DSA33 - Eating and Feeding Disorders

1) Persistent disturbance

2) Altered consumption or Absorption

3) Significant impairments

What characteristics are shared by Feeding and Eating Disorders?

Infancy and Childhood

Around what age is the age of onset for Feeding Disorders?

•Pica

•Rumination Disorder

•Avoidant/Restrictive Food Intake Disorder

List the Feeding Disorders

Pica

Define Feeding Disorder:

SEVERE (enough to warrant clinical attention) Repeated ingestion of inedible non-food objects:

- MC = Dirt, Clay, Flaking Paint

- Others = paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, pebbles, ash, ice, starch, buttons, coins, feces

Criteria:

1. Persistent eating of non-food items (over at least 1 month)

2. Developmentally inappropriate

3. Not part of a culturally supported or socially normative practice

4. Sufficiently severe to warrant separate clinical attention from another disorder (if present)

-Hx:

> Age > 2 y/o for Dx

>> May occur in Pregnancy

> Equal in MALES and

FEMALES

> May be culturally appropriate behavior --> Can't Dx

-Path:

> Often Developmental Delay or Severe IDs

> Hx of Neglect/Lack of Supervision

> Theories

>> Nutritional Theory (unclear)

>> Delayed Development Theory

>> Cultural Theory

-Assoc Sx:

> Stomach upset/Pain

> Blood in Stool (development of ulcer)

> Bowel Issues (Constipation/Diarrhea)

-DDx:

> Anorexia Nervosa (ingest non-food to control wt gain)

> Factitious Disorder (cause physical sx on purpose)

> Non-suicidal self-injury in PDs (deliberately cause injury)

-Tx:

> 1st = Behavioral Therapy (Positive reinforce alt behaviors, Environmental enrichment)

> Nutritional Rehab

> Pharm (2nd = SSRIs)

-Prog:

> Mechanical bowel issues

> Intestinal obstruction

> Intestinal perforation

> Infex (ex: feces)

> Poisoning (ex: flaking lead paint)

Rumination Disorder

Define Feeding Disorder:

Regular regurgitation of food (re-chewed, spit out, swallowed) w/o trying (doesn't cause distress); Several times per week

Criteria:

1. Food is regurgitated at least over a one month period (may be re-chewed, re-swallowed, or spit out)

2. It is not attributable to an associated GI or other medical condition (e.g. reflux, pyloric stenosis)

3. It occurs separately from other feeding/eating disorders (if present)

4. Sufficiently severe to warrant separate clinical attention from another disorder (if present) (for example, separate treatment from usual treatment for intellectual developmental or autism spectrum disorder)

-Hx:

> COMMON Onset = Infancy (3-12 mo)

>> If AFTER infancy --> Usually ID associated

> Equal in MALES and FEMALES

> May be episodic or continuous (infants = remits spontaneously)

-Path

> Lack of stimulation in Environment

> Neglect

> Stress

> Parent-child relationship issues

> May be self-soothing or self-stimulating (May have Hx of Physical Illness OR Severe Stress)

-Sx:

> Wt Loss

> Bad Breath

> Tooth Decay

> Repeated stomachaches & Indigestion

> Raw/Chapped Lips

> +/- Growth Delay in children

-Sx for Specific Ages:

> Infants = Strain/Arch back + Head back + Sucking movement w/ tongue --> Wt loss & Unable to gain wt

> Older Children/Adults = Disguise w/ hand over mouth or cough (avoid eating socially)

-DDx:

> GI Conditions (Gastroparesis, Pyloric Stenosis, Hiatal Hernia)

> Anorexia Nervosa/Bulimia Nervosa (control caloric intake/wt gain)

-Tx:

> 1st = Behavioral Therapy

>> Change child's posture during and after eating

>> Positive reinforce feeding

>> Positive reinforce alt behaviors

-Prog:

> Medical Emergencies/Fatal for Infants

Avoidant/Restrictive Food Intake Disorder (ARFID)

Define Feeding Disorder:

Either avoids food or restricts intake of food to the point that they are significantly underweight, nutritionally deficient, has to have some form of assistance or supplementation, or can’t function socially

Criteria:

1. Restricting or avoiding food intake to the point of at least one of the following:

> Significant weight loss or failure to achieve expected weight

> Significant nutritional deficiency

> Dependence on enteral feeding or oral supplements

> Interferes with psychosocial function

2. Not due to lack of available food or because of religious or cultural practice

3. Does not have anorexia nervosa or bulimia nervosa

4. Is not due to a medical condition or another mental disorder

-Hx:

> Age = Infancy or Early Childhood --> May persist into Adulthood

> Equal in MALES and FEMALES

> Hx of GI issues

> Mental PMHx = Anxiety D/O, ASD, ADHD, ID

-Path: FHx of Anxiety around food intake

-Sx:

