Eating Disorders

List the Presenting Complaints of Patients with Eating Disorders

• Obsession w/ dieting/thinness

• Fatigue, inability to exercise, or other sequelae of malnutrition

• Uncontrolled binge eating and/or purging 

• Symptoms of depression

• Functional impairment (inability to focus)

• Family/marital discord related to eating

• Dental erosion or salivary gland enlargement 

• Desire to lose weight despite being normal/low weight 

• Other:

  • Weakness, 

  • light-headedness,

  • amenorrhea, 

  • bloating, 

  • Abdominal discomfort, 

  • blood in vomitus

List the factors contributing to eating disorders:

• Biochemical

• Familial

• Psychological

Biochemical Factors

• Imaging studies

  • Reduced brain volumes (AN and BN)

  • Frontal cortex 

    • Hypometabolism before eating 

    • Hyperarousal after eating (AN)

  • Hyperactivity 

    • caudate, 

    • temporal cortex,

    • lentiform nucleus

    • brain stem (AN)

  • Loss of symmetry of frontal and prefrontal areas (BN)

• Reduced brain serotonin transporter activity

• Decreased Serotonin + impaired secretion of cholecystokinin in response to meal 

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Familial factors

• Family members of patients with anorexia and bulimia nervosa have a 10 to 20 fold likelihood of having the disorders

• Twin studies: Monozygotic 55%, dizygotic 5%

• More likely in families with obese members

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Psychological factors

• Cognitive distortions about self Perfectionism

• “Black and white” thinking

• Childhood anxiety disorder

• Significant comorbidity w/ personality disorders

• Calorie labeling on foods 

List the Lab. Findings of:

• Anorexia nervosa

• BULIMIA NERVOSA

Laboratory Findings

ANOREXIA NERVOSA

• Leukopenia

• Elevated BUN

• Elevated liver function tests (AST,ALT)

• Hyponatremia

• Hypokalemia

• Low estradiol

• Low LH and FSH

• GFR may decline over time

• High cortisol

• High growth hormone

• Low triiodothyronine,

• high reverse

• triiodothyronine

• Head CT: mild atrophy

• and increased

• ventricle/brain ratio

• EKG: sinus bradycardia,

• rarely prolonged QT

• interval

• Bone scan: osteoporosis

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BULIMIA NERVOSA

• Hypokalemia

• Hyponatremia

• Hypochloremia

• Hypomagnesemia

• Elevated serum amylase

• Metabolic alkalosis

• Metabolic acidosis (laxative abuse)

List the Psychological Findings of:

• Anorexia

• Bulimia

ANOREXIA NERVOSA

• Alertness:

  • Early: alert and cheerful

  • Later: sad and withdrawn

• Rigid thinking

• controlling and manipulative

• Often deny illness or intellectualization

• Absolute thinking

• Socially isolative and hyposexual

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BULIMIA NERVOSA

• Superficially sociable

• Low self-esteem

• Conflicts with intimacy

• Difficulty managing anger

• Preoccupied with control over eating

• May have other impulsive behaviors

List the APA Guideline for Treating Eating Disorders

APA Guideline for Treating Eating Disorders

• Screen for eating disorders during initial psychiatric evaluation

  • Weight

  • Eating behaviors and weight control behaviors

  • Co-occurring medical and psychiatric conditions

  • Review of systems

• PE 

  • General appearance

  • Vital signs and orthostatic pulse

  • Height/weight/BMI

• Labs:

  • CBC

  • CMP

• EKG’s 

  • Known to have prolonged QTc

Describe Anorexia Nervosa

• Dx criteria

• Subtypes

• Risk Factors

• Comorbidity

• DDX

• Tx

Dx criteria:

• Restriction of Calories -> Clinically sig. Low body weight 

• Fear of gaining weight or becoming fat; even though currently underweight

• Disturbance in perception of body’s weight/shape Or Denial of underweight’s seriousness

