Download Eating Disorders - Resmy Palliyil Gopi, M.D.

EATING DISORDERS
Resmy Palliyil Gopi
OBJECTIVES
Discuss the signs and symptoms of eating
disorders, the appropriate evaluation, and
treatment options:
– Anorexia nervosa
– Bulimia nervosa
– Binge Eating Disorder
– Eating disorder NOS
DSM-IV CRITERIA-Anorexia Nervosa
Refusal to maintain weight within a normal
range for height and age (weight loss leading
to maintenance of body weight less than 85%
of that expected)
Intense fear of gaining weight or becoming fat,
even though underweight.
Disturbance in the way in which one’s body
weight or shape is experienced, undue
influence of body weight or shape on selfevaluation, or denial of the seriousness of the
current low body weight.
In postmenarchal females, amenorrhea or the
absence of at least three consecutive
menstrual cycles.
SUBTYPES
Restricting
– Restriction of intake to reduce weight
Binge eating/purging
– May binge and/or purge to control weight
– 50% of patients go through a phase during
their illness when they binge eat.
Anorexia nervosa
Outstanding feature of AN is persistent
and severe restriction of energy intake,
delusion of being fat and obsession to be
thinner.
SIGNS AND SYMPTOMS
Dry skin
Cold extremities,
acrocyanosis
hypothermia
Sinus bradycardia
Pitting edema
Weakness, fatigue
Cardiac murmurs
Fainting
Orthostatic hypotension
Lanugo hair
Scalp hair loss
Early satiety
Constipation
Short stature
Osteopenia
Breast atrophy
Atrophic vaginitis
Primary or secondary
amenorrhea
Delayed puberty
DSM-IV CRITERIA- Bulimia
Episodes of binge eating with a sense of loss of
control
Binge eating is followed by compensatory
behavior of the purging type (self-induced
vomiting, laxative abuse, diuretic abuse) or
nonpurging type (excessive exercise, fasting, or
strict diets).
Binges and the resulting compensatory behavior
must occur a minimum of two times per week for
three months
Dissatisfaction with body shape and weight
Bulimia nervosa
Hallmark of BN is binge eating followed by
compensatory methods to rid the body of
effects of calories.
More likely to be impulsive, not only in
eating behavior, but also in their use of
drugs, alcohol, self mutilation, lying,
stealing and other manifestations of
personality disturbance.
SIGNS AND SYMPTOMS
Mouth sores
Pharyngeal trauma
Dental enamel
erosions
Heartburn, chest pain
Esophageal rupture
Impulsivity
– Stealing
– Alcohol abuse
– Drugs/tobacco
Muscle cramps
Weakness
Bleeding or easy
bruising
Irregular periods
Fainting
Swollen parotid
glands
hypotension
Binge Eating Disorder
RESEARCH CRITERIA
Eating, in a discrete period of time, an
amount of food that is larger than most
people would eat in a similar period
Occurs 2 days per week for a six month
duration
Associated with a lack of control and with
distress over the binge eating
BED
Must have at least 3 of the 5 criteria
– Eating much more rapidly than normal
– Eating until uncomfortably full
– Eating large amounts of food when not feeling
physically hungry
– Eating alone because of embarrassment
– Feeling disgusted, depressed or very guilty
over overeating
Eating Disorder NOS DSM-IV CRITERIA
All criteria for anorexia nervosa except has regular
menses
All criteria for anorexia nervosa except weight still in
normal range
All criteria for bulimia nervosa except binges < twice
a week or for < 3 months
Patients with normal body weight who regularly
engage in inappropriate compensatory behavior after
eating small amounts of food (ie, self-induced
vomiting after eating two cookies)
A patient who repeatedly chews and spits out large
amounts of food without swallowing
EPIDEMIOLOGY
Incidence rates have increased in the past 25
years More than 90% are females, more than
95% are Caucasian, more than 75% are
adolescents
Anorexia
– Affects 1% of adolescent females
– Age of onset is lower in AN: 12–16yrs
– In AN females outnumber males 9 to 1
Bulimia
– Occurs in 5% of older adolescents and young adult
females.
– Age of onset is 15-20yrs
– In BN females outnumber males 5 to 1
Epidemiology
Eating Disorder NOS (ED-NOS)
– Occurs in 3-5% of women between the ages
of 15 and 30 in Western countries
– As minority culture groups assimilate into
American society, rates increase
Binge Eating Disorder (BED)
– Occurs more commonly in women
– Depending on population surveyed, can vary
from 3% to 30%
PATHOGENESIS
No consensus on precise cause
Combination of psychological, biological,
family, genetic, environmental and social
factors
Imbalance of neurotransmitters of which
serotonin is the most extensively studied.
