Transcript Diagnostic Criteria

Eating Disorders
From a Psychiatrists Perspective: Diagnostic and
Treatment Considerations
Preferred Provider Conference
Sunday, January 31st
Anna Jurec, M.D.
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.com
[email protected]
Anorexia Bulimia
Diagnostic Criteria
Case 1
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The refusal to maintain body weight at or above a
minimally normal weight for age and height.
Maintaining a body weight less than 85% of the expected
weight.
An intense fear of gaining weight or becoming fat, even
though the person is underweight
Self-perception that is grossly distorted, excessive
emphasis on body weight in self-assessment, and weight
loss that is either minimized or not acknowledged
completely.
In women who have already begun their menstrual cycle,
at least three consecutive periods are missed
(amenorrhea), or menstrual periods occur only after a
hormone is administered
The DSM-IV-TR further identifies two subtypes of
anorexia nervosa. In the binge-eating/purging type, the
individual regularly engages in binge eating or purging
behavior which involves self-induced vomiting or the
misuse of laxatives, diuretics, or enemas during the
current episode of anorexia. In the restricting type, the
individual severely restricts food intake but does not
regularly engage in the behaviors seen in the bingeeating type.
23 YO female with 64% IBW reports inability
to maintain healthy weight because of severe
preoccupation with food, its taste and “its
justification” for weight restoration. She also
describes intrusive fear that food, mainly its taste
which she fears might be contaminated with
soap, perfume, lotion, cleaning agents, etc.
She compulsively evaluates its taste, brushes
teeth compulsively, washes her lips, hands etc to
create safe environment for consumption.
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Obsessive Compulsive Disorder
Diagnostic criteria
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The individual expresses either obsessions or compulsions
At some point during the course of the disorder, the person
recognizes that the obsessions or compulsions are excessive or
unreasonable. This does not apply to children.
The obsessions or compulsions cause marked distress; are time
consuming (take >1 h/d); or significantly interfere with the
person's normal routine, occupational or academic functioning,
or usual social activities or relationships.
If another Axis I disorder is present, the content of the
obsessions or compulsions is not restricted to it, such as
preoccupation with food and weight in the presence of an
eating disorder, hair pulling in the presence of
trichotillomania, concern with appearance in body dysmorphic
disorder, preoccupation with drugs in substance use disorder,
preoccupation with having a serious illness in
hypochondriasis, preoccupation with sexual urges in
paraphilia, or guilty ruminations in the presence of major
depressive disorder.
The disorder is not due to the direct physiologic effects of a
substance or a general medical condition.
The additional specification of "with poor insight" is made if,
for most of the current episode, the person does not recognize
that the symptoms are excessive or unreasonable.
Obsessions are defined by the following 4 criteria.
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Recurrent and persistent thoughts, impulses, or images are
experienced at some time during the disturbance as
intrusive and inappropriate and cause marked anxiety and
distress. Those with this disorder recognize the craziness
of these unwanted thoughts (such as fears of hurting their
children) and would not act on them, but the thoughts are
very disturbing and difficult to tell others about.
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The thoughts, impulses, or images are not simply
excessive worries about real-life problems.
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The person attempts to suppress or ignore such thoughts,
impulses, or images or to neutralize them with some other
thought or action.
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The person recognizes that the obsessional thoughts,
impulses, or images are a product of his/her own mind
(not imposed from without, as in thought insertion).
Compulsions are defined by the following 2 criteria:
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The person performs repetitive behaviors (e.g., hand
washing, ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) in response to an
obsession or according to rules that must be applied
rigidly.
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The behaviors or mental acts are aimed at preventing or
reducing distress or preventing some dreaded event or
situation; however, these behaviors or mental acts either
are not connected in a realistic way with what they are
meant to neutralize or prevent or they are clearly
excessive
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Treatment
Medical complications
Psychiatric complications
• Potential for electrolyte imbalance
• Nutritional deficiencies(vitamin,
mineral, protein etc.)
