Difficult to differentiate between causes of the eating disorder and effects of the eating disorder

Biological changes - GI system dysfunction, Immune system alterations

Hormonal Changes - Dysfunctional Hypothalamic-pituitary axes

Neurotransmitter dysfunction - 5HT, NE, DA

Eating Disorder - Patient driven to be thin, distorted body image, high motivation to lose weight, patients improve with re-feeding

Psychological Disorder - Decrease in appetite or purging due to other factors, loss of interest, paranoia, decreased appetite, patients will improve with pharmacologic treatment and symptom resolution

- Most prevalent in late adolescence, ~90% are females

- 57% higher incidence of suicide

- Potential genetic influence regarding serotonin receptors

- Psychosocial influences: family environment, history of neglect or abuse, lower weight duration or alcohol abuse increases mortality

- Sexual abuse and other aggravated trauma is found in 25-50% of cases

- Refusal to maintain a normal body weight or to make expected weight gains

- Intense fear and obsession about being fat or gaining weight

- Distorted body image

- Lack appreciat for degree of weight loss

- Amenorrhea for at least 3 cycles

- Patients cannot sense when they are full and complain of bloating when they start eating

- Need to be in control of caloric consumption

- Depression mood

- Social withdrawal

- Irritability

- Insomnia

- Diminished interest in sex

- Abdominal pain

- Constipation

- Lethargy

- Cold intolerance

- Emaciation

- Dental erosion

- Hand calluses

- Edema

- Suicide

- Nutrional Rehabilitation

- Psychosocial therapy and/or cognitive behavioral therapy

- Pharmacotherapy:  SSRI's, Atypicals, Benzos, Promotility agents, Calcium and Vitamin D

- To obtain healthy weight increase by 1-3 pounds per week

- Healthy weight targets need to be negotiated

- Refeeding programs must be supportive and nurturing overall (positive and neg. reinforcements

- Supervised setting with oral liquid  replenishment

- Severe conditions require feeding tubes

Psychocial counseling - addresses body concerns

Education regarding dietary practices

Cognitive Behavioral Therapy - Helpful in preventing relapses and to overcome distorted thinking and denial of problems

- Fluoxetine is most studied

- Utilized after weight has been normalized (>85% expected weight)

- Treatment for patiens with residual depressive, anxiety, or obsessive-compulsive sx

- High dose fluoxetine usually impairs appetite, but this doesn't happen in AN patients

- Always with psychotherapy for one year

- To address anxiety (anticipatory) associated with putting on weight, use a Benzo

- Use sparingly due to high incidence of dependence

- Use pro-motility agents to improve bloating and abdominal pain

- Metoclopramide 5-10mg with meals

Tricyclics - Dangers in AN patients due to hightened sensitivity of adverse events (cardiac)

MAOI's - Dietary restrictions are problematic, pronounced adverse effects

Bupropion - Contraindicated due to increase risk of seizure in malnourished patients

- For patients with severe resistance to weight gain

- Decrease obsessive thoughts

- Alleviate paranoid ideation regarding weight gain

- Address anxiety

- Promote weight gain

- Evidence inconclusive at this time

- Atypicals showed minimal improvement, QT prolongation

- Malnutrition

- Weakness

- Dehydration

- Hypothermia

- Bradycardia

- Orthostatic Hypotension

- Chest pain

- Dizziness

- Lanugo (fine hair)

- Decreased bone density

- Cold extremities

- Cognitive impairment

- Irritability

- Seizures

- Neuropathy

- Fatigue

- Vomiting

- Constipation

- Dental erosion and irritation

- Most prevalence in adolescents up to young adult, usually older age than AN

- Women more affected than males

- Undecided genetic influence

- May be diagnosed for bullemia after previous treatment for anorexia

Recurrent binge eating with inappropriate compensatory actions to prevent weight gain

Purging - Self induced vomiting or laxative abuse

Non-purging - Excessive exercising, strict dieting/fasting

- Often felt to be an embarassment and done in private

- Triggered by: depressed mood, stressor, hunger due to dietary restraint

- Rapid ingestion in a frenzied state but can stop if in the presence of another person

- After binging person is uncomfortably full and often dysphoric and remorseful

- OFTEN NORMAL WEIGHT

- Poor self or body image

- High prevalence of substance abuse

- Eroded dental enamel

- Calluses on back of hand

- Depression or anxiety

- Alkalosis from vomiting

- Acidosis from laxative use

- Weakness

- Palpitations

- Cognitive impairment

- Irritability

- Neuropathy

- Heartburn

- Constipation

- Enlarged salivary glands

- Scarring of the hands

- Edeman

- Muscle cramping

- Dental erosion

- Amenorrhea

- Potential decreased bone density

- Cardiac arrhythmias

- Electrolyte disturbances

-  Weight fluctuations

- Psychosocial Therapy

- CBT

- SSRI

- Topiramate

- Fluoxetine and Sertraline are helpful in patients with residual depression, anxiety, obsessive or impulsive symptoms.  Dosages should be higher than in depression

- Many providers start at 60mg then taper downwards based on S/E

- If lack of efficacy look at timing of medication and vomiting

- Common side effects include sexual, insomnia, nausea, asthenia

- TCA's dangerous in the malnourished

- HTN crisis in MAOI's

- Short term efficacy in reducing binging episodes and days, small sample size and large dropout

- Study with lithium found no benefit

- Unchanging refusal to gain weight

- Severe, unchanging obession with food and weight

- Denial that becomes delusional

- Relapse prevention with Fluoxetine has limited evidence

- Significant rates of relapse occur even with treatment

- Continue antidepressant for 9-12 months - consensus recommendation

- Binge eating episodes without any compensatory behaviors to prevent weight gain

- Occurs in overweight or obese patients

- Episodes are distressful and may occur once or more weekly

- Patients feel that they lack control

- Often have depression and/or low self esteem

- Address appropriate dietary practices

- Help break the yo-yo cycle

- Encourage healthy weight loss