eating disorders

Question 1

what is body image

Answer 1

• perception that a person has of their physical self
• thoughts and feelings as a result of that perception
• Influenced by individual and environmental factors

Question 2

How we see ourselves
what is this called?

Answer 2

Perceptual

Question 3

How we feel about how we look
what is this called?

Answer 3

affective
Can be positive, negative, or both

Question 4

Our thoughts and beliefs about our body
what is this called?

Answer 4

cognitive
ex: “I will feel better about myself if I tone up”
“I won’t lose weight no matter how much I exercise”

Question 5

What we do in relation to how we look
what is this called

Answer 5

behavioral
Destructive behaviors
Self-isolation
Wearing revealing / “bodycon” clothing

Question 6

Developed countries tend to place a very heavy emphasis on what type of image on women and men that causes body dissatisfaction

Answer 6

thin body types for females
lean/muscular body types for men

Question 7

where is body dissatisfaction more common?

Answer 7

Post-industrialized, high-income countries such as:
- USA
- European countries (especially Western Europe)
- Australia and New Zealand
- Japan and South Korea

Question 8

implication of body dissatisfaction

Answer 8

If we achieve this body type, love, success and happiness will result

Question 9

What makes body dissatisfaction different from an eating disorder?

Answer 9

“Morbid fear of weight gain”
The idea that “one cannot be too thin” overrides all other interests and affairs

Question 10

general risk factors for body dissatisfaction

Answer 10

1. Age - late childhood/adolescence
2. Gender - female
3. Low self esteem
4. Personality - perfectionism, high achievers, anxiety, “black and white” world views
5. Appearance teasing
6. Activities - with emphasis on “thinness” - ballet, modeling, athletics
7. Friends/Family - frequent dieting for weight loss or high body image concerns expressed around patient
8. Larger body size
9. Homosexuality - in males
10. Acculturation into Western society - from a developing country

Question 11

what is the biological link for body dissatisfaction

Answer 11

Possible genetic link
1. Mothers/sisters of anorexic pts - 8x as likely to also have
2. Twin studies
- 50-90% will have anorexia if their twin does
- 35-50% will have bulimia if their twin does
- More common in identical (monozygotic) twins
3. Anorexia - disturbances in serotonin, dopamine, norepinephrine
4. Bulimia - disturbances in serotonin (deficient)
5. Possible difficulty with recognizing hunger and satiety states

Question 12

what are the commonly associated psychological problems with body dissatisfaction

Answer 12

Obsessive-compulsive
Anxiety
Depression
Low self-esteem
Social anxiety disorder
Phobias
Body dissatisfaction
Body dysmorphic disorder

Question 13

what are the familial risk factors for body dissatisfaction

Answer 13

1. Enmeshed parenting
2. Conflict-avoidant families
   - Inflexibility
3. Push for very high levels of success
4. Family members with body dissatisfaction or poor eating habits/eating disorders
   - Patients may have childhood memories of being “made” to eat more or less food than they desired or go on diets
5. Anorexic families - rigid, controlling, organized
6. Bulimic/BED families - chaotic, critical, conflicted

Question 14

sociocultural risk factors for body satisfaction

Answer 14

1. Western society’s ideals
2. People elicit different reactions in social situations based in part on physical and psychological traits
   - Physical - body build, degree of “attractiveness”, clothing, hygiene, grooming, etc.
   - Psychological - temperament, behavioral style, social skills
3. Social feedback then shapes positive or negative adjustment of our self-image
4. Related to effectiveness or ineffectiveness of parents
   - Ineffective parents don’t respond appropriately to child’s needs
   — Feeding at times of anxiety instead of hunger
   — Comfort at times of hunger rather than times of anxiety
5. Interferes with self-ability to accurately identify hunger versus emotions and feeling helpless as a result
   - Parents of pts tend to define the pt’s needs for them
   - Pts display alexithymia and dependency
6. Eventually causes abnormal eating habits as pt attempts to regain control over their own bodies

Question 15

cognitive risk factors for body dissatisfaction

Answer 15

1. Pts with eating disorders often feel that their body size is the only important part of their self-image
   - If they are not exceedingly thin, they feel it “proves” they are weak, lazy, inferior, unlovable, incompetent
2. Mistrust for comparisons of their appearance
3. Often ignore or have difficulty accepting objective evidence of their body’s state

Question 16

what % of the population has had tried dieting

Answer 16

80%
40% of 9-year-old girls have dieted

Question 17

How do we tell the difference between normative vs abnormal dieting

Answer 17

Patient’s weight
Health status
Body perception
Healthful or harmful?

