Karen-Rose Wilson Academic Half Day- Thursday August 30 2012 Preceptor: Dr. Jorge Pinzon Approach to...
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Transcript of Karen-Rose Wilson Academic Half Day- Thursday August 30 2012 Preceptor: Dr. Jorge Pinzon Approach to...
Karen-Rose WilsonAcademic Half Day- Thursday August 30 2012Preceptor: Dr. Jorge Pinzon
Approach to Eating Disorders
Outline of presentation
DemographicsDiagnosisDifferential diagnosisScreening for eating disordersInitial evaluationPhysical examination findingsMedical complicationsTreatmentPrognosis
Demographics
Incidence rates steadily increasing Prevalence of anorexia nervosa in adolescent girls = 0.5% Prevalence of bulimia nervosa in adolescent girls = 1-3%
Large number of children with eating disorders do not meet DSM-IV criteria- prevalence of ED-NOS= 0.8%-14%
Epidemiology has gradually changed increasing prevalence in: Males- 5-10% of all cases of eating disorders Minority populations In children 8-14 years old
Anorexia nervosa has highest fatality rate of any mental health disorder- mortality rate ~5% (Steinhausen, 2009)
Eating disorders
Anorexia nervosa (AN)Bulimia nervosa (BN)Eating disorder not otherwise specified (ED-
NOS)Appetite loss secondary to depressionFood avoidance emotional disorderSelective eating
Diagnosis
What are the DSV- IV criteria for anorexia nervosa?
Diagnosis- Anorexia Nervosa
Diagnosis- Anorexia Nervosa
Ideal body weight calculation:Square of height in metres x 50th percentile BMI for age and
sex
For example, the ideal weight of a 14 year old female who is 1.626 m in height is calculated as follows:
(1.626m)2 x 19.4kg/m2 = 1.626 x 1.626 x 19.4= 51.3 kg
Diagnosis- Anorexia Nervosa
What are the subtypes?
Diagnosis- Anorexia Nervosa
Subtypes:1.Restricting type: no regular bingeing or
purging (self-induced vomiting or use of laxatives and diuretics)
2.Binge eating/ purging type: regular bingeing or purging behaviour
Diagnosis
What are the DSM-IV criteria for bulimia nervosa (BN)?
Diagnosis- Bulimia Nervosa (BN)
Diagnosis- Bulimia Nervosa
What are the subtypes?
Diagnosis- Bulimia Nervosa
Subtypes:1.Purging type: the person has regularly
engaged in self-induced vomiting or misuse of laxatives, diuretics, or enemas
2.Nonpurging type: the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Diagnosis- ED NOS
Disorders of eating that do not meet criteria for either AN or BN; examples include: Patients that have not yet missed three menstrual cycles Not quite 15% below IBW All criteria for AN are met except that despite significant
weight loss, weight remains in normal range All criteria for BN are met except that binge-eating &
inappropriate compensatory behaviours occur less frequently than twice per week or <3 months duration
Children 8-12 years old who eating disorder behaviours are not driven by a specific fear of gaining weight
Outline of presentation
DemographicsDiagnosisDifferential diagnosisScreening for eating disordersPhysical examination findingsMedical complicationsInitial evaluationTreatmentRefeeding SyndromeOutcomes
Differential Diagnosis
Conditions that may cause weight loss with or without amenorrhea?
Differential Diagnosis
Screening for eating disorders
16 year old who initially was underweight has been dieting and lost 20 lbs in the last 3 months….
14 year old boy has been exercising 3 hours a day and eliminated all fat from his diet to “increase my muscle mass and decrease my fat”...
