Eating Disorders
Eating Disorder Clinical Assessment, Signs and Symptoms
-Anemia -Amenorrhea (absence of period) -Dehydration, dry brittle hair, dry skin -Constipation -Lanugo; yellow skin -Cold extremeties -Muscle weakness -Decreased bone density -Low T3, T4 -Hypotension, bradycardia, hypokalemia -Electrolyte imbalance: cardiovascular abnormalities, and impaired kidney function
Eating Disorders
-Anorexia nervosa -Bulimia nervosa -Binge eating disorder: recurrent episodes of binge eating with no compensatory mechanisms to purge (laxatives, self-induced vomiting, over exercising, etc.) -Night eating disorder: characterized by morning anorexia and excessive evening hyperphagia -Pica: persistent ingestion of nonfood substances (dirt, rocks, clay, etc.)
Affective Charaacteristics
-Anorexia: feels in control when avoiding food. High need of approval from others. Attempts to hide how thin they are i.e. wears baggy clothing... -Bulimic: fear of loss of control, nut just eating, but also their emotions. Inability to identify feelings-negative emotions get confused with sensations of hunger -Obsessive-compulsive characteristics (overlap) -Mood, Anxiety Disorders, Borderline Personality Disorders (overlap)
American Psychiatric Associated Practice Guidelines for inpatient eating disorders
-BMI less than 17 or less than 85% of IBW -Weight loss over 30% over 6 months -Inability to gain weight as outpatient -P less than 40BPM -Systolic PB less than 70 mm Hg -Temperature below 96.8F -Hypokalemia (under 3mEq/L) -High risk for refeeding syndrome (start slowling introducing foods back in) -Bradycardia, Arrhythmias, abnormal EKG, abnormal electrolytes, abnormal pancreatic and liver enzyme levels -Physical presentation: cachectic (wasting of the body), muscle wasting, lanugo, thinning hair and skin, poor pallor, significant edema -Failure to comply with treatment: pervasive refusal to eat or unable to curb behaviors even with high levels of supervision -Chronic episodes of binge/purge/restrict resulting in abnormal electrolyte levels, esophageal tears, stomach ruptures, etc. -IV fluids or NG tube feeds needed for medical and nutritional stabilization -Suicidal/self-mutilating and/or psychiatric instability -Co-ocurring substance use -Family crisis ***You can force a patient to eat because its considered a danger to themselves, might have to appear before a judge to get order for mandatory treatment***
Community/Long-term therapy
-Behavioral: pt. needs to be certain weight and electrolytes in balance before she can gain from psychotherapy -Cognitive restructuring -Feeling work (how to express feelings) -Assertiveness training (especially for anorexia nervosa) -Family therapy
Laboratory Tests in Eating Disorders
-Blood Chemistery Studies (CMP) -Phosphorus and magnesium levels -Liver function tests (AST, ALT, ALK Phos) -Thyroid stimulating hormone (A high TSH and low T4 means an underactive thyroid) -Complete blood count including differential -Erythrocyte sedimentation rate -Urinalysis -Urine toxicology -Electrocardiagram (EKG) -Urine pregnancy test -PT/PTT -Serum albumin/prealbumin -Amylase/lipase
Additional laboratory tests to consider
-Consider Dual-Energy x-ray Absorptiometry (DEXA) Bone Scan in patients with amenorrhea > 6 months and no DEX in past 2 years (osteopenia or osteoporosis) -Luteinizing hormone (LH), follicle-stimulating hormone (FSH), beta human chrionic gonadotropin, free and total testosterone levels, prolactin for patients with amenorrhea but who are normal weight -Brain MRI or head CT for patients with significant cognitive deficits, atypical features, other neurological signs (people with brain injuries can have loss of appetitie and significant weight loss) -Echocardiogram
Anorexia Nervosa
-Denial early on; depression and liability with progression; isolation; medical complications -Treatment: often difficult, patient resistance, uninterested, denies problem -Re-feeing syndrome (appears when food is introduced too quickly after a period of malnourishment.)
