• Refusal to maintain body weight at or above minimally normal weight for age and height (wt loss = body wt < 85% of that expected
• Intense fear of gaining wt or becoming fat
• Disturbance in the way 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
• In postmenarcheal females, amenorrhea (absence of at least 3 consecutive menstrual cycles)

Restricting Type

During current episode of AN, pt has not regularly engaged in binge eating or purging behavior

Binge eating/purging type

During current episode of AN, pt has regularly engaged in binge eating or purging behavior

< 17.5

 BMI = wt (kg)/ht (m²)

• Cutting food into small pieces
• Moving food to center of the plate
• Avoid eating b/w meals; avoid breakfast
• Eating low calorie foods only; vegetarian; not eating out
• Calorie counting
• Excessive exercising
• Water loading
• Gum chewing; cigarette smoking

• Recurrent episdoes of binge eating
• Recurrent inappropriate compensatory behavior to prevent wt 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/wk for 3 mo
• Self-evaluation is influenced by body shape and wt
• The disturbance does not occur exclusively during episodes of AN

Purging Type

During current episode of BN, the pt regularly engages in self-induced vomiting or misuse of laxatives, diuretics, or enemas

Nonpurging Type

During current episode of BN, the pt has used inappropriate compensatory behaviors (fasting and exercise) but NOT by purging

• Induction of vomiting
• 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

AN

• Emaciated or underweight
• Restricting and ritualistic
• Social withdrawal
• Strong need to control
• Obsessive-compulsive

BN

• Normal or slightly overweight
• Binging and purging
• Impulsive/moody
• Substance abuse
• Borderline personality

• Not classified as mental health disorder in DSM-IV-TR
• Defined as recurrent binge eating episodes without compensatory behavior to prevent wt weight

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 > 2x/wk for > 6 mo

"Atypical Eating Disorder

• Meet characteristics of BN and AN, but do not meet the complete diagnostic criteria of either disorder
• > 50% of pts presenting for tx are dx with eating disorder, NOS having failed to meet 1 DSM IV TR criteria

• Increased rates among 1st degree biological relatives (mood disorders, obsessive-compulsive disorders, substance abuse)
• Chromosome 1 defect
• 2 genes have demonstrated significant association to AN -- HTR1D, OPRD1

• Starvation, chronic stress, excessive exercise
• Increased release of cortisol from adrenal glands
• Suppression of HPA, HPT, HPG axes

↓

• Inhibits TSH = decreased T4 to T3 conversion = decreased resting metabolic rate
• decreased estradiol, progesterone, and LH = decreased libido, amenorrhea

5-HT

• Partially synthesized from diet
• Regulates postprandial satiety, anxiety, sleep, mood, obsessive-compulsive, and impulse-control disorders

NE

• Starvation = decreased NE = hypotension, bradycardia, hypothermia

• High parental expectations
• Families with difficulty managing conflict
• Poor communication
• Enmeshment and/or estrangement
• Devaluation of mother or maternal role
• Marital tension/divorce

• Childhood sexual abuse
• Rape/physical assault
• Death of a loved one
• Beginning college/university
• Athletics: ballet, running, wrestling, gymnastics

Obsessive Compulsive Personality

• Preoccupied with mental and interpersonal control
• Preoccupied with detalis, rules, lists, order, organization
• Perfectionism
• Excessively devoted to work and productivity

Borderline Personality

• Unstable interpersonal relationships and self image
• Impulsivity (spending, sex, binge eating)
• Recurrent suicidal behavior, self-mutilating behavior
• Affective instability (splitting) -- black/white thinking

1. GI
2. Endocrine
3. Electrolyte
4. Reproductive
5. Cardiac
   

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 -- cut on dorsal side of hand
• Esophageal tears, gastric rupture

Starvation, Psychosocial stress, Chronic Exercise = Increased cortisol = inhibition of T4 and T3

