Term
| Eating Disorders- clearing the misconceptions |
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Definition
Eating disorders are not a lifestyle choice.
Eating disorders are drastically underrecognized by health plans.
Eating disorders affect approximately 30 million Americans.
Eating disorders have the highest mortality rate of any mental illness. |
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Term
| Eating Disorders: Risk Factors |
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Definition
| • Complex interaction of genetic, biological, behavioral, psychological, and social factors |
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Term
| Eating Disorders: Emotional Changes |
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Definition
• Changes in attitude or work/school performance
• Expresses complaints or concerns with current body image; speaks negatively about self
• Incessant discussion of food, weight, shape, recipes, groceries, meal preparations
• Obsessive thoughts or talk about food labels
• Sets rigid rules regarding food intake, labeling foods “good” and “bad”
• Appears sad, anxious, ashamed, embarrassed
• Intolerance for imperfections in other areas of life
• Withdraws from friends or family
• Unable or unwilling to acknowledge any changes |
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Term
| Eating Disorders: Physical Changes |
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Definition
• Sudden or rapid weight loss, gain, or fluctuations over a short period of time
• Frequent complaints of abdominal pain, bloating, fullness, constipation
• Feeling tired or cold
• Bloodshot eyes
• Calluses on knuckles
• Dry skin, signs of dehydration
• Lanugo
• Feeling dizzy with standing
• Thinning, dry, brittle hair |
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Term
| Eating Disorders: Behavioral Changes |
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Definition
• Cutting out entire groups of foods, suddenly becoming vegan
• Becomes a self-proclaimed nutrition expert
• Forgoing former activities for exercise
• Refusing meals prepared by other people
• Does not sit still, finding excuses to walk or move
• Purchasing large quantities of unhealthy foods
• Frequent bathroom trips post meals
• Creates detailed lists of food intake
• Wears baggy clothing (to hide)
• Works through lunch, states already ate
• Shows other compulsive behaviors
• Denies difficulty with food or body image |
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Term
| Eating Disorders: Screening |
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Definition
• SCOFF
– Do you make yourself SICK because you feel uncomfortably full?
– Do you worry you have lost CONTROL over how much you eat?
– Have you recently lost more than ONE stone (14 pounds) in a 3-month period?
– Do you believe yourself to be FAT when others say you are too thin?
– Would you say that FOOD dominates your life? |
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Term
| Eating Disorders: High-Risk Groups |
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Definition
• Adolescents
• Women
– High stress or large life transitions
• Athletes
• Family history of eating disorders • Seeking weight-loss help |
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Term
| Eating Disorders: Barriers to Treatment |
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Definition
• There is an average delay of 4 years between the start of disordered eating and initiation of treatment
• Physical signs are not apparent early on
• Patients typically present complaints that appear unrelated
• Initial presentation is usually a test for attitude and judgment by provider |
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Term
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Definition
• Characterized by persistent intake restriction, intense fear of weight gain, and distorted body self-perception
• Typical onset in adolescence (median age of 18 at diagnosis), but affects all ages, races, ethnicities, and socioeconomic
backgrounds |
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Term
| Anorexia Nervosa: Pathogenesis |
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Definition
• Pathogenesis is unknown
• Recent research has suggested a genetic link
– 3,500 individuals with lifetime diagnosis of anorexia
nervosa compared to 11,000 controlsàidentified a significant locus on Chromosome 12 that was
associated with anorexia nervosa
• Altered brain function has been found, but unclear whether changes lead to or result from anorexia nervosa
• Disrupted neurotransmitter systems:
– Dopaminergic function (involved with eating behavior, motivation, reward)
– Serotonergic function (involved with mood, impulse control, obsessional behavior) |
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Term
| Anorexia Nervosa: Evaluation |
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Definition
• SCOFF • History
– Amenorrhea
– Exertional fatigue – Weakness
– Cold intolerance
– Palpitations
– Dizziness
– Abdominal pain, bloating – Early satiety
– Constipation – Pedal edema – Irritability |
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Term
| Anorexia Nervosa: Evaluation Additional information to gather |
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Definition
– Frequency of self-weighing, hx of eating disorders (including prior treatment)
– Meal patterns, tracking methods
– Evaluation of self-esteem, comorbid mental health disorders, suicidality
– Support network |
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Term
| Anorexia Nervosa: Evaluation Physical signs |
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Definition
– BMI < 17.5
– Emaciation (body weight < 70% of ideal)
– Hypothermia (core temp < 35 °C/95 °F) – Bradycardia (< 60 bpm)
– Hypotension (< 90/50)
– Hypoactive bowel sounds – Xerosis
– Brittle hair, hair loss
– Lanugo
– Abdominal distension |
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Term
| Anorexia Nervosa: Evaluation Lab assessment |
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Definition
– CBC
– CMP
– Albumin, prealbumin
– TSH
– Vit D
– UPT
– EKG
– Additional testing based on suspected medical complications |
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Term
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Definition
A. Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health).
B. Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even through significantly low weight).
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
Further specified: restricting or binge-eating/purging type, in partial or full remission, and severity level based on BMI.
Amenorrhea is common but removed from DSM-5. |
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Term
| Anorexia Nervosa: Medical Complications |
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Definition
• Myocardial atrophy
• Mitral valve prolapse
• Pericardial effusion
• Functional hypothalamic amenorrhea
• Antenatal and postpartum complications
• Osteoporosis
• Gastroparesis
• Constipation
• Growth disturbances (adolescents)
• Impulsive or compulsive nonsuicidal self-injury |
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Term
| Anorexia Nervosa: Treatment |
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Definition
• Treatment setting should be determined with help of a specialist
– General rule for inpatient: unstable vitals and/or BMI < 15 • Example:5'5",90lbs=BMIof15
• Standard of care is nutritional rehabilitation with psychotherapy (long term)
• Pharmacotherapy is not recommended for primary treatment
– Olanzapine (Zyprexa) has been used for patients who do not respond to nutritional rehab with psychotherapy
• Mixed research on pharmacotherapy for comorbid depression or anxiety (SSRI)
• Avoid bupropion (lowers seizure threshold) and
antidepressants that impact cardiac function (like TCAs) |
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Term
| Anorexia Nervosa: Prognosis |
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Definition
• ~ 50% have good outcomes
• ~ 25% intermediate outcomes
• ~ 25% poor outcomes
• Better outcomes are associated with personal insight, strong interpersonal relationships
• Poor outcomes are associated with later age at
onset, longer duration of illness, lower minimal weight, lower percent body fat, comorbid mental disorder(s)
• “Cure” is a controversial word; many specialists
prefer “full remission” as it is an ongoing, lifelong battle |
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Term
| Anorexia Nervosa: Mortality |
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Definition
• All-cause mortality is 4–14x greater
• ~ 60% of deaths are caused my medical complications
• Increased rates of suicide
– Studies report rates as high as 25% of all deaths in anorexia nervosa
– Report rates 6x higher than the normal population |
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Term
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Definition
• Characterized by consuming large amounts of food with a feeling of little control, followed
by compensatory actions
– Vomiting, laxatives, diuretics, fasting, excessive exercise
• Usually maintain a healthy or normal weight
• Median age at onset is 20 years old
• High rates of comorbid mental health disorders |
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Term
| Bulimia Nervosa: Pathogenesis |
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Definition
• Pathogenesis is unknown
• Unclear whether observed brain changes lead to or result from bulimia nervosa
– Possibly resulting from not accurately recognizing satiety or hunger
– Reduced cerebral surface in frontal and temporoparietal areas, also related to poor neuropsychological functioning |
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Term
| Bulimia Nervosa: Evaluation |
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Definition
• SCOFF
• History
– Chronically sore throat – Lethargy
– Irregular periods
– Abdominal pain
– Abdominal bloating
– Constipation |
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Term
| Bulimia Nervosa: Evaluation Additional information to gather |
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Definition
– Frequency of self-weighing, hx of eating disorders (including prior treatment)
– Meal patterns, tracking methods
– Triggers or times of day for vomiting
– Food intake when not bingeing episodes
– Evaluation of self-esteem, comorbid mental health disorders, suicidality
– Support network |
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Term
| Bulimia Nervosa: Evaluation Physical signs |
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Definition
– Tachycardia
– Hypotension – Xerosis
– Callused knuckles
– Dental enamel erosion
– Subconjunctival hemorrhages
– Parotid gland swelling (sialadenosis) |
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Term
| Bulimia Nervosa: Evaluation Lab assessment |
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Definition
– CBC
– CMP –UA
– UPT
– Consider EKG |
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Term
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Definition
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a
similar period of time under similar circumstances
2. A sense of lack of control over eating during the episodes
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Further specify partial or full remission, mild to extreme |
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Term
| Bulimia Nervosa: Medical Complications |
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Definition
• Dehydration
• Hypokalemia
• Menstrual irregularities
• Mallory-Weiss syndrome
• Boerhaave syndrome
• Dental enamel erosion
• GERD
• Diarrhea, malabsorption
• Constipation
• Parotid, submandibular gland hypertrophy |
