The Eating Disorders
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1
Kendall L. Stewart, MD, MBA, DLFAPA
February 15, 2013
1 This
presentation will focus on the most serious Eating Disorder, Anorexia Nervosa.
Why is this important?
• These are common, serious
disorders.
• Anorexia Nervosa affects up to
2.1% of women.
• Up to 15% of patients are male.
• Only about 40% of these
patients recover completely.
• The reported mortality rate is as
high as 22%.
1
• After mastering the information
in this presentation, you will be
able to
– Describe how patients with
Anorexia Nervosa often present,
– Detail the diagnostic criteria,
– Describe some of the associated
features,
– List some differential diagnoses,
– Identify some of the common
clinical problems
– Write a preliminary treatment plan,
and
– Identify some of the frequent
treatment challenges.1
Families are not always as helpful as you would wish. I asked a patient to tell her mother about purging.
What specific diagnoses are included
here?
• Eating Disorders1,2
– Anorexia nervosa
• Restricting type
• Binge-eating /Purging type
– Bulimia nervosa
• Purging type
• Nonpurging type
– Eating Disorder NOS
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1
2
Explore one of the best health and fitness sites on the Web
here.
In DSM-5, this category will likely be renamed Feeding and
Eating Disorders, and several new diagnoses will be added.
Obesity is not a mental disorder, but it is an epidemic and you should consider making it a priority.
Begin by making permanent changes in your own life.
How might a patient with anorexia
nervosa present?
• This is a17-year-old high school
senior.
• “I started dieting last year to
lose a few pounds, but I’m still
fat.”
• “There’s nothing wrong with
me.”
• “She’s too thin, and she’s
obsessed with food and
exercise.”
• “She won’t believe that she’s too
thin, and she resents our
comments.”
• “She used to be a sweet girl, but
now she’s sullen and hostile.”
1
These patients regularly post videos on YouTube™.
• “I’m cold all the time.”
• “I can’t concentrate; I’m in a
fog.”
• “I’m afraid to leave home to go
away to college, but no one
stays in this town after high
school.”
• “My parents fight all the time;
they may get a divorce when I
leave home.”
• “I can’t make friends.”
• “People don’t like me because
I’m fat.”1
• You can view some of their
stories here.
What are the diagnostic criteria1 for
anorexia nervosa?
• Refusal to maintain normal body weight
leading to body weight less than 85% of what
would be expected
• Intense fear of gaining weight or becoming fat
• Disturbance of body image
• In postmenarchal females, amenorrhea
1 Specify
whether the diagnosis is Restricting Type or Binge-Eating/Purging Type.
What other diagnoses might you
include in your differential?
•
Normal dieting
– Thinness is holy grail for most women.
•
Another eating disorder
– In Bulimia Nervosa, normal body weight is maintained.
•
Weight loss secondary to a general medical condition
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•
GI disease
Brain tumors
Occult malignancies
AIDS
Substance-induced weight loss
– Stimulants
•
Weight loss secondary to other psychiatric disorders
– Depression and others1,2
1
2
A woman presented with severe depression and weight gain.
I was consulted to see a paranoid patient who believed that her food was poisoned.
What associated features might you
see?
• About two-thirds of these patients also have a mood
disorder.
• Anxiety disorders are also very common.
• Personality disorders are common.
• These patients are at increased risk for substance
abuse disorders.
• Starvation also produces psychiatric symptoms
including
–
–
–
–
Dysphoria
Anxiety
Obsessiveness
Hyperactivity
Physical findings in Anorexia Nervosa include lanugo, dry skin, emaciation, cold intolerance, hair loss,
sunken eyes, bradycardia, hypotension, edema and hypothermia.
1
What are some treatment challenges
you can expect?
• These patients are often sullen, resistant and
noncompliant.
• Their families often minimize the problem.
• The patient may have trouble building and
sustaining a therapeutic relationship.
• Medication is not helpful for the disorder itself,
but when used for comorbid problems, these
patients may be very sensitive to drug side
effects.
• They may refuse medication for fear of weight
gain.
• They will want to talk about food and weight and
avoid the painful feelings that trouble them.1,2
1
2
Those who do best decide to maintain a healthy weight in spite of how they feel.
The weight at which their menstrual flow changed is a good target weight.
What might a typical treatment plan
look like?
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Medical Complications
– Dehydration
– Electrolyte imbalance
Hospitalization
– Fainting
– CHF
– Bradycardia
– Cognitive impairment
– Failure of outpatient treatment
Laboratory investigation
– Initial evaluation should be
extensive.
Nutritional Balance
– Behavior modification
– Consider medication with weight
gain as a side effect
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•
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Other comorbid disorders
– Diagnose and treat these conditions
vigorously.
Maladaptive attitudes and behaviors
– Acceptance
– Consider cognitive behavioral
psychotherapy (CBT)
Education and self help
– Provide educational resources.
– Recommend a daily exercise
regimen.
– Recommend a healthy diet.
– Suggest healthy distractions.
– Recommend online resources.
– Recommend self help groups with
caution.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry,
Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology,
April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at
Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition,
2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry,
2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second
Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth
Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work
and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
Are there other questions?
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