Transcript Eating Disorders - Civic/Riverside Units

Fazanah Khan
Eating Disorders - Overview
 Anorexia Nervosa
 Bulimia Nervosa
 Avoidant/Restrictive
Food Intake Disorder
 Binge Eating Disorder
 Pica
 Rumination
You are conducting a periodic physical for a 15 year old
male. He has no concerns and BMI is at 23. He tells you
he plays competitive soccer and is part of the school
swim team. He also goes to the gym 1-2 times a week.
While continuing with your HEADSS assessment you
would..
a) Briefly ask about having a balanced diet and any further
exercise before moving on
b) Not bother asking about diet and exercise as he’s at a
healthy weight
c) Ask specific questions using either the SCOFF or the ESP
d) …what was the previous option? Do I SCOFF at ESP…?
Sure…….”c” it is….
The SCOFF and ESP?
a) I’ve used one or both in clinical practise
before
b) I’ve heard of them, but don’t really find them
necessary in the assessment of eating
disorders
c) I’ve never used them before, but have heard
of them
d) Never heard of them
The SCOFF
 Do you make yourself Sick because you feel
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uncomfortably full?
Do you worry you have lost Control over how much you
eat?
Have you recently lost more than One stone (14 pounds
or 6.35 kg) in a three month period?
Do you believe yourself to be Fat when others say you are
too thin?
Would you say that Food dominates your life?
Eating Disorder Screen for Primary Care
 Are you satisfied with your eating patterns? (No is
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abnormal)
Does your weight 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 ever eat in secret? (Yes is abnormal)
Do you currently suffer with or have you ever suffered in
the past with an eating disorder? (Yes is abnormal)
What else should you ask about?
Risk Factors
 History of dieting in childhood
 First degree family member
with an eating disorder
 Childhood preoccupation with
weight and diet
 Childhood maltreatment
 Co-morbid psychiatric illness
(depression, OCD, anxiety,
substance addictions)
National Eating Disorder Association <http://www.nationaleatingdisorder.org>
National Eating Disorder Information Centre <http://www.nedic.ca/>
Epidemiology
 Prevalence 0.6% of adults
and 0.3% of adolescence
 bimodal age of onset: ages
13-14 due to hormonal
influences and ages 17-18
due to environmental
influences
 more common in athletic
(ballet dancers, jockeys)
and modeling occupations
for both males and females
The Alliance for Eating Disorder Awareness, 2013
DSM V Criteria
A. Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a
weight that is less than minimally normal or, for children and adolescents,
less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour
that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one's body weight or shape is
experienced, undue influence of body weight or shape on self-evaluation,
or persistent lack of recognition of the seriousness of the current low body
weight
DSM V Criteria
Restricting type: During the last three months, the individual has not
engaged in recurrent episodes of binge eating or purging behaviour
(i.e. self-induced vomiting or the misuse of laxatives, diuretics, or
enemas.) This subtype describes presentations in which weight loss is
accomplished primarily through dieting, fasting, and/or excessive
exercise.
Binge-eating/purging type: During the last three months, the
individual has engaged in recurrent episodes of binge eating or
purging behaviour (i.e. self-induced vomiting or the misuse of
laxatives, diuretics, or enemas.