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Term
| Bulimia Nervosa: Treatment |
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Definition
• First-line treatments: nutritional rehabilitation and psychotherapy
– Added pharmacotherapy has proven effective
• First line: SSRI (fluoxetine)
• Second line: a different SSRI
• Third line: TCA
• Bupropion is c/i for bulimia nervosa |
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Term
| Bulimia Nervosa: Prognosis |
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Definition
• Mortality is 2–8x greater than general population
• Elevated risk of suicide
• Relapse is common (~ 30% at 6 months of remission) |
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Term
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Definition
• Characterized by consuming large
amounts of food with feelings of little control, but not followed by compensatory actions
– May represent different stages as same underlying disorder of bulimia nervosa
• More prevalent in those who are pursing weight-loss treatment
• Median age at onset is 23 years |
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Term
| Binge-Eating Disorder: Evaluation History |
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Definition
– Weight dissatisfaction
– Large weight fluctuations
– Depression
– Eating unusually large amounts of food at a time
– Eating excessively when full or not hungry
– Eating rapidly during binge episodes
– Eating until uncomfortably full
– Eating alone, in secret
– Feeling distressed, ashamed, or guilty postconsumption
– Frequent dieting without weight loss |
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Term
| Binge-Eating Disorder: Evaluation Physical signs, Lab assessment |
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Definition
• Physical signs
– No specific findings
• Lab assessment – No specific labs
Medical evaluation should be guided by the medical status of the patient, the same as the
general population. Obesity evaluation is usually necessary. |
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Term
| Binge-Eating Disorder: DSM-5 |
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Definition
DSM-5 criteria
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
2. A sense of lack of control over eating during the episodes
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty afterward
C. Markeddistressregardingbingeeatingispresent.
D. Thebingeeatingoccurs,onaverage,atleastoncea week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in
bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. |
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Term
| Binge-Eating Disorder: Treatment |
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Definition
• First-line treatment is psychotherapy
• May use adjunct pharmacotherapy
– SSRIs, topiramate
– Research is weak, not recommended
– Antiobesity medications are not recommended |
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Term
| Atypical anorexia nervosa |
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Definition
| all of the cxriteria for anorexia nervosa are met, except that despite significant weight loss, the individual's weight is within or above the normal range |
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Term
| bulimia nervosa (of low frequency and/or limited duration) |
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Definition
| all of the criteria for bulimia nervosa are met, ewxcept that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 motnhs |
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Term
| bing-eating disorder (of low frequency and/or limited uration) |
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Definition
| all of the criteria for binge-eating disorder are met, except that the binge eating occurs on average less than oce a week and/or for less than 3 months |
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Term
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Definition
| recurrent purgin behavior to influewnce weight or shape (eg self-induced vomiting, misuse of laxatives diuretics or other medications ) in the absence of binge eating |
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Term
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Definition
| recurrent episodes of night eatisng as manifested by eating after awakening from sleep or by excessive food consumption after the eneving meal. there is awareness and recall of the eating. the night eating is not better explained by external influences such as changes in the individual's sleep-wake cycle or by local social nroms. the night eating causes significant distress and/or impairment in functioning. the disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical disorder or to an effect of medication |
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Term
| Unspecified Feeding or Eating Disorder |
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Definition
• Reserved for individuals who present with characteristic symptoms of an eating disorder but do not meet all of the
specified criteria. The behavior causes significant distress or impairment of social, workplace, or other areas of functioning. |
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Term
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Definition
• Deliberate underuse of insulin by individuals with type 1 diabetes solely for weight control