Question 18

classic presentation of Avoidant / Restrictive Food Intake Disorder

Answer 18

underweight child (average BMI - 16)
- Decreased bone mineral density
- 60% have comorbid anxiety
- 50% have a comorbid general medical disorder

Question 19

criteria for Avoidant / Restrictive Food Intake Disorder

Answer 19

1. Avoiding or restricting food intake:
   - May be due to lack of interest in food, sensory characteristics of food, or conditioned negative response following an aversive experience
2. Avoiding/restricting food intake leads to a persistent failure to meet nutritional or energy needs, as manifested by at least 1 of the following:
   - Clinically significant weight loss, poor growth or failure to achieve expected weight gain
   - Nutritional deficiency
   - Oral supplements or enteral feeding required to achieve adequate nutrition
   Impaired psychosocial functioning
3. Not due to lack of available food or associated with a culturally sanctioned practice
4. Not due to a general medical condition or another mental disorder

Must have each of the following

Question 20

epidemiology of Anorexia Nervosa

Answer 20

1. Lifetime prevalence - 0.6%
2. 3x more common in women
   - In women - 0.9%; in men - 0.3%
   - Gender gap appears to be decreasing
3. Bimodal peak onset
   - Early adolescence - 12-15 yrs
   - Late adolescence/early adulthood - 17-21 years
   - Average age at onset - 18 years
4. Classic patient - adolescent white female

Question 21

characterization/clinical findings of anorexia nervosa

Answer 21

1. Restricted energy intake → low body weight
2. Intense fear of weight gain, or persistent behavior preventing weight gain
3. Distorted perception of weight, undue influence of weight on self-worth, or denial of the medical seriousness of low weight
4. Abnormal Food Behaviors
   - Reduction in total food intake
   - Exclusion of highly caloric foods
   - May claim distaste for food or epigastric pain
   - May have food-related obsessions
5. Other Common Behavioral Disturbances
   - Distorted perception of part or all of body weight
   - May admit to being high achiever or perfectionist
   - Can have limited social activities
6. Psych
   - Depression, irritability
   - Fatigue and weakness
7. Bone pain
8. Amenorrhea
9. GI
   - Constipation
   - Abdominal pain
10. Derm
    - Hair loss, brittle nails
    - Russell’s sign

Question 22

severity classification for anorexia nervosa

Answer 22

1. Mild - BMI ≥17
2. Moderate - BMI 16 - 16.99
3. Severe - BMI 15 - 15.99
4. Extreme - BMI <15

Question 23

subtypes of anorexia nervosa

Answer 23

1. Binge-Eating - engage in “purging” behaviors (laxatives,
   vomiting, enemas)
   - Usually smaller binges and less frequent purges than bulimia
2. Restrictive - no purging behaviors

Question 24

what are the severe signs of starvation

Answer 24

1. General
   - Emaciation
   - Hypothermia
2. Cardiovascular
   - Significant hypotension
   - Bradycardia
   - Peripheral edema
3. Derm
   - Dry and flaky skin
   - Lanugo
   - Petechiae on extremities
   - Sallow complexion
4. Bone
   - Dental enamel erosion
   - Osteoporosis

Question 25

MC result from AN from consequences of starvation, suicide, or electrolyte imbalance

Answer 25

Death

Question 26

labs/workup for AN

Answer 26

1. ECG for cardiac dysrhythmias 2. UA for specific gravity 3. Serum labs: - CMP - lytes, kidney and liver function, protein, glucose - phosphorus - magnesium - INR - CBC with diff

Question 27

what signs mean that the pt needs to be admitted for AN

Answer 27

1. Unstable vitals or Hypothermia (<35 C or 95 F) 2. End-organ complications - seizures, failure (heart, kidneys, liver, etc.) 3. Cardiac complications - HR <30 bpm or <40 bpm w/hypotension or dizziness - Cardiac dysrhythmia (other than bradycardia) 4. Psych complications - Suicidal ideation with high lethality plan or suicide attempt - Acute food refusal, very poor compliance or other acute psych emergency 5. Nutrition complications - Weight <70% ideal body weight - Marked dehydration - Refeeding syndrome

Question 28

Main goals of treatment for AN

Answer 28

1. Medical stability and management of complications 2. Weight stabilization and eventual return to healthy weight 3. Adoption of healthy nutrition and eating patterns 4. Treating underlying disordered psychopathology 5. Preventing relapse

Question 29

tx for AN

Answer 29

1. Multimodal approach is essential! - Nutritional rehabilitation, psychotherapy, medical management 2. Psych meds are not first line treatment - 2nd gen antipsychotic (olanzapine), anxiolytic (lorazepam) may help with patients not gaining weight with above - SSRI may help if comorbid anxiety/depression

Question 30

what medication at higher doses can prevent relapse once weight is restored?

