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Flashcards in Eating Disorders Part 1 Deck (34):
1

What are the 6 types of eating disorders?

  • Anorexia Nervosa
  • Bulimia Nervosa
  • Binge Eating Disorder (most common)
  • Avoidant/Restrictive Food Intake Disorder
  • Other Specified Eating Disorder
  • Unspecified Eating Disorder 

2

What are the characteristics of Anorexia Nervosa?

  • An intense pursuit of weight loss & self-induced starvation
    • Fear of becoming obese
    • Engages in dieting & excessive exercise
    • Paradoxically focused on food
  • A disturbance in body image
    • Belief they are fat even though they are thin
  • Medical signs/symptoms of starvation 

3

Anorexia Nervosa according to DSM 5

  • Removal of less than 85th percentile of IBW criteria
    • “significantly low weight”
  • Intense fear of gaining weight or behaviors that interfere w/ weight gain
  • Disturbance of how one perceives their body
  • Amenorrhea criteria removed 

4

Anorexia Nervosa 

Subtypes 

Severity (BMI)

  • Subtypes
    • Restricting type
    • Binge-eating/purging type
  • Severity (BMI)
    • BMI = weight (kg)/height (m2)
    • Mild: >17
    • Moderate: 16-16.99
    • Severe: 15-15.99
    • Extreme: <15 

5

What is the definition of binging/purging? 

  • Eating a large amt of food in a short period of time
  • Engaging in compensatory behavior to get rid of the food or weight
  • Feelings of loss of control during the episode 

6

What are the vital sign changes with starvation?

  • Hypotension
  • Bradycardia
  • Hypothermia 

7

Starvation on organ systems

  • Cardiac
  • Skeletal
  • Endocrine
  • Dermatology
  • Hematologic 
  • GI
  • Neurologic 

  • Cardiac: bradycardia, hypotension, syncope, EKG changes, arrhythmias & sudden death
  • Skeletal: Osteopenia, osteoporosis
  • Endocrine
    • Hormonal changes: decreased LH, FSH & estradiol, abnormal TSH
    • Cold intolerance, hypothermia
    • Decreased libido, amenorrhea
  • Dermatology: dry skin, alopecia, lanugo (fine baby-like hair over the body)
  • Hematologic: pancytopenia, anemia, leukopenia
  • GI: delayed gastric emptying, constipation
  • Neurologic: fatigue, weakness, reduction in brain mass volume & cognitive deterioration 

8

Epidemiology of Anorexia Nervosa 

  • Females > males (1:10)
  • Onset usually in mid-teens, increasing in pre-adolescents
  • 1% of population, 5% of the population show subclinical signs
  • Higher SCE & US vs. other developed countries, but equalizing 

9

What is the etiology of Anorexia Nervosa?

  • Multifactoral
  • Biological, psychological & social factors
  • Different for almost every patient
  • Dieting is #1 risk factor
  • From normal eating to eating disorders (picture)

10

Biological Factors of Anorexia Nervosa

Genetic

Hormonal, biochemical 

  • Genetic
    • Higher rates in monozygotic twins
    • Strong FaHx for mood disorders
  • Hormonal, biochemical & starvation effects
    • Associated w/ onset of puberty
    • Endorphin increases
    • Hypothalamic-pituitary-adrenal axis changes
    • NT: decreased NE turnover, decreased dopamine response, serotonin increases w/ food 

11

Psychological Factors of Anorexia Nervosa 

  • Temperament
  • Control Issues
  • Maturation fears
  • Independence
  • Beliefs

  • Temperament – perfectionist, harm avoidant, high-achieving
  • Control issues – feeling helpless, not able to establish autonomy
  • Maturation fears – fear of becoming an adult, being shapely or sexual
  • Demands to increase independence
    • Overwhelming, focuses on food vs. “normal” activities
  • Beliefs – moral desires are greedy/unacceptable

12

Social factors of Anorexia Nervosa 

  • Media influence
  • Obesity education
  • Family concerns about weight
  • Teasing about weight
  • Dieting information
  • Performance pressures in sports
  • Interfamily conflicts
  • Close but troubled to hostile, chaotic, isolative, controlling, not nurturing, not empathic (esp. binge-purge type) 

13

What do you need to rule out when diagnosing Anorexia Nervosa?

How is this complicated?

Lab tests?

  • Rule out
    • Brain tumor or cancer
    • Other psychiatric disorders: depression, somatization, schizophrenia, bulimia
  • Complicated by
    • Denial, secrecy
    • Disinterest or resistance to treatment
  • No laboratory tests “diagnose” AN, but for medical assessment
    • CBC, electrolytes, magnesium, phosphorus, FSH/LH/estradiol, thyroid, LFTs, amylase, UDS, specific panels (i.e. diuretics), ECG, urine pregnancy 

14

______ ______ is the most lethal psychiatric disorder

Anorexia Nervosa 

  • May require inpatient medical stabilization
  • Don’t ignore weight loss in teenage patients!

15

What are the treatment options for Anorexia Nervosa?

  • Hospitalization
  • Psychotherapy
  • Psychopharmacology

16

Hospitalization for Anorexia Nervosa 

Treatment & Goals 

  • Food is the best medicine!
  • May require hospitalization
  • If nutritionally unstable: dehydration, electrolyte abnormalities
  • Goal: reinstate nutrition, correct metabolic abnormalities, maintain structure/cooperation
  • Treatment team is KEY
  • Primary care physician, Psychiatrist, Dietician, Psychotherapist 

17

What is Refeeding Syndrome?

  • Fluid & electrolytes shift during nutritional rehabilitation
  • Risk is related to
    • Amt of weight lost during the current episode
    • Rapidity of weight restoration
  • Potentially life-threatening
    • Hypophosphatemia, delirium, arrhythmias, cardiac arrest 

18

What are the forms of psychotherapy used to treat Anorexia Nervosa?

