Eating Disorders

What is an eating disorder?

Persistent disturbance in eating behaviors that alters food consumption, absorption, and physical health and/or psychosocial functioning

What factors contribute to the etiology of eating disorders?

- Biological factors

- Psychological factors

- Societal factors

What are the hallmark features of anorexia nervosa?

- Caloric restriction

- Significantly low body weight

- Intense fear of gaining weight

- Distorted perception of body image

What behavioral characteristics are associated with anorexia nervosa?

- Lack of insight into degree of weight loss

- Social withdrawal

- Irritability

- Perfectionism

- Ritualistic behaviors

- Obsessive behaviors

- Restrictive behaviors

What psychiatric comorbidities are commonly associated with anorexia nervosa?

- Depressive disorders

- Anxiety/anxiety-related disorders

- Obsessive-compulsive personality disorder

What are the treatment goals for anorexia nervosa?

- Weight restoration

- Nutritional rehabilitation

- Manage physical complications

- Reduce distorted body image

- Manage psychiatric comorbidities

- Prevent relapse

What are the goals of nutritional rehabilitation in anorexia nervosa?

- Normalize eating patterns

- Normalize hunger and satiety perceptions

- Gradually restore weight

- Improve mood/anxiety

- Restore gonadal function

- Restore menstruation

What is the target weight gain for hospitalized patients with anorexia nervosa?

2-3 lb/week

What is the target weight gain for outpatient anorexia treatment?

0.5-1 lb/week

What is the complication of aggressive refeeding of a severely malnourished patient?

Refeeding Syndrome

What metabolic change triggers refeeding syndrome?

Transition from a catabolic to anabolic state causes increased insulin secretion

What major electrolyte abnormality is associated with refeeding syndrome?

Hypophosphatemia

What is the primary treatment approach for anorexia nervosa?

- Psychotherapy + nutritional rehabilitation

- Pharmacotherapy is not the initial or primary treatment.

What forms of psychotherapy may be used for anorexia nervosa?

- Family-based therapy

- Group-based therapy

- Cognitive behavioral therapy

When is pharmacotherapy generally considered in anorexia nervosa?

After weight has been restored, particularly for persistent psychiatric comorbidities

Are any medications FDA approved specifically for anorexia nervosa?

No

Why should caffeine be avoided in high-risk patients with anorexia nervosa?

To reduce the risk of arrhythmias

Which antidepressant class is preferred in anorexia nervosa when medication is needed?

SSRIs, because of their tolerability and safety profile

How long may an SSRI trial be continued in anorexia nervosa before re-evaluation?

6-12 months

Is Bupropion appropriate for patients with eating disorders?

No

Why is Bupropion contraindicated in eating disorders?

Electrolyte abnormalities increase the risk of seizures

Why are tricyclic antidepressants generally avoided in anorexia nervosa?

- Anticholinergic effects

- Arrhythmia risk

When may second-generation antipsychotics be considered in anorexia nervosa?

For severe symptoms that interfere with treatment engagement

What can be used for bloating or gas in anorexia nervosa?

- Simethicone

- AVOID Metoclopramide

What can be used for constipation in anorexia nervosa?

- Osmotic laxatives

- Stool softeners

- AVOID stimulant laxatives

What medications may be used for meal-related anxiety in anorexia nervosa?

- Hydroxyzine

- Benzodiazepines before meals

What are the hallmark features of bulimia nervosa?

- Recurrent binge eating

- Compensatory behaviors

- Distorted body image

- Usually normal or overweight body habitus

What commonly triggers binge episodes in bulimia nervosa?

Dysphoric mood states

What psychiatric comorbidities are associated with bulimia nervosa?

- Depressive disorders

- Anxiety disorders

- Substance use disorders

- Impulse-control disorders

- Borderline personality disorder

What are the diagnostic criteria for bulimia nervosa?

- Recurrent episodes of binge eating

- Inappropriate compensatory behavior to prevent weight gain

- Binging + compensatory behaviors occur at least once weekly for 3 months

- Self-worth is unduly influenced by body weight and shape

What are purging compensatory behaviors in bulimia nervosa?

- Self-induced vomiting

- Misuse of diuretics

- Misuse of laxatives

- Misuse of enemas

What are non-purging compensatory behaviors in bulimia nervosa?

- Fasting

- Strict dieting

- Excessive exercise

What are other possible compensatory behaviors in bulimia nervosa?

- Misuse of thyroid medication

- Omitting insulin doses

What is Russell's sign?

Calluses or scraped areas on the knuckles caused by repeated self-induced vomiting

What dental finding is commonly associated with recurrent vomiting in bulimia nervosa?

Dental enamel erosion

What are the treatment goals for bulimia nervosa?

- Decrease binge eating

- Decrease purging

- Nutritional rehabilitation

- Treat psychiatric comorbidities

- Manage physical complications

- Prevent relapse

What psychotherapy is effective for bulimia nervosa?

Cognitive behavioral therapy (CBT)

What is the ONLY FDA-approved medication for bulimia nervosa?

Fluoxetine

What medication class is first-line pharmacotherapy for bulimia nervosa?

Antidepressants, especially SSRIs.

Can pharmacotherapy be used alone for bulimia nervosa?

It is generally used as an adjunct to psychotherapy, especially when response to psychotherapy is inadequate.

What is the target Fluoxetine dose for bulimia nervosa?

60 mg/day

What is the minimum duration fluoxetine should generally be continued when effective for bulimia nervosa?

6 months

Which antidepressant is contraindicated in bulimia nervosa?

Bupropion

What role does topiramate have in bulimia nervosa?

An alternative treatment, but not first-line.

What are important adverse effects of topiramate?

- Cognitive impairment/symptoms

- Paresthesias

- Kidney stones

Which eating disorder consists of frequent episodes of binge eating accompanied by a sense of loss of control, WITHOUT compensatory behaviors?

Binge Eating DIsorder

What is the major distinction between binge eating disorder and bulimia nervosa?

- BED = binge eating without compensatory behaviors

- Bulimia = binge eating with compensatory behaviors

What eating behaviors are commonly seen with binge eating disorder?

- Eating rapidly

- Eating until uncomfortably full

- Eating when not hungry

- Repeated history of weight gain and loss

What are the diagnostic criteria for binge eating disorder?

- Recurrent binge-eating episodes

- No compensatory behaviors

- Episodes associated with ≥3 characteristic symptoms

- Marked distress about binge eating

- Episodes occur at least once weekly for 3 months

What 5 features may accompany binge episodes in binge eating disorder?

1. Eating much more rapidly than normal

2. Eating until uncomfortably full

3. Eating large amounts despite not being hungry

4. Eating alone because of embarrassment

5. Feeling disgusted, guilty, or depressed afterward

What are the treatment goals for binge eating disorder?

- Reduce binge eating

- Nutritional rehabilitation

- Treat comorbidities

- Weight loss

What is the ONLY FDA-approved medication for binge eating disorder?

Lisdexamfetamine

What is the target Lisdexamfetamine dose for binge eating disorder?

50-70 mg/day

What are important concerns with lisdexamfetamine?

- Weight loss

- Insomnia

- Misuse potential

What antidepressant class is preferred for binge eating disorder?

SSRIs (at higher doses)