Feeding and Eating Disorders

• 1 in 10 people in the United States have an eating disorder.
• Anorexia contributes to mortality more than any other mental illness.
• Only 6% of those with an eating disorder are overweight.
• 1/3 of individuals with an eating disorder are men.
• Eating disorders are more common in the LGBTQI+ community.
• Eating disorders that are officially diagnosed last at least 3 months.
  • Rumination and PICA are exceptions, as they only require a 1-month duration for diagnosis.
• Up to 80% of patients who receive treatment for an eating disorder recover or improve significantly.
• Concerns about eating in public are associated with eating disorders.
• Eating disorders can be related to a need for control.
• Perfectionism is an associated factor where individuals excel in everything they do.
• Guarded emotional expression is often seen with eating disorders.
• Impulse control problems such as bingeing or purging can be part of an eating disorder.
• A high level of comparison occurs in individuals with eating disorders.
• Difficulty recognizing, processing, and expressing emotions, or alexithymia, is present in eating disorders.
• Eating disorders are very difficult to treat.
• Multiple relapses can occur.
• Eating disorders are underreported.
• Individuals rarely seek help on their own and may be unreliable historians.

Mental Health & Eating Disorder Statistics

• 97% of people hospitalized for an eating disorder have at least one co-occurring mental health disorder.
• 94% of those hospitalized also suffer from mood disorders like major depression.
• 69% of patients with anorexia nervosa also have obsessive-compulsive disorder.
• 81% of people with bulimia nervosa also have an anxiety disorder.
• 1/3 of people with binge eating disorder are also diagnosed with major depression.
• 1/4 of people with an eating disorder also have symptoms of post-traumatic stress disorder.

Anorexia Nervosa (AN)

• Anorexia Nervosa was described almost 300 years ago when cultural pressures were different.
• It is a combination of phenotypic expression and cultural factors.
• Genes exist that confer susceptibility, including norepinephrine transporter (NET), monoamine oxidase A (MAO-A), and serotonin transporter (SERT).
  • These gene are not be on the exam.
• Abnormal glucose/hypothalamic relation can affect appropriate behavior and signals for hunger and time to feed.

AN Etiology

• It is more common in monozygotic twins and first-degree relatives, especially those with mood disorders.
• Family history is the most significant risk factor.
• It is a condition of industrialized societies.
• Cases are found in immigrants when they assimilate to ideals of thin body appearance.
• Abuse and bullying can be causes.
• Other causes include low self-esteem and family dysfunction.
• Families with eating disorders and chronic dieting can cause AN.
• History of physical or sexual abuse can cause AN.
• Peer, family, and cultural pressures can cause AN.
• Other traumatic life experiences can result in AN.
• Athletes in aesthetic and weight-class sports are at risk. -Female and male athletes are at risk especially those competing in sports that emphasize diet, appearance, size, and weight.
• Aesthetic sports include bodybuilding, gymnastics, and figure skating.
• Weight-class sports include wrestling, rowing, and horse racing.
• Disordered eating affects 62% of female athletes and 33% of male athletes in aesthetic and weight-class sports.

Risk Factors For Athletes

• Training for a sport since childhood or being an elite athlete is a risk factor.
• Focus primarily on success and performance rather than on the athlete as a whole person.
• Identity solely based on participation in athletics is a risk factor.

DSM 5 TR AN Diagnosis

• Requires all three of the following for diagnosis:
  • Food restriction leading to below normal body weight.
  • Intense fear of gaining weight or becoming fat or behavior to prevent weight gain, despite being underweight.
  • Hunger can be present.
  • Distorted perception of body weight/shape with undue self-worth, or denial of the medical seriousness of low body weight.
• The criteria for diagnosis must be present for 3 months.

Comorbidity of Anorexia Nervosa

• Anxiety disorders exhibit a 60-65% comorbidity. -Phobia: 40-61%
• Obsessive-compulsive disorder exhibits a 26-48% comorbidity.
• Mood disorders exhibit a 36-68% comorbidity.
• Substance abuse exhibits a 23-35% comorbidity.
• Personality disorders exhibit a 23-35% comorbidity. -Cluster A is less than 5% -Cluster B is 15-55% -Cluster C is 15-60%

AN Types

• Purging type: -Self-induced vomiting: -Laxative abuse: -Diuretic abuse: -Enema abuse:
• Non-purging type: -Fasting: -Excessive exercise: -Hormones (thyroid): -Supplements:

AN Current Severity

• Mild: BMI ≥ 17 kg/m²
• Moderate: BMI 16–16.99 kg/m²
• Severe: BMI 15–15.99 kg/m²
• Extreme: BMI < 15 kg/m² -Criteria for hospitalization

AN Demographics

• Peaks early adolescence (age 12–15 years) and late adolescence/early adulthood (age 17–21 years).
• Rarely appears before puberty or after age 40 years.
• Inciting incident(s) may occur.
• Patients feel a sense of "reward" or "payoff" such as feeling safer, secure, and in control.
• It can also be a way of showing distress and avoiding "growing-up".

Anorexia Affects the Whole Body

• Brain and Nerves: Inability to think right, fear of gaining weight, sadness, moodiness, irritability, bad memory, fainting, changes in brain chemistry.
• Hair becomes thin and brittle.
• The heart experiences low blood pressure, slow heart rate, fluttering of the heart, and heart failure.
• Muscles and joints experience weakness, swelling and fractures.
• Kidneys can develop kidney stones and kidney failure.
• Fluide deficiency includes low potassium, magnesium, and sodium.
• Intestines lead to constipation and bloating.
• Hormones: Periods stop, bone loss, problems growing, trouble getting pregnant. If pregnant, higher risk for miscarriage, having a C-section, baby with low birthweight, and post-partum depression.
• Skin: Bruise easily, dry skin, growth of fine hair all over body, get cold easily, yellow skin, and nails get brittle.
• This leads to total body malnourishment.
• Additional signs and symptoms of anorexia nervosa are bloating and early satiety.

Anorexia Nervosa: Reproductive

• Functional hypothalamic amenorrhea occurs due to secondary decreased nutrition and increased stress.
• Delayed puberty, breast atrophy, and atrophic vaginitis occur.

Fasting/Purging: Possible Consequences

• Gastrointestinal: -Esophagitis -Mallory-Weiss tears -Esophageal or stomach rupture -Barrett esophagus -Acute pancreatitis -Loss of protein and antioxidants -Gallstones
• Neurologic: -Seizures -Myopathy -Peripheral neuropathy
• Cardiac: -Arrhythmias
• Metabolic: -Electrolyte disturbances

AN Physical Exam Findings: Lanugo Hair

• Soft, downy hair grows on the arms and chest secondary to severe weight loss and emaciation.
• The hair provides insulation to stay warm.

AN: Purging Physical Exam Findings

• Parotid gland hypertrophy may occur due to excess saliva production from vomiting.
• It can occur from anorexia without vomiting.
• Erosion of the dental enamel occurs secondary to vomiting gastric acid.
• Palate trauma may be apparent from finger-inducing vomiting.
• Trauma from teeth can occur while inducing frequent vomiting, resulting in Russell's sign.

AN: Differential Diagnosis

• Type I Diabetes mellitus
• Adrenal insufficiency (decreased fat, glucose, etc metabolism)
• Inflammatory bowel disease: abdominal pain and melena
• Abdominal masses
• Hyperthyroidism
• Gastric paresis
• GI Cancer
• Anxiety with anorexia
• Major depression with anorexia

AN: Labs/ Imaging

• CBC -Check for Iron, TIBC if anemic
• Electrolytes
• BUN/Cr
• Vitamin A
• Mg, PO4 (phosphate)
• Calcium, Zinc
• Amylase
• UA: specific gravity
• TSH: see notes
• GH (growth hormone)
• FSH/LH/estradiol/ prolactin
• HCG (human chorionic gonadotropin: pregnant?)
• Bone density
• 25-hydroxyvitamin D
• EKG

