eating disorders
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eating disorders power pointTRANSCRIPT
Eating Disorders Eating Disorders
Three Categories:
Anorexia Nervosa
Bulimia Nervosa
Bing Eating Disorder
Eating Disorders In General
Main Etiological Factors:
a) Family history of:
1) eating disorder
2) affective disorder
3) substance abuse
4) obesity
b) Personal History of:
1) affective disorder
2) obesity
3) sexual abuse
Etiology Continued:
c) History of disturbed family relations and /or parenting
d) Parental over-concerns about dieting, eating and body shape and weight
Etiology of Eating Disorders Ties in Strongly With a Persons Beliefs About:
- Self Esteem
- Attractiveness
- Beauty
- The “Relational Self”
Taking A Look at Diagnosing
• History Taking• MSE
“Ruling Out” May lead to delays in treatment and co-morbidity
Medical Assessment-good for understanding consequences and complications and decision making about treatment. Is NOT necessarily used for diagnosis.
DSM-IV Criteria
DSM-IV Handout
Anorexia Nervosa
Bulimia Nervosa
Risk Factors That Increase Probability of Eating Disorders
Gender: >females than males by 6-10:1
Age: Teens & 20’s mostly
Location: Western Societies that value thinness
Personality: Anorexia-sensitive, self-critical
persevering
Bulimia-unstable mood, impulsive
dramatic features
Family History: depressive illness, obesity, eating
disorders
Interest Groups: Ballet dancers, wrestlers, models,
jockeys, gymnasts
Risk Factors Continued:
Sexual Orientation: Gay males (not lesbians),
heterosexual females
Critical Sensitizing Events: Teasing, criticism for
overweight, especially comments
by mothers, coaches, peers,
occasional iatrogenic onset
Onset of Drive for Thinness: 40% by age 9 or 10 in
girls
Racial Group: Caucasians > African Americans but
depends on valuation of thinness
Eating Disorders Have Considerable:
* Morbidity and Mortality
* Relatively High Rates of Relapse
All Eating Disorders Share a Common Theme:
Body Shape & Body Image
Caveot
Symptoms of Starvation Resemble
Symptoms of Depression:• Dysphoria• Anhedonia• Poor sleep• Decreased energy• Decreased concentration• Decreased libido• Socially withdrawn
Anorexia Nervosa (AN)• Relatively Rare• High Mortality• Sensitive, self critical, persevering perfectionist• Obcessional, introverted, overly formalistic
(refer to hand-out)
Characteristics
Symptoms
Physical Findings
Bulimia Nervosa (BN)
Essential Features:
* overvaluation of weight and shape
* dietary restriction
* binging
* purging
* age of onset approximately 19
Two Sub-Categories:
Purging Type Non-Purging Type
laxatives exercise to compensate
Induced vomiting fasting
Bulimia Nervosa-continued
(refer to handout) Clinical and Physical Features
There exists similar incidences of co-morbidity inBulimia Nervosa as in Anorexia Nervosa: * depression * anxiety particularly OCD * alcohol and drug abuse * personality disorders
Persons with BN are more: impulsive, dramatic, unstable moods (Mehler & Andersen, 1999)
Binge Eating Disorder (BED)
Essential Features:
* Eating large amounts of food in short period
* Loss of control during the binge
* Associated with 3 or more of the following:
a) eating more rapidly than normal
b) eating until uncomfortably full
c) eating large amounts when not hungry
d) eating alone/hiding
e) feeling disgusted, depressed, guilty after
over-eating
Binge Eating continued: * The binge occurs minimum 2x/week for duration
of 6 months
* Not associated with purging, fasting, or
excessive exercise
BED also associated with co-morbidity (60%)
* Major Depression
*Obsessive Compulsive Disorder
* Panic Disorder
*Substance Abuse
* 35% have personality disorder
Assessment of Eating Disorders
Medical History
Screening Questions
Physical Exam
Signs and Symptoms
Assessment Continued
Common GI Symptoms with Weight Loss:
* bloating
* nausea
* constipation
* heartburn
