Module 22: Eating disorders

Question 1

Which eating disorder has the highest mortality rate among all mental illnesses?

Answer 1

Anorexia Nervosa (AN) has the highest mortality rate of any mental illness.

Question 2

What is the estimated mortality rate for Anorexia Nervosa per 1000 person-years?

Answer 2

The mortality rate for Anorexia Nervosa is estimated to be 5.39 per 1000 person-years.

Question 3

How does the mortality rate of anorexic patients compare to schizophrenic patients and the general young female population?

Answer 3

The mortality rate of anorexic patients is twice as high as the rate in schizophrenic patients and 12 times higher than the mortality rate of the young female population.

Question 4

What percentage of patients with anorexia or bulimia are male, and what percentage of binge eating disorder patients are male?

Answer 4

Approximately 5-15% of patients with anorexia or bulimia are male, and up to 40% of patients with binge eating disorder are male.

Question 5

What are the three core clinical features (DSM-5 criteria) of Anorexia Nervosa?

Answer 5

The three DSM-5 criteria for Anorexia Nervosa are: 1) Persistent restriction of food intake leading to a significantly low body weight; 2) An intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain; and 3) A distorted body image, undue influence of body shape/weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

Question 6

What is the estimated heritability of Anorexia Nervosa?

Answer 6

Anorexia Nervosa has an estimated heritability of 58%.

Question 7

What are some common food-related rituals seen in patients with Anorexia Nervosa?

Answer 7

Patients may severely restrict food types (e.g., low-calorie or specific food groups), cut food into small pieces, not allow different foods on their plate to touch, overuse condiments, or refuse to eat in public.

Question 8

What is a common general symptom of Anorexia Nervosa related to patient insight?

Answer 8

Anorexic patients commonly have limited insight into their condition and are reluctant to get treatment and gain weight.

Question 9

What is the most common comorbid psychiatric illness seen in Anorexia Nervosa patients?

Answer 9

The most common comorbid psychiatric illness in Anorexia Nervosa patients is Major Depressive Disorder.

Question 10

What percentage of adolescent Anorexia Nervosa patients meet criteria for at least one comorbid psychiatric illness?

Answer 10

About 50% of adolescent patients with Anorexia Nervosa meet criteria for at least one comorbid psychiatric illness.

Question 11

Do psychiatric comorbidities in Anorexia Nervosa typically resolve with weight gain?

Answer 11

Many comorbid mental disorders in AN emerge due to altered neurotransmitter metabolism or endocrine changes from caloric deprivation and tend to resolve as the patient gains weight.

Question 12

What percentage of anorexic patients are estimated to have attempted suicide at least once in their lives?

Answer 12

Reviews estimate that 8-27% of anorexic patients have attempted suicide at least once in their lives.

Question 13

What two factors increase the rates of suicide attempts in anorexic patients?

Answer 13

Higher rates of suicide attempts are seen in patients with substance abuse disorders or those who are victims of sexual abuse.

Question 14

What percentage of deaths due to Anorexia Nervosa are accounted for by sudden cardiac death and suicide?

Answer 14

Sudden cardiac death and suicide account for 60% of the deaths due to Anorexia Nervosa.

Question 15

What is a common cardiac complication in Anorexia Nervosa, and at what heart rate should a patient be hospitalized?

Answer 15

Most patients have bradycardia (resting heart rate < 60 bpm). Patients with a heart rate less than 40 bpm should be hospitalized for monitoring.

Question 16

What gastrointestinal complication in Anorexia Nervosa leads to early satiety, nausea, and bloating?

Answer 16

Patients with anorexia have significantly slowed gastric emptying (gastroparesis).

Question 17

What is Superior Mesenteric Artery Syndrome (SMAS) and how is it caused in Anorexia Nervosa patients?

Answer 17

SMAS is caused by extrinsic compression of the third portion of the duodenum by the superior mesenteric artery due to loss of a fatty tissue pad that normally maintains this space.

Question 18

What is the treatment for SMAS in Anorexia Nervosa?

Answer 18

Treatment involves weight gain with a soft or liquid oral diet or enteral feeds to restore the fat pad.

Question 19

What hematologic complications are commonly seen in Anorexia Nervosa, and what causes them?

Answer 19

Anemia (40%), leukopenia (30%), and thrombocytopenia (10%) are common. These cytopenias are due to marrow fat atrophy and replacement with mucopolysaccharide.