Distorted thinking in eating disorders
-Dichotomous thinking: "if I'm not thin, I'm fat" -Magnification: "If I gain 2 lbs, I know everyone will notice" -Personalization: "those people talking and laughing are talking about how fat I am" -Superstitious thinking: "If I gain weight, I will never succeed"
Signs and symptoms of purging
-Disappearing after eating (possibly to engage in self-induced vomiting) -History of cycles of losing and regaining weight -Hiding emesis -Sounds of purging in the bathroom
Signs and symptoms of binge eating
-Eating large portions or food is found missing -Hiding food wrappers -Hiding food to eat later
Signs and symptoms of restricting behavior
-Eating tiny portions of food, skipping meals, denying hunger, and eating very little in public -Exercising compulsively and excessive movement -Wearing loose or baggy clothes -Checking body in mirror/grabbing body parts to assess thickness (hips, abdomen, wrists, etc.) -Believing fat when underweight or normal weight
Mental Health Promotion
-Education of parents, children, young people about strategies to prevent eating disorders -Early identification, appropriate referral -Routine screening of young women for eating disorders
What should an assessment include?
-Full physical exam (wieght patient backwards or with a blindfold) -Laboratory and other diagnostic tests (assess liver & kidney functions, and electrolytes) -A general diagnostic interview -Specific interview that goes into more detail about symptoms (also good idea to interview family members)
Eating Disorder Laboratory Features
-Leukopenia (low white blood cells) -Anemia -Thrombocytopenia -Metabolic alkalosis -Hypophosphatemia -Hypokalemia -Hypomagnesemia -Hypocalcemia -Mildly elevated AST, ALT (liver function) -Normal or elevated TSH, normal or low T4, Low T3, Increased reverse T3 -Decreased ESR (Erythrocyte sedimentation rate) -Increased cholesterol -Increased serum carotene -Decreased vitamin A levels -ECG: Bradycardia, Low voltage changes, T-wave inversion, ST segment depression
Overview of eating disorders
-Many people under the belief that eating disorders are a new diagnosis -Documents from Middle Ages indicate "willful" dieting and starvation in female saints who fasted to achieve purity -In the late 1800's there was a case study showing a female starving to avoid obesity -Finally, in the 1960's the diagnosis of anorexia was established -The diagnosis of Bulimia nervosa was established in 1979 -Anorexia nervosa has the highest mortality rate of any psychiatric illness (5-18% mortality rate). Problems include cardiac (losing alot of the heart muscle), osteopenia, stunted growth, kidney damage, leukopenia -One is 5 deaths from anorexia nervosa is from suicide -Bulimia nervosa has a mortality rate of 2-3% and medical complications include electrolyte abnormalities, dental erosion, and seiuzres -Denial and lack of insight impact treatment
Assessing Eating Disorders
-No specific tests to diagnose -No routine screeing for eating disorders -Medical history, physical exam, and specific screening questions, along with other assessment tests help to identify eating disorders
Bulimia Nervosa Clinical Assessment
-Normal to slightly low or overweight -Tooth decay and staining from stomach acids released during frequent vomiting -Inflammation and possible rupture of the esophagus from frequent vomiting -Gastric rupture is an uncommon but possible side effects of binge eating -Calluses, scars on dominant hand -Parotid gland swelling (chipmunk cheeks) -Peripheral edema -Muscle weakness -Abnormal K, Na values -EKG changes, cardio-myopathy
Bulimia Nervosa
-Onset: late adolescence, early adulthood (average age is 18 to 19 years) -Often begins during or after dieting episodes -Possible restrictive eating between binges; secretive storage/hiding of food -Depression -Chemical Dependency -Treatment Cognitive-behavioral therapy and Psychopharmacology (antidepressants)
Statistics of eating disorders
-Over 1/2 of teenage and 1/3 of teenaged boys use unhealthy weight control behaviors such as skipping meals, smoking, fasting, vomiting, or taking laxatives -The average woman is 5'4" and weights 140 lbs. The average supermodel is 5'11" and weighs 117lbs. =Americans spend over $40 billion on dieting and diet related products each year -Anorexia nervosa age of onset: usually between ages 14-18 -Bullimia nervosa age of onset: usually between 18-19
Diagnosing
-Physical Exam: may incluse measuring weight and height, checking vital signs such as heart reate, blood pressure and temperature, checking skin and nails, listening to heart and lung sounds, and examining abdomen -Lab tests: these may include a complete blood count and more specialized tests to check electrolytes and protein, as well as liver, kidney and thyroid functions. A urinalysis may also be performed -Psychological evaluation: A therapist or mental health provider will likely ask about thoughts, feelings, and eating habits. You may also be asked to complete a psychological self-assessment quiestionnaire. -Other studies: x-rays may be taken to measure bone density, check for stress fractures or broken bones, or evaluate for pneumonia or heart problems. Electrocardiograms may be used to identify heart irregularities. Tests may also be used to determine how much energy your body uses, which can help in planning nutritional requirements. Based on the results of the exams and tests, an appropriate treatment program will be recommended