DSM V Criteria
Mild: BMI ≥17 kg/m2
Moderate: BMI 16 to 16.99 kg/m2
Severe: BMI 15 to 15.99 kg/m2
Extreme: BMI <15 kg/m2
Presentation
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Amenorrhea
Cold intolerance
Hypotension (orthostatic)
Bradycardia
Arrhythmias (QTc
prolongation)
 Acute coronary syndrome
 Cardiomyopathy
 MVP
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Constipation
Lanugo hair
Alopecia
Edema
Dehydration
Peripheral neuropathy
Seizures
Hypothyroidism
Osteopenia/osteoporosis
Laboratory
 Hyponatremia
 Hypoglycemia
 Hypochloremic hypokalemic alkalosis (if vomiting)
 Hypercholesteremia
 Transaminitis
 Leukopenia
 Anemia (normocytic normochromic)
 Elevated BUN, GH and cortisol
 Reduced LH/FSH, estrogen, testosterone
Differential Diagnosis
 Medical conditions
 Psychiatric disorders
 Endocrine disorders (DM,
 MDD
hyperthyroidism)
 Bulimia
 GI illnesses
 Somatization disorder
(malabsorption, IBD)
 Schizophrenia
 Genetic disorders (Turner
syndrome, Gaucher
disease)
 Cancer
 AIDS
 Brain tumors
Ask about appetite
Comorbidities
 Anxiety disorders
 Obsessive-compulsive –
 OCD
 Body dysmorphic
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disorder
PTSD
Mood disorder
Substance use disorder
Disruptive, impulse
control and CD
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15%
Avoidant – 14%
Dependent – 7%
Narcissistic – 6%
Paranoid- 4%
Borderline – 3%
Course and Prognosis
 Chronic and relapsing illness
 10% die due to starvation or
suicide
 57 times higher than the
average individual
 poor outcomes are associated
with later age at onset, longer
duration of the illness, lower
minimal weight, lower percent
body fat after weight
restoration, and comorbidity
Treatment
 Treat as an outpatient unless they are more than
20% below ideal body weight or if there are
medical and/or psychiatric complications
 CBT, motivational interviewing and family therapy
 Supervised weight gain programs
 *Note: SSRIs not as effective in anorexia due to
inadequate dietary tryptophan
Treatment
 Nutritional Rehabilitation
 First line treatment to promote weight gain to correct
physiological effects of AN
 2 to 3 lbs per week in patient or 0.5 to 1lb per week in
patient
 1000-1600 kcal/day
 May gain weight rapidly early in process because of fluid
retention and low metabolic rate
Refeeding Syndrome
 occurs when a malnourished patient is refed to quickly
 Risk factors include: little or no energy intake for more
than 10 days, history of diuretic, laxative or insulin
misuse, hypophosphatemia or other electrolyte
abnormality prior to refeeding.
 Look for fluid retention and decreased levels of
phosphorous, magnesium, and calcium
 Complications include arrhythmias, respiratory failure,
delirium and seizures
 Replace electrolytes and slow the feeding
Follow-up Management
 Weight patient in hospital gown facing away from the
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screen after voiding at each follow-up
Daily caloric intake
Number of hours spent exercising and walking each day
Number of binge-eating and purging episodes each week
Symptomatic change can be assessed using the Eating
Disorder Examination Questionnaire (36 items; selfreport)
Case
A 21-year-old woman is brought into an outpatient clinic. Her
mother observes her to eat large amounts of food, when she is
alone. She often isolates herself in the bathroom for 10-20
minutes after a large meal.
When the patient was asked about her eating habits, she
admitted to a “loss of control.” She described feeling so laden
with guilt about her eating binges that she purposefully
induces vomiting at least once every other day for relief from
her guilt. She feels that she is “fat” and “out of shape.” She
also admits to feeling sad most days, experiencing occasional
missed menstrual periods, low libido, low energy, and
intermittent sore throat.
Case continued...
She is an only child whose parents divorced when she was 9
years old. Patient has few friends and tends to isolate herself.
However, she was valedictorian of her high school.
PE: BP - 90/60, HR - 100, and BMI is 25. Her oropharynx
appears injected without areas of erosion, and multiple dental
caries are seen. Bilateral parotid enlargement with minor
tenderness is present. The patient is tachycardic and bowel
sounds are hyperactive.
The patient is methodical about her statements, she often
takes time to clarify what she “really means.” Thought content
displays themes of shame, guilt, and self-reproach.
Labs reveal a serum potassium level of 3.8 Meq/L and serum
amylase level of 140 Units/L.
Cardiac dysfunction is one of the most
common causes of mortality in people
with bulimia
Epidemiology
 Prevalence of 2-4% in
the general population
 High incidence of
comorbid mood, anxiety
and impulse control
disorders, substance
abuse, sexual abuse and
increased prevalence of
cluster B and C
personality disorders
DSM V Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
1) Eating, in a discrete period of time (e.g. within any two-hour
period), an amount of food that is definitely larger than most
people would eat during a similar period of time and under
similar circumstances.
