Diagnosis and Management of Eating Disorders - UCLA Med-Peds

Report
Stephanie Bui MD FAAP
Assistant Clinical Professor of Medicine and Pediatrics
UCLA Health System – Brentwood
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K.P. is a 17 year old female presenting to your
office for “irregular periods”.
Had been seen 8 months prior for a well visit.
At that time height was 65 inches, weight 140
lbs (BMI 22.6). Menarche age 13, having
normal menstrual cycles every 28-32 days
Today height is 65 inches, weight 115 lbs (BMI
18.6). Last period was 3 months previously
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Patient denies sexual activity
Patient says that she has just been “getting
healthy” by cutting out snacks
Patient says she started exercising as well to
“get healthy”
Is very evasive and defensive when asked
how much she eats/how much exercises
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Mom asks to see you outside of the room
 Has noticed that K.P. is eating less meals with the
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family
Has noticed a weight loss (unsure how much)
Scale is now moved from bathroom to K.Ps room
Mom has not been able to discuss this with K.P. as
patient gets defensive
Worried that K.P. has an eating disorder
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As stated – weight 115 lbs. Blood pressure
100/60. Heart rate 50. Temp 96.7
HEENT – Lanugo noted on face
Neck – Thyroid – normal size, no masses
CV: Bradycardia
Breasts: Tanner 4, Pubic Hair Tanner 4
Abdomen: Soft/non tender/no masses
Extremities: Cool fingertips and Toes
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What labs do you want?
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Urine Pregnancy test – negative
CBC – WBC 3.1 otherwise normal
Chem 10 – Normal
Prolactin – Normal
TSH – Normal
FSH – 2.0
LH – 2.0
Estradiol <30
EKG – Sinus bradycardia at 50 BPM otherwise
normal
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You tell K.P that her lack of periods is likely
due to her weight loss
You begin to discuss healthy ways of gaining
weight, she storms out of the room and says
“No Way I’m doing that – I’m fine the way I
am”
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DSM IV-TR Criteria
A. Refusal to maintain body weight at or above a
minimally normal weight for age and height
B. Intense fear of gaining weight or becoming
fat, even though underweight
Disturbance in the way in which one’s body
weight of shape is experienced
Amennorhea (in post menarchal females) –
absence of at least 3 menstrual periods
Type – Restricting Type or Binge-Eating/purging
Type
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Genetic: First degree relative 3x risk
Biologic: neurotransmitter abnormalities
Sociocultural: obsession with thinness
Psychological
 Low self esteem
 Conflict about identity, sexuality
 Obsessive-compulsive
 40% history of abuse, being teased
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Family: enmeshed, overprotective
Sports: gymnastics, ice skating ballet
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Prevalence – Estimated at 1%
90-95% are female
Bimodal peaks of onset at ages 13-14 and 1718
Prepubertal may be associated with more
severe profile
Adolescent onset associated with better
prognosis that prepubertal and adult onset
30% of patients were obese
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Determine Level of Care:
 Medically Unstable: medical hospital
▪ Heart rate <40, glucose < 60 mg/dl, potassium <3 mEq/l,
orthostatic hypotension
 Psych Unstable: psych hospital
 Med/Psych stable:
▪ <70% IBW: Inpatient
▪ 70-85% IBW: Partial/Day treatment
▪ >85%: Outpatient
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Create treatment team
 Therapist: individual and family
 Nutritionist
 Medical provider
 Psychiatrist
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Coordination between all providers is KEY
Start with therapeutic alliance
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School – Consider reduced schedule
Exercise: limit activities, team sports, gym
Amennorhea: consider OCP >6-12 months
 Calcium 1200-1500 mg
 Vitamin D 400-800 IU
 Dexa Scan if no menses > 6 months
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Standardized tables
Premorbid weight
Weight at which patient had last period
Progressive weight goals
Weight at which patient feels safe and
healthy
May need to postpone discussion
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Close monitoring: every 1-2 weeks
Standardized weights: gown, empty bladder
Weight gain: ½-1 lb per week
 If faster risk refeeding syndrome
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Ask patient if they want to know weight
Avoid comments about weight
During treatment constantly assess:
 Resistance, denial, non-compliance, deception
 Depression, anxiety
 Purging activities
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Treat psychiatric co-morbities
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Cardiac: Arrhythmias, prolonged QT, heart
failure, pericardial effusions
Neurologic: cerebral atrophy
Endocrine:Osteoporosis
Renal: renal failure, nephrolithiasis
GI: gastric dysmotility
Dental: enamel erosions
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Initial visit – after coaxing back into room,
you explain your concerns about health
She reluctantly agrees to see a nutritionist,
refuses to see a therapist
Follow-up one week later, weight is down 2
pounds – refused to implement changes
suggested by nutritionist
Admitted to day treatment program
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< 50% achieve full recovery
 Predictors of recovery: higher body weight at intake,
shorter duration of intake episode, and atypical features
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1/3 improve with lingering symptoms
1/5 remain chronically ill
Mortality
 Mortality rate is 12x higher than that for age matched
women
 24% of deaths due to suicide
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K.P. presents to your office 5 years since
initial diagnosis of anorexia nervosa – since
that time, she has had one inpatient
admission and 3 partial hospitalizations – last
at age 19.
