be due to…

A

Abnormal autonomic NS function

Predictor of sudden cardiac death

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42
Q

Hypotension with AN may be due to…

A

Chronic volume depletion
Decreased cardiac output

Orthostatic hypotension is very common since the body cannot compensate since it’s already under so much stress

43
Q

Most CV abnormalities in AN will normalize with…

A

Weight restoration

QTc would return to baseline

44
Q

Irreversible myocarditis may be occur in AN, and is usually seen with…

A

Chronic ipecac ingestion

45
Q

Pharmacist role in caring for AN patients with cardiac complications includes…

A

ECG monitoring (arrythmias, HR, QTc)
Monitoring for electrolyte abnormalities
Monitoring for orthostatic hypotension
Avoiding medications that prolong QT

46
Q

To avoid refeeding induced CV commplications, we should…

A

Refeed slowly
Offer phosphorus supplementation (+ other electrolytes)
Clinical surveillance in hospital

47
Q

In a review of systems in a patient with AN, GI system will likely be impacted by…

A

Hypertrophy of salivary glands
Hypoactive bowel sounds, hypomotility
Gastritis
Abdominal pain/distension
Bloating, constipation

48
Q

In a review of systems in a patient with AN, genitourinary systems will likely be impacted by…

A

Amenorrhea
Infertiliity
Low estrogen/testosterone levels
Low FSH/LH

49
Q

Gastroparesis refers to…

A

No peristalsis evident; food stuck in stomach

50
Q

For treatment of gastroparesis, we could use…

A

Domperidone

Peripheral dopamine antagonist

51
Q

Domperidone may help with gastroparesis via…

A

Reducing abdominal distension, pain and bloating
Increase GI motility and esophageal peristalsis

52
Q

Domperidone should not be added if the patient has…

A

A high QTc interval - domperidone is QT prolonging

53
Q

Domperidone should be used short-term due to…

A

Adverse effects

Even though it does not cross BBB

54
Q

Metoclopramide should be avoided for gastroparesis treatment, because…

A

It crosses BBB and can cause EPS

55
Q

For treatment of constipation, we could use…

A

PegLyte 250mL TID-QID
Peg 17g po daily
Milk of Magnesia 15-30 mL

Sennosides PRN

Individualize regimen based on individual patient

56
Q

In a review of systems in a patient with AN, liver will likely be impacted by…

A

Hypoalbuminemia
Increase in INR and other LFT’s
Petechiae and purpura (bruising)

Increase in GGT if alcohol abuse

57
Q

In a review of systems in a patient with AN, renal will likely be impacted by…

A

Elevations in BUN (dehydration)
Decreased GFR

58
Q

In a review of systems in a patient with AN, endocrine will likely be impacted by…

A

Reduction in T3 + T4
Increase in cortisol
Metabolic alkalosis if vomiting
Metabolic acidosis if laxative abuse

59
Q

In a review of systems in a patient with AN, musculoskeletal system will likely be impacted by…

A

Osteoporosis, osteopenia
Muscle weakness + leg cramps (electrolyte imbalance)
Delayed linear growth

60
Q

Osteoporosis early-on usually has no symptoms, but may lead to…

A

Increased risk of fractures
Kyphosis (curving of upper spine)
Pain
Reduced height

Loss of bone mass, breakdown of bone tissue

61
Q

An eating disorder contributes to osteoporosis via…

Hormones + external factors

A

Decrease in nutrition = decreased peak bone mass
Decreased body weight lowers estrogen levels due to amenorrhea
Decreased serum androgen levels, IGF-1 (bone formation + growth factors)
Increased cortisol levels

Smoking, ETOH abuse may contribute

62
Q

Osteoporosis risk is important to address in AN, especially adolescents because…

A

Most bone is built during adolescent years - issues with bone formation during these years can result in permanent deficit

AN = highest risk
People with bulimia with amenorrhea can also be affected

63
Q

Can estrogen replacement help increase BMD in eating disorders?

A

Has not been found to be helpful for increasing BMD in eating disorders

64
Q

Are calcium + vitamin D supplements recommended in eating disorders?

If so, how much calcium + vitamin D?

A

No direct studies to show increase in BMD, but may be helpful since they have been shown to decrease fractures in post-menopausal women

Calcium 1200-1500mg
Vitamin D 1000IU

65
Q

In studies of teenagers with eating disorders, bisphosphonates…

Good? Not good?

A

Have not shown benefit in improving BMD

66
Q

In adult women with eating disorders, bisphosphonates…

Good? Not good?

A

Have no good quality studies -mixed results… Case by case basis, but not strong evidence

Could extrapolate results in women without anorexia (shown to prevent fractures)

67
Q

The best method to prevent further bone breakdown and recover BMD is…

A

Weight recovery

68
Q

To see an increase in BMD with sustained weight recovery, it may take…

A

As long as 1-2 years

Some people may still have permanent deficits so this is really important to treat

69
Q

In a review of systems in a patient with AN, the skin will likely be impacted by…

A

Dry, scaling skin
Hair loss, or lanugo hair (fine hair growing on skin)

Calluses may be present on the back of the hand if patient has been hand-induced vomiting

70
Q

AN patients are treated inpatient if…

A

Acute risks present - continued weight loss despite outpatient tx, severe hypotension, cardiac irregularities, severe electrolyte abnormalities, suicidality

71
Q

Goals of therapy for AN include…

(5)

