Term
| criteria for anorexia nervosa |
|
Definition
refusal to maintain body weight at or above minimally normal weight for age and height (weight loss = body weight < 85% of that expected)
intense fear of gaining weight or becoming fat
disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
in postmenarcheal females, amenorrhea (absence of at least 3 consecutive menstrual cycles) |
|
|
Term
| 2 subtypes of anorexia nervosa |
|
Definition
RESTRICTING TYPE:
during current episode of AN, patient has not regularly engaged in binge eating or purging behavior
BINGE EATING/PURGING TYPE:
during current episode of AN, patient has regularly engaged in binge eating or purging behavior
patients with binge/purging type are still underweight |
|
|
Term
|
Definition
|
|
Term
| etiology of anorexia nervosa |
|
Definition
onset: 13-18 yo (rare > 40 yo)
onset frequently associated with major life change or stressful event
mortality: > 10% if hospitalized
suicide, starvation, arrhythmia, electrolyte imbalance |
|
|
Term
| ritualistic and restrictive behavior of AN |
|
Definition
cutting food into small pieces
moving food to center of the plate
avoid eating b/w meals; avoiding breakfast
eating low calorie foods only; vegetarian; not eating out
calorie counting
excessive exercising
water loading (concerned about hyponatremia)
water loading
gum chewing; cigarette smoking |
|
|
Term
| criteria for bulimia nervosa |
|
Definition
recurrent episodes of binge eating
eating, in discrete period of time, amount of food larger than most people would eat during a similar period of time
a sense of lack of control over eating during the episode
recurrent, inappropriate compensatory behavior to prevent weight gain (self-induced vomiting, misuse of laxatives, diuretics, enemas, fasting, or excessive exercise)
the binge eating and inappropriate compensatory behaviors both occur at least 2x per week for 3 months
self evaluation is influenced by body shape and weight
the disturbance does not occur exclusively during episodes of anorexia nervosa |
|
|
Term
| 2 subtypes of bulimia nervosa |
|
Definition
PURGING TYPE:
during current episode of BN, the patient regularly engages in self-induced vomiting or misuse of laxatives, diuretics, or enemas
NONPURGING TYPE:
during current episode of BN, the patient has used inappropriate compensatory behaviors (fasting and exercise) but NOT by purging |
|
|
Term
| etiology of bulimia nervosa |
|
Definition
onset: 15-24 yo
before onset of BN, most will have tried "fad" diests
course: intermittent with periods of remission
mortality: ~1% |
|
|
Term
|
Definition
occurs when control is lost over food restriction
triggered by dysphoric mood states (depression, anxiety) interpersonal stressors, boredom
anxiety decreases during binge
often concealed and planned in advance
food hoarding or buying excessive amounts of food
rapid consumption of food
sweets, high calorie foods (ice cream, cake)
one binge may contain > 20,000 calories
continues until uncomfortably full or interrupted
binges may range from 1-20 x per day |
|
|
Term
| compensatory behaviors in bulimia nervosa |
|
Definition
induction of vomiting (most common 80-90%)
fingers or instruments to stimulate gag reflex
syrup of ipecac
misuse of laxative and diuretics
fasting for several days
exercise excessively
substance abuse (cocaine, crystal meth, nicotine)
after the purge -> feelings of guilt, depression, and anxiety |
|
|
Term
| descriptive features of anorexia nervosa and bulimia nervosa |
|
Definition
anorexia nervosa:
emaciated or underweight
restricting and ritualistic
social withdrawal
strong need to control
obsessive-compulsive
bulimia nervosa:
normal or slightly overweight
binging and purging
impulsive/moody
substance abuse (30%)
borderline personality
BOTH: PREOCCUPATION WITH THOUGHTS OF FOOD |
|
|
Term
| characteristics of binge eating disorder |
|
Definition
not classified as mental health disorder in DMS-IV
defined as recurrent binge eating episodes without compensatory behavior to prevent weight gain (purging, laxative abuse)
binge eating associated with 3 of these factors:
eating rapidly
eating until uncomfortably full
eating large amounts when not hungry
eating alone out of embarrassment
feeling disgusted, depressed, or guilty after eating
binge eating must occur > or equal to 2x per week for > or equal to 6 months |
|
|
Term
| characteristics of eating disorder not otherwised specified (NOS) |
|
Definition
"atypical eating disorder"
meet characteristics of BN and AN, but do not meet the complete diagnostic criteria or either disorder
> or equal to 50% of patients presenting for treatment are diagnosed with eating disorder NOS |
|
|
Term
| eating disorders: pathogenesis |
|
Definition
