1 eating disorders based on dsm-iv-tr and apa practice guidelines unless otherwise indicated. as of...
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Eating Disorders
Based on DSM-IV-TR and APA Practice Guidelines unless otherwise
indicated. As of 1 Feb 2013.
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Hormone
• Q. What human hormone signals the brain to cease eating? Where does it originate in the body?
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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.
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Types - 2
Ans:
• Two Types:
• Restricting type: current episode with no binge eating/purging.
• Binge eating/Purging type: current episode with binge eating/purging
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Cultural Impact
Ans. More common in:
• Industrial societies
• Where food is abundant
• Where thinness is considered attractive
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Suicide
Q. What co-morbid psychiatric disorders increase chances of suicide in people with anorexia nervosa?
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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.]
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Comorbidity
Q. Most common three comorbid psychiatric disorders, other than substance-related disorders, with eating disorders?
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Differential Diagnoses
• Q. List some of the more important differential diagnoses [other than the co-occurring just listed in the prior slides].
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Differential Diagnoses
• Bulimia Nervosa
• Medical Conditions like brain tumor or cancer
• Somatization Disorder
• Schizophrenia
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Levels of care
Q. In communities with comprehensive eating disorder programs, what are the five levels of care?
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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?
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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%
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Hospitalization
• Q. Under what circumstances should someone with anorexia nervosa be hospitalized? List five.
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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]
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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]
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General or Psych ward?
Q. When should you hospitalize pt on general medical ward? When on psychiatry ward?
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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.
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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
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Russell’s sign
Ans. Abrasions or scars on the back of the hands. These suggest manual attempts at self-vomiting.
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Physical Exam
• Ans. Results that suggest hospitalization are:
• 1. P < 40
• 2. BP < 90/60
• 3. Temp < 97.0
• 4. Signs of dehydration
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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.
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Hospital discharge andweight level
Q. What weight level can be the sole criterion for discharge from the hospital?
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Hospital discharge andweight level
Ans. Weight level should “never” be used as the sole criterion for hospital discharge.
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Essential on discharging
Q. What is essential to establish when the pt is discharge from the hospital?
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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.}
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Partial program indications
Ans.
1. Need for structure to gain weigh
2. Need to prevent compulsive exercising
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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 program5. Needs close supervision of meals and exercise6. Can’t live at home for geographic reasons or
because of family conflicts.
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Complications
• List as many of the ten or so complications as you can, complications that are related to weight loss?
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Wt. loss related complications - 1
Ans.• cachexia, • prolonged QT interval, • PVC’s, • bloating, • constipation,• amenorrhea
• [see next slide]
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Wt loss complications - 2
• lanugo,
• leucopenia,
• zinc deficiency (abnormal taste sensation),
• osteoporosis
• sudden death
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Purging-related complications
Ans. • hypomagnesemia, • hypokalemic hypochloremic alkalosis, • salivary gland inflammation• pancreatic inflammation,• Amylase, • erosion of frontal teeth enamel, • seizures, • mild cognitive disorder
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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.
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Monitoring
Ans.1. Food intake2. Fluid intake and output3. Electrolytes, including phosphorus4. Edema5. Weight 6. Congestive heart failure7. Constipation and bloating
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Q. Weight gain goal while in hospital?
• Q. When hospitalized, what is a reasonable weight gain goal for most of the pts?
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Weight gain as an outpt
Q. What is the desired weight gain of a pt who is being treated as an outpt?
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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?
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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.
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Suspected of over-hydration
Ans. At morning weighing, obtain urine sample and check for specific gravity.
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Persistent vomiters – lab test
Ans. Obtain K+ level. It is often low with such pts, sometimes dangerously low.
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Physical activity
Q. With eating disorders, the level of physical activity, in general, should be?
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Exercise program
Q. Once the pt weight has been achieved, what is the goal of an exercise program?
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Exercise program
Ans. The exercise program should be focused on physical fitness, not on expending calories.
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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]
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Treatments - 3
Continued on usefulness of psychodynamic, in addressing:
Transference
Symptom symbolism
Key conflicts
Narcissistic vulnerabilities
Relational dynamics
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Family therapy
Ans. While could be useful with anyone, it is especially likely to be helpful with children and adolescent pts.
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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]
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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.
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Medications - 2
Ans. There are no medications that have been shown to decrease the pt’s desire to lose weight.
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Nasogastric feeding - 2
Ans. Pt refuses to eat and requires life-preserving nutrition.
Improved results when combined with CBT.
There are potential harms to nasogastric feeding, so not recommended for normal wait pts.
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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
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DX continued
• 4] self-evaluation is unduly influenced by body image
• 5] Above does not occur within episode of anorexia nervosa
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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.
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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.
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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.]
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Bulimia
Ans. Highest treatment results achieved with combination of psychotherapy and meds. Nutritional counseling will be needed with some.
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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.
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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.
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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.
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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.
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Treatment – 2
Ans.
1.CBT, individually or group
2.Meds:
imipramine
citalopram/escitalopram
topiramate