• Cardiovascular(bradycardia,
hypotension)
• Amenorrhea
• Risk of refeeding syndrome
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Depression
Suicidality
Cognitive impairment
Anxiety
Risk of adverse reactions to
medication
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Treatment, cont.
Medical goals:
Psychiatric goals:
• Restoration and maintenance of
an appropriate nutritional status
• Close monitoring for reemergence
of Refeeding Syndrome
• Decreasing long term health risks
associated with Anorexia
• Decreasing symptoms of anxiety
and depression.
• Improving thought process by
decreasing obsessionality.
• Improving ability to refrain from
compulsive behaviors.
• Regain appropriate insight into
her illness.
• Improve quality of life.
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Pharmacological Treatment
Medical
• Supplements
• GI
• Endocrine
Psychiatric:
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Antidepressants
Anxiolytics
Antipsychotics
Mood stabilizers/anticonvulsants
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Bulimia Nervosa
Diagnostic Criteria
A. Recurrent episodes of binge eating.
B. Recurrent inappropriate compensatory
behavior in order to prevent weight gain, such as
self-induced vomiting, misuse of laxatives,
diuretics, enemas, or other medications; fasting,
or excessive exercise
C. The binge eating and inappropriate
compensatory behaviors occur, on average, at
least twice 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.
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An episode of binge eating is
characterized by both of the following:
(1) Eating, in a discrete period of time
(e.g., within any 2-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).
Type: Purging Type vs. Non-purging Type
(exercise & fasting to compensate).
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Case II
• 25 YO female with multiple daily episodes of binging and
purging as well as periods of fasting. She admits to using
cocaine and stimulants to suppress appetite. She admits to
binge drinking on weekends. She has significant history of
sexual abuse in childhood.
• She is very ashamed of her symptoms and has been feeling
very guilty about her life and being a failure. She hates herself
and self mutilates frequently.
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Co-occurring Issues
Substance Abuse
Substance dependence
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The essential feature of abuse is a pattern
of substance use that causes someone to
experience harmful consequences.
Clinicians diagnose substance abuse if, in
a twelve-month period, a person is in one
or more of the following situations related
to drug use:
Failure to meet obligations, such as
missing work or school
Engaging in reckless activities, such as
driving while intoxicated
Encountering legal troubles, such as
getting arrested
Continuing to use despite personal
problems, such as a fight with a partner
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Dependence is more severe. Medical professionals
will look for three or more criteria from a set that
includes two physiological factors and five
behavioral patterns, again, over a twelve-month
period. Tolerance and withdrawal alone are not
enough to indicate dependence. And not all
behavioral signs occur with every substance.
The physiological factors are:
Tolerance, in which a person needs more of a drug
to achieve intoxication
Withdrawal, in which they experience mental or
physical symptoms after stopping drug use
The behavioral patterns are:
Being unable to stop once using starts
Exceeding self-imposed limits
Curtailing time spent on other activities
Spending excessive time using or getting drugs
Taking a drug despite deteriorating health
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Borderline Personality Disorder
Diagnostic criteria DSM IV TR
A. An enduring pattern of inner
experience and behavior deviating
markedly from the expectations of
the individual's culture. This
pattern is manifested in two (or
more) of the following areas:
cognition (perception and
interpretation of self, others and
events)
• Affect (the range, intensity,
lability and appropriateness of
emotional response)
• interpersonal functioning
• impulse control
B. The enduring pattern is inflexible and
pervasive across a broad range of personal
and social situations. C. The enduring
pattern leads to clinically significant
distress or impairment in social,
occupational or other important areas of
functioning. D. The pattern is stable and of
long duration and its onset can be traced
back at least to adolescence or early
adulthood. E. The enduring pattern is not
better accounted for as a manifestation or
consequence of another mental disorder F.
The enduring pattern is not due to the
direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition (e.g., head
trauma).
