Download Clinical Slide Set. Eating Disorders

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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
in the clinic
Eating Disorders
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
Who is at risk for an eating disorder?
 Females
 Particularly adolescent, young adult
 Participants in activities that emphasize low weight
 Dancing, modeling, certain sports
 Patients with family history of eating disorders
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
How should a patient be screened for an
eating disorder?
Screen all patients in high-risk groups…
 Ask about eating practices and weight concerns
 Beware patients often deny or underreport symptoms
 Use SCOFF Questionnaire
 BMI <18.5 kg/m2: ? anorexia nervosa
 High BMI + weight fluctuations: ? binge eating
 In children and adolescents, use percentiles to follow
status (normal BMI ranges vary)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
Can eating disorders be prevented?
 Screening can identify early symptoms
 Early identification = better outcomes
 Even in individuals not yet meeting full criteria:
 Aim to reverse early signs
 Emphasize normal weight and eating
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
CLINICAL BOTTOM LINE: Screening and
Prevention…
 Systematically screen: as part of general health assessment
 High risk groups
 Adolescents and young adult females
 Individuals with family history
 Athletes, models, dancers
 Early recognition and treatment improve outcomes
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What are the major categories of eating
disorders?
 Anorexia nervosa
 Weight < minimum normal range for age and height
 Bulimia nervosa
 Binge eating + inappropriate compensatory behaviors
 (self-induced vomiting, laxative misuse, diuretics, enemas)
 Binge eating disorder (BED)
 Eating lots of food during brief period
 Sense of loss of control and marked distress
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What signs or symptoms should alert the
clinician to a possible eating disorder?
 Anorexia nervosa
 Weight loss
 Hypometabolism (bradycardia, hypotension, hypothermia)
 If underweight: amenorrhea, stress fractures, hair loss, fine
lanugo hair
 Bulimia nervosa
 Dental erosion or excess cavities
 Prominent or inflamed parotid glands
 Calluses or abrasions on hand
 Dehydration, electrolyte imbalances
 BED
 Overweight or obese and distressed over binging
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What features should be evaluated in the
physical exam of a patient with a possible
eating disorder?
 Height and weight
 Heart rate, blood pressure, and temperature
 Heart sounds
 Flow murmurs consistent with mitral valve insufficiency
sometimes seen in anorexia
 Skin
 Dry, scaly; lanugo; poor turgor; thinning hair; brittle nails
 Head and neck
 Note appearance of salivary glands and general dentition
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What other problems should be considered
in the evaluation of a patient with a
possible eating disorder?
 Other causes for weight loss
 Chronic infections
 Intestinal disorders with malabsorption
 Endocrinopathies
 Cancer
 Psychiatric illness
 Other causes of vomiting or diarrhea
 Eating disorders differentiated by…
 an extreme fear of becoming fat
 and a relentless pursuit of thinness
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
Are there other conditions that are
associated with eating disorders?
 Depression
 Common with all types of eating disorders
 High suicide rate in anorexia nervosa
 Anxiety disorders (OCD specifically)
 Associated with anorexia nervosa
 Substance abuse disorders
 More common among individuals who binge or purge
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
How is anorexia nervosa diagnosed?
 Refusal to maintain body weight at or above minimally
normal weight
 Intense fear of gaining weight or becoming fat
 Disturbance in perception of body weight or shape
 Undue influence to body weight and shape
 Denial of seriousness of current low body weight
 Amenorrhea (absence ≥3 consecutive menstrual cycles)
 No objective “test” confirms presence (and affected
individuals may obfuscate symptoms)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
How is bulimia nervosa diagnosed?
 Recurrent episodes of binge eating
 Recurrent compensatory behavior to prevent weight gain
 Self-induced vomiting; misuse of laxatives
 Diuretics, enemas, fasting
 Excessive exercise
 Undue influence to body weight and shape
 Disturbance not only during episodes of anorexia
nervosa
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
How is BED diagnosed?
 Regular episodes of binge eating
 At least weekly for 3 months
 Associated with distress and sense of lack of control
 Not accompanied by compensatory behaviors aimed at
weight loss
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What tests are used in evaluating a patient
with an eating disorder?