Answer 30

fluoxetine (Prozac)

Question 31

prognosis for AN

Answer 31

1. 50% - good outcomes 2. 25% - intermediate outcomes 3. 25% - poor outcomes - Later age at onset, longer duration, lower minimal weight, lower body fat after weight restoration, psych comorbidities 4. 35-55% eventually relapse 5. All-cause mortality - 6x higher risk of death - Medical complications - 50% of deaths - Suicide - 25% of deaths

Question 32

epidemiology of BN

Answer 32

1. Lifetime prevalence - 1.0% - In women - 1.5%; in men - 0.5% 2. 3x more common in women 3. Median age of onset - 18-20 years 4. Classic patient - adolescent white female

Question 33

criteria for BN

Answer 33

Recurrent binge eating and inappropriate compensatory behaviors at least once a week for three months Self-evaluation is unduly influenced by body weight

Question 34

MC compensation for BN

Answer 34

**vomiting** (80-90%) Laxative use in ⅓ Less common - Enemas, diuretics, fasting

Question 35

subtypes for BN

Answer 35

1. Purging - engage in self-induced vomiting or misuse of laxatives, diuretics, enemas 2. Nonpurging - engages in other inappropriate compensatory behaviors such as fasting, excessive exercise

Question 36

Typical pattern of behavior of BN

Answer 36

1. Caloric restriction 2. Binge - Consumption of large quantities of foods - Often in in secret 3. Compensatory mechanism - Often with guilt and depression Slightly more control over timing of behaviors - arrange around work, school, etc.

Question 37

clinical findings of BN

Answer 37

1. Lethargy 2. Irregular menses 3. Cardiac - Hypotension - Tachycardia - Peripheral edema 4. GI - Constipation, abdominal pain, bloating - If vomiting - eroded dental enamel and “puffy cheeks” due to parotid hypertrophy may be seen 5. Derm - Hair loss - Russell's sign 6. Body weight typically within or above the normal range

Question 38

severe signs of BN

Answer 38

1. Dehydration 2. Hypokalemia 3. Hypochloremia 4. Metabolic alkalosis

Question 39

what is the major complication of BN

Answer 39

GI - salivary gland hypertrophy, loss of gag reflex, GI tract dysmotility, GERD, esophageal tears or rupture, malabsorption, diarrhea, constipation, pancreatitis cardiac more rare than AN

Question 40

labs for BN

Answer 40

1. UA and serum labs - BUN/Cr, electrolytes, LFTs, CBC with diff 2. If severely ill - ECG and serum calcium, magnesium and phosphorus

Question 41

Admit if BN patient displays signs of:

Answer 41

1. Unstable medical condition 2. Suicidal ideation or other severe psychiatric decompensation 3. Refusal of treatment with potential to become unstable

Question 42

tx for BN

Answer 42

1. Nutritional rehabilitation, psychotherapy, pharmacotherapy - Unlike anorexia, **CBT shows clear advantage** 2. Antidepressants are often helpful - SSRIs - fluoxetine (1st line) or other SSRI - TCA if no improvement on SSRIs

Question 43

what antidepressant is contraindicated for AN and BN

Answer 43

Bupropion can cause seizures

Question 44

prognosis for BN

Answer 44

1. 2x increase in all-cause mortality 2. High comorbidity with anxiety, depressive disorders, personality disorders, PTSD, and substance use - 25-40% of bulimic patients have a positive lifetime history of suicide attempt 3. 50-70% short-term reduction of symptoms - 60% recover in longer follow-up - 28% relapse rate

Question 45

epidemiology of BED

Answer 45

1. Lifetime prevalence (US) - 2.6% - 30% prevalence in weight-control clinical programs 2. More common in women - In women - 3.5%; in men - 2.0% 3. Median age of onset - 23 years 4. Less researched despite higher prevalence

Question 46

Recurrent binge eating without compensatory behaviors is what disorder?

Answer 46

BED

Question 47

what is the severity classification of BED

Answer 47

1. Severity - ranked by frequency of episodes per week - Mild: 1-3 - Moderate: 4-7 - Severe: 8-13 - Extreme: 14+

Question 48

common reported symptoms of BED

Answer 48

1. Food is seen as a coping or comfort mechanism 2. Patients continue eating even after they feel full, or if they do not feel hungry to begin with 3. Many eat large quantities of food very quickly 4. Feelings of shame, guilt, and hopelessness frequently occur during or immediately following a binge-eating episode 5. Patients typically try to hide part or all of their eating habits

Question 49

what comorbidties contribute to BED

Answer 49

1. About 50% of patients are overweight or obese - More likely to be overweight or obese prior to BED onset - Less likely to seek treatment if they are of normal weight 2. Most have at least some degree of impaired functioning 3. Frequent comorbid psychological disorders - Anxiety disorders (specific phobia, social phobia) - ADHD - Depressive disorders - PTSD - Alcohol use - Personality disorders - History of abuse

Question 50

complications with BED

Answer 50

1. General - sleep changes, higher risk of cancer 2. MSK - muscle and joint pain, limited mobility 3. CV - heart disease, atherosclerosis, HTN, HF, CVA 4. Pulm - dyspnea on exertion, sleep apnea 5. Metabolic - development or worsening of obesity, DM and/or HLD 6. GI - abdominal pain, GI upset 7. Psych - development or worsening of comorbid psych disorders, social difficulties, impaired functioning

Question 51

management/tx for BED

Answer 51

1. Psychotherapy - first line treatment (especially CBT) 2. Behavioral weight loss therapy 3. May try using pharmacotherapy - SSRIs (first line) - Antiepileptic (topiramate, zonisamide) - Lisdexamfetamine (Vyvanse) - Antiobesity drugs not recommended due to SE, limited efficacy in BED patients