Question 20

Are neutropenic Anorexia Nervosa patients more susceptible to infections?

Answer 20

Interestingly, neutropenic patients are not more susceptible to infections, but they don’t manifest a typical febrile response and inflammatory markers are suppressed, potentially delaying infection diagnosis.

Question 21

Which complication of Anorexia Nervosa may leave irreversible damage even after recovery?

Answer 21

Osteoporosis is one of the few complications of anorexia that may leave irreversible damage even after recovery.

Question 22

What is the main treatment for osteoporosis in Anorexia Nervosa?

Answer 22

The mainstay of treatment for osteoporosis is weight gain and resumption of menses.

Question 23

What endocrine abnormality is common in both male and female Anorexia Nervosa patients, and what is its effect?

Answer 23

Both male and female patients are hypogonadal with low levels of FSH and LH, resulting in amenorrhea in most female patients and low testosterone in males.

Question 24

What is a poor prognostic sign related to blood glucose in severe Anorexia Nervosa?

Answer 24

Hypoglycemia occurs as anorexia becomes more severe due to depleted hepatic glycogen stores and is a poor prognostic sign requiring close monitoring.

Question 25

Do brain atrophy changes in Anorexia Nervosa patients improve with weight gain?

Answer 25

Yes, brain atrophy changes due to malnutrition improve with weight gain, but neurocognitive function may be permanently affected.

Question 26

What dermatologic complication of Anorexia Nervosa involves fine, downy hair growth?

Answer 26

Lanugo hair growth on the spine and sides of the face is a dermatologic complication.

Question 27

What is lagophthalmos and how is it treated in Anorexia Nervosa patients?

Answer 27

Lagophthalmos is a condition where the eyelids do not fully close during sleep, leading to corneal irritation. Treatment includes applying a sterile lubricant and taping the eyes shut at night.

Question 28

What factors increase the likelihood of a poor outcome in Anorexia Nervosa?

Answer 28

Later age at onset, longer disease course, lower body weight, and psychiatric comorbidities increase the chances of a poor outcome.

Question 29

What are the two key elements in the DSM-5 definition of a binge eating episode for Bulimia Nervosa?

Answer 29

A binge eating episode is defined as eating an unusually large amount of food in a discrete period of time (e.g., 2 hours), and a feeling of lack of control over eating during the episode.

Question 30

What is the objective amount of food typically consumed during a binge eating episode in Bulimia Nervosa?

Answer 30

Objectively, a binge is equal to at least 2 meals or about 2000 kcal.

Question 31

What is the required frequency and duration for binge eating and inappropriate compensatory behaviors to meet DSM-5 criteria for Bulimia Nervosa?

Answer 31

Binge eating and inappropriate behaviors must occur, on average, at least once a week for 3 months.

Question 32

What is the lifetime prevalence of Bulimia Nervosa in women and men in the US?

Answer 32

The lifetime prevalence in women is 1.5% and in men is 0.5%.

Question 33

What is the median age of onset for Bulimia Nervosa?

Answer 33

The median age of onset for Bulimia Nervosa is 18 years old.

Question 34

What percentage of purging behaviors in Bulimia Nervosa involve self-induced vomiting or abuse of stimulant laxatives?

Answer 34

90% of purging behaviors found in bulimia are self-induced vomiting or abuse of stimulant laxatives.

Question 35

What is the sequence of behaviors in the 'Restriction model' of Bulimia Nervosa?

Answer 35

The Restriction model's sequence of behavior is caloric restriction, binge eating, then self-induced vomiting.

Question 36

What is a key characteristic of body weight in Bulimia Nervosa patients compared to Anorexia Nervosa?

Answer 36

Body weight in Bulimia Nervosa patients is usually within or above the normal range.

Question 37

What is the suicide rate in Bulimia Nervosa patients compared to the general population?

Answer 37

The rate of suicide in Bulimia Nervosa patients is 7 times greater than in the general population.

Question 38

What percentage of Bulimia Nervosa patients have at least one mental disorder, and what percentage have three or more?

Answer 38

95% of patients with bulimia suffer from at least one mental disorder, and 64% have three or more comorbid disorders.

Question 39

Which comorbid psychiatric disorder often precedes the onset of Bulimia Nervosa?

Answer 39

Anxiety usually precedes bulimia, whereas depression or substance abuse typically follow.

Question 40

What is considered the most common comorbid personality disorder and a poor prognostic indicator in Bulimia Nervosa?