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Treatment
Medical
• Stabilize and correct
electrolyte imbalance
• GI /GERD
• Cardiovascular
Psychiatric:
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Alcohol withdrawal
Mood/anxiety/ Impulse control
Self harm vs. suicide
Decrease binge/purge
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Psychological Treatment
Medical
• Supplements
• GI medications antacids,
antiemetic etc
Psychiatric:
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Anxiolytics
Antidepressants
Mood stabilizers
Antipsychotics
Stimulants
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Psychological Treatment
Diagnostic Criteria:
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The EDNOS category include disorders that do not meet the
criteria for a specific eating disorder. Each one of the
following disorders is an example:
For females, all of the criteria for anorexia nervosa are met
except that the individual has regular menses.
All of the criteria for anorexia nervosa are met except that,
despite substantial weight loss, the individual's current weight
is in the normal range.
All of the criteria for bulimia nervosa are met except that
binge eating and inappropriate compensatory mechanisms
occur at a frequency of less than twice a week or for a duration
of less than 3 months.
The regular use of inappropriate compensatory behavior by an
individual of normal body weight after eating small amounts
of food (eg; self-induced vomiting after the consumption of
two cookies).
Repeatedly chewing and spitting out, but not swallowing,
large amounts of food.
Binge eating disorder: recurrent episodes of binge eating in the
absence of the regular use of inappropriate compensatory
behaviors characteristic of bulimia nervosa.
Purging disorder
Nighttime eating disorder
Binge Eating Disorder
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Case III
• 30 year old female with BMI of 34
• She reports eating excessively trough the day and having
occasional binges on food, especially sweets
• She reports being very disorganized, emotional, having mood
swings and being ”all over the place”
• She feels that marijuana helped not to feel as overwhelmed
and admits she has been self medicating her anxiety with it.
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Treatment Considerations
Medical:
• Obesity
• Dyslipidemias
• Insulin resistance
• Cardiovascular
deconditioning
Psychiatric:
• Marijuana Abuse
• Impulse Control
• Affective instability
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Pharmacological Treatment
• Orlistat
• Sybutramine
• Lipid Lowering agents
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Anxiolytics
Antidepressants
Stimulants
Mood Stabilizers
Antipsychotics
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PTSD
A.
The person has been exposed to a traumatic event in which both of the following were present:
the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical
integrity of self or others.
the person’s response involved intense fear, helplessness, or horror.
B.
The traumatic event is persistently reexperienced in one (or more) of the following ways:
recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
recurrent distressing dreams of the event
acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes,
including those that occur on awakening or when intoxicated)
intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C.
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by
three (or more) of the following:
efforts to avoid thoughts, feelings, or conversations associated with the trauma
efforts to avoid activities, places, or people that arouse recollections of the trauma
inability to recall an important aspect of the trauma
markedly diminished interest or participation in significant activities
feeling of detachment or estrangement from others
restricted range of affect (e.g., unable to have loving feelings)
sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D.
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
difficulty falling or staying asleep
irritability or outbursts of anger
difficulty concentrating
hypervigilance
exaggerated startle response
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Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
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PTSD
Dissociative Identity Disorder
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The presence of two or more distinct identities or personality states (each with its
own relatively enduring pattern of perceiving, relating to, and thinking about the
environment and self).
At least two of these identities or personality states recurrently take control of the
person's behavior.
Inability to recall important personal information that is too extensive to be
explained by ordinary forgetfulness.
The disturbance is not due to the direct physiological effects of a substance (e.g.,
blackouts or chaotic behavior during Alcohol Intoxication) or a general medical
condition (e.g., complex partial seizures). Note: In children, the symptoms are not
attributable to imaginary playmates or other fantasy play.
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Case IV
• 36 YO female with history of severe childhood sexual abuse
and periods of starvation, binge/purge. Currently at 95 % IBW,
reports symptoms of depression, anxiety and inability to
remember parts of the day.
• She is unable to eat because of severe nausea and feeling
repulsed by food. She is having frequent panic attacks
especially around food.
• She has profound difficulties sleeping and feels “on the edge”
all the time
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