2) A sense of lack of control over eating during the episode (e.g. a
feeling that one cannot stop eating or control what or how much
one is eating).
B. Recurrent inappropriate compensatory behaviour to prevent weight
gain, such as self-induced vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or excessive exercise.
DSM V Criteria
C. The binge eating and inappropriate compensatory behaviours both
occur, on average, at least once a week for three months
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of
anorexia nervosa.
DSM V Criteria
Mild: An average of 1 to 3 episodes of inappropriate compensatory
behaviours per week.
Moderate: An average of 4 to 7 episodes of inappropriate
compensatory behaviours per week.
Severe: An average of 8 to 13 episodes of inappropriate
compensatory behaviours per week.
Extreme: An average of 14 or more episodes of inappropriate
compensatory behaviours per week.
Name that clinical sign!
a) Tinnel’s sign
b) Russell’s sign
c) Purging sign
d) No idea!
Name that clinical sign!
a) Chipmunk cheeks
b) Moon facies
c) Sialadenosis
d) ….?
Presentation
 Purging type
 Salivary gland enlargement
(sialadenosis)
 Dental erosion/caries
 Calluses/abrasion on dorsum
of hand (Russell’s sign)
 Aspiration
 Esophagitis
 Petechiae
 Peripheral edema
Laboratory
 Hypochloremic hypokalemia alkalosis
 Metabolic acidosis (laxative abuse)
 Elevated bicarbonate (compensation)
 Increased BUN, amylase
 Altered thyroid hormone and cortisol levels
Comorbidities
 Unipolar Major
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Depression – 50%
Specific phobia – 50%
PTSD – 45%
Social anxiety – 41%
ADHD – 35%
Alcohol abuse – 34%
ODD – 27%
CD – 27%
Illicit drug use – 26%
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Borderline e – 21%
Avoidant – 19%
Dependent – 10%
Paranoid- 10%
Histrionic – 9%
Obsessive-compulsive –
9%
Diabetes type II is 2 fold greater in
Individuals with a lifetime history
of BN
Course and Prognosis
 Chronic and relapsing
 50% have a chronic course
and the other half recovers
fully with treatment
 Good prognostic factors:
onset before age 15,
achieving healthy body
weight within 2 years of
diagnosis
Treatment
 Nutritional Rehabilitation
 CBT therapy is superior
 SSRIs are first-line and second-line pharmacotherapy
 Fluoxetine
 Citalopram, fluvoxamine, sertraline
 Third-line TCA s (desipramine, imipramine, nortriptyline),
topiramate, trazadone, or a MAOI (phenelzine)
 Buproprion is contraindicated in BN and AN since it can
lower the seizure threshold
Pre-treatment Assessment and
Follow-up
 Prior to starting pharmocotherapy clinician should assess:
 Intentions regarding pregnancy
 Frequency of binge eating and purging episodes
 Time of day that patients purges
 Concerns about body weight and shape
 Comorbid anxiety and depressive disorder
 Sexual functioning
 Psychosocial impairment
 These Baseline frequency of binging and purging provide and
index for tracking progress and should be assessed at each
follow up
During a three year old WBC your patient’s mother brings
up her concerns that her child is a very picky eater and it’s
hard to get her to eat certain foods. She constantly
refuses meats and breads. Mom states at first it was just
fruits, but now patient is getting progressively more
“picky” with her foods. If tries to eat it will throw up.
Mom notes patient is very sensitive to certain clothing
materials and can’t stand clothing tags. You review her
growth chart and notice that she has dropped from the
60th to 30th percentile in the last year.
