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Toronto Notes 2019 Eating Disorders
• typicalpresentation:beginsinchildhoodorearlyadolescence;increasingcomplexityandstabilitywithage
• chronic,decreaseswithadvancingagebutmayincreasewithstress
Treatment
• anti-androgendrugs
• behaviourmodification • psychotherapy
SEXUAL DYSFUNCTION
• seeGynecology,GY32andUrology,U32 Eating Disorders
Definition
• eating disorders are characterized by a persistent disturbance of eating that impairs psychosocial functioning or health
• disorders include: anorexia nervosa, avoidant/restrictive food intake disorder, binge eating disorder, bulimia nervosa, pica, and rumination disorder
Epidemiology
• anorexianervosa(AN):1%ofadolescentandyoungadultfemales;onset13-20yrold • bulimianervosa(BN):2-4%ofadolescentandyoungadultfemales;onset16-18yrold • F:M=10:1;mortality5-10%
Etiology
• multifactorial:psychological,sociological,andbiologicalassociations
• individual:perfectionism,lackofcontrolinotherlifeareas,historyofsexualabuse
• personality: obsessive-compulsive, histrionic, borderline
• familial:maintenanceofweightequilibriumandcontrolindysfunctionalfamily
• culturalfactors:prevalentinindustrializedsocieties,idealizationofthinnessinthemedia • geneticfactors
■ AN: 6% prevalence in siblings, with one study of twin pairs finding concordance in 9 of 12 monozygotic pairs versus concordance in 1 of 14 dizygotic pairs
■ BN: higher familial incidence of affective disorders than the general population
Risk Factors
• physicalfactors:obesity,chronicmedicalillness(e.g.DM)
• psychologicalfactors:individualswhobycareerchoiceareexpectedtobethin,familyhistory(mood
disorders, eating disorders, substance abuse), history of sexual abuse (especially for BN), homosexual males, competitive athletes, concurrent associated mental illness (depression, OCD, anxiety disorder [especially panic and agoraphobia], substance abuse [specifically for BN])
Anorexia Nervosa
DSM-5 Diagnostic Criteria for Anorexia Nervosa
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. 2013. American Psychiatric Association
A. intake and weight: restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected
B. fear or behaviour: intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight
C. perception: disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight
• specifiers: partial remission, full remission, severity based on BMI (mild = BMI >17 kg/m2, moderate = BMI 16-16.99 kg/m2, severe = BMI 15-15.99 kg/m2, extreme = BMI <15 kg/m2), type (restricting = during last 3 mo no episodes of binge-eating or purging vs. binge-eating/purging type = in last 3 mo have participated in recurrent episodes of binge-eating/purging)
Management
• psychotherapy: individual, group, family: address food and body perception, coping mechanisms, health effects
• medications of little value
• outpatient and inpatient programs are available
• inpatient hospitalization for treatment of eating disorders is rarely on an acute basis (unless there is a
concurrent psychiatric reason for emergent admission e.g. suicide risk)
• criteria to admit to medical ward for hospitalization: <65% of standard body weight (<85% of standard
body weight for adolescents), hypovolemia requiring intravenous fluid, heart rate <40 bpm, abnormal
serum chemistry, or if actively suicidal
• agree on target body weight on admission and reassure this weight will not be surpassed
Psychiatry PS31
Eating Disorder Screening
Method to identify patients with eating disorders. A “Yes” to two or more questions is associated with a sensitivity and specificity of 78 and 88 percent, respectively
SCOFF
• Do you make yourself Sick because you
feel uncomfortably full?
• Do you worry you have lost Control over
how much you eat?
• Have you recently lost more than One
stone (14 pounds or 6.35 kg) in a three
month period?
• Do you believe yourself to be Fat when
others say you are too thin?
• Would you say that Food dominates your
life?
Athletic Triad
• Disordered eating • Amenorrhea
• Osteoporosis
Some patients with insulin-dependent DM may stop their insulin in order to lose weight