Eating Disorders
Based on DSM-IV-TR and APA
Practice Guidelines unless otherwise
indicated. As of 1 Feb 2013.
1
Hormone
• Q. What human hormone signals the brain
to cease eating? Where does it originate in
the body?
2
Hormone
Ans. Leptin from fat cells signals the brain to
cease eating.
3
Hormone
• Q. What human hormone signals the brain
to eat? Where does it originate?
4
Hormone
Ans. Ghrelin from the stomach signals the
brain to eat.
5
Ghrelin in anorexia nervosa
Ghrelin level in anorexia nervosa?
6
Ghrelin in anorexia nervosa
Ghrelin is usually highly elevated in anorexia
nervosa.
7
DX
• DSM-IV-TR criteria for anorexia nervosa?
8
DX
•
•
•
•
•
•
•
•
Ans.
1] < 85% of expected weight
2] Intense fear of gaining weight
3] Disturbance is the way in which one’s body weight or
shape is experienced
4] In women, amenorrhea for 3 consecutive months.
Two Types:
Restricting type: current episode with no binge
eating/purging.
Binge eating/Purging type: current episode with binge
eating/purging.
9
Types - 1
Q. What are the two types?
10
Types - 2
Ans:
• Two Types:
• Restricting type: current episode with no
binge eating/purging.
• Binge eating/Purging type: current episode
with binge eating/purging
11
Cultural Impact
• Q. What cultural factors contribute to the
prevalence of anorexia nervosa?
12
Cultural Impact
Ans. More common in:
• Industrial societies
• Where food is abundant
• Where thinness is considered attractive
13
Gender
• Ans. Percentage men?
14
Gender
• 10 % are men.
15
Prevalence/Age of Onset
• Q. Prevalence in the United States?
• Q. What is the age of onset?
16
Prevalence/Age of Onset
• 0.5% in the US
• DSM-IV-TR: 14-18 years most common
age of onset.
17
“severe malnutrition”
Q. Definition of “severe malnutrition”?
18
“severe malnutrition”
Ans. <70% standard body weight.
19
Suicide
Q. What co-morbid psychiatric disorders
increase chances of suicide in people with
anorexia nervosa?
20
Suicide
Ans. Substance-abuse/dependence.
[Independent of co-morbidity, there is at
least one major report that has eating
disorders as having the highest rate of
suicides of any psychiatric disorder. So,
depending on the wording of the question,
“anorexia nervosa” may be the correct
answer as to the psychiatric disorder with
highest suicide rate.]
21
Comorbidity
Q. Most common three comorbid psychiatric
disorders, other than substance-related
disorders, with eating disorders?
22
Comorbidity
• Depression – 65%
• Social Phobia – 34%
• OCD – 26%
23
Differential Diagnoses
• Q. List some of the more important
differential diagnoses [other than the cooccurring just listed in the prior slides].
24
Differential Diagnoses
• Bulimia Nervosa
• Medical Conditions like brain tumor or
cancer
• Somatization Disorder
• Schizophrenia
25
Levels of care
Q. In communities with comprehensive
eating disorder programs, what are the
five levels of care?
26
Levels of care
Ans.
1. Outpt
2. Intensive outpt
3. Partial
4. Residential
5. Inpt
27
Levels of care and weight
Q. While rigid rules as to weight are to be
avoided, in general, for the five levels of
care on the prior screen, what level of care
suggests what level of care?
28
Levels of Care - weight
Ans.
1. Outpt = >85% of desired weight
2. Intensive outpt = > 80% of desired
weight
3. Partial = >75%
4. Residential = <85%
5. Inpt = <75%
29
Hospitalization
• Q. Under what circumstances should
someone with anorexia nervosa be
hospitalized? List five.
30
Ans. Hospitalization
Ans.
• 1] Rapid and persistent decline in weight
despite outpt or partial hospitalization
treatment.
• 2] Presence of additional stressors that
lead to more inability to eat, e.g., a bad GI
viral illness
• [see next slide]
31
Hospitalization
Ans. continued.
• 3. Prior history of anorexia weight loss that
led to instability.
• 4. Comorbid psychiatric illnesses that,
given both, require hospitalization.
• 5. Comorbid somatic illnesses that, given
both, require hospitalization.
• [Suicidal also might be an answer]
32
General or Psych ward?