  • Forms: family, individual & group therapy (inpatient & ED)
  • Methods
    • “Maudsley” Family Based Treatment
      • Parents play an active role in restoring weight & gradually hand over control back to the patient
    • Cognitive behavioral therapy (CBT)
      • Address cognitive distortions
    • Dialectical behavioral therapy (DBT)
      • Address treatment interfering behaviors
  • Goal: stabilize & improve primary relationships 

19

How is psychopharmacology used for Anorexia Nervosa? 

  • No medications are indicated or have consistently shown benefit for the core symptoms of anorexia nervosa
  • Medications are generally used to treat psychiatric comorbidities (depression, social phobia, OCD) 

20

What is the prognosis of Anorexia Nervosa? 

Mortality rate?

  • Good to moderate in 75% of patients
    • ¼ have complete recovery
    • ½ have overall good function despite ongoing issues
  • Some continue a waxing & waning course
  • Increased risk of poor prognosis & death
    • Persisting food obsessions
    • Complication by bulimia
    • Low albumin, very low weight
  • Mortality: 7-18% 

21

What are the characteristics of Bulimia Nervosa?

  • Episodes of overeating
  • Compensatory behavior to prevent weight gain
    • May engage in purging or excessive exercise
    • May have normal weight, by overweight or obese
  • Clinical signs/symptoms 

22

Bulimia Nervosa according to DSM 5

  • Recurrent episodes of binge eating following by inappropriate compensatory behavior in order to prevent weight gain
  • Episodes occur at least 1X/wk for 3 mo
  • Severity can be specified (based on compensatory behaviors/wk)
    • 1-3 = mild
    • 4-7 = moderate
    • 8-13 = severe
    • 14+ = extreme 

23

What are the compensatory behaviors of Bulimia Nervosa?

  • Purging 
    • Misuse of laxatives, diuretics, enemas
    • Vomiting
  • Other
    • Excessive exercise
    • Restrictive dieting
    • Skipping meals 

 

24

What are some clinical signs of Bulimia Nervosa on observation?

  • Swollen cheeks: parotid gland hypertrophy/infection
  • Metacarpal-phalangeal calluses (Russel’s signs): abrasions on knuckles from scraping against teeth
  • Dental erosions & caries: from gastric acid in the mouth
  • Front teeth that are chipped or ragged & “moth-eaten”

25

Bulimia Nervosa 

  • Labs
  • GI
  • Cardiac
  • Endocrine
  • Neuro

  • Labs: fluid & electrolyte imbalance
  • GI: GERD, esophageal varices or rupture; melanoisis coli (laxative use)
  • Cardiac: arrhythmias & myopathies
  • Endocrine: menstrual abnormalities
  • Neuro: neuropathy, fatigue, cognitive slowing, seizures 

26

What are some common lab abnormalities of Bulimia Nervosa?

  • Associated w/ vomiting & diuretic use
    • Metabolic alkalosis: low K+, low Na2+, high bicarb
    • Hypochloremia
  • Associated w/ laxative abuse
    • Hyperchloremic metabolic acidosis
    • Low K+, high chloride, low bicarb
  • Other
    • Low magnesium
    • Elevated serum amylase level, generally normal lipase level 

27

Hypokalemia in Bulimia Nervosa

  • Excessive vomiting leads to loss of K+
    • potentially lethal arrhythmias
  • If purging >3X/day refer for inpatient evaluation

28

What is the epidemiology of Bulimia Nervosa?

  • More common than Anorexia Nervosa
    • 1-3% of population
  • Onset is generally later than in AN
    • late adolescence/early adulthood
  • Surveys of college women: 20-40% report binging & purging 

29

What are the biological factors of Bulimia Nervosa?

  • Genetic
    • 1st degree relatives w/ BN or depression
  • Biochemical
    • Increased rate of mood disorders & impulse control disorders
    • More responsive to serotonin fluctuations
    • Endorphin release (reinforces vomiting) 

30

What are the psychological factors of Bulimia Nervosa? 

  • Temperament
    • Overachiever, competitive
    • Secretive, ego-dystonic, self-critical
    • Outgoing, angry, impulsive
  • Associated w/ depression, alcohol & other substance use disorders, impulse control disorders, personality disorders, emotional lability, anxiety, dissociative disorders, history of abuse 

31

What are the social factors of Bulimia Nervosa? 

  • Media influence
  • Anti-obesity education
  • Weight teasing/bullying
  • Family conflict
    • Less close, more confrontational
    • Control issues
    • Neglectful/rejecting 

32

What do you have to rule out when diagnosing Bulimia Nervosa? Lab tests?

  • Rule out
    • Neurologic disorders: seizures, tumors, Kluver-Bucy, Klein-Levin
    • Other psychiatric diagnoses, comorbidities?
  • Can be complicated by denial & secrecy but tend to seek treatment
  • No lab tests to diagnose but for medical assessment (similar to AN)

33

How is Bulimia Nervosa treated?

  • Most don’t require hospitalization
  • Most effective treatment is therapy
    • Cognitive Behavioral Therapy (CBT)
    • Dialectical Behavioral Therapy (DBT)
    • Family Therapy
    • Group Therapy (inpatient or partial hospitalization)
  • SSRI antidepressant medication have shown to be effective
    • Fluoxetine (Prozac) is the only FDA approved agent
  • Bupropion (Wellbutrin) is contraindicated b/c of increased seizure risk 

34

What is the prognosis of Bulimia Nervosa compared to Anorexia Nervosa? 

  • Higher potential for full recovery
  • If untreated, remains chronic
  • If complicated by substance use issues, poor prognosis