• ~ 38% of females and 16% of males with DM1 have disordered eating habits
• High rates of comorbidities with other eating disorders |
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Term
| Avoidant/Restrictive Food Intake Disorder |
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Definition
• Onset typically occurs during infancy or early childhood, can persist into adulthood
• Clinical features – Underweight
– Comorbid anxiety |
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Term
| Avoidant/Restrictive Food Intake Disorder: DSM-5 |
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Definition
A. Avoiding or restricting food intake, which may be based upon lack of interest in food, the sensory characteristics of food, or a
conditioned negative response associated with food intake
following an aversive experience (e.g., choking). The eating behavior leads to a persistent failure to meet
nutritional and/or energy needs, manifested by at least one of the
following:
1. Clinically significant weight loss, or in children, poor growth or failure to achieve expected weight gain
2. Nutritional deficiency
3. Supplementary enteral feeding or oral nutritional supplements are required to provide adequate intake
4. Impaired psychosocial functioning
B. The eating or feeding disturbance is not due to lack of available food or associated with a culturally sanctioned practice.
C. The disturbance does not occur solely in the course of anorexia nervosa or bulimia nervosa, and body weight and shape are not distorted.
D. The disturbance is not due to a general medical condition (e.g., gastrointestinal disease, food allergies, or occult malignancy) or another mental disorder. When avoidant/restrictive food intake disorder occurs in the context of another illness, the eating disturbance is both out of proportion to what is expected for the other illness and warrants additional clinical attention. |
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Term
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Definition
• Prevalence is unknown
– Thought to be greater in those with intellectual disability
• Onset is typically in childhood
• Can be a clinical manifestation of iron- deficiency anemia |
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Term
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Definition
A. Repeatedeatingofnonfoodsubstances(chalk,clay, cloth, coal, dirt, gum, hair, metal, pain, paper,
pebbles, soap, string, wool) that are not nutritional, for at least 1 month.
B. Theeatingbehaviorisinappropriatetothepatient’s developmental level and is not culturally supported or socially normal.
C. Iftheeatingbehavioroccursinthecontextofanother mental disorder (autism, intellectual disability, or
schizophrenia) or a general medical condition
(including pregnancy), the severity of the eating behavior warrants additional clinical attention.
Distinguished from nonsuicidal self-injurious behaviors. |
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Term
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Definition
• Typically begins in childhood; little is known about course of disease
• DSM-5
A. Repeated regurgitation of food, which may be rechewed, reswallowed, or spit out; the eating disturbance occurs for at
least 1 month.
B. Regurgitation of food is not due to general medical condition, such as GERD or pyloric stenosis.
C. Regurgitation does not occur solely during the course of avoidant/restrictive food intake disorder, anorexia nervosa,
binge-eating disorder, or bulimia nervosa.
D. If the eating behavior occurs in the context of another mental
disorder (e.g., intellectual disability) or general medical
condition (including pregnancy), the severity of the eating behavior warrants additional clinical attention. |
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Term
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Definition
• Obesity is a physical condition that is deeply rooted in psychology
• Obesity typically results from an intricate web of psychosocial, environmental, and genetic/biologic factors
• Psychological disorders —> difficulty controlling food consumption or staying motivated for exercise |
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Term
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Definition
| mood disturbance -> overeating -> weight gain -> guild -> mood disturbance |
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Term
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Definition
• Society has a negative view of obesity
– Obesity is often wrongly linked to individual
worth, work-ethic, laziness, willpower, and motivation
– Face personal and workplace discrimination, further leading to mood disturbances
• Most individuals have attempted to lose weight on their own; limited success leads
to feelings of worthlessness, diminished self-esteem, failure |
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Term
| Obesity: Psychological Treatment |
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Definition
• Cognitive behavioral therapy: used to
reinforce positive behavior and lifestyle changes
• Classical conditioning: break the strong associations between unhealthy eating behaviors and specific activities
• Majority of research surrounding psychotherapy for weight loss is from bariatric surgery programs |
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