EATING DISORDERS; - University of Washington (PDF)

UW PACC ©2017 University of Washington UW PACC Psychiatry and Addictions Case Conference UW Medicine | Psychiatry and Behavioral Sciences EATING DISORDERS: An introduction for clinicians Megan Riddle, MD PhD MS  UW PACC ©2017 University of Washington SPEAKER DISCLOSURES Nothing to disclose  UW PACC ©2017 University of Washington GENERAL DISCLOSURES The University of Washington School of Medicine also gratefully acknowledges receipt of educational grant support for this activity from the Washington State Legislature through the Safety-Net Hospital Assessment, working to expand access to psychiatric services throughout Washington State.  UW PACC ©2017 University of Washington OBJECTIVES • Understand the importance of recognizing eating disorders • Describe key features of eating disorders and review the importance of screening • Describe the components of eating disorder treatment http://www.zastavki.com/pictures/originals/2014/Drawn_wallpapers___Painted_girls_Girl_eating_watermelon_084414_.jpg  UW PACC ©2017 University of Washington WHY TALK ABOUT EATING DISORDERS? • Eating disorders have a high morbidity and mortality • 30 million people in the US have eating disorders • Often go unrecognize – Only 1 in 10 of bulimia patients are diagnosed http://images.suite101.com/2553402_com_119900915_.jpg  UW PACC ©2017 University of Washington • Recurrent binge episodes associated with eating an excess amount in a discrete period and lack of control • Compensatory behaviors to prevent weight gain • Binge eating and purging occur on average at least weekly for 3mo • Excess concerns about shape and weight • Restriction of energy intake leading to low body weight • Intense fear of weight gain or behaviors that interfere with weight gain • Excess concerns about weight and shape Anorexia nervosa Bulimia nervosa http://images.suite101.com/2553402_com_119900915_.jpg https://advocateglobalhealth.wordpress.com/eating-disorders/bulimia-nervosa/  UW PACC ©2017 University of Washington • Eating disturbance (i.e. concern about eating certain food types/textures) that prevents patient from meeting nutritional needs leading to: o Weight loss o Nutrient deficiency o Dependence on supplements/feeding tube o Interference with psychosocial • Not in the setting of AN or BN or explained by other medical condition • Recurrent binge episodes associated with eating an excess amount in a discrete period and lack of control • No compensatory behaviors to prevent weight gain • Binge eating occurs on average at least weekly for 3mo https://alternefit.wordpress.com/2011/10/02/picky-eaters-can-i-get-them-to-eat/ http://www.freakingnews.com/Woman-in-Renaissance-Painting-Eating-Donuts-Pics-117495.asp Binge Eating Disorder Avoidant/Restrictive Food Intake Disorder  UW PACC ©2017 University of Washington THE CASE: SARA • Sara is a 28yo woman who newly presents to your clinic for fatigue https://otrwjam.files.wordpress.com/2013/08/dsc08205-copy.jpg • On her new patient screener, she reports a PMHx of anxiety • Vitals: − BP 110/70; P 87 − Wt 145lbs; Ht 5’6”; BMI 23.4 • PHQ9: 5 (mild depression) • GAD7: 8 (mild to moderate anxiety)  UW PACC ©2017 University of Washington THE CASE: SARA • Increasingly tired over the past 2 months, but denies all other physical symptoms • Asked if she’s made any changes recently, she says she’s had a lot of stress at work, but is pleased to report she is trying to take good care of herself, losing weight by increasing her exercise and eating “better” • “I’m wanting to be healthier”  UW PACC ©2017 University of Washington THE CASE: SARA • Physical exam is wnl • Lab work, including CBC, BMP, LFTs, TSH, UPreg, UA are all wnl • She returns for a follow up visit in a month, still struggling with fatigue • Vitals: − BP 110/75; P 85 − Wt 135lbs; Ht 5’6”; BMI 21.8  UW PACC ©2017 University of Washington MAKING A DIAGNOSIS • “Eating disorder” is rarely the chief complaint (unless they are dragged in by a worried family member) • Instead… Fatigue Cold intolerance Amenorrhea Sore throat Dizziness Constipation Bloating Palpitations Heart burn Fertility issues Changes in weight Polyuria Polydipsia Stress fractures  UW PACC ©2017 University of Washington MAKING A DIAGNOSIS Anorexia nervosa • Usually related to organ dysfunction due to malnutrition and the person being underweight • Starvation affects all organs of the body Bulimia nervosa* • Usually related to the type of purging used, frequency, and duration *Of note, patients with AN, binge/purge type, can have these issues as well  UW PACC ©2017 University of Washington MAKING A DIAGNOSIS Anorexia nervosa Bulimia nervosa Cardiac: Bradycardia, Orthostatic hypotension, Syncope, Arrhythmias, CHF, Sudden death Cardiac: Arrhythmia, Ipecac-induced cardiomyopathy GI: Gastroparesis, GERD, Abnormal Liver Function Tests SMA Syndrome GI: GERD, Odynophagia, Dysphagia, Hoarseness, Hematemesis, Diarrhea, Cramping, Hematochezia Endocrine: Menstrual irregularity, Hypothalamic and thyroid dysfunction, Osteoporosis, Glucose dysregulation, Low Testosterone (in men), Hypercholesterolemia Endocrine: Menstrual irregularity, PCOS Electrolytes: Hypochloremia Hypokalemia, Metabolic alkalosis, Hyponatremia Electrolytes: Usually normal Hyponatremia, Hypophosphatemia  UW PACC ©2017 University of Washington WHO TO SCREEN? • Preteens and Adolescents: ALL • Adults: high risk – Young adults – Women under stress – Rapid changes in weight or asking about weight loss – Athletes – Positive Family History http://az616578.vo.msecnd.net/files/2016/07/01/636029376698418322620701959_Eating%20disorders.jpg You need to ask!  UW PACC ©2017 University of Washington EATING DISORDERS: QUICK SCREEN • Eating Disorder Screen for Primary Care – Are you satisfied with your eating patterns? (No is abnormal) – Do you ever eat in secret? (Yes is abnormal) – Does your weight affect the way you feel about yourself? (Yes is abnormal) – Have any members of your family suffered with an eating disorder? (Yes is abnormal) – Do you currently suffer with or have you ever suffered in the past with an eating disorder? (Yes is abnormal) • Two abnormal questions gives sensitivity 100% and specificity 71% (Cotton et al, 2003)