• Cold intolerance (hypothermia)
• Decreased metabolic rate
• Lanugo
• Lethargy
• Dryness of the skin
• Yellowing of skin (hypercarotenemia)

• Hypochloremia, hypokalemia, hyponatremia
• Persistent vomiting and/or chronic diarrhea = 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

Amenorrhea and Osteopenia

• Hypothalamic suppression = hypoestrogenic state (from diminished pituitary secretion of FSH and LH -- a consequence of the extreme wt loss)
• Associated with delayed or interrupted puberty and decreased bone density (osteopenia)

Infertility

Increased risk for miscarriages and premature births

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 pt with wasted heart muscle and bradycardia (< 50 bpm)

• Restore and maintain healthy body weight and gonadal function
• Reestablish normal eating patterns
• Reduce distorted body image
• Resolve family dynamic issues
• Prevent relapse

24 hr/day; 7 days/wk

Criteria for Inpatient Hospitalization

• Suicidal ideation or psychosis
• Excessive purging --> severe fluid/electrolyte abnormalities
• Rapid wt loss
• Cardiac disturbances
• Non-responsive to outpatient tx

Refeeding Syndrome

• Gastric bloating, edema, cardiovascular collapse (CHF), possible death
• Increased wt by 2-3 lbs/wk

• CBC
• Electrolytes
• Thyroid function
• Bone density scan
• ECG
• Liver function
• Amylase
• Pulse BP
• Temp
• Skin
• Reproductive
• Dental

• Partial Hospitalization/Day Treatment

8-10 hrs/day; 5-7 days/wk (~8-12 wks)

• Emphasive behavioral changes
• Supervised meals
• Increase wt by 0.5-1 lb/wk
• Group therapy, family therapy

Individual CBT

Pharmacotherapy (once wt is restored)

TPN, multivitamin

Not first line -- do not force feed pts unless you have to

Conjugated estrogens

Controversial -- better to have menses restart naturally

• Never indicated as sole tx for eating disorders
• Often based on co-morbid psychiatric disorders (anxiety, depression, delusions)
• Restore 5-HT
• Restore DA
• Malnourished pts are sensitive to anticholinergic and cardiovascular side effects (orthostasis)
• Electrolyte abnormalities = increased seizure risk
• Changes in fat and protein = altered pharmacokinetics -- hypoalbuminemia (more free unbound drug), decrease in body fat can decrease Vd of fat soluble drugs = increased steady state plasma levels

• Medication typically not effective in malnourished, underweight pts
• Once wt is restored, antidepressants reserved for pts with prominent depression and obsessive compulsive symptoms
• SSRIs = 1st line antidepressants -- does not treat anorexia, only the compulsive behaviors and depression
• Continue Rx for at least 6-12 months

• Pts 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, impulsivity, and depression
• Fluoxetine is only antidepressant FDA indicated for tx of bulimia nervosa

• Phenelzine, tranylcypromine -- dangerous for someone that is still binging/purging
• Bupropion -- increased seizure risk
• Nortriptyline, Imipramine -- cardiovascular risk problems, lethal in overdose
• Mirtazapine -- weight gain

2nd Gen Antipsychotics

• Risperidone/Paliperidone -- EPS is significant
• Ziprasidone -- has to be taken with food, 500 cals, QTc prolongation
• Olanzapine, Quetiapine -- Weight gain

"Start low and go slow" when dosing

• malnourished, sensitive to ADRs
• Hypoalbuminemia = increase in free unbound drug

Consider 2nd Gen Antipsych

Aripiprazole 5 mg qAM

Recognize Drug Interactions

Aripiprazole (2D6, 3A4 substrate); Fluoxetine (2D6, 3A4 inhibitor)

Used in pts with concomitant bipolar disorder/mood disorder

• Lithium (cardiotoxic, lethality in OD)
• Divalproex Na+
• Carbamazepine, Oxcarbazepine (hyponatremia)

Ineffective unless mood disorder present

Topiramate: controlled trials demonstrate efficacy in binge-eating disorder -- causes weight loss