Her weight has been stable at 135 for the past
2 years
On exam, you noticed parotid enlargement,
and scars on her knuckles
Recurrent episodes of binge eating
Recurrent inappropriate compensatory behaviors in
order to prevent weight gain (self induced vomiting,
misuse of laxatives, diuretics, enemas or other
medications, fasting, excessive exercise)
 At least 2 episodes of binge eating per week for 3
months
 Two types:
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 Purging
 Non purging
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Similar to anorexia nervosa
Borderline personality disorder
Impulse Control
Perfectionism
Disturbances in family function
History of sexual abuse
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Lifetime Prevalence 1%-4.2%
90-95% femaile
Onset later than in anorexia nervosa
Less common in African Americans
50% of patients with anorexia nervosa will
migrate to Bulimia Nervosa
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Eating and Body image questions
Questions about binge eating
 Frequency, amounts
 Triggers – specific foods, situations, feeling
 Facillitators
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Questions about purging
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Frequency, techniques
After purge, how do you feel?
Dental Care
Vomited Blood, reflux symptoms
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Determine Level of Care
Create treatment team
Focus on the binge, not the purge
Dental Care
 Rinse teeth immediately, don’t brush for 30 minutes
 Sensitive toothpaste
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Medications
 SSRIs – most studied is fluoxetine 60 mgs/day
 Bupropion – black box warning re: seizures
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Related to purging activity
Dental: erosion, false teeth
GI: esophageal tears, cathartic colon, GERD
Metabolic: electrolye imbalance, dehydration
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Mortality – low
50% will achieve full recovery at 5 – 12 years
 1/3 of these will go on to relapse
Eating Disorder “not otherwise specified”
Binge eating Disorder
Disordered Eating
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21 year old female, no past medical history
Height 5 ft 8 lb, weight 140 lbs
On routine history – exercises 7 days/week for
60 minutes – because “if I don’t I feel fat”
Counts calories
Eats same foods every day
Weighs herself daily
Physical exam normal, Labs normal
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When thoughts about your body and/or
eating interfere with your life
 “If I were just 5 lbs thinner I would be happy”
 “If I were thinner, then people would like me
more”
 “ I feel so fat; I am so fat; I will eat today and start
my diet tomorrow”
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Eating rituals – same food, same schedule
Cutting out fat, favorite foods
Weighing self a lot
Excessive exercising
Eating only if “good”
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Do you make yourself Sick “purge” because
you feel uncomfortalby full?
Do you worry that you have lost Control
Have you recently lost more than 14 lbs (One
Stone) in a 3 month period
Do you think you are too Fat
Would you say that Food dominates your life
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15 year old male new patient presented to
office for “anorexia nervosa”
Recently discharged from inpatient eating
disorder facility
Previous to his admission there, had lost 15
pounds with decreased intake. Vague
complaints of abdominal pain
On review of labwork, had microcytic anemia
prior to admission to eating disorder facility
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Gained weight only with tube feeds in
hospital (was refusing po)
Repeat labs after hospitalization – persistent
microcytic anemia, low Fe levels, elevated
ESR
Dad with “colitis”
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Bottom line – severe Crohn’s disease
Ultimately required ileocecal resection.
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If your patient says “I feel fat”, it is code for
 I feel sad
 I feel angry
 I feel stupid
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Don’t dismiss the feeling, normalize it
Emphasize health and fitness for patient and family
 People are different shapes and sizes
 Everyone can try to be healthy, fit and heave healthy body
image
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Routinely ask about body image
Set follow up appointments
For families
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Be Direct: “I am worried about you”
Be prepared: show direct evidence
Be Firm
Don’t bribe or monitor
Get help – Earlier the diagnosis, better the
prognosis

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