Q. When should you hospitalize pt on
general medical ward? When on
psychiatry ward?
33
General or psych ward
Ans.
1. Depends on the skills of the two units.
2. Depends on how pressing are the pt’s
non-psychiatric medical needs.
34
Physical exam foci
Q. In doing the physical examination, what
to focus on?
35
Physical exam foci
Ans.
1. Dehydration
2. Acrocyanosis
3. Lanugo
4. Salivary gland enlargement
5. Russell’s sign
6. Sexual development in younger pts looking for
less than expected development
36
Acrocyanosis
Q. What is acrocyanosis?
37
Acrocyanosis
Ans. Acrocyanosis is circulatory disorder in
which the hands are cold and blue.
38
Russell’s sign
Q. What is Russell’s sign?
39
Russell’s sign
Ans. Abrasions or scars on the back of the
hands. These suggest manual attempts at
self-vomiting.
40
Physical Exam
• Q. What physical examination findings
suggests a need for hospitalization?
41
Physical Exam
• Ans. Results that suggest hospitalization
are:
•
•
•
•
1. P < 40
2. BP < 90/60
3. Temp < 97.0
4. Signs of dehydration
42
Lab tests
• Q. Lab tests that suggest a need to
hospitalize?
43
Lab tests
Ans.
• Lab tests that suggest a need to
hospitalized:
• 1. k < 3.0
• 2. electrolyte imbalance
• 3. Lab tests that suggest hepatic, renal or
cardiovascular signs of deterioration.
44
Hospital discharge and
weight level
Q. What weight level can be the sole
criterion for discharge from the hospital?
45
Hospital discharge and
weight level
Ans. Weight level should “never” be used as
the sole criterion for hospital discharge.
46
Essential on discharging
Q. What is essential to establish when the pt
is discharge from the hospital?
47
Essential on discharging
Ans. Discharge document should state
where and when the pt will next be seen.
{This answer will fit any discharge of any
disorder as Joint Commission and CMS
[Medicare] expect this continuity with all
psychiatric discharges.}
48
Partial program indications
Q. When are partial programs indicated?
49
Partial program indications
Ans.
1. Need for structure to gain weigh
2. Need to prevent compulsive exercising
50
Partial programs
Q. How intense, i.e., how many hours/week,
should a partial program be?
51
Partial program
Ans. At least five 8-hour days/week. So, a
40 hour week.
52
Indications for residential program
Q. What are the indications for residential
programs
53
Indications for residential program
Ans.
1. >75% and <85% desired weight [but some
flexibility on this requirement is desired]
2. Medically stable, does not need IVs,
nasogastric feedings or multiple daily lab tests.
3. Not planning suicide.
4. Cooperative with highly structured program
5. Needs close supervision of meals and exercise
6. Can’t live at home for geographic reasons or
because of family conflicts.
54
Complications
• List as many of the ten or so complications
as you can, complications that are related
to weight loss?
55
Wt. loss related complications - 1
Ans.
• cachexia,
• prolonged QT interval,
• PVC’s,
• bloating,
• constipation,
• amenorrhea
• [see next slide]
56
Wt loss complications - 2
•
•
•
•
•
lanugo,
leucopenia,
zinc deficiency (abnormal taste sensation),
osteoporosis
sudden death
57
Purging-related complications
• Q. Purging-related complications?
58
Purging-related complications
Ans.
• hypomagnesemia,
• hypokalemic hypochloremic alkalosis,
• salivary gland inflammation
• pancreatic inflammation,
•  Amylase,
• erosion of frontal teeth enamel,
• seizures,
• mild cognitive disorder
59
Long range goals
Q. Long range treatment goals in the
treatment of anorexia nervosa?
60
Long –range Treatment Goals
Ans.
• 1] “healthy weight”
• 2] For females, weight at which menses
and ovulation return.
• 3] For men, weight at which normal sex
drives and testosterone return to normal
level.
61
Gender and therapist
Q. Should choice of therapist’s gender be an
issue?
62
Gender and therapist
Ans. Yes, it should be attended to in
selecting health care clinician.
63
Monitoring
Q. What should be monitored in eating
disorder programs?
64
Monitoring
Ans.
1. Food intake
2. Fluid intake and output
3. Electrolytes, including phosphorus
4. Edema
5. Weight
6. Congestive heart failure
7. Constipation and bloating
65
Q. Weight gain goal while in
hospital?