DSM V Criteria
 Avoiding or restricting food intake, which may be
based upon lack of interest in food, the sensory
characteristics of food, or a conditioned negative
response associated with food intake following an
aversive experience (eg, choking). The eating
behaviour leads to a persistent failure to meet
nutritional and/or energy needs, manifested by at
least one of the following:
DSM V Criteria
Clinically significant weight loss, or in children, poor growth or
failure to achieve expected weight gain
Nutritional deficiency
Supplementary enteral feeding or oral nutritional supplements
are required to provide adequate intake
Impaired psychosocial functioning
DSM V Criteria
 The eating or feeding disturbance is not due to lack of
available food or associated with a culturally sanctioned
practice
 The disturbance does not occur solely in the course of AN or
BN, and body weight and shape are not distorted
 The disturbance is not due to a general medical condition (eg,
gastrointestinal disease, food allergies, or occult malignancy)
or another mental disorder. When avoidant/restrictive food
intake disorder occurs in the context of another illness, the
eating disturbance is both out of proportion to what is
expected for the other illness and warrants additional clinical
attention.
DSM V Criteria
 Recurrent episodes of binge eating
 Three or more of the following are present
 Eating very rapidly
 Eating until uncomfortably full
 Eating large amounts when not hungry
 Eating alone due to embarrassment over eating habits
 Feeling disgusted, depressed or guilty after overeating
 Episodes occur, on average, at last once a week for 3 months
 No regular use of compensatory behaviours
 Does not occur solely during the course of BN on AN
DSM V Criteria
 Repeated eating on non-food substances that are not
nutritional, for at least one month
 The eating behaviour is inappropriate to the patient’s
developmental level, and is not culturally supported or
socially normal
 If the eating behaviour occurs in the context of another
mental disorder or general medical condition (including
pregnancy), the severity of the eating behaviour warrants
additional clinical attention
DSM V Criteria
 Repeated regurgitation of food, which may be rechewed,
reswallowed, or spit out; the eating disturbance occurs
for at least one month
 Regurgitation of food is not due to a general medical
condition (like GERD or pyloric stenosis)
 Regurgitation does not occur solely during
avoidant/restrictive food intake disorder, AN, BED, or BN
 If the eating behaviour occurs in the context of another
mental disorder or general medical condition (including
pregnancy), the severity of the eating behaviour warrants
additional clinical attention
Hospitalization Criteria
Medically Unstable (HR <50, hypotensive, dehydration etc.)
Suicidality
Weight <85% of normal or rapid decline
Refusing food or treatment
Take home points
 Treatment of eating disorders is multidisciplinary and
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requires dietician, psychiatry, psychologist and family
physicians
Mainstays of treatment for long-term effect usually are
motivational therapy, CBT, family therapy
Remember to screen your adolescence for eating
disorders at periodic physicals
Suspect eating disorders when work-up for physical
symptoms come back negative
Remember to check weight and quantify eating habits for
follow up care
Objectives 1 to 6
completed!!!
Resources
National Eating Disorders: <nationaleatingdisorders.org>
2. Centre for Eating Disorders and Dieting
<http://cedd.org.au/health-professionals/test-healthprofessionals-clinical-resources-tools/test-healthprofessionals-treatment/test-health-professionalstreatment-tips-facts/>
3. National Eating Disorder Information Centre
<http://www.nedic.ca/>
1.
References
1.
Black, D.W. And Andreasen, N.C. (2011). Introductory textbook of psychiatry. 5th
edition. American Psychiatric publishing, Washington. pp (343-357)
2.
Chen, A.A., and Tran, C. (2011). Toronto Notes. 27th edition. Toronto Notes for Medical
Students, Toronto. pp (PS29-PS31)
3.
Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening
tool for eating disorders. BMJ. Dec 4 1999;319(7223):1467-8
4.
Osterhou, C.I. (2011). Bulimia Nervosa Clinical Presentation. Retrieved from
<http://emedicine.medscape.com/article/286485-clinical>
5.
Stead, L.G., Kaufman, M.S., and Yanofski, J. (2011). First Aid for the psychiatry
clerkship. 3rd edition. McGraw-Hill Medical, New York. pp (146-151)
6.
Waldrop, R.D. (2011). Emergent Management of Anorexia Nervosa Clinical
Presentation. Retrieved from http://emedicine.medscape.com/article/805152-clinical
UptoDate
7.