ASSOCIATED FACTORS
History of dieting in adolescent children
Childhood preoccupation with a thin body and
social pressure about weight
Sports and artistic endeavors in which leanness
is emphasized, young women with restrictive
eating disorders and amenorhea referred to as
female atheletic triad
Association of eating disorders and sexual
abuse
Women whose first degree relatives have eating
disorders– 6 to 10 fold increased risk for
developing an eating disorder
ASSOCIATED PSYCHIATRIC
CONDITIONS
affective disorders
anxiety disorders
obsessive-compulsive disorder
personality disorders
substance abuse
Screening
Screening questions about eating patterns
and satisfaction with body appearance
should be asked to all preteens and all
adolescents as part of routine pediatric
health care
Questionnaire
What is the most you ever weighed? How tall were you then? When was
that?
What is the least you ever weighed in the past year? How tall were you
then? When was that?
What do you think you ought to weigh?
Exercise: how much, how often, level of intensity? How stressed are you if
you miss a workout?
Current dietary practices: ask for specifics—amounts, food groups, fluids,
restrictions?
–
–
–
–
–
24-h diet history?
Calorie counting, fat gram counting? Taboo foods (foods you avoid)?
Any binge eating? Frequency, amount, triggers?
Purging history?
Use of diuretics, laxatives, diet pills, ipecac? Ask about elimination pattern,
constipation, diarrhea.
– Any vomiting? Frequency, how long after meals?
Any previous therapy? What kind and how long? What was and was not
helpful?
Questionnaire
Family history: obesity, eating disorders,
depression, other mental illness, substance
abuse by parents or other family members?
Menstrual history: age at menarche? Regularity
of cycles? Last menstrual period?
Use of cigarettes, drugs, alcohol? Sexual
history? History of physical or sexual abuse?
Questionnaire: Review of
symptoms
Dizziness, syncope, weakness, fatigue?
Pallor, easy bruising or bleeding?
Cold intolerance?
Hair loss, lanugo, dry skin?
Vomiting, diarrhea, constipation?
Fullness, bloating, abdominal pain, epigastric burning?
Muscle cramps, joint paints, palpitations, chest pain?
Menstrual irregularities?
Symptoms of hyperthyroidism, diabetes, malignancy,
infection, inflammatory bowel disease?
SCREENING TOOL
Are you satisfied with your eating patterns? (No
is abnormal)
Do you ever eat in secret? (Yes is 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 currently suffer with or have you ever
suffered in the past with an eating disorder?
(Yes is abnormal)
PHYSICAL EXAM: anorexia
Vital signs to include orthostatics
Skin and extremity evaluation
– Dryness, bruising, lanugo
Cardiac exam
– Bradycardia, arrhythmia, MVP
Abdominal exam
Neuro exam
– Evaluate for other causes of weight loss or vomiting
PHYSICAL EXAM: bulimia
All previous elements plus:
– Parotid gland hypertrophy
– Erosion of the teeth enamel
– Skin lesions on the fingers (Russel’s sign)
LABORATORY ASSESSMENT
Diagnosis is clinical, there is no confirmatory lab
test
CBC, Electrolytes, UA, LFT, TSH
B-HCG, Serum prolactin, FSH, LH
EKG
Bone density
DIFFERENTIAL DIAGNOSIS
Malignancy, central nervous system tumor
Gastrointestinal system: inflammatory bowel
disease, malabsorption, celiac disease
Endocrine: diabetes mellitus, hyperthyroidism,
hypopituitarism, Addison disease
Depression, obsessive-compulsive disorder,
psychiatric diagnosis
Other chronic disease or chronic infections
Superior mesenteric artery syndrome (can also
be a consequence of an eating disorder)
Medical Complications Resulting
From Purging
Fluid and electrolyte imbalance; hypokalemia;
hyponatremia; hypochloremic alkalosis
Use of ipecac: irreversible myocardial damage and a
diffuse myositis
Chronic vomiting: esophagitis; dental erosions; MalloryWeiss tears; rare esophageal or gastric rupture; rare
aspiration pneumonia
Use of laxatives: depletion of potassium bicarbonate,
causing metabolic acidosis; increased blood urea
nitrogen concentration and predisposition to renal stones
from dehydration; hyperuricemia; hypocalcemia;
hypomagnesemia; chronic dehydration
Amenorrhea ,menstrual irregularities, osteopenia
Medical Complications From
Caloric Restriction
Cardiovascular: Electrocardiographic
abnormalities: low voltage; sinus bradycardia
(from malnutrition); T wave inversions; ST
segment depression (from electrolyte
imbalances). Prolonged corrected QT interval is
uncommon but may predispose patient to
sudden death. Dysrhythmias include
supraventricular beats and ventricular
tachycardia, with or without exercise. Pericardial
effusions can occur in those severely
malnourished. All cardiac abnormalities except
those secondary to emetine (ipecac) toxicity are
completely reversible with weight gain.
Medical Complications From
Caloric Restriction
Gastrointestinal system: delayed gastric
emptying; slowed gastrointestinal motility;
constipation; bloating; fullness;
hypercholesterolemia; abnormal liver function
test results. All reversible with weight gain.
Renal: increased BUN concentration (from
dehydration, decreased GFR) with increased
risk of renal stones; polyuria; with refeeding,
25% can get peripheral edema attributable to
increased renal sensitivity to aldosterone and
increased insulin secretion
Medical Complications From
Caloric Restriction
Hematologic: leukopenia; anemia; iron
deficiency; thrombocytopenia.
Endocrine: euthyroid sick syndrome;
amenorrhea; osteopenia.
Neurologic: cortical atrophy; seizures.
AMENORRHEA
Secondary amenorrhea affects more than
90% of patients with anorexia
Caused by low levels of FSH and LH
Withdrawal bleeding with progesterone
challenge does not occur due to the
hypoestrogenic state
Menses resumes with 6 months of
achieving 90% of IBW
REFEEDING SYNDROME
Severe hypophosphatemia
–
–
–
–
Cardiovascular collapse
Rhabdomyolysis
Seizures
Delirium
TREATMENT AND OUTCOME
ANOREXIA
Multifaceted and interdisciplinary
Interdisciplinary care team
– Medical provider
– Dietician: regain to goal of 90-92% of IBW
– Mental health professional
Cognitive behavioral therapy
– Best proven approach to the treatment
– Focuses on reconstructing thinking errors.
MEDICATIONS
Overall, disappointing results
Effective only for treating comorbid
conditions of depression and OCD
Anxiolytics may be helpful before meals to
suppress the anxiety associated with
eating
Criteria for hospital admission: AN
< 75% ideal body weight, or ongoing weight loss
despite intensive management
Refusal to eat
Body fat <10%
Heart rate <50 beats per minute daytime; 45
beats per min nighttime
Systolic pressure <90
Orthostatic changes in pulse (>20 beats per min)
or blood pressure (>10 mm Hg)
Temperature < 96°F
Arrhythmia
BULIMIA
Cognitive behavioral therapy is effective
Pharmacotherapy—high success rate
– Fluoxetine—studies reveal up to a 67%
reduction in binge eating and a 56% reduction
in vomiting
– TCAs
– Topiramate—reduced binge eating by 94%
and average wt. loss of 6.2 kg
– Ondansetron, 24 mg/day
Criteria for hospital admission: BN
Syncope
Serum potassium concentration < 3.2 mmol/L
Serum chloride concentration < 88 mmol/L
Esophageal tears
Cardiac arrhythmias including prolonged QTc
Hypothermia
Suicide risk
Intractable vomiting
Hematemesis
Failure to respond to outpatient treatment
OUTCOME
75-85% of individuals hospitalized for AN
recover fully
25% poor outcome
–
–
–
–
–
–
Associated with later age of onset
Longer duration of illness
Lower minimal weight
Vomiting
Concomitant personality disorder
Disturbed parent child relation
In BN, 60% have good outcome, 30% have
intermediate outcome
Question 1
You are evaluating a 17-year-old girl who has
anorexia nervosa for possible hospital admission.
She denies a recent history of vomiting, syncope,
and hematemesis. Of the following physical findings,
the most appropriate indication for hospitalization
includes:
A. Hyperthermia.
B. Lower extremity edema.
C. Orthostatic changes.
D. Resting tachycardia.
E. Tachypnea.
Question 2
An afebrile 15yr old girl presents with bilateral swelling of
the parotid glands She has lost 30lb(18kg) in the last 6
months. Her current weight is at the 75th percentile for
age. She has had an endoscopy for recurrent epigastric
pain. She admits to inducing vomiting after meals. Of the
following the clinical feature most specific to her
diagnosis.
A. A body mass index that is less than 15
B. A distorted perception of body size
C. Amenorrhea for more than 3 months
D. Binge eating at least twice a week for 3 months
E. Hypokalemic hypochloremic metabolic alkalosis
Question 3
A.
B.
C.
D.
E.
The parents of a 14-yr-girl are concerned about her weight loss. Her
weight today is 20 lb less than a documented wt obtained 1 yr ago at
her camp PE. She complains of frequent nausea, decreased
appetite, and early satiety, even after eating very small portions. She
has no vomiting or diarrhea, but frequent constipation. She
complains of increased fatigue but is still able to participate in diving
5 days/wk. She is doing well in school academically. She attained
menarche at 12 and had monthly periods for about 18 months, but
she has had no menses for the past 7 months. She has been a
vegetarian for the past 18 months and feels she is at a good weight
currently. On PE, her BMI is 17.0. Her UPT test result is negative. Of
the following, the MOST likely diagnosis is
anorexia nervosa
Depression
hypothalamic tumor
Hypothyroidism
inflammatory bowel disease
Question 4
A. Achalasia
B. BN
C. Crohn’s disease
D. Duodenal ulcer
E. Gall stones
Question 5
A. AN
B. Hyperthyroidism
C. Crohn’s disease
D. Depression
E. Tuberculosis
Thank you!