• Q. When hospitalized, what is a
reasonable weight gain goal for most of
the pts?
66
Ans. Weight gain goal while in
hospital
• 2-3 lbs/week
67
Weight gain as an outpt
Q. What is the desired weight gain of a pt
who is being treated as an outpt?
68
Weight gain goals
while an outpt:
Ans. ½ to 1 lb/week
69
Nutritional needs
Q. In addition to a well balanced diet, what
are the beginning kcal for a typical pt in
treatment? What kcal for weight gain?
What for weight maintenance?
70
Nutritional needs
Ans. Begin at 30-40 kcal/kg/d [1,000 - 1,600
kcal] and increase periodically until the
kcal/d leads to weight gain, usually means
70-100 kcal/day.
After desired weight is attain, 40-60
kcal/kg/d is the usual desired level.
71
Supplements
Q. What supplements are used in eating
disorder programs?
72
Supplements
Ans.
1. Vitamins
2. Minerals, especially phosphorus
73
Rapid weight gain
Q. Your pt gains weight very rapidly. What
should be your concern?
74
Rapid weight gain
Ans. Fluid overload.
75
Suspected of over-hydration
Q. How to evaluate if you suspect your pt is
over-hydrating?
76
Suspected of over-hydration
Ans. At morning weighing, obtain urine
sample and check for specific gravity.
77
Persistent vomiters – lab test
Q. What lab test is recommended to identify
persistent vomiters?
78
Persistent vomiters – lab test
Ans. Obtain K+ level. It is often low with
such pts, sometimes dangerously low.
79
Physical activity
Q. With eating disorders, the level of
physical activity, in general, should be?
80
Physical activity
Ans. Physical activity should be consistent
with food intake.
81
Exercise program
Q. Once the pt weight has been achieved,
what is the goal of an exercise program?
82
Exercise program
Ans. The exercise program should be
focused on physical fitness, not on
expending calories.
83
Treatments - 1
• Q. What is status of CBT, family therapy
and psychodynamic therapy?
84
Treatments - 2
• CBT – effective for weight gain
• Family Therapy – Often used
• Psychodynamic Therapy – not very
successful due to resistance, but there are
anecdotal reports of success. Also recent
reports suggest psychodynamic
psychotherapy can be useful in [see next
screen]
85
Treatments - 3
Continued on usefulness of psychodynamic,
in addressing:
Transference
Symptom symbolism
Key conflicts
Narcissistic vulnerabilities
Relational dynamics
86
Family therapy
Q. Under what circumstances should family
therapy be considered
87
Family therapy
Ans. While could be useful with anyone, it is
especially likely to be helpful with children
and adolescent pts.
88
Olanzapine in anorexia nervosa
Use of olanzapine in anorexia nervosa?
89
Olanzapine - 2
Olanzapine has been shown to be effective
in raising the body mass index and reduce
obsessionality, including obsessional
thoughts about food. Olanzapine is one of
the most potent appetite stimulants known,
and causes the body to preferentially store
fat. [next slide has references]
90
Olanzapine -- references
• Brambilla, Francesca; Garcia, Cristina Segura; Fassino,
Secondo; Daga, Giovanni Abbate; Favaro, Angela;
Santonastaso, Paolo; Ramaciotti, Carla; Bondi, Emilia et
al. (2007). "Olanzapine therapy in anorexia nervosa:
psychobiological effects". International Clinical
Psychopharmacology 22 (4): 197–204.
doi:10.1097/YIC.0b013e328080ca31. PMID 17519642.
• ^ Bissada H, Tasca GA, Barber AM, Bradwejn J (2008).
"Olanzapine in the treatment of low body weight and
obsessive thinking in women with anorexia nervosa: a
randomized, double-blind, placebo-controlled trial". The
American Journal of Psychiatry 165 (10): 1281–8.
doi:10.1176/appi.ajp.2008.07121900. PMID 18558642.
91
Medications
Q. Name medications shown to reduce
desire of these pts to lose weight?
92
Medications - 2
Ans. There are no medications that have
been shown to decrease the pt’s desire to
lose weight.
93
Nasogastric Feeding - 1
Q: Status of nasogastric feeding in pts with
anorexia nervosa?
94
Nasogastric feeding - 2
Ans. Pt refuses to eat and requires lifepreserving nutrition.
Improved results when combined with CBT.