 Electrocardiography
 Arrhythmias  ? electrolyte disturbances
 Complete laboratory assessment
 Hypokalemia  ? purging
 Hyponatremia or hyperchloremia  ? excessive water intake
 Hypophosphatemia, hypomagnesemia; hypoalbuminemia,
elevated liver enzymes; leucopenia, anemia  if underweight
 Radiography or endoscopy
 If clinical presentation unusual  ? bulimia nervosa
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
When should a consultation be sought to
aid in the diagnosis of an eating disorder?
 When eating disorder suspected but not confirmed
 When comorbid conditions or atypical features present
Consult:
 Adolescent medicine specialist, pediatrician
 Endocrinologist
 Psychologist / psychiatrist with expertise in this area
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Anorexia nervosa
 Weight loss, hypometabolism, amenorrhea, stress fractures,
hair loss, lanugo hair, arrhythmias
 Underweight but fearful of gaining
 Bulimia nervosa
 Dehydration, electrolyte imbalances, dental erosion,
prominent parotid glands, abrasions on hand
 Binge eating + inappropriate compensatory behaviors
 BED
 Likely overweight or obese and distressed over binging
 Affected individuals commonly obfuscate symptoms
 Associated conditions: depression, anxiety, substance abuse
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
When do patients with eating disorders
require hospitalization?
 Medical or psychiatric instability manifests
 Less-invasive attempts at refeeding fail
 Need to interrupt use of laxatives, diuretics, enemas or
diet pills
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What is the therapy for an eating disorder?
 Cognitive-behavioral therapy
 Challenges distorted thoughts contributing to aberrant habits
 Decreases undue concern about body shape and weight
 Replaces dysfunctional dieting with normal eating habits
 Interpersonal therapy
 Targets interpersonal problems contributing to disorder
 Family-based treatment
 Aids nutritional rehabilitation & recovery
 Empowers parents to refeed their underweight child
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
Are there useful principles to guide
treatment of patients with this illness?
 Nutritional rehabilitation: central to anorexia nervosa
treatment
 Weight restoration is essential
 Emphasize normalizing weight and eating behaviors
 Behavioral management reinforces healthy behaviors
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
Is there a role for pharmacologic interventions?
 Antidepressants
 If CBT alone not enough or significant depression present
 Decreases binge-purge behaviors, regardless of depression
 Fluoxetine: FDA-indicated for bulimia nervosa
 Tricyclics, MAOIs, SSRIs: better than placebo
 Topiramate
 Antiseizure mood-stabilizer
 May aid treatment of bulimia nervosa
 Use caution due to risk for weight loss
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
When should consultation be sought to
assist in treatment of an eating disorder?
When the disorder is identified
 Mental health provider with expertise in eating disorders
 For bulimia nervosa or BED: CBT
 For children or adolescents anorexia nervosa: FBT
 For anorexia nervosa: Nutritional rehabilitation
 Multidisciplinary clinical treatment team, including an
experienced nutritionist
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What is the prognosis for a patient with an
eating disorder?
 The course of eating disorders varies
 Mortality rates are elevated for all with eating disorders
 Highest rate with anorexia nervosa (≈5%)
 Early intervention may improve clinical outcomes
 BED: tend to have long Hx of intermittent binge eating
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What is the appropriate follow-up for
patients with an eating disorder?
 Regularly monitor weight and other vital signs
 Regularly check for medical complications
 Provide ongoing treatment & support to prevent relapse
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
What should patients be taught about their
eating disorder?
 Risk for medical complications from eating disorders
 Association between eating disorders and mood,
anxiety, and substance use disorders
 Information on the basics of healthy eating and exercise
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.
CLINICAL BOTTOM LINE: Treatment…
 Anorexia nervosa
 Focus on nutritional rehabilitation and weight restoration
 Recommend FBT for younger patients
 Hospitalization may be needed if no response as outpatient
 Bulimia nervosa and BED
 Focus on CBT, IPT, or self-help based on CBT principles
 Consider adding antidepressants to treatment plan
 Monitor weight and symptoms regularly
 Relapse may occur after short-term resolution
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 156 (7): ITC4-1.