A

Stabilize medical + nutritional status
Restore + maintain healthy body weight
Re-establish healthy eating patterns
Reduce distorted body image concerns, and identify and tx underlying psych conditions
Prevent relapse

72
Q

The foundation of AN treatment is primarily…

A

Non-Pharm related

73
Q

Nutritional rehabilitation refers to…

A

Restoration of weight gradually, to prevent re-feeding syndrome

74
Q

Caloric intake levels usually start at ____ and may advance to ______

A

30-40 kcal/kg/day, advance to 70-100 kcal/kg/day

75
Q

Nasogastric feeding may be preferred over IV when…

A

Life-preserving nutrition must be provided to a patient who refuses to eat

76
Q

During nutritional rehabilitation, the following should be monitored…

A

ECG as needed
PO4, Mg, K, Na, Ca for first 5 days of refeeding then every other day for several weeks

Provide electrolyte replacements PRN

77
Q

Refeeding syndrome occurs when…

A

Malnourished patients are fed high carbohydrate loads

Rapid uptake of electrolytes into cells; body retains fluid + extracellular space expands

78
Q

Symptoms of refeeding syndrome may include…

A

Gastric bloating, nausea, diarrhea, edema

79
Q

Refeeding syndrome is dangerous because it may…

A

Cause cardiac decompensation due to fluid and electrolyte shifts

Morbidity can occur

Phosphorus incorporation into tissue; ATP depletion, depleted cardiac muscles

80
Q

Supplementation to help prevent refeeding syndrome includes…

A

Phosphate supplementation

81
Q

Other non-pharm treatment besides nutritional supplementation that is crucial includes…

A

CBT - address relationship among thoughts, affect, and behaviour

Restructure thought process and improve coping with life stressors

82
Q

Adjunctive pharmacotherapy is ____ for malnourished, underweight patients

A

NOT effective

Increases risk

83
Q

Options for AN pharmacological treatment includes…

A

Zinc
Antipsychotics
Antidepressants

84
Q

Zinc is often suggested as pharm treatment because…

A

Individuals with zinc deficiency exhibit symptoms similar to AN

85
Q

The evidence for zinc for AN is…

A

Mixed for weight/BMI restoration (1/3 trials = benefit)
May benefit mood/anxiety

Remains controversial

86
Q

Evidence for AP usage in AN is…

A

Very limited evidence of effect with SGA’s. No difference in BMI, psychopathology, or depressive sx’s.

FGA does not help with eating attitudes/behaviours, or ADR’s; no longer recommended

87
Q

The only SGA that showed modest weight increase was…

A

Olanzapine

But still no benefit for ED cognitions or obsessionality; with ADE’s involved

88
Q

AN patients are more predisposed to the ADE’s of AP’s, such as…

A

EPS
Anticholinergic toxicity
QTc Prolongation
Tardive dyskinesia

More sensitive to cardiac and movement related ADE’s

89
Q

Antidepressant evidence in AN is…

A

Limited, not beneficial for weight gain/BMI increase

90
Q

Risk of TCA includes…

A

Lethal risk with oerdose, and potential for fatal arrythmia at low body weight

Not currently recommended

91
Q

SSRI’s may be helpful in AN with…

A

Comorbid depression and OCD AFTER weight restoration has occurred

Still limited + mixed efficacy data

Trial for 6-12 months

92
Q

Complications of BN include…

CV, bone, mental health, abused substances

Somewhat similar to AN

A

Consequences of abused substances (electrolyte, cardiac, nerve issues)

Amenorrhea
Osteoporosis/osteopenia
Orthostatic hypotension, bradycardia, ECG changes
Guilt + depression

93
Q

Goals of therapy for BN include…

Quite similar to AN goals:

A

Decrease + eventually eliminate binging/purging behaviours

Stabilize medical and nutritional status
Restore and maintain healthy body weight
Re-establish healhy eating patterns
Identify and treat any underlying psychiatric conditions
Prevent relapse

94
Q

Treatment plans for BN includes…

A

Psychotherapy
Nutritional rehabilitation
Pharmacotherapy

95
Q

CBT is ____ in efficacy to drug therapy

A

Superior; 50-60% symptom remission

96
Q

Medical treatment with BN may involve correcting and preventing complications of low weight/purging, such as…

A

Electrolyte abnormalities
Constipation
Malnutrition

97
Q

An ideal goal weight for BN is…

A

90% of IBW, or when menses start

Ideally improves dysphoric mood and OCD behaviours

98
Q

The drug of choice for BN patients are…

A

SSRI’s

99
Q

Do BN patients need to be depressed to benefit from an SSRI?

A

No - at high doses, SSRI’s decrease binge-purge episodes regardless of co-occurring depression

100
Q

The SSRI’s that are well studied for BN include…

A

Fluoxetine
Citalopram
Sertraline

Fluoxetine is the only FDA approved medication for BN

101
Q

Onset of effect for BN treatment using SSRI is…

A

2-4 weeks

102
Q

Duration of BN treatment with SSRI may be…

A

6-12 months

103
Q

Topiramate has shown ____ in BN by ____, but use is limited by…

A

Short-term efficacy in BN by decreasing binge/purge episodes, but use is limited by ADE’s; Brain fog

104
Q

Important monitoring parameters for BN includes…

A

Frequency and severity of binge/purge episodes
Exercise patterns
Eating habits, daily caloric intake, weight & BMI
Mood and anxiety symptoms
Labs

Use of laxatives, enemas, ipecac, diuretics

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