Answer 40

Borderline Personality Disorder is the most common comorbid personality disorder and a poor prognostic indicator.

Question 41

What are the two most common electrolyte abnormalities seen due to self-induced vomiting in Bulimia Nervosa?

Answer 41

The most common electrolyte abnormalities are metabolic alkalosis and hypokalemia.

Question 42

What is 'pseudo-Barrett's syndrome' in Bulimia Nervosa?

Answer 42

Pseudo-Barrett's syndrome refers to the metabolic alkalosis and hypokalemia resulting from the loss of acid and potassium in vomitus and increased aldosterone secretion in a volume-depleted state to maintain blood pressure.

Question 43

What specific dental complication is associated with repeated exposure to stomach acid from vomiting in Bulimia Nervosa?

Answer 43

Perimolysis, the erosion of teeth due to repeated exposure to stomach acid, is a local adverse effect.

Question 44

When does bilateral parotid gland enlargement (sialadenosis) typically develop in Bulimia Nervosa patients who cease chronic self-induced vomiting?

Answer 44

Bilateral parotid gland enlargement commonly develops 3-4 days after cessation of chronic self-induced vomiting.

Question 45

Why is syrup of ipecac abuse more dangerous than other methods of self-induced vomiting?

Answer 45

The alkaloid emetine in ipecac is a direct cardiac toxin, and its toxicity is cumulative, potentially leading to irreversible cardiomyopathy and severe congestive heart failure.

Question 46

What is 'cathartic colon syndrome' and what is its consequence?

Answer 46

Cathartic colon syndrome is a major complication of chronic laxative abuse where the colon becomes an inert tube incapable of propagating feces, leading to severe constipation that may require a colectomy.

Question 47

What is the primary characteristic of Avoidant/Restrictive Food Intake Disorder (ARFID)?

Answer 47

ARFID involves avoiding or restricting food intake, which leads to a persistent failure to meet nutritional or energy needs.

Question 48

What distinguishes ARFID from Anorexia Nervosa or Bulimia Nervosa regarding body image?

Answer 48

In ARFID, the disturbance does not involve a distorted body weight or shape.

Question 49

What is the average BMI of patients with Avoidant/Restrictive Food Intake Disorder?

Answer 49

Patients with ARFID are typically underweight, with an average BMI of 16.

Question 50

What is the definition of a binge eating episode for Binge Eating Disorder (BED)?

Answer 50

A binge eating episode for BED is defined as consuming an amount of food in a discrete period of time (2 hours) that is definitely larger than what most people would eat, with a feeling of lack of control over eating.

Question 51

What is the mean lifetime duration of Binge Eating Disorder compared to Bulimia Nervosa and Anorexia Nervosa?

Answer 51

The mean lifetime duration of BED is 14 years, compared to 6 years for bulimia and anorexia.

Question 52

What is the key diagnostic criterion for Pica?

Answer 52

Pica requires the repeated eating of nonfood substances that are not nutritional for at least one month.

Question 53

What is the key diagnostic criterion for Rumination Disorder?

Answer 53

Rumination disorder is characterized by the repeated regurgitation of food, which may be rechewed, reswallowed, or spit out, at least once a month.

Question 54

What is one example of an 'Other Specified Feeding or Eating Disorder'?

Answer 54

Atypical Anorexia Nervosa, which presents with all criteria for AN except the patient's BMI is less than 18.5, is an example. Other examples include Bulimia Nervosa of low frequency/limited duration, Binge Eating Disorder of low frequency/limited duration, Purging Disorder, and Night Eating Syndrome.

Question 55

What two qualities are important when assessing patients with suspected eating disorders?

Answer 55

It is important to be direct but empathetic, as individuals struggling with these conditions are often ashamed.

Question 56

What common physical symptoms might clue a clinician into covert eating disorders?

Answer 56

Common symptoms include dry eyes, altered hearing, abdominal discomfort, focal pain, and abnormal liver or blood tests.

Question 57

What is the SCOFF questionnaire used for, and what indicates a high sensitivity and specificity for an eating disorder diagnosis?

Answer 57

SCOFF is a five-item self-report measure that screens for eating disorders. A 'yes' to two or more questions (Sick, Control, One stone, Fat, Food dominates) is associated with high sensitivity and specificity.

Question 58

What is considered a clinically significant response to treatment for bingeing and purging behaviors?