Refeeding syndrome
-Potentially deadly syndrome that occurs when a starved person begins to take in nutrition -The term "refeeding syndrome" was coined and brought to attention in 1981 by Weinsier and Krumdieck when they reported death of two malnourished patients who were fed "overzealously" -Early signs: *Low phosphorus *Elevations in the liver function tests *Swelling in legs *Rapid weight gain indicating fluid overload -Vital sign abnormalities -Gastroparesis (partical paralysis of stomach) -It can be defined as potentially fatal shifts in fluids and electrolytes that occur in malnourished patients after refeeding. -The hallmark is hypophasphatemia, however, may also feature changes in sodium, fluid balance, changes in glucose, protein and fat metabolism, hypokalemia, hypomagnesemia, vitamin deficiency (B1; thiamine) ***can cause cardiac problems, electrolyte imbalances, ...*** ***Someone who is severly anorexic, start them on a liquid diet***
Bulimia Nervosa
-Recurrent episodes of binge eating (secretive); compensatory behaviors to avoid weight gain (purging, use of laxatives, diuretics, enemas, emetics, fasting, excessive exercise) -Eating, in a discrete period of time (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 -A sense of lack of control over eating during the episode (feeling that one cannot stop eating or control what or how much one is eating) -Recognition of behavior as pathologic; feeling of guilt, shame, remorse, contempt -Usually normal weight, can be abover or below weight
Anorexia Nervosa: Counselors or family might notice
-Refusal or inability to maintain minimal normal body weight -Intense fear of gaining weight or becming fat -Denial of hunger -Excuses to aboid mealtimes -Extreme weight loss -Significantly disturbed perception of body shape or size -Steadfast inability or refusal to acknowledge seriousness of problem or even that one exists -Peculiar ways of handling food -Preoccupation with food -Judges self-worth by weight -Excessive, often rigid exercise regimens
DSM-5 An Diagnostic Specifiers
-Restricting type -Binge/eating/purging type -In partial remission -In full remission -Specify severity based on body mass index (BMI) Mild: BMI greater than 17 Moderate: BMI 16-16.99 Severe: BMI 15-15.99 Extreme: BMI less than 15
Overlap of eating disorders
-There is much overlap among the eating disorders -With this in mind, you can think of eating disorders as being on a spectrum -30-35% of normal weight people diagnosed with bulimia nervosa have had a history of Anorexia nervosa -50% of people diagnosed with anorexia nervosa have some purging compensatory behaviors -The clear difference is that people diagnosed with Anorexia nervosa must have "significantly low body weight" which is "less than minimally normal." People diagnosed with Bulimia nervosa can be overweight, slightly underweight, or of average weight.
DSM-5 Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in descrete period of time (within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances 2. A sense of lack of control over eating during the episode (feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 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-5 Diagnostic criteria for Anorexia nervosa
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 behavior 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.
Etiology of eating disorders (biological factors)
Biologic factors -Genetic vulnerability -Disruptions in the nuclei of the hypothalamus relating to hunger and satiety (satisfaction of appetite) -Neurochemical changes (norepinephrine, serotonin); not known if these changes cause disorders or are results of eating disorders -Physical abuse -Sexual abuse
Etiology of eating disorders (Developmental factors)
Developmental factors -Struggle for autonomy, identify (especially true for anorexia nervosa ,often times with overcontrolling family members that put extra pressre on patient) -Overprotextive or enmeshed families -Body image disturbance/dissatisfaction -Separation-individuation difficulties
Other historical information
Dietary History of Patients -Foods avoid/fear foods -Dietary restrictions (good foods vs. bad foods) -Vegetarian or Vegan -Quantify intake (adding all calories) -Binge eating -Food Rules (ex: can't eat past 5pm) ***would not pertain if its a religious or spiritual reason for obstaining from certain foods***
Relapse Triggers
Factors that may cause relapse: -Allowing to become excessively hungry: may lead to overeating and temptation to purse -Frequent weight-ins on the scale: weight gain may cause anxiety and high chance of relapse -Depriving self of good tasting food: deprivation can lead to cravings and food binges, and may build to include most foods resulting in relapse -Not paing attention to emotions: certain emotions may be triggers, and not learning alternative ways to deal with strong emotions may cause relapse