There are potential harms to nasogastric
feeding, so not recommended for normal
wait pts.
95
Bulimia
DSM-IV criteria?
96
Bulimia
• DSM-IV:
• 1] Recurrent binging
• 2] Recurrent inappropriate compensatory
actions, such as self-induced vomiting
• 3] Above two occur, on average, 2x/week for at
least 3 months
• See next slide
97
DX continued
• 4] self-evaluation is unduly influenced
by body image
• 5] Above does not occur within
episode of anorexia nervosa
98
Types of bulimia- ?
What are the types of bulimia?
99
Types of bulimia - answer
• Two types:
• Purging: current episode with regular
self induced vomiting or use of
laxatives, diuretics, and enemas.
• Non-purging: current episode using
other means like fasting or exercise.
100
Family therapy - 1
Q. Role of family therapy?
101
Family therapy - 2
Ans. Valuable, especially for adolescents.
102
Bulimia
• Q. What psychotherapies are
recommended for bulimia?
103
Ans. Psychotherapies for
bulimia are
• 1. CBT has most evidence. If asked for
“treatment of choice,” CBT is the correct
answer.
• 2. Interpersonal has some evidence, a
choice if CBT fails.
• 3. Psychodynamic therapy my be helpful
once pt is improving.
104
Preferred Class of meds
for bulimia?
Q. What is the preferred class of meds for
bulimia?
105
Meds for bulimia
Ans. SSRIs [fluoxetine is FDA approved]
106
Meds - Bulimia
• Q. SSRI dosing with this disorder?
107
Meds - Bulimia
• SSRIs are often prescribed at higher
doses than with pts with MDD.
108
Meds
• Q. What about TCAs for bulimia?
109
Meds
Ans.
• Cautious because of suicidal potential with
these pts.
110
Meds for bulimia
• Q. What about MAOIs being used with
bulimia?
111
Meds -- MAOIs
Ans.
• Should be avoided because of the
potential of binge eating.
112
Meds - Bulimia
Q. What about Li with bulimia?
113
Meds - Bulimia
Ans. Vomiting makes it difficult to maintain
the desired blood levels.
114
Meds for bulimia
Q. What about using bupropion?
115
Meds - Bulimia
Ans. Don’t use bupropion because of
increased chances of seizures.
[Some think this is not correct, but the above
is still the answer usually expected.]
116
Bulimia
Q. Highest remission rates in bulimia
achieved with what treatment
approaches?
117
Bulimia
Ans. Highest treatment results achieved with
combination of psychotherapy and meds.
Nutritional counseling will be needed with
some.
118
Group therapy for bulimia
Q. What would be goal of group therapy for
people with bulimia?
119
Bulimia – Group Therapy
Ans. Probably has many uses given the pt’s
needs. “To reduce shame” is probably a
use that is appropriate for every pt.
120
FDA approved for bulimia?
Q. FDA approved for bulimia?
121
FDA approved for bulimia:
Ans. Fluoxetine
122
Meds
• Q. What meds are recommended for
weight restoration per se in eating
disorders?
123
Meds for weight restoration
Ans. None established for that specific
purpose. But if the pt is also depressed,
has OCD or another anxiety disorder,
then, obviously, an SSRI would help the pt
maintain their weight.
124
Hospitalization - Bulimia
Q. Under what conditions should someone
with bulimia be hospitalized?
125
Hospitalization - Bulimia
Ans. Not a common need, but consider
hospitalization when:
• 1] Disorder still at severe level after outpt
treatment.
• 2] Pt has serious, concurrent general
medical illness.
• 3] Suicidal
• 4] Pt has another psychiatric disorder that
merits hospitalization on its own.
126
Binge eating disorder
essential characteristics - 1
Q: Essential features?
127
Essential characteristics - 2
Ans: Recurrent episodes of binge eating
associated with subjective and behavioral
indicators of impaired control over, and
significant distress about binge eating
AND
Lacking signs of bulimia.
128
Treatment of binge eating disorder
-1
Q: Treatment?
129
Treatment – 2
Ans.
1.CBT, individually or group
2.Meds:
imipramine
citalopram/escitalopram
topiramate
130
Binge Eating Disorder – meds - 1
Q: status of sibutramine?
131
Bing Eating Disorder – meds - 2
Ans. Sibutramine has been withdrawn from
US markets after FDA withdrew its
approval.
132