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Subtypes:

• Restricting Type

  • During last 3 months; person not binge-eating/purging

• Binge-Eating/Purging Type

  • During last 3 months; person regularly binge-eating/purging

  • NOTE: often progressed from Restricting

• Based on BMI:

  • Mild: BMI at least 17 kg/m sq

  • Moderate: BMI 16-16.99 kg/m sq

  • Severe: BMI 15-15.99 kg/m sq

  • Extreme: BMI less than 15 kg/m sq

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Risk Factors

• History of trauma

• Living in society that values thinness

• In utero exposure to rubella 

• Multiple birth and preterm birth 

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Comorbidity

• MDD

• Lifetime depression: 

• Lifetime anxiety disorder: 

  • MC OCD and Social Phobia

• Substance abuse: 

  • especially stimulants 

• Personality Disorders:

  • Cluster B: 

  • Cluster C:

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DDX:

• Superior mesenteric artery syndrome

• Celiac disease

• Inflammatory bowel disease

• Bowel adenocarcinoma

• Intestinal motility disorders

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Treatment

• Inpatient behavior management:

  • Diet designed to gain weight:

    • Goal: 90% normal

    • Typically 1200 kcal/d to avoid refeeding syndrome

  • Nutritional counseling

  • Management of Bone Loss

  • Eating autonomy gradually shifted back to pt

• Pharmacotherapy

  • Usually directed at comorbid conditions

  • fluoxetine, duloxetine, second generation antipsychotics, dronabinol, oxytocin

• Psychotherapy

  • CBT, interpersonal; psychodynamic; Family therapy

Describe WEIGHT RESTORATION Treatment:

• Goals

• When is Higher level of care needed? Factors for less relapse/readmission?

• Method

Describe Refeeding Syndrome:

• Occurrence

• Symptoms

• Prevention

WEIGHT RESTORATION

• Goals:

  • Outpatient: 1 to 2 Ibs

  • Intensive outpatient: 1 to 2 Ibs

  • Partial hospital: 1 to 3 Ibs

  • Residential: 2 to 4 Ibs

  • Inpatient: 2 to 4 Ibs

• Higher level of care needed when:

  • no progress after 6 weeks of treatment 

• Factors for less relapse/readmission:

  • The closer pt is to target before discharge

  • If Pt maintain weight for a period of time before discharged

• Method:

  • 1,500-2,000 kcal/day, -> 3,000-4,000 kcal/day (rapidly)

    • Formulas for calculating calories = underestimate b/c pt’s = hypermetabolic

  • Involve registered dieticians

  • Increase dietary variety.

  • Meal-based nutrition > tube feeding

    • Calorie dense liquid supplements can be given in between meals

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Refeeding Syndrome:

• Occurance:

  • Recent rapid weight loss + low BMI

• Symptoms:

  • Main:

    • Hypophosphatemia 

  • Less common:

    • Rhabdomyolysis

    • Seizure

    • Severe Edema -> Heart Failure 

• Prevention:

  • Continuing adequate nutrition;

  • Examining pt for signs of heart failure;

  • Monitoring lab values

    • (e.g., glucose and electrolytes including magnesium and phosphorous);

  • Replacing phosphorous orally when clinically indicated.

Describe these AN Treatments:

• Acceptance and Commitment Therapy

  • Method?

• List the efficient Psychotherapy Tech:

• Describe FAMILY-BASED TREATMENT IN ADOLESCENTS AND EMERGING ADULTS

  • Philosophy

  • Method

Acceptance and Commitment Therapy

Method:

• Help pt 

  • understand relationship btw internal urges/symptoms

  • understand that Identity not defined by thoughts of themselves

  • define recovery

• Instill:

  • Thoughts are not facts

  • Mindfulness 

• Have goals/Monitoring

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Psychotherapy Tech:

• CBT

• Focal psychodynamic psychotherapy (FPT)

• Interpersonal therapy (IP T)

• Maudsley Model of Anorexia Nervosa Treatment for Adults

  • (MANTRA)

• Specialist Supportive Clinical Management (SSCM)

• Experienced Carers Helping Others (ECHO)

  • aimed at supporting carers of patients with AN but can also contribute to improved outcomes.

