Eating Disorders – BCED2012

Eating Disorders
  • F:M = 10:1; mortality 5-10%
  • AN 1% onset 13-20yo & BN 2-4% onset 16-18yo
Etiology
  • Personality: OCPD, histrionic, borderline
  • Familial: maintenance of equilibrium in dysfunctional family
  • Individual: perfectionism, lack of control in other life area, hx of sexual abuse
  • Cultural: idealization of thinness in the medial, prevalent in industrialized societies
  • Genetic: higher familial incidence of affective disorders (BN)

1 Whenever teenagers present for care, include an assessment of their risk of eating disorders (e.g., altered body image, binging, and type of activities, as dancers, gymnasts, models, etc., are at higher risk). as this may be the only opportunity to do an assessment.

SCOFF:
• Do you make yourself Sick (induce vomiting) because you feel uncomfortably full?
• Do you worry that you have lost Control over how much you eat?
• Have you recently lost more than One stone (14 lb {6.4 kg}) in a three-month period?
• Do you think you are too Fat, even though others say you are too thin?
• Would you say that Food dominates your life?
Risk Factors
  • Physical: obesity, chronic medical illness (eg DM – use insulin to lose weight)
  • Psychological:
    1. Cultural: idealization of thinness – altered body image
    2. Individual: perfectionism
    3. Binging activities – ” to lose weight, some people will use laxatives or vomit, have you ever tried that or used other ways to lose weight?”
    4. Family Hx of mood disorders, eating disorders, substance abuse
    5. Hx of sexual abuse, homosexual males
    6. Competitive athletes: Athletic Triad – disordered eating, amenorrhea, osteoporosis
    7. Career expected to be thin – dancers, gymnasts, models etc
    8. Concurrent mental illness – depression, OCD, anxiety disorder (panic & agoraphobia), OCPD, BPD, HPD
    9. Substance abuse (specifically for BN)

2 When diagnosing an eating disorder, take an appropriate history to differentiate anorexia nervosa from bulimia, as treatment and prognosis differ.

DSM4 for Anorexia Nervosa (AN)
  1. Refusal to maintain body weight at or above a min normal wt for age & ht, eg. wt loss leading to maintenance of <85% expected body wt, failure to make expected wt gain during period of growth
  2. Intense fear of gaining wt or becoming fat, even thought underweight
  3. Disturbance in the way in which one’s body wt or shape is experienced, undue influence of body wt or shape on self-evaluation, or denial of the seriousness of the current low body wt
  4. In postmenarcheal females, amenoorhea (≥3 missed consecutive cycles) – removed in DSM5
Specific Type
  1. Restricting: No binge-eating or purging behaviour
  2. Binge-Eating/purging: Regularly engaged in binge-eating or purging

DSM4-TR Bulimia Nervosa
  1. Recurrent episodes of binge eating characterized by both
    • Eating, in a discrete period of time, an amount of food that is larger than most people would eat
    • A sense of lack of control over eating during the episode, eg. can’t stop eating or control what / how much one is eating
  2. Recurrent inappropriate compensatory behaviour in order to prevent wt gain, eg self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, xs exercise
  3. The binge eating & inappropriate compensatory behaviours both occur, on average, ≥ 2x / wk x 3mo
  4. Self-evaluation is unduly influenced by body shape & wt
  5. The disturbance doesn’t occur exclusively during episodes of AN
Specific Type
  1. Purging: Regular self-induced vomiting or the misuses of laxatives, diuretics, or enemas
    • Ipecac Syrup – used to induce vomiting in poisoning
  2. Non-purging: Other inappropriate compensatory behaviours: fasting or xs exercise, but no regular purging
Associated Features
  • Fatigue, trouble concentrating & muscle weakness due to repetitive vomiting & fluid/lyte imbalance
  • Tooth decay, swollen around angle of jaw & puffiness of eye sockets due to fluid retention
  • Reddened knuckles, Russell’s sign (knuckle callus)
  • Wt fluctuation over time

 3 In a patient with an eating disorder, rule out co-existing psychiatric conditions (e.g., depression, personality disorder, obsessive-compulsive disorder, anxiety disorder).


4 When managing a patient with an eating disorder, use a multidisciplinary approach (e.g., work with a psychiatrist, a psychologist, a dietitian).

  • Psychotherapy – individual, group, family – addressing food and body perception, coping mechanisms, health effects
  • Biological:
    • Tx of starvation effects, SSRIs
  • Psychological:
    • develop trusting relationship with therapist to explore personal etiology & triggers
    • CBT, Family therapy, recognition of health risks
  • Social:
    • challenge destructive societal views of women,
    • Use of hospital environment to provide external patterning for normative eating behaviour
  • Monitor for complications of AN (See objective 5)
  • Monitor for refeeding syndrome
    • A potentially life-threatening metabolic response to refeeding in severely malnourished pt resulting in severe shifts in fluid and electrolyte levels
    • Complications:
      • hypophophatemia
      • CHF, cardiac arrhythmias
      • delirum, death
    • Prevention:
      • slow refeeding, gradual increase in nutrition
      • supplemental phosphorus
      • close monitoring of electrolytes and cardiac status

Hospitalization is rare, unless:
  1. < 75% of ideal body weight or ongoing weight loss, Body fat < 10%
  2. Heart rate < 50 bpm daytime; < 45 bpm night time
  3. Orthostatic HoTN, Systolic blood pressure < 90 mmHg, Syncope
  4. abnormal serum chemistry – significant electrolyte abnormalities
  5. actively suicidal or concurrent psychiatric reason
  6. Temperature < 35.6°C or 96.0°F
  7. Potassium imbalance
  8. Dehydration, hopovolemia requiring IV fluid
  9. Cardiac arrhythmias including prolonged QTc
  10. Intractable vomiting, Esophageal tears, Hematemesis
  11. Poorly controlled diabetes
  12. Failure to respond to outpatient treatment

Agree on target body weight on admission & reassure this weight will not be surpassed


5 When assessing a patient presenting with a problem that has defied diagnosis (e.g., arrhythmias without cardiac disease, an electrolyte imbalance without drug use or renal impairment, amenorrhea without pregnancy), include “complication of an eating disorder” in the differential diagnosis.