* abdominal pain
* diarrhea
Assessment Continued
Common GI Symptoms with Bulimia:
* vomiting related
a) heartburn, hoarseness, sore throat,
dysphagia, (difficulty swallowing),
odynophagia (pain on swallowing)
* Purging related
a) diarrhea, abdominal cramping
Assessment Continued
(Handouts)
Recommended Laboratory Tests
Lab Results Indicating Possible Eating Disorder
Common Lab Abnormalities
Electrolytes (Serum and Urinary)
Differential Diagnosis for Eating Disorders
Anorexia Nervosa:
hyperthyroidism
diabetes mellitus
malignancies – lymphoma, stomach cancer
chronic infection – TB, AIDS, fungal diseases
cystic fibrosis
Inflammatory bowel disease – Crohn’s, colitis
chronic pancreatitis
malabsorption syndromes
psychiatric disorders associated with weight loss
Differential continued
Bulimia Nervosa
Inflammatory bowel disease
peptic ulcer disease
parasitic intestinal infections
chronic pancreatitis
hypothalmic lesions or tumors
diverticulum
scleroderma or other connective tissue disorder
with GI involvement
Differential Continued
Binge-Eating Disorder
temporal lobe or limbic seizures
lesions of the hypothalamus, frontal lobe,
or temporal lobe
degenerative neurologic conditions i.e.: Pick
disease, Alzheimer disease, Huntington
disease, Parkinson disease
Clinical Pearls
Anorexics are proud of their weight loss
Bulimic behavior is usually shameful or guilt-producing
Binge–Eating usually occurs in the obese and in older patients (ages 30s-50s)
Eating Disorders in older people are usually complicated by concurrent medical or psychiatric
Once EA is diagnosed, assess for psychiatric disorders as well as medical consequences as both these usually occur
Treatment for Eating Disorders
Goals: * nutritional rehabilitation and a “set point” weight maintenance
* Normal eating behavior
* Healthy thinking about weight
* Appropriate treatment plan with behavioral and pharmacological therapies
* Increased family awareness
* Relapse prevention with continued treatment
Treatment Continued
Mental Health treatments:
* Cognitive Behavioral Therapy (CBT)
* antidepressants
* self help plus brief therapy
* Interpersonal therapy (IP)
* Dialectic Behavioral Therapy (DBT)
Mental Health Treatment
Cognitive Behavioral Therapy-superior to others
* Phase I : focus on regular eating
(3 meals/day plus 2 snacks regardless if
hungry or not)
* Phase II : Modification of thoughts involving
diet and body shape
* Phase III : Relapse Prevention
Treatment Model: Cognitive Maintenance (specifically for BN)
When to Use Antidepressant?
Agras (2001) demonstrated that if patient does not have 70% reduction in symptoms by week 4 of CBT, he recommended initiating SSRI (Fluoxetine). Beginning dose 20 mg and titrate in 2-4 days to 60mg.
Use of antidepressants rational is linked to affective disorders. Possible role of serotonin in feeding behaviors ( serotonin =satiety)
Patients on 60mg Fluoxetine showed 80% response rate within two weeks of treatment
Physical Complications of BN
Metabolic: * weakness, poor skin turgor, dehydration
Gastrointestinal: * abd pain, blood in vomit
Reproductive: * fertility problems, scanty menses, possible hypoestrogenemic
Oropharyngeal: * dental decay, erosion of dental enamel painful throat, swollen cheeks & neck (painless), enlarged salivary glands
Cardiomuscular: * weakness, palpitations, cardiomyopathy, cardiac abnormalities
Physical Complications of AN
CNS: * apathy, poor concentration, depressed, irritable, cognitive impairment
Cardiovascular: * palpitations, dizziness, SOB, chest pain, cold extremities, irregular pulse, BP changes
Skeletal: * bone pain, point tenderness, arrested skeletal growth
Muscular: * weakness, muscle aches, muscle wasting,
Endocrine: * fatigue, cold intolerance, hypothermia
Hematologic: * rare bruising, clotting abnormalities
GI: vomiting, abd pain, bloating, constipation, pitting edema, abnormal bowel sounds