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FAMILY-BASED TREATMENT IN ADOLESCENTS AND EMERGING ADULTS

• Philosophy:

  • considers effects of severe weight loss as being central to the core psychology of AN

• Method:

  • Parents oversee and take responsibility for nourishing pt 

  • Therapist = knowledge expert and facilitator.

• NOTE:

  • Not limited to family members; could involve other non- family caregivers with whom the patient resides

When to hospitalize AN?

When to hospitalize AN

• BMI 15 kg/ m sq or less (under 13 very high risk)

• Greater than 30 BPM increase in orthostatic HR (40 BPM in children)

• Greater than 20 mm drop in orthostatic sBP

• Greater than 10% weight loss in 6 months or 20% in past year

• Bradycardia (<50 BPM) or arrhythmia

• Blood pressure <90/60 adults, adolescents 90/45

• Severe hematemesis

• Severe neutropenia or thrombocytopenia

• Severe hypokalemia (<3 mEq/L)

• Hypophosphatemia or hypomagnesemia

• Uncontrolled type I diabetes or glucose <60 mg/dL

• Temp <96.8 F

• QTc >450

• Acute medical complications or physiologic consequence

Describe Atypical anorexia nervosa

• What is it?

Atypical anorexia nervosa

What is it?

• All AN Criteria are met + pt experience associated physiological complications 

  • BUT: Individual = w/in normal or above normal weight

NOTE:

• Little is known about the course or response to treatment of this condition

Describe Bulimia Nervosa

• Dx Criterai

• Physician instruction if there is purging

• Tx

Dx Criteria:

• Recurrent episodes of Binge eating; defined by both:

  • Eating # of food > than most people would eat 

    • during similar discrete period of time and circumstances

  • Lack of control over eating during episode

• Recurrent inappropriate compensatory behavior

  • Vomiting; Lax misuse; diuretics, enemas, fasting; or excessive exercise

• Both occurs once a week for 3 months

• Self-eval = unduly influenced by body shape/weight

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Physician instructions if there is purging:

• Refer for a dental evaluation.

• Instruct patients not to brush teeth after vomiting.

• Oral rinsing with water after vomiting and avoiding ingestion of carbonated beverages or citrus fruits may help to reduce effects on dentition

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Treatment

• outpatient

• Nutritional counseling

• Psychotherapy

  • develop a better integrated view of herself

• Pharmacotherapy

  • SSRI’s, MAOI’s, atypical antidepressants

Describe these treatment for BN:

• NUTRITIONAL INTAKE

  • Why assess?

  • Method:

• CBT AND SSRI TREATMENT FOR ADULTS

  • Method

  • Rationale

• FAMILY-BASED TREATMENT IN ADOLESCENTS AND EMERGING ADULTS,

  • Method

NUTRITIONAL INTAKE

• Why assess?

  • Normal body weight or BMI does not imply appropriate nutritional intake

• Method:

  • Structured meal plan 

    • Can reduce episodes of restriction + binge/purge urges

  • Cooperate w/ dietitian 

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CBT AND SSRI TREATMENT FOR ADULTS

• Method:

  • CBT

    • eating disorder-focused 

  • SSRI

    • fluoxetine 

• Rationale:

  • Greater binge/purge abstinence/reduction

  • Also good for depression

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FAMILY-BASED TREATMENT IN ADOLESCENTS AND EMERGING ADULTS,

• Method:

  • Similar to AN but more focus on:

    •  secrecy, shame, and dysfunctional eating patterns

Describe Binge Eating Disorder

• Dx criteria

• Assessment Tools

• Tx

Dx Criteria:

• Recurrent episodes of binge eating

• Episodes associated w/ 3:

  • Eating more rapidly than normal

  • Continuing to eat until uncomfortable

  • Eating large amount despite lack of hunger

  • Reluctantancy eating  w/ others b/c embarrassment

  • Afterward: Guilty, depressed, disgusted 

• At least once a week for at least 3 months

• Not accompanied by compensatory behaviors 

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Assessment Tools

• Eating Disorder Examination-Questionnaire (EDE-Q)

• Questionnaire for Eating and Weight Patterns- Revised (QEWP-R)

• Eating Disorder Diagnostic Scale (EDDS)

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Treatment

• Cognitive-behavioral therapy

  • Correct maladaptive cognitions

  • Remission 50-70%

• Interpersonal therapy

  • Identifying interpersonal problems that contribute 

  • Make changes to relationships

  • Prepare for future interpersonal problems

• Pharmacotherapy

  • SSRI’s

    • Effective but long-term data unavailable

  • Opioid antagonists?

• CBT>SSRI but combo best

• Bariatric Surgery

  • Should have behavioral or psychotherapy first

  • procedure takes away coping mech

1. List the Bed meds we can use

   1. Lit; Specific Types

   2. Benefits; Dosage

   3. Caution

BED Meds

Antidepressants

• Literature:

  • Some benefit to meds alone

  • Generally no weight changes

• Specific types:

  • TCA + MAO = less used due to AE profile

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Lisdexamfetamine

• Benefits:

  • Generally, well tolerated.

• Dosage:

  • Normal = Dosage adjustment (increase)

  • Hepatic dysfunction = no Adj

  • Renal Impairment = Lower Dosage 

• Caution:

  • Pt w/ hypertension or cardiac disease.

Describe Avoidant/Restrictive Food Intake Disorder

• Dx criteria

• Avoidance due to?

• Tx

Dx Criteria:

• Feeding/eating disturbance associated w/ inadequate intake + 1

  • Significant weight loss

  • Significant nutritional deficiency

  • Dependence on enteral feeding or oral nutritional supplements

  • Marked interference with the individual’s social and psychological functioning

• Inadequate intake = NOT:

  • Lack of food or cultural sanctioned practace

• No disturbed Body image

• Not due to medical Problem

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Avoidance of food usually due to:

• Fear of negative consequences of eating 

  • N/V (MC)

  • abdominal pain

• Low appetite or disinterest in food

• Based on sensory characteristics such as taste, texture or smell (picky eaters)

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Treatment

• Family-based therapy

  • Lifting blame

  • Raising family’s anxiety about dangers of low weight and malnutrition in young people

  • Empowering parents to take charge of nutrition and focus on the goal of weight gain

• CBT

What is Pica

Dx Criteria:

• Persistent eating of nonnutritive, nonfood substances

  • Inappropriate to dev. Level

  • Not culturally/socially supported

• over a period of at least 1 month

Describe Rumination Disorder

• Dx criteria

• Med. Complications

• Tx

Rumination Disorder

• Dx Criteria:

  • Regurgitation of food over a period of at least one month

  • Can’t be part of AN/BN or other

• Medical complications 

  • Malnutrition,

  •  dehydration, 

  • Esophageal ulceration, 

  • tooth decay

• Tx:

  • Maybe Negative reinforcement or reward

Describe Deliberate Foreign Body Ingestion (DFBI)

• Associated w/

• Subgroups

• Tx

Deliberate Foreign Body Ingestion (DFBI)

• Associated with:

  • Male gender

  • Incarceration (2% of inmates)

  • History of substance abuse

  • Psychiatric disorders

• Four psychiatric disorder subgroups:

  • Malingering

  • Psychosis

  • Pica

  • Personality disorders

• Management

  • Safe environment

  • Manage surgical and medical needs 

  • Work toward reducing frequency 

  • Manage the countertransference of the treatment team

  • Address issues of the environment the patient returns to