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Flashcards in Eating Disorders Deck (62):
1

three main features of anorexia

1. an intense pursuit of weight loss & self-induced starvation

- fear of becoming obese
- engages in dieting and excessive exercise
- paradoxically focused on food

2 a disturbance in body image: belief they are fat even though they are thin

3. medical signs/symptoms of starvation 

2

DSM IV version of anorexia

Weight loss to less than 85% of ideal body weight or failure to make expected weight gains in children and adolescents

Intense fear of gaining weight

Disturbance in how one perceives their body

Amenorrhea for 3 months in post-menarcheal females 

3

DSM 5 changes to Anorexia 

Removal of less than 85 percentile of IBW criteria -> “significantly low weight”

Intense fear of gaining weight or behaviors that interfere with weight gain

Disturbance in how one perceives their body 

4

Two subtypes of anorexia

• Restricting Type
• Binge-eating/purging type 

5

What are the different levels of severity of anorexia

• Mild: BMI >17
• Moderate: 16-16.99

• Severe: 15-15.99
• Extreme: <15 

6

• Eating a large amount 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 

Binge/Purge 

7

What vital sign changes do we see as physiological effects of starvation?

 • Hypotension

• Bradycardia

• Hypothermia 

8

Effect of heart, skeletal, endocrine from anorexia

• 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 

9

Skin/GI/Heme/Neuro changes with anorexia

• Dermatology: Dry skin, alopecia, lanugo (fine baby-like hair over the body)

• Hematologic: Pancytopenia - anemia, leucopenia

• Gastrointestinal: Delayed gastric emptying, constipation

• Neurologic: Fatigue, weakness, reduction in brain mass volume & cognitive deterioration 

10

Epidemiology of Anorexia nervosa

• Females > males, 1:10

• Onset is usually in the mid-teens, increasing in preadolescents

• 1% of the population, with 5% of the population showing subclinical signs

• Higher socioeconomic status and US versus other developed countries, but equalizing 

11

Etiology of anorexia nervosa, #1 risk factor

• Multifactorial
• Biological, psychological and social factors

• Different for almost every patient

• Dieting is the #1 Risk factor 

12

Steps to food disorders

Food/body acceptance--> Food/body obssessed--> disordered eating --> eating disordres: anorexia, bulimia, binge eating disorder

13

What genetc factors play a role in eating disorders?

Genetic:
• Higher rates in monozygotic twins
• Strong family history for mood disorders 

14

What hormonal changes are seen with disordered eating?

Hormonal, biochemical and starvation effects

associated with onset of puberty

endorphin increases

hypothalamic-pituitary-adrenal axis changes

neurotransmitter: decreased norepinephrine turnover, decreased dopamine response, serotonin increases with food 

15

Psychological Factors in eating disorders

 

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 versus “normal” activities

Beliefs: moral desires are greedy/unacceptable 

16

What social factors have a role in eating disorders?

• Media influence
• Obesity education
• Family concerns about weight
• Teasing about weight
• Dieting information
• Performance pressures in sports 

17

Key DDX to consider before dx with eating disorder

• Rule out
• Brain tumor or cancer
• Other psychiatric disorders: depression, somatization, schizophrenia, bulimia 

18

Complications of AN and how we can use Labs to support Dx

• 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 

19

is the most lethal psychiatric disorder

May require inpatient medical stabilization

Key point: Don’t ignore weight loss
in teenage patients! 

Anorexia Nervosa (AN) 

20

Treatment for severe AN

• 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 

21

What is Refeeding syndrome

• Fluid and electrolytes shift during nutritional rehabilitation

• Risk is related to: amount of weight lost during the current episode , rapidity of weight restoration

• Potentially life-threatening
Hypophosphatemia, delirium, arrhythmias and cardiac arrest 

22

What types of pyschotherapy are available to tx AN

• “Maudsley” Family Based Treatment:parents play an active role in restoring weight and 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 and improve primary relationships 

23

What type of pharmacology is available for AN tx?

• 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 

24

25

Prognosis for AN

• Good to moderate in 75% of patients
• 1⁄4 have a complete recovery
• 1⁄2 have overall good function despite ongoing issues

Some continue a waxing and waning course

• Increased risk of poor prognosis and death :persisting food obsessions,  complicated by bulimia,  low albumin, very low weight

• Mortality: 7-18% 

26

Characteristics of Bulemina nervosa

1. episodes of overeating

2. compensatory behavior to prevent weight gain - may engage in purging or excessive exercise
- may have normal weight, be overweight or obese

3. clinical signs/symptoms 

27

DSM IV criteria for bulemia nervosa

Recurrent episodes of binge eating followed by inappropriate compensatory behavior in order to prevent weight gain

Episodes occur at least twice a week for 3 months

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa 

28

Subtypes of bulemia

Subtypes
• Purging type

• Nonpurging type 

29

 DSM 5 for bulemia nervosa

Recurrent episodes of binge eating

Recurrent inappropriate compensatory behavior in order to prevent weight gain

Episodes of A and B occur at least once a week for 3 months

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during anorexia nervosa 

30

What changes were made to the DSM 5 for bulemia nervosa

• Subtypes were removed
• Severity can be specified: based on number of compensatory behaviors episodes per week

• 1-3 = mild
• 4-7 = moderate
• 8-13 = severe

• 14+ = extreme 

31

What are some compensatory behaviors seen in bulemia?

• Purging
• Misuse of laxatives, diuretics, enemas

• Vomiting

• Other
• Excessive exercise • Restrictive dieting • Skipping meals 

32

What are some observational signs of bulemia nervosa?

• Swollen cheeks: parotid gland hypertrophy or infection

• Metacarpal-phalangeal calluses (Russel’s signs): abrasions on knuckles from scraping against teeth

• Dental erosions and caries: from gastric acid in the mouth • Front teeth that are chipped or ragged and “moth-eaten” 

33

What physiologic changes do we see from bulemia nervosa?

Labs: fluid and electrolyte imbalance

GI: GERD, esophageal varices or rupture; melanoisis coli (laxative use)

Cardiac: arrhythmias and myopathies

Endocrine: menstrual abnormalities

Neuro: neuropathy, fatigue, cognitive slowing, seizures 

34

• Metabolic alkalosis: low potassium, low sodium, high bicarb

• Hypochloremia 

• Associated with vomiting and diuretic use:

35

Hyperchloremic metabolic acidosis: low potassium, high chloride, low bicarb 

Associated with laxative abuse:

36

How does bulemia lead to Hypokalemia?

Hypokalemia

• Excessive vomiting leads to loss of potassium-->potentially lethal arrhythmias

• If purging more than 3 times/day refer for inpatient evaluation 

37

Epidemiology of Bulemia Nervosa

• More common than Anorexia Nervosa 1% to > 3% of the population

• Onset is generally later than in AN: Late adolescence/early adulthood

• Surveys of college women found up to 20-40% report binging and purging 

38

Genetic and biochemical factors of Bulemia Nervosa

• Genetic: First degree relatives with BN or depression

• Biochemica:  Increased rate of mood disorders and impulse control disorders,  More responsive to serotonin fluctuations
• Endorphin release (reinforces vomiting) 

39

Common temperments seen in Bulemia Nervosa

• overachiever, competitive
• secretive, ego dystonic, self-critical • outgoing, angry, impulsive 

40

What types of pysch disorders is Bulemia Nervosa associated with?

Associated with depression, alcohol and other substance use disorders, impulse control disorders, personality disorders, emotional lability, anxiety, dissociative disorders, history of abuse 

41

Social and famliy factors that affect Bulemia Nervosa

• Media influence:  Anti-obesity education , Weight teasing/bullying

• Family conflict
• less close, more confrontational • control issues• neglectful/rejecting 

42

Key to consider when Dx bulemia

• Neurologic disorders: seizures, tumors, Kluver-Bucy, Klein-Levin • Other psychiatric diagnoses, comorbidities?

• Can be complicated by: denial & secrecy but tend to seek treatment

• No laboratory tests to diagnose, but for medical assessment (similar to AN) 

43

Most effective tx for bulemia nervosa

 

• Most do not require hospitalization

• Most effective treatment is therapy • Cognitive Behavioral Therapy (CBT)
• Dialectical Behavioral Therapy (DBT)
• Family therapy

• Group therapy (particularly inpatient or partial hospitalization) 

44

Pharm tx for bulemia nervosa

• SSRI antidepressant medication have shown to be effective

• Fluoxetine (Prozac) is the only FDA approved agent
Bupropion (Wellbutrin) is contraindicated because of increased seizure risk 

45

Prognosis of bulemia compared to AN

 

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

46

How is binge eatig disorder simular to bulemina nervosa?

• Similar features to BN:
• Recurrent episodes of binge eating
• Marked distress regarding eating binge eating

• Occurs once per week for 3 months
• Same severity scale as bulimia nervosa

 

47

What are distinguishing features of binge eating compared to bulemia nervosa

• Not associated with recurrent use of inappropriate compensatory behavior

• Not exclusively during BN or AN 

48

How is Avoidant/Restrictive Food Intake Disorder have Similar features to AN

Persistent failure to meet appropriate nutritional/energy needs

Not better explained by lack of food or cultural practice

Not attributable to a concurrent medical condition or other mental disorder, or beyond what one would expect for another condition/disorder 

49

What distinguishes Avoidant disorder from AN

Not associated with a disturbance in the way one’s body weight/shape is experienced

Not part of AN or BN 

50

What is the definition of Obesity

• Obesity:

• weighing >20% ideal body weight (IBW) or having a body mass index (BMI) of 30+

• Overweight: BMI 25-29.9 

51

Epidemiology of obesity in children and adults

• US Adults:

Upwards of 2/3 of US adults are considered overweight/obese

>1/3 of US adults are obese

• Children:

rates in children who are overweight/obese were increasing for many years, but arel eveling off and decreasing for very young children (<5)

25% preschool & 35% school-aged children are overweight/obese 

52

Etiology of obesity

Balance energy IN > energy OUT

• Environmental

• Increased availability of high calorie foods

• Decreased requirement for physical activity
• 78% Americans don’t meet activity level requirements; 25% are completely sedentary 

53

Genetic, biological and pyschosocial factors of obesity

• Genetic: identical twins have the greatest risk
• Biological: set point/satiety, development, medical issues, medications

• Psychological/Social: culture, family habits, psychiatric comorbidity (i.e. binge-eating disorder), low socioeconomic status 

54

Risks associated with obesity

Cardiovascular: diabetes type 2, hypertension, coronary artery disease, stroke, cardiovascular death**Cancer***Depression, quality of life

Reproduction and sexual function

Lung function: respiratory disease, asthma, obstructive sleep apnea

Memory/cognitive function: Alzheimer’s disease

Musculoskeletal: osteoarthritis, hip replacement, chronic back/limb pain

Other: gallstones, gout, kidney, fatty liver, mortality 

55

Treatment options for obesity

• Commercial dieting and weight loss programs: regain weight in 5 years

• Bariatric surgery
• including banding, gastrectomy, gastric Bypass
• for BMI >40 or >35 with life-threatening condition
• initially effective, but questionable regarding long-term weight loss

• Pharmacologic agents: variably efficacy and safety • Sensible diet and exercise 

56

pancreatic lipase inhibitor limits breakdown of dietary fats

5-10lb weight loss in first 6 months, maintained at 24mo 

• Orlistat (Xenical and Alli)

57

• symapthomimetic amine that decreases appetite 

 

• Phentermine (lonamin)

58

gold Standard for weight loss

Obesity: Gold Standard

Sensible diet and exercise: calorie intake

most effective way to maintain long-term weight loss 

59

REasonable weight loss in adults

5-10 % loss of initial body weight over 6 months or 1-2 pound weight loss per week

• cutting back calorie intake by 500-1000 calories/day

• Women: total 1000-1200 calories/day
• Men or women who exercise routine: 1200-1600 

**After 10% body weight lost and kept off for 6 months, consider further weight loss if still overweight 

60

Weight loss for children and teens

• Children and teens:
• Initial goal: maintain weight or slow weight gain by healthy eating and physical activity

• Obesity: maintenance for 3 months, then slow weight loss

• Slower weight loss than with adults: from 1 lb/mo
• Half weight loss from diet, half from exercise 

61

What are reasonable changes we can make to lose weight

• Diet: limit portion size, cut out second helpings, limit high calorie foods, high sugar, sugar additives, fast food, high fat

• Behavioral modification (MOST SUCCESSFUL): recognize external cues, keep food diary, develop new eating patterns (i.e. eat slowly, chew food well, stay seated, etc.), use rewards/reinforcements

• Group therapy 

62

Reasonalbe physical activity for weight loss

• Needs/options vary

• Example: 150 minutes of moderate-intensity aerobic activity weekly and muscle-strengthening activities 2+ days/week; or shorter duration, with more vigorous activity

• If with a heart problem, chronic disease, or having chest pain or dizziness, seek medical advice