predisposing factors + traumaticf events -> use of food and weight to provide a sense of stability or control
1)genetic predisposition
increased rates among 1st degree biological relatives: mood disorders, obsessive-compulsive disorders, substance abuse
chromosomal defect
2) neurobiologic dysfunction
starvation, chronic stress, excessive exercise ->
increased release of cortisol from adrenal glands and suppression of HPA, HPT, HPG axes ->
inhibits TSH = decreased T4 to T3 conversion = decreased resting metabolic rate
and
decreased estradiol, progesterone, and LH = decreased libido, amenorrhea
3) neurotransmitter dysregulation
serotonin: partially synthesized from diet; regulates postprandial satiety, anxiety, sleep, mood, obsessive-compulsive and impulse control disorders
NE: starvation = decreased NE = hypotension, bradycardia, hypothermia
4) family dynamics
high parental expectations (achievement and appearance)
families with difficulty managing conflict
poor communication
enmeshment and/or estrangement
devaluation of mother or maternal role
marital tension/divorce
5) trauma and life stressors:
childhood sexual abuse
rape/physical assault
death of loved one
beginning college/university
athletics: ballet, running, wrestling, gymnastics
6) personality disorders
7) societal pressures
the media stimulates vulnerable individuals to make comparisons between idealized bodies and their own promoting body dissatisfaction and ultimately disordered eating |
|
|
Term
| obsessive compulsive personality disorder |
|
Definition
more associated with anorexia nervosa
peroccupied with mental and interpersonal control
preoccupied with details, rules, lists, order, organization
perfectionism
excessively devoted to work and productivity |
|
|
Term
| borderline personality disorder |
|
Definition
more associated with bulimia nervosa
unstable interpersonal relationships and self image
impulsivity (spending, sex, binge eating)
recurrent suicidal behavior, self mutilating behavior
affective instability (splitting) |
|
|
Term
| gastrointestinal complications to an eating disorder |
|
Definition
starvation = delayed gastric emptying and slowed GI motility
severe constipation
abdominal discomfort/pain
purging = significant and permanent loss of dental enamel
increased frequency of dental cavities
parotid gland enlargement
Russell's sign (cuts on knuckles)
esophageal tears, gastric rupture |
|
|
Term
| endocrine compilations from eating disorderss |
|
Definition
starvation, psychosocial stress, chronic exercise = increased cortisol = inhibition of T4 and T3
cold intolerance (hypothermia)
decreased metabolic rate
lanugo: thin, fine hair develops all over the body
lethargy
dryness of skin
yellowing of the skin (hypercarotenemia) |
|
|
Term
| electrolyte complications of eating disorders |
|
Definition
hypochloremia, hypokalemia, hyponatremia
persistent vomiting and/or chronic diarrhea (laxative abuse) = hypokalemia =
skeletal and smooth muscle weakness
cardiac conduction abnormalities
metabolic alkalosis (increased serum bicarbonate) from loss of stomach acid through vomiting
metabolic acidosis from chronic diarrhea |
|
|
Term
| reproductive complications of eating disorders |
|
Definition
amenorrhea and osteopenia
hypothalamic suppression = hypoestrogenic state (from diminished pituitary secretion of FSH and LH - a consequence of the extreme weight loss)
associated with delayed or interrupted puberty and decreased bone density (osteopenia)
infertility: increased risk for miscarriages and premature births |
|
|
Term
| cardiac complications of eating disorders |
|
Definition
starvation = cardiac muscle atrophy = decreased contractile force and cardiac output
decreased cardiac output = fatigue and decreased exercise tolerance
cardiac vagal hyperactivity = bradycardia
caffeine and exercise should be avoided to prevent arrhythmia in patient with wasted heart muscle and bradycardia (<50bpm) |
|
|
Term
| 3 tiered treatment system for eating disorders |
|
Definition
most patients are resistant to treatment/hospitalization
3 tiers:
inpatient
intensive outpatient
partial outpatient
long-term outpatient psychotherapy to prevent relapse |
|
|
Term
| inpatient hospitalization treatment of eating disorders |
|
Definition
24 hours/day
criteria for inpatient hospitalization:
suicidal ideation or psychosis
excessive purging -> severe fluid/electrolyte abnormalities
rapid weight loss
cardiac disturbances
non-responsive to outpatient treatment
refeeding syndrome - gastric bloating, edema, cardiovascular collapse (CHF), possible death
INCREASE WEIGHT BY 2-3 POUNDS / WEEK IN AN INPATIENT SETTING |
|
|
Term
| outpatient treatment of eating disorders |
|
Definition
partial hospitalization/day treatment
8-10 hours/day