11 year old girl has grown 2 inches but has gained no weight since her last check-up 1 year ago…
15 year old girl is found to have empty boxes of laxatives hidden under her bed but denies they are hers…
Screening for eating disorders
Suspicious behaviour? Assumption of a vegetarian, vegan, low fat or
“healthier” diet Scrutiny of ingredient lists Initiation of precise calorie counting Weighing one’s self several times a day Mealtime behaviours- smaller portions, longer time to
eat, hiding food Difficulty eating in social settings Avoiding eating with family and friends Frequent trips to the bathroom after meals Dressing with extra layers of clothing to cover up
signs of emaciation
Screening for eating disorders
The SCOFF Questionnaire: Do you make yourself Sick because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? In any recent 3-month period, have you lost Over 6.5 Kg or 15 lbs? Do you believe yourself to be Fat when others say you are thin? Would you say that Food dominates your life?
One point for every “yes” answer; a score of ≥2 indicates a likelihood for AN or BN.
The BMJ Publishing group, Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319(7223):467-8.
Initial Evaluation
History- child/adolescent, collateral hxPhysical examinationInitial investigations
Initial Evaluation- history
Questions for children/adolescents with a possible eating disorder?
Initial Evaluation- History
Initial Evaluation- Review of systems/ Physical examination
Break for 5-10 minutes to brainstorm physical exam findings and medical complications of eating disorders
Initial Evaluation- Review of systems/ Physical examination
Multisystem disorder: Fluids & Electrolytes Metabolic Cardiovascular Pulmonary Gastrointestinal Renal Endocrine Hematologic Immunologic Neurologic Dermatologic
Physical findings & medical complications
System Anorexia Bulimia
General Cachexia, facial wastingHypothermiaEdema
Normal weight
Dermatologic
Dry, sallow skin; lanugoDull, thinning scalp hair, alopeciaCold extremities; acrocyanosis; poor perfusionCarotenemia (orange discoloration of skin, particularly palms, soles)Cheilosis
Periorbital petechiaRussel sign (calluses over PIP joints of hands)
Orofacial Halitosis Injury to palate and posterior pharynxDental caries, enamel erosionParotid gland enlargement, Submandibular adenopathy
Physical findings & medical complications
System Anorexia Bulimia
Cardiac Palpitations, chest pain, shortness of breath, exercise intoleranceSinus bradycardiaOrthostatic changes in pulse or blood pressureArrhythmiaProlonged QT intervalMurmur- 1/3 with mitral valve prolapsePericardial effusions
Arrythmia, orthostasisIrreversible cardiomyopathy and myositis (ipecac toxicity)
Pulmonary Pneumothorax or aspiration secondary to vomiting, pulmonary edema during refeeding
Pneumothorax or aspiration secondary to vomiting
Physical findings & medical complications
System
Anorexia Bulimia
GI Palpable stool secondary to constipationScaphoid abdomenDelayed gastric emptying and impaired GI tract motiltiyBloating: postprandial fullnessTransaminitisFatty degeneration of the liverSuperior Mesenteric artery syndrome
Abdominal fullness, gastric dilatation
Vomiting related:•Hypocholoremic metabolic alkalosis•Esophagitis•Gastroesophageal reflux•Mallory-Weiss tears•Esophageal or gastric rupture (rare)
Laxative related:•Hyperchloremic metabolic alkalosis•Hyperuricemia•Hypocalcemia•Fluid retention (may gain up to 10lbs in 24 hrs) with laxative withdrawal
Physical findings & medical complications
System Anorexia
Breasts & GU
Breast atrophy, atrophic vaginitis and atrophy of the female genitalia
Bone FracturesLow bone mineral density- osteopenia, osteoporosis
Endocrine & metabolic
Amenorrhea (1o or 2o) and menstrual irregularities- hypogonadotrophic hypogonadism with estrogen deficiencyDelayed puberty, reduced beard growth in malesArrested growthEuthyroid sick syndrome- T4/ TSH low-normal range, decrease conversion of reverse T3 to T3HypercortisolismWeakness- loss of muscle mass
Physical findings & medical complications
System Anorexia Bulimia
FEN Usually normalDehydrationHyponatremia/ hypernatremiaHypophosphatemiaEdema
HypochloremiaHypokalemiaