Flashcards in Eating Disorders Deck (32)
Case 1: 18 yo female presents with 5 mo h/o wt loss
- she began reducing the fat in her diet - lost 22 lbs and now weighs 95 lbs
- she hardly eats has a BM 4-5 days, runs 4 miles q day and does 100 sit ups, LMP was 6 mo, not sexually active
- She constantly feels cool and is dizzy upon standing, hair is dry, feels bloated after meals, she still thinks she is too large and she doesn't think she has a problem
- DSM 5 criteria?
- classic example of anorexia nervosa
- DSM-5 criteria:
restriction of energy intake relative to requirements, leading to sig. low body wt in context of age, sex, developmental trajectory and physical health
- fear of wt gain
- severe body image disturbance in which body image is predominant measure of self worth with denial of the seriousness of the illness
Subtypes of anorexia nervosa?
- restricting: restriction of intake to reduce wt
- binge eating/purging: may binge and/or purge to control wt
considered anorexic if she/he is 15% below ideal body wt
Signs and sxs of anorexia nervosa?
- dry skin
- cold intolerance
- blue hands and feet
- delayed puberty
- primary or secondary amenorrhea
- orthostatic hypotension
- lanugo hair: fine hair - body's response to malnourishment, keeping warm
- scalp hair loss
- early satiety
- weakness, fatigue
- short stature
- breast atrophy
- atrophic vaginitis
- pitting edema
- cardiac murmurs
- sinus brady
Case 2: 20 yo female - presents for eval of hematemesis - admits to self-induced vomiting for past 3 yrs, 62" tall, 140 lbs - gorges and vomits 3-5x week, uncontrollable eating binges, feels guilty, smokes 1 pack of cigs a day, gets drunk weekly - binge drinks, irregular menses, hasn't lost wt. Characteristic of? DSM-V criteria?
A. recurrent of binge eating. An episode of binge eating is characterized by both of the following:
1. eating in a discrete period of time, an amt of food that is definitely larger than what most individuals would eat
2. a sense of lack control over eating during the episode
B. recurrent inappropriate compensatory behaviors in order to prevent wt gain, such as self-induced vomiting, misuse of laxatives, diuretics, other meds, fasting, or excessive exerciese
C. binge eating and inappropriate compensatory behaviors both occur, on average at least 1x a week for 3 months
D. self eval is unduly influenced by body shape and wt
E. the disturbance doesn't occur exclusively during periods of anorexia nervosa
Signs and sxs of bulimia?
- mouth sores
- pharyngeal trauma
- dental caries
- heartburn, chest pain
- esophageal rupture
- impulsivity: stealing, ETOH abuse, drugs/tobacco
- muscle cramps
- bloody diarrhea
- bleeding or easy bruising
- irregular periods
- swollen parotid glands (from overuse)
- russell's sign: callouses on knuckles
Binge eating disorder?
- eating, in a discrete period of time, an amt of food that is larger than most people would eat in similar period
- occurs 2 days/week for 6 month duration
- assoc with lack of control and with distress over the binge eating
Binge eating disorder criteria?
must have at least 3 of 5:
- eating much more rapidly than normal
- eating until uncomfortably full
- eating large amts of food when not feeling physically hungry
- eating alone b/c of embarrassment
- feeling disgusted, depressed or very guilty about overeating
Eating disorder, NOS - DSM-5 criteria?
1. all criteria for anorexia nervosa except has regular menses
2. all criteria for anorexia except wt still in normal range
3. all criteria for bulimia except binges less than 2x a week for less than 3 months
4. pts with normal body wt who regularly engage in inappropriate compensatory behavior after eating small amts of food (self induced vomiting after eating 2 cookies)
5. a pt who repeatedly chews and spits out large amts of food without swallowing
Epidemiology of eating disorders?
- anorexia: incidence rates have increased in past 25 years, affects 1% of adolescent females, rates for men only 10% of those for women, seen in pts as young as 6
- bulimia: occurs in 1-5% of high school girls, and as high as 19% in college women
- eating disordre NOS: occurs in 3-5% of women b/t ages 15-30 in western countries, as minority culture groups assimilate into american society - rates increase
- binge eating disorder: occurs more commonly in women, depening on pop surveryed, can vary from 3%-30%
Assoc psych conditions with Eating disorders?
- anxiety disorders
- personality disorders
- substance abuse
Pathogenesis of eating disorders?
- no consensus on precise cause
- combo of psychological, biological, family, genetic, enviro and social factors
Screening tools - SCOFF questionnaire?
- do you make yourself Sick b/c you feel uncomfortably full?
- do you worry you have lost Control over how much you eat?
- have you recently lost more than 14 lbs (One stone) in a 3 month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
Screening tool - eating disorder screen for primary care (ESP)?
- are you satisfied with your eating patterns? (no is abnormal)
- do you ever eat in secret? (yes is abnormal)
- does your wt affect the way you feel about yourself? (yes is abnormal)
- have any members of your family suffered with an eating disorder? (yes is abnormal)
- do you currently suffer with or have you ever suffered in the past with an eating disorder? (yes is abnormal)
Impt hx ?s to hit?
- max ht and wt
- exercise habits: intensity, hrs/week
- stress level
- habits and behaviors: smoking, ETOH, drugs, sexual activity
- eating attitudes and behaviors
PE findings in anorexia?
- vital signs to include orthostatics
- skin and extremity eval: dryness, bruising, lanugo
- cardiac exam: bradycardia, arrhythmia, MVP (heart muscle shrinks but valves don't)
- abdominal exam
- neuro exam: eval for other causes of wt loss or vomiting (brain tumor)
PE findings in bulimia?
- all previous elements seen in anorexia plus:
parotid gland hypertrophy
erosion of the teeth enamel
Lab assessment in Eating disorders?
- CBC: anemia
- lytes, BUN/Cr
- Mg, PO4, Calcium, k+
- albumin, serum protein
- UA: specific gravity
- thyroid fxn tests
- serum prolactin
- bone density
DDx of eating disorder?
- new onset diabetes
- adrenal insufficiency
- primary depression with anorexia
- abdominal masses
- CNS lesions
Complications of eating disorder?
- fluid and lytes imbalance:
inability to concentrate urine
Complications - osteopenia? Tx?
- one of the most severe complications
- difficult to reverse
1200-1500 mg/day of elemental Ca2+
multivitamin w/ 400 IU vit D
consider estrogen/progesterone replacement
Complications - amenorrhea? Tx?
- secondary amenorrhea affects more than 90% of pts with anorexia
- caused by low levels of FSH and LH
- menses resumes w/in 6 months of achieving 90% IBW
Complications - cardiac changes? When is risk of heart failure the greatest?
- MVP: occurs in 32-60% of pts with anorexia
- long QT: one study found as many as 33% of pts:
independent marker for arrhythmia
immediate attention if pt is bradycardic and underwt as well
- risk of heart failure is greatest in first 2 weeks of refeeding: reduced cardiac contractility and refeeding edema, slow referring, repletion of K+, avoidance of Na+ intake
non pharm Tx of anorexia?
- CBT: emphasizes the relationship of thoughts and feelings to behavior
- limited efficacy
- interdisciplinary care team: medical provider, dietician with experience in eating disorders, mental health professional
med use for anorexia?
- overall, disappointing results
- effective only for tx co-morbid conditions of depression and OCD
- anxiolytics may be helpful b/f meals to suppress the anxiety assoc with eating
- case reports in the literature supporting use of olanzapine (zyprexa) - atypical antipsychotic
When should pt with anorexia be hospitalized?
- severe malnutrition (less than 75% IBW)
- lyte disturbances
- cardiac dysrhymia
- arrested growth and development
- physiologic instability
- failure of outpt tx
- acute psychiatric emergencies
- comorbid conditions that interfere with tx of the ED
Nutrition goals in anorexia tx?
- goal: regain to goal of 90-92% of IBW
- inpt tx varies by facility:
oral liquid nutrition
- NG tube feedings
- gradula caloric increase with "regular" food
- parenteral nutrition (IV feeding) rarely indicated
Outcome for pts with anorexia?
- 50% good outcome: return of menses and wt gain
- 25% intermediate outcome: some wt regained
- 25% poor outcome:
assoc with later age onset
longer duration of illness
lower min. wt
overally mortality rate: 6.6%
Bulimia - tx?
- CBT: effective
pharm: high success rate
- fluoxetine (prozac) SSRI studies reveal up to a 67% reduction in binge eating and 56% reduction in vomiting
- topiramate (topamax - antiepileptic) reduced binge eating by 94% and average wt loss of 6.2 kg
- ondansetron (zofran) 24 mg/day for nausea
***better outcome with tx than anorexia
Tx of binge eating disorder?