Complications of Eating Disorders
  • General:
    • Starvation/Restriction: low BP/HR/temperature, significant orthostatic changes ± syncopal episodes, vitamin deficiencies
    • Binge-Purge: Russell’s sign, parotid gland enlargement, perioral skin irritation, periocular and palatal petechiae, loss of dental enamel & caries, aspiration pneumonia, metabolic alkalosis 2º to hypokalemia & loss of acid
  • Endocrine – 1° / 2° amenorrhea, decreased T3/T4
  • Neurologic – Grand Mal Sz (↓ Ca, Mg, phosphate)
  • Cutaneous – Dry skin, lanugo hair, hair loss or thinning, brittle nails, yellow skin from high carotene
  • GI –
    • Starvation/Restriction: Constipation, GERD, delayed gastric emptying
    • Binge-Purge: Acute gastric dilation / rupture, pancreatitis, GERD, hematemesis – Mallory-Weiss tear
  • CVS
    • Starvation / Restriction: Arrhythmias, CHF
    • Binge-Purge: Arrhythmias, cardiomyopathy (from use of ipecac), sudden cardiac death (↓ K)
  • MSK: osteoporosis from hypogonadism, muscle wasting
  • Renal: pre-renal failure (hypovolemia), renal calculi, renal failure from electrolyte disturbances
  • Extremities: pedal edema (decreased albumin)
  • Lab: 
    • Starvation ↓ RBCs, WBCs, LH, FSH, estrogen, testosterone, ↑ Growth hormone, cholesterol & dehydration ↑ BUN
    • Vomiting: ↓ Na, K, Cl, H+ – hypokalemia with metabolic alkalosis; increased amylase
    • Laxative: ↓ Na, K, Cl, ↑ H+, metabolic acidosis

6 In the follow-up care of a patient with a known eating disorder:

a) Periodically look for complications (e.g., tooth decay, amenorrhea, an electrolyte imbalance).

b) Evaluate the level of disease activity (e.g., by noting eating patterns, exercise, laxative use).

Hx:

Establishing rapport:
• Open-ended questions such as, “How have things been going with your eating?” or “Do you have concerns about your eating?” or “What is most important to you about your eating and health?”
Assessing Readiness:
• “How do you feel about making changes to your eating?” or “How do you feel about making changes to improve your physical health?”
Provide Feedback:
• “What is your reaction to these test results?” or “Would more information be helpful?” Offer further support targeted to level of readiness for change:
• For clients who are not “ready” to make change: “What would it take for you to consider thinking about change?”
• For clients who are unsure about change: “What are the things you like and don’t like about your eating disorder?”
• For clients who are ready to make change: “What would you like to work on changing?”

Screening Physical Exam:

Malnutrition Risk Assessment with weight & height for age over time + BMI

Muscular weakness is a common indicator of serious prolonged malnutrition that results in muscle wasting. For all age groups, the sit up, squat-stand test (SUSS) is recommended to test muscle weakness.

Vital signs

• Establish baseline set of vital signs (low pulse and temperature may indicate poor nutrition, pulse in AN reported to be bradycardic < 60 beats per minute in most patients and majority may have hypotension with pressures 90/60
• Heart rate and rhythm (should be taken lying and then standing)
• Establish baseline set of orthostatic pulse and blood pressure (decrease of 10 to 30 mm Hg systolic blood pressure or 10mm Hg diastolic blood pressure with rise in pulse of 20 beats per minutes indicates orthostatic hypotension)
• Hydration
• Sit Up-Squat-Stand Test to test muscle weakness

Skin Exam

• Examine cutaneous changes associated with starvation (brittle hair, brittle fingernails, dry skin with scaling, loss of subcutaneous fat, pretibial edema without hypoproteinemia, and the appearance of lanugo hair)
• Skin appearance (examine skin turgor and mucous membranes); pallor, acrocyanosis, carotenaemia
• Russell sign (callous in knuckles from self-induced emesis) Head and neck
• Enlargement of parotid or submandibular salivary glands is a common finding in BN
• Dental erosion due to frequent vomiting

Investigations: to determine medical acuity:

• ECG: abnormalities include bradycardia, non-specific ST-T wave changes including ST segment depression, U waves in the presence of hypokalemia and hypomagnesemia
• Blood chemistry
– Complete blood count with differential
– Serum electrolytes
– Glucose
– Calcium
– Magnesium
– Phosphate
– Thyroid function tests (T3, T4, and TSH)
– Liver function tests (AST, ALT, bilirubin)
– Albumin, transferrin
– Blood urea nitrogen
– Creatinine

• Urinalysis


References:
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Posted in 34 Eating Disorder, 99 Priority Topics, FM 99 priority topics, Psych

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