Feeding and eating disorders

Anorexia Nervosa

  • Deliberate ↓ BMI from fear of weight gain (despite low body weight)

  • Body image disturbance and lack of awareness of seriousness

  • Disorder within reward system

  • Genetic component

  • Associated with trauma hx, OCD, anxiety, mood/personality disorders

  • Restricting type

    • Excessive dieting, exercise, or fasting (no binging/purging over 3mo)

  • Binge-eating/purging type

    • Vomiting, diuretic or laxative abuse, or enemas

Severity

    • < 20yo - below 10th percentile

  • >20yo

    • Mild: BMI 17-18

    • Mod: BMI 16-17

    • Severe: BMI 15-16

    • Extreme: BMI < 15

SSX

  • Hypothermia

  • ↓ concentration/personality changes

  • Seizures (2° to electrolyte imbalance)

  • Secondary amenorrhea

  • Bradycardia and hypotension

  • Osteoporosis

  • Hair loss and fine lanugo body hair

  • Teeth and salivary gland issues from vomiting

DX

  • ↓ K, Na, Cl, P, Mg

  • ↑ Bicarb (alkalosis from vomiting HCl)

  • ↑ amylase (from vomiting)

  • ↑ cholesterol

TX

  • Weight gain via psychotherapy (CBT) and nutritional rehabilitation

    • Olanzapine if acutely ill and not gaining weight despite psycho/nutritional therapy

    • ± antidepressants to help with anxiety or comorbid conditions

    • Avoid bupropion and tricyclics (↑ risk of seizures)

  • Admit if:

    • Brady <40 or prolonged QTc

    • Hypotensive/orthostatic/markedly dehydrated

    • BMI <14 or <70% ideal body weight

  • BOLO refeeding syndrome

    • Restoring weight too rapidly and/or aggressively is potentially fatal

    • Insulin dump in malnourished pt ➔ hypophosphatemia and hypokalemia

      • Edema, tachy, seizures

      • TX by repleting K and Mg

Bulimia Nervosa

  • Both are present at least 1/wk for 3mo:

    • Binge eating

      • More than normal amount AND sense of loss of control

    • Compulsive behavior to counteract weight gain from binging

      • Vomiting, laxatives, starvation, exercise

  • Self-worth influenced by physical appearance

Severity

  • Mild: average 1 -3 episodes/wk

  • Moderate: average of 4-7 episodes/wk

  • Severe: average of 8-13episodes/wk

  • Extreme: average of 14 episodes/wk

SSX

  • BMI usually normal or elevated

  • Teeth and salivary gland issues from vomiting

    • Russel sign (calluses on knuckles)

DX

  • ↓ K, Na, Cl, P, Mg

  • ↑ Bicarb (alkalosis from vomiting HCl)

  • ↑ amylase (from vomiting)

TX

  • Psychotherapy (CBT) and nutritional rehabilitation

  • ± fluoxetine