Laboratory Abnormalities in AN

• Hematology: -Common: Leukopenia -Less Common: Thrombocytopenia
• Chemistry: -Common: Elevated liver enzymes, Elevated serum bicarbonate, Hyperamylasemia, Hypercholesterolemia/hypocholesterolemia, Hypochloremia, Hypokalemia/hyponatremia, Hypozincemia, Low estrogen , Low luteinizing hormone (LH), Low T3 or T4, Low parathyroid hormone, Metabolic alkalosis (vomiting and diuretics) -Less Common: Hypomagnesemia, Hypophosphatemia, Metabolic acidosis (laxative abuse)
• Miscellaneous: Positive fecal occult blood
• ECG: -Common: Sinus bradycardia -Less Common: Arrhythmias

Medical Instability in Patients with Anorexia Nervosa

• Medical instability is characterized by one or more of the following: -Pulse less than 40 beats per minute -Blood pressure less than 80/60 mmHg -Orthostatic increase in pulse (>20 beats/minute) or decrease in systolic blood pressure (>20 mmHg) -Cardiac dysrhythmia eg, QTc >0.499 msec), or any rhythm other than normal sinus rhythm or sinus bradycardia -Cardiovascular, hepatic, or renal compromise requiring medical stabilization -Marked dehydration -Serious medical complication of malnutrition (eg, electrolyte imbalance, hypoglycemia, or syncope)
• Body mass index <15 kg/m² or ideal body weight <70%
• Interdisciplinary Care Team includes a Mental Health Professional/Psychiatrist, Physician or Physician Assistant or ARNP, Family support, and Dietician.

AN: Treatment Goals

• Medical management: correcting and preventing physical complications -There is no specific FDA approved AN drug
• Reestablishing normal eating patterns and weight -Gain 2-3 lbs week/hospital, 0.5-1 lb/week outpatient -Menstrual periods return
• Develop coping mechanisms and effective problem-solving and uncouple with the condition.
• Reestablish a healthy, realistic body image.
• It is difficult to treat because of the shame, denial, and lack of insight concomitant with the disorder. -"addiction + delusion"
• Asking them to give up an integral part of their identity.

AN Primary Treatment: Behavioral Therapy

• CBT or interpersonal psychotherapies that addresses dysfunctional thoughts and behaviors.
• DBT (dialectical behavioral therapy) as well as dietician/nutritional therapy.
• Journaling to treat alexithymia.
• Family therapy, group therapy, and 12-step programs can be used.
• Inpatient treatment center.

AN Medication: Secondary Treatment

• Metoclopramide: pro-mobility, can cause extrapyramidal symptoms -For early satiety
• Cyproheptadine (Periactin): antihistamine -appetite stimulant -best for restrictive type AN
• Some second-gen antipsychotics to increase appetite -Olanzapine (Zyperxa)
• Benzodiazepines for anxiety-related eating before meals at lower doses.

AN Medication: Secondary Treatment

• Dronabinol (Marinol) synthetic THC increases appetite similar to olanzapine and is approved to treat weight loss in HIV/AIDS.
• Restore zinc levels to increase appetite.
• SSRIs: fluoxetine (Prozac) for relapse prevention, not initially.
• Behavioral/therapy is the primary treatment.
• Anorexia affects the whole body, which can lead to the inability to think right, fear of gaining weight, affect mood, and bad memory.
• Visit https://www.healthline.com/health/top-eating-disorder-iphone-android-apps#recovery-record for application management of eating disorder.
• Anorexia treatment includes feeding tubes via a NG tube. -If a patient refuses oral intake -Studies support success in weight gain -Controversial: action against a patient's wishes --Patient well being vs patient self-determination
• Potential Refeeding Syndrome: Treat AN -Stores of phosphate are depleted during episodes of anorexia nervosa and starvation -When carbs are consumed, glucose causes the release of insulin, with cellular uptake of phos, potassium and magnesium thus a decrease in serum level -Insulin causes cells to produce depleted molecules that require phosphate eg, adenosine triphosphate (ATP) and 2,3-diphosphoglycerate, which further depletes the body's stores of phosphate -Causes tissue hypoxia, myocardial dysfunction, respiratory failure (weak diaphragm), hemolysis, rhabdomyolysis, and seizures
• Refeeding Syndrome Treatment -Prevention: electrolyte replacement: K+, Mg++,Ca++ phosphate- -Reduce nutritional support and aggressively correct hypophosphatemia, hypokalemia, and hypomagnesemia -Patients with seizures, marked edema or a serum phosphorous less than 2 mg/dL (2.5-4.5) should be hospitalized -Remember thiamine.
  • Continuous telemetry.