> Physical = GI complaints, dizziness, difficulty concentrating, feeling cold, sleep problems, dry skin, lanugo hair, thin hair, weakness, brittle nails

> Behavioral = Severely reduces food intake or the types of food they will eat + Dresses in LAYERS (stay warm/hide wt)

> Psych = Fear of choking/vomiting OR lacks interest in food

-Sx for Specific Groups:

> Infants

>> No interest in eating (won't communicate hunger)

>> Too sleepy/distressed to feed

>> Apathetic, Withdrawn, or Irritable

> Older Children/Adults = Generalized emotional issues that DON'T meet other Mental D/o (anxiousness, depressed mood, moodiness)

-DDx:

> Other Med/Neuro (GI reflux, structural or congenital issues)

> ASD (rigid eating/sensitivities)

> Anorexia Nervosa (fear of wt gain)

-Tx:

> Psychotherapy (CBT/Exposure Therapy)

> Family Therapy

> Nutritional Tx (re-introduce foods)

> HOSPITAL if extremely low wt/medically unstable

Adolescence and Early Adulthood

Around what age is the age of onset for Eating Disorders?

•Anorexia Nervosa

•Bulimia Nervosa

•Binge Eating Disorder

List the Eating Disorders

Anorexia Nervosa (AN)

Define Eating Disorder:

Not consuming enough calories to maintain a normal body Wt (BMI < 18.5 OR less than 5th percentile for peds) + Intense fear of Wt Gain (Distorted Body Image)

Criteria:

1. Restriction of food intake leading to a significantly low body weight

> For youth: <5th percentile is below minimally expected weight

> For adults a normal BMI > 18.5; therefore a person will be at least below 18.5 to be considered as significantly underweight

2. Intense fear of gaining weight or of becoming fat

3. Disturbance in the body image or lack of recognition of how serious their low body weight is.

-Subtypes:

> Restricting = Wt loss ONLY via RESTRICTION often to COMPENSATE for calories consumed (diet, fasting, excessive exercise)

> Binge-Eating/Purging = Recurrent Eps of binge eating OR Purging to PREVENT absorption of calories (vomiting, laxatives, diuretics, enemas)

-Hx:

> More in FEMALES

> More in Adolescence/YA (14-18 y/o)

> More in INDUSTRIALIZED countries (more in White pts also)

-Path:

> Over-represented in occupations/interests that require rigorous control of body shape or strict weight criteria (e.g. modeling, ballet, wrestling, jockey)

> More in RELATIVES (highest in MZ twins)

> Possible disturbance in 5-HT neurotransmission (reduced basal CSF 5-HIAA)

> FEAR OF LACKING CONTROL OR FINDS CONTROL VIA CONTROLLING EATING

-Sx:

> Physical (D/t malnutrition) =

>> Headaches

>> Fatigue

>> Anxiety/Depression/Stress

> Behavioral =

>> Skipping meals

>> Repetitive weighing

>> Frequent mirror checking

>> Dress in layers (stay warm/hide wt)

> Psych =

>> CONSISTENT complaints of "being fat"

>> Denial of low wt/eating issues

>> Fear of eating in public

-Tx:

> Psychotherapy/CBT

> Family Therapy

> Nutritional Tx (increase intake)

> HOSPITAL if low wt or medically unstable (ex: Met Alk)

> Pharm (maybe SSRIs)

> Exhaustion (inanition)

> Bradycardia

> Orthostatic hypotension

> Low body temperature

> Peripheral edema

> Alopecia

> Lanugo hair formation

> Acrocyanosis

> Dry skin

> Brittle hair/nails

> Muscle wasting

What PE findings are attributable to STARVATION seen in AN?

> Hematology = leukopenia, mild anemia, low platelets

> Serum Chemistry = Elevated blood urea nitrogen & liver enzymes + Metabolic ALKALOSIS from vomiting OR ACIDOSIS from laxative abuse

> Endocrine = Decreased T3 & T4, Low estrogen (females); low testosterone (males)

> Bone Mass = Low bone mineral density

> Electrocardiography = Sinus bradycardia

> Electroencephalography = Diffuse abnormalities (metabolic encephalopathy)

What Diagnostic Markers findings are attributable to STARVATION seen in AN?

-Other Medical and Neurological Conditions

> e.g. GI disease, hyperthyoridism, malignancies, AIDS

-Avoidant/Restrictive Food Intake Disorder (ARFID)

> Restriction is a core feature of ARFID, but there is no fear of weight gain or distress about body image

-Bulimia Nervosa (BN)

> In BN, BMI is normal or higher; may diet but does not engage severe restriction to the point of becoming underweight

-Major Depressive Disorder

> May have low appetite, but no desire for excessive weight loss & no fear of gaining weight

-Anxiety Disorders

> AN has fears and obsessions that are limited to eating behavior and body shape and size

What are the DDx for AN?