Prognosis for improvement
Factors that predict good outcomes: -Early age at diagnosis -Beginning treatment as soon as possible -Good parent-child relationships -Having other healthy relationships with friends or therapists Anorexia Poorer Prognosis with: -Initial lower weight -Presence of vomiting -Failure to respond to previous treatment -Bad family relationships before illness Bullimia Poorer prognosis with: -High number hospitalizations because of severity -Extreme disordered eating symptoms at start of treatment -Low motivation to change habits
Etiology of eating disorders (Family influences)
Family influences -Family dysfunction -Childhood adversity
Eating Disorder Physical Exam
General -Marked weight loss, gain, or fluctuations -Weight loss, maintenance, or failure to gain weight in developing child/adolescents -Weakness -Cold intolerance -Fatigue or lethargy -Lightheadedness, fainting
Community-Based Care
Hospital admission only for medical necessity Community settings -Partial hospitalization or day treatment programs -Individual or group outpatient therapy -Self-help groups -Healthy People 2020
Levels of care
Inpatient -Most supervised intensive treatment, 24/7 medical supervision Residential -Therapeutic community 24/7 but medical services are not provided onsite -Team includes dietician, therapist, and psychiatric providers Partial Hospitalization -Intensive outpatient program that acts like a hospital during the day but the patient goes home after the program (6 days/7-12 hours) Intensive Outpatient program -Intensive outpatient in the evening where people can work/school during the day and bring stress to program to work on it Outpatient Team -Includes dietician, therapist, psychiatric and medical physicians
Anorexia Nervosa Treatments
Medical Management -Weight restoration/nutritional rehabilitation -Rehydration/correction of electrolyte imbalances Pscyhopharmacology Medication for symptoms: depression and anxiety related to eating disorder Pscyhotherapy -Family therapy -Individual therapy -Cognitive-behavioral therapy
Anorexia Nervosa Treatment
Medical management: -Weight restoration/nutritional rehabilitation -Rehydration/correction of electrolyte imbalances Psychopharmacology Psychotherapy -Family therapy -Individual therapy -Cognitive-behavioral therapy
Interventions
Milieu: model functional group with healthy communication patterns -patient weighed regularly (blind) -normalization of eating -awareness and healthy expressions of feelings, fears, thoughs encouraged -group therapy for mirroring of own cognitive distortions and emotinal struggles -Health teaching; coping skills
Psychiatric medications
Several commonly used meds are prescribed frequently by medical providers that may interfere with recovery. Provider may consider tapering down medications to wean patient off of: -Benzodiazepine Tranquilizers: Diazepam (Valium), Alprazolam (Xanax), Clonazapine (Klonopin), Clordiazepoxide (Librium), Zolpidem (Ambien), Eszopiclone (Lunesta) (avoid meds that blunt emotional response to clinical work) -Amphetamines: Methylphenidate (Ritalin), Amphetamine (Adderall), Methylphenidate HCL (Concerta), cocaine, methamphetamine (avoid meds that interfere with normal perception of appetite cues) -Topiramate (Topomax): epilepsy medication helpful in chronic migraine headache (avoid meds that interfere with normal perception of appetite cues) -Buproprion (Wellbutrin): antidepressant that increase seizure risk in patients who purge
Etiology of eating disorders (sociocultural factors)
Sociocultural factors -media -pressure from others -ideal in our society is "thin"; may start out dieting and pregress to a ED -Pro-AnaMia websites: some aregue support does not encourage anorexia or bulimia, but only wish to support those who have the condition to not feel shame and rejection (houseofthin). Others defend the "conditions" as not illness/disease/disorder, but as "lifestyle" (fading-obsession)
Medications
Symptom dependent: -Antidepressants (Fluoxetine (Prozac) now FDA approved for bulimia), TCAs -There is no medication that is FDA approved for anorexia nervosa. However, there is some support for use of low-dose antipsychotic medication as adjunct in acute anorexia nervosa.Mitarpizine (Remeron), an antidepressant, can cause an increase in appetite -Lisdexamfetamine dimesylate (Vyvanse) is FDA approved for treatment of binge eating disorders -Anti-anxiety drugs, anticonvulsants -Antipsychotics
Anorexia: What to look for?
What do counselors look for? -Rapid loss of weight -Change in eating habits -Withdrawal from friends or social gatherings -Peach fuzz (lanugo): when body weight gets too low -Hair loss or dry skin -Extreme concern about appearance or dieting -Creating of lifestyle schedules and rituals around food -Withdrawal from friends and activities -In general, behaviors and attitudes indicating that weight loss, dieting, and control of food are becoming primary concerns