AN Nourishment

• Remember thiamine
• Wait to start supplemental iron 1 week after hospitalization.

AN Prognosis

• 45% of patients have an overall good outcome.
• 30% have an intermediate outcome (i.e., still having considerable difficulty with the symptoms of the illness).
• 25% have a poor outcome and rarely achieve a normal weight.
• Patients who have had AN for 12 years or more have death rates as high as 20%: starvation, suicide, or electrolyte imbalance.

Bulimia Nervosa (BN)

• Greek derivation meaning "ox hunger"
• Repetitively consumes a large quantity of food then purges

Binge Eating Disorder (BED)

• Strong genetic component
• Associated with more severe obesity, earlier onset of obesity, and greater levels of psychopathology than in other obese individuals.
• Rewards/conditioned response
• High impulsivity and compulsivity
• Psychosocial distress -useful vs not useful suffering -"stuffing feelings"

BN Causes and Characteristics

• As in AN.
• 1/3 of patients have a sexual abuse history.
• Prevalence is as high as 30% of the general population.
• Purging Types: -Induced vomiting (80-90%) -Diuretics -Laxatives
• Non-purging: fasting, exercise, thyroid hormones, diet pills.

DRM5 TR BN Diagnostic Criteria

• Eating a significant amount of food in a limited time (binging) -Within 2 hour period (high calorie/ fat) a loss of control.
• Experiencing feelings of guilt, shame, or anxiety after eating
• Preoccupation with body weight or shape -Weight is usually normal (can be overweight)
• Purging food from the body after eating or the use of diet pills or diuretics to control weight.
• Excessive exercise to prevent weight gain.
• Binging/compensatory behaviors occur at least once a week for 3 months.

BN Level of Severity

• Mild: average of 1-3 episodes compensatory behaviors/week.
• Moderate: average of 4-7 episodes compensatory behaviors/week.
• Severe: average of 8-13 episodes of compensatory behaviors/week.
• Extreme: average of ≥14 episodes of compensatory behaviors/week. -Not on exam but be aware of qualifiers

BN Signs and Symptoms

• Similar to AN, depending on net nutritional intake.
• GI: -Cathartic colon from laxative abuse: -Bloating, a feeling of fullness, abdominal pain, and incomplete fecal evacuation -Normal colon functioning is loss: "a long tube," atonic, constriction -Melanosis coli: cell death with lipofuscin deposits
• Electrolyte abnormalities are common. -As in AN, check for dehydration and hypokalemia. -Metabolic alkalosis (vomiting) or acidosis (diarrhea) can occur.

BN Treatment: Behavioral Therapy

• Apply the same conditions to AN but includes bright light therapy and mindful eating with emotional tracking (journaling).
• Apply Weekly Mindful Eating Checklist -Eat slowly and put my utensil down in between bites -Take smaller bites. -Honor my body's hunger cues. -Turn off devices while eating. -Eat a rainbow. -Avoid sugary, processed, and refined foods. -Eat good fats: avocados, nuts, seeds, olives,. -Appreciate my food before indulging. -Avoid fried food. -Chew my food thoroughly. -Drink enough water. -Address stress eating. -Use my senses while eating. -Eat healthy portions. -Plan my meals and snacks. -Address sitting down. -Choose healthy snacks.

Binge Eating Disorder Treatment: same as BN

• Nutritional education and counseling.
• Weight loss programs/support groups.
• Mindful eating and Individual psychotherapy/CBT.
• Medication is not first line.
• Can uses SSRIS or weight loss medication.

Bulimia Medication Treatment

• Pharmacology includes Fluoxetine (Prozac).
  • Other SSRIs are second line: -Avoid citalopram/ escitalopram (Celexa/ Lexapro): QT prolongation. -Avoid paroxetine (Paxil): weight gain. -Avoid bupropion (Wellbutrin): seizures.

BN Prognosis

• 50-70% improve.
• 30-85% Relapse.

