refusal to maintain body weight over 85% expected weight (look like concentration camp victims)
Intense fear of gaining weight or becoming fat
Body Image Disturbance, feel fat even when emaciated, however can accurately estimate other peoples weight.
amenorrhea, need >16% body fat to menstruate.
2 types
(1)
Restricting - "classic" type, more typical
(2)
Binge/Purge - "mixed picture," low weight, amenorrhea, when patient does eat they get rid of it
Associated features
Medical and physiological sequelae of starvation
Endocrine abnormalities
Metabolic abnormalities
Cardiovascular complications
Gastrointestinal complications
Electrolyte abnormalities
Family Characteristics
Family history of affective disorders
history of EtOH abuse
Pathological family interactions
Personality and Behavioral characteristics
Perfectionism and high achievement orientation
Hypersensitivity to criticism and rejection
Obsessive-Compulsive tendencies - compulsive exercise early in disease when they have the energy
Cognitive distortions - "enjoy" being hungry, need to rule out other delusional processes
Major Depression - often comes to the surface once Anorexia has been resolved
Treatment Approaches
Pharmacological Treatment - SSRIs work. Appetite stimulants are contra-indicated (only feeding into patient’s masochism, increasing the degree to which the patient feels they are succeeding)
Inpatient treatment
Total Parenteral Nutrition (TPN), force feeding through an IV on a medical floor
Behavioral management - try to Ý PO (by mouth) feedings and ß TPN
Psychotherapy - in conjunction with meds, Individual therapy, Family and Cognitive-Behavioral therapies
Cognitive-Behavioral Treatment - attempt to normalize weight and eating by challenge irrational beliefs and assumptions, change attitudes of body shape
Bulemia
Diagnostic Criteria (DSM-IV)
Recurrent episodes of binge eating (rapid frantic consumption of large amounts of food in a short period of time)
Feeling of lack of control over eating behavior during the eating binges
Purging, patient regularly engages in self-induced vomiting, laxative or diuretic use, strict dieting, or vigorous exercise to prevent weight gain. (DM patients may underinsulinize to spill calories into their urine)
Greater than 2 binge episodes/week for at least 3 months
Persistent overconcern with body shape and weight
2 types
(1)
Purging type - binges then purges (vomits, laxatives, etc.)
(2)
Nonpurging type - binges then exercises
Bulimia is very resistant to treatment because it is a reinforcing pattern (can become OCD)
Self induced vomiting may become so routine that patient can vomit at will
Associated Features
Medical and Physiological
Renal complications
Electrolyte abnormalities(hypokalemia)
Dental problems (that stomach acid is rough on the teeth, Dentists often refer)
GI complications (delayed gastric emptying)
Endocrine abnormalities(no amenorrhea, often irregular cycling)
Family Characteristics
Family History of Affected Disorders
Presence of family stressors (high pressure families, often a controlling mother)
History of EtOH abuse
Personality and Behavioral Characteristics
Low self esteem
Poor stress management skills
Cognitive distortions - borderline irrational ideas about body image and self esteem
IMPULSIVITY - "all or none", can’t tolerate normal dieting behavior
Depression and suicidal ideation - Depression + Impulsivity puts patients at high risk for suicide
Treatment Approaches
Pharmacological treatment - SSRIs are useful
Cognitive-Behavioral therapy - Exposure plus Response Prevention Treatment - exposure to feared issue (food) then prevent their habitual escape (purging)
Group therapy - only after patient has 1 month without purging; if too early, only helps patient get better at being bulimic
later can help the patient with self-esteem issues
Differentiating Between Anorexia and Bulimia
Anorexics are underweight, Bulimics are normal or up to 5% above normal weight
Anorexics have an intense fear of gaining weight, Bulimics use purging to maintain weight