Bulimia Nervosa (BN)

Define Eating Disorder:

Engages in BINGING AND PURGING, but w/n normal wt range for adults (may even by slightly overweight)

Criteria:

1. Episodes of binge eating. (Eating excessive amount of food within a 2 hour period and feeling a lack of control over it)

2. Episodes of purging and/or other compensatory behaviors to offset weight gain.

> Purging = Self-induced vomiting, misusing laxatives/diuretics/enemas

> Compensatory = Misusing Insulin, Fasting, Excessive Exercise

3. Binge eating and purging/compensatory behaviors occur, on average, at least once a week for 3 months.

4. Body shape and weight overly influences self-evaluation.

5. The disturbance does not occur exclusively during episodes of Anorexia Nervosa

-Hx:

> More in FEMALES

> Age = Late Adolescence OR Early Adulthood

> More in INDUSTRIALIZED countries (more in White pts, but may be in other ethnic groups)

> FHx of this

-Path:

> Hx of childhood obesity/Early pubertal maturation

> FHx of this

> Disturbance in 5-HT Neurotransmission

> LOW SELF-ESTEEM

-Sx:

> Physical (D/t malnutrition) =

>> Headaches

>> Fatigue

>> Anxiety/Depression/Stress

> Behavioral =

>> Restrict calories/fasts btwn binges

>> Repetitive weighing

>> Diet supplements OR Herbal products EXCESSIVELY for Wt Loss

> Psych =

>> Preoccupied w/ Wt and Body Shape

>> Fear gaining wt

>> Denial of bingeing and purging behaviors

-DDx:

> AN (Binge-Purge Type) (only if the binging purging was NOT more than 3 mo)

> Depressive D/Os (inc appetite, but don't purge or compensate nor over-concern of wt and shape)

> BPD (binging = impulsive, so can be both)

-Tx:

> 1st = CBT/Psychotherapy to STOP STRICT DIETING (Break Binge-Purge Cycle) + Enhance Self-Esteem in healthy ways

> Nutritional Tx (stabilize caloric intake)

> Pharm = Fluoxetine

> HOSPITAL if extremely low wt OR medically unstable (Met Alk or Met Acid)

•Parotid and salivary gland enlargement

•"Russell's sign" - calluses or abrasions on the skin of the hand (from manual stimulation of the gag reflex to induce vomiting)

•Dental enamel erosion

What PE findings are attributable to PURGING seen in BN?

-Serum Chemistry

> ELECTROLYTE ABNS from frequent purging (low potassium, sodium, chloride)

> Metabolic ALKALOSIS from vomiting OR ACIDOSIS from laxative abuse

> Elevated serum amylase

-Electrocardiography

> DEPRESSED T-WAVES

-More rare but potentially fatal:

> Esophageal tears

> Gastric rupture

> Rectal prolapse

What Diagnostic Markers findings are attributable to PURGING seen in BN?

Binge Eating Disorder

Define Eating Disorder:

Normal to obese wt range (BMI > 18.5) in Adults + ONLY engages in BINGING

Criteria

1. Episodes of binge eating. (Eating excessive amount of food within a 2 hour period and feeling a lack of control over it)

2. Binge eating is characterized by at least 3 of the following:

> Eating rapidly

> Eating until uncomfortably full

> Eating large amounts even though not hungry

> Eating alone out of embarrassment

> Feeling disgusted, depressed, or guilty afterward.

3. Highly distressed about their binge eating.

4. Episodes occur, on average, at least once a week for 3 months.

5. No compensatory or purging behavior.

6. It does not occur by itself during episodes of Bulimia Nervosa or Anorexia Nervosa

-Hx:

> Somewhat more in FEMALES (less skewed than BN)

> Similar frequency across ethnic groups

> A/w... (related to OBESITY)

>> Joint problems

>> Heart disease

>> T2DM

>> GERD

>> Some sleep-related breathing disorders

-Path:

> More in persons seeking Wt Loss Tx

> FHx

> Triggers = Stress, Poor body self-image + Availability of preferred binge foods

-Assoc Sx:

> Poor quality of life

> Problems functioning at work, and with personal life and social situations

> Social isolation

-DDx:

> BN

> Obesity

> Bipolar/Depressive Disorders

> BPD

-Tx:

> 1st = Psychotherapy/CBT (cope w/ triggers + modify thoughts)

> Pharm (only for MOD to SEVERE) = Lisdexamfetamine dimesylate