Avoidant/Restrictive Food Intake Disorder (ARFID)

-Occurs in infancy or early childhood but may persist into adulthood. -Failure to nutritional or energy needs which includes: -Significantly losing weight. -Nutritional deficiencies . -A need for supplements. - Interfering with psychosocial functioning.

• Not better explained by lack of available food, eating disorders or other diagnosis.
• "Super picky eater", don't fear weight gain, no body distortion.

ARFID PE

-May be similar to AN without purging behaviors

• Unlike anorexia or bulimia, ARFID is not driven by body image concerns but rather issues related to food itself, such as sensory sensitivities, fear of negative consequences (e.g., choking), or loss of interest in eating.
• Common in Autism, anxiety, and issues of GI -IBD or history of a picky eater has never resolved

ARFID Treatment

• Meeting the caloric and nutritional goals.
• Exposure/ desensitization therapy.
• CBT
• Education and is medication is "not" helpful.

Night Eating Disorder (NED): NOS Disorder

• Recurrent episodes of night eating.
• Excessive food consumption after the evening meal, before sleep. -25% of daily calories Lack of appetite in the morning.
• Insomnia 4-5 nights a week with eating after awakening from sleep.
• An urge to eat so that can sleep/back to sleep
• Depressed mood becomes worse during the evening hours.
• NED Work Up
• As for other psychiatric disorders

NED Treatment

• CBT is useful as well as to treat any anxiety/ depression.
• Mind-body: progressive muscle relaxation, can lead to calm down sleep
• Sleep hygiene
• Light therapy
• Weight management program and exercise program.
• Persistent eating of nonnutritive/nonfood substances of at least 1month -Must be >2 years of age

PICA: DSM 5 TR Diagnostic Criteria

• Persistent eating of nonnutritive/ nonfood substances that lasts at least 1 month. -Typical substances: paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal, ash, clay, starch and ice. -It must be inappropriate for the level of development, and cannot be culturally influenced, and must be >2 years of age.

Culturally Sanctioned Pica

• In cases where the patient ingests keolin (white clay) among the women in Georgia and Afirca. -May stem from health benefits as clay has the ability to absorb toxins.
• Regions with starvation.
• Starts in infancy, and can extend into adulthood if there are developmental disabilities , OCD, pregnancy, trichotillomania or comorbid anxiety -Abuse

Pica

• No definitive evidence that patients eat PICA for nutritional deficiencies.
• Bezoar from Pica
• A solid mass which accumulates in GI tract as obstruction

PICA Presentation

• Manifestation of toxin
• Manifestation of parasitic infection
• GI manifestation or obstruction and swelling dental is traumatic from nutritional deficiency
• CBC: anemia

Pica Work Up

• H and P: -Lead line" -Anemia
• Lead: Toxin
• Imaging
• heavy metal ingestion -Ingestion of heavy metals or metal salts. -Along the gingiva of cavities -Metallic line found with gray or black in those metals

Pica Treatment

-Address psychological issues/therapy

• Treat associated medical conditions
• Behavior/Modification -Surgery if necessary Esophageal/ sphincter relaxation from the gastric distention. Most common among the infants but not limited to all ages associated for intellectual disability.

Rumination: Disorder

• Criteria Repeated regurgitation after food (at least 1 mo}
• Food may be re=chewed re-swallowed or spit out
• not attributable to a GL condition- not during another eating disorder
• Occurs hours per week - Without Nausous, or disgust

Rumination Disorder Causes:

• Inconsistent nurturance of infant.
• Adverse pyschosocial issues. -Learned Behavior" -Associated Conditions- Like with -Upper Respiratory distress
• Aspiration PNA
• Death

Rumination: Work up-

"Rule/ Out GI conditon"

• Esophogus achaiasia As in Bulimia, GI

Rumination Disorder: RX treatment

• Educate. Behavioral Modificaton., Treat Depression and or anxiety, relaxation, diaphragmatic breathing, Baclofen, raises tone as suppression.

Clinical Interview:

"Take me" thru day' Describe weight etc

Communicating:

Good Bad fat Skinny etc

• Discuss the concept Weight issues

• Avoid Valuing appearance

• And sizes- Talk about dieting -Dieting exercise and Calories

• Never say Anoreixc or Buiimic

• Use compassionate care

• https://vimeo.com/94547857 example used