Answer 58

Many authorities regard a 50-75% reduction in the frequency of bingeing and purging as a clinically significant response.

Question 59

What is the recommended macronutrient distribution for patients recovering from malnutrition, specifically regarding fat intake?

Answer 59

Macronutrient distribution should be altered to include a higher fat percentage of calories, up to as high as 40%. It is important that anorexia nervosa patients replenish lipid stores by eating lipid-rich foods, as neuronal walls and wiring between brain regions are highly dependent on lipid function.

Question 60

What caloric intake might be necessary to support nutritional recovery and weight gain in patients with eating disorders?

Answer 60

Most patients will eventually require 2500-3500 calories or more per day.

Question 61

What is the definition of Refeeding Syndrome and how can it be prevented?

Answer 61

Refeeding syndrome is a multisystem disorder resulting from fluid and electrolyte shifts during nutritional rehabilitation. It can be prevented by avoiding rapid increases in daily caloric intake and close monitoring.

Question 62

What is the general effectiveness of psychiatric medications in treating patients with Anorexia Nervosa?

Answer 62

The general effectiveness of psychiatric medications in treating patients with Anorexia Nervosa is limited and often not sufficient alone.

Question 63

What is the general effectiveness of psychiatric medications in treating patients with Anorexia Nervosa?

Answer 63

There is little evidence that psychiatric medications are efficacious in treating patients with Anorexia Nervosa.

Question 64

Which class of medication is approved for patients with Bulimia Nervosa, and what is its mechanism of action in this context?

Answer 64

SSRIs are approved for patients with bulimia. Their mechanism is related to the effects of the medication on satiety, not on mood, thus reducing binge eating.

Question 65

Which medication is contraindicated in bulimic patients?

Answer 65

Bupropion, a norepinephrine-dopamine reuptake inhibitor, is contraindicated in bulimic patients.

Question 66

What is Appetite-Focused Dialectical Behavior Therapy (DBT-AF)?

Answer 66

DBT-AF is a modified version of Dialectical Behavior Therapy (DBT) that integrates Appetite Awareness Training (AAT) and DBT strategies for the treatment of bulimia nervosa.

Question 67

What are the primary objectives of Appetite Awareness Training (AAT)?

Answer 67

AAT aims to teach individuals to use internal appetite signals to guide food intake, distinguish between eating urges driven by physical hunger versus negative emotions, and to develop a more natural pattern of eating.

Question 68

What specific modification did DBT-AF make to the DBT Diary Card?

Answer 68

The DBT Diary Card was modified to include appetite monitoring.

Question 69

What two additional eating disorder skills were taught in DBT-AF to target dietary restriction?

Answer 69

The two additional skills were appetite awareness (avoid getting too hungry) and antideprivation eating (choosing to eat treats to prevent feelings of deprivation).

Question 70

How acceptable was appetite monitoring compared to food monitoring in the DBT-AF study?

Answer 70

Participants rated appetite monitoring as more helpful than their past experiences with food monitoring, and none indicated a preference for food monitoring.

Question 71

What was a key finding regarding anxiety and caloric intake in the Anorexia Nervosa Exposure and Response Prevention (AN-EXRP) pilot study?

Answer 71

Change (decrease) in anxiety over the course of AN-EXRP was significantly associated with increased caloric intake in the post-treatment laboratory meal.

Question 72

What is the rationale behind using Exposure and Response Prevention (EXRP) for Anorexia Nervosa (AN-EXRP)?

Answer 72

AN-EXRP is based on the idea that AN involves similarities to anxiety disorders and OCD, with fears related to food, avoidance behaviors, and ritualized behaviors to manage these fears, suggesting anxiety is a useful treatment target.

Question 73

How did AN-EXRP therapists address feared eating situations in sessions?

Answer 73

Sessions included an exposure to a feared eating situation, starting low on the patient's individualized hierarchy and progressively moving up the hierarchy.

Question 74

What were the three main modules taught in DBT-AF treatment?

Answer 74

The three modules taught were 1) appetite awareness and mindfulness, 2) distress tolerance, and 3) emotion regulation.

Question 75

What is 'culinary therapy' and what aspects of eating disorders does it address?

Answer 75

Culinary therapy is the process of working with food in a therapeutic environment, incorporating exposure and skills-based therapy. It addresses behaviors like chronic dieting, eliminating food items/groups, obsessive calorie counting, difficulty eating socially, and making food decisions.