emphasize behavioral changes
supervised meals
INCREASE WEIGHT BY 0.5-1 POUND / WEEK
group therapy, family therapy
individual CBT
pharmacotherapy once weight is restored |
|
|
Term
|
Definition
CBC: hypoalbumemia, anemia, thrombocytopenia
electrolytes: low Na, low K, low Mg, low Cl
thyroid function: low TSH, low T4
bone density scan: osteopenia
ECG: QT prolongation, AV block, ST depression
liver function: hypoalbumemia
amylase: extremely elevated (from hypersalivation from binging/purging)
pulse: bradycardia
blood pressure: hypotension
temperature: hypothermia, cold intolerance
skin: decrease in turgor (dehydrated), lanugo, hair loss, Russell's sign
reproductive: menstrual irregularities
dental: tooth enamel loss |
|
|
Term
| psychotherapy for eating disorders |
|
Definition
cognitive behavioral therapy (CBT):
focus on change of thought patterns and specific behaviors
most effective therapy
interpersonal therapy (IPT):
focus on interpersonal relationships
dialectical behavior therapy (DBT):
used for borderline personality disorder
family therapy |
|
|
Term
| medical treatments for eating disorders |
|
Definition
malnutrition -> TPN, multivitamin
constipation -> flax seed, OTC bulk-forming laxatives, stool softeners (docusate)
abdominal bloating and pain -> metoclopramide
amenorreha -> conjugated estrogens (would rather have patients develop their menstrual cycle on their own with weight gain; could cover up the problem)
osteopenia -> calcium 1500 mg/day + viatmin D 400 IU/day |
|
|
Term
| pharmacotherapy for patients with eating disorders |
|
Definition
never indicated as sole treatment for eating disorders
ofen based on co-occuring psychiatric disorders (anxiety, depression, delusions)
restore 5HT:
decreased 5HT = depressed mood, anxiety, poor impulse control, obsessive thinking
restore DA:
decreased DA = decreased memory, decreased alertness, fatigue, poor concentration, decreased rewarding feelings
MALNOURISHED PATIENTS ARE SENSITIVE TO ANTICHOLINERGIC AND CARDIOVASCULAR ADRS (ORTHOSTASIS)
electrolyte abnormalities = increased seizure risk
changes in fat and protein = altered pharmacokinetics:
hypoalbuminemia = more free (unbound) drug
decrease in body fat can decrease volume of distribution of fat soluble drugs = increased SS plasma levels (diazepam, alprazolam, SSRIs, trazodone, opioids)
paroxetine has mild antichollinergic ADRs = not first choice in someone with anorexia
TCAs cause orthostasis
bupropion is contraindicated in patients with eating disorders b/c of icnreased seizure risk |
|
|
Term
| pharmacotherapy for anorexia nervosa |
|
Definition
MEDICATION TYPICALLY NOT EFFECTIVE IN MALNOURISHED, UNDERWEIGHT PATIENTS
ONCE WEIGHT IS RESTORED, ANTIDEPRESSANTS RESERVED FOR PATIENTS WITH PROMINENT DEPRESSION AND OBSESSIVE COMPULSIVE SYMPTOMS
SSRIS = 1ST LINE ANTIDEPRESSANTS
continue Rx for at least 6-12 months |
|
|
Term
| when are 2nd generation antipsychotics used in eating disorder treatment? |
|
Definition
used in patients with psychosis (delusions regarding food); self-mutilating behaior
aripiprazole is the most appropriate b/c it is weight neutral
genodon = increased risk of QT prolongation
zyrexa = forced weight gain
risperidone = EPS (potent D2 blocker) |
|
|
Term
| pharmacotherapy for bulimia nervosa |
|
Definition
patients do NOT have to be depressed to benefit from antidepressant therapy
more extensively evaluated in the treatment of bulimia
antidepressants (SSRIs) are DOC to decrease binge/purge behavior, anxiety, obsessions, impulsiveness, and depression
FLUOXETINE IS THE ONLY ANTIDEPRESSANT FDA INDICATED FOR TREATMENT OF BULIMIA NERVOSA
higher doses (60 mg/day) superior to antidepressant doses of 20 mg/day
the following antidepressants have been studied in BN with some efficacy in decreasing binge/purge and increased mood:
phenelzine and trnylcypromine (patient must understand tyramine interaction!)
pubropion (but increases seizure risk!)
nortiptyline and imipramine (TCAs are risk b/d of anticholinergic ADRs, CV abnormalities and seizure risk)
ANTIDEPRESSANTS THAT SHOULD BE AVOIDED:
bupropion
mirtazapine (weight gain concern)
TCAs (imipramine and clomipramine) |
|
|
Term
| when should mood stabilizers/anticonvulsants be used in eating disorders? |
|
Definition
used in patients with concomitant bipolar disorder/mood disorder:
lithium
divalproex Na
carbamazepine
oxcarbazepine
ineffective unless mood disorder present
topiramate in controlled trials demonstrated efficacy in binge-eating disorder |
|
|
Term
| pharmacotherapy for binge eating disorder |
|
Definition
SSRIs: decrease binge frequency; higher doses used
topiramate, sibutramine, zonisamide = effective in binge suppression + weight loss
orlistat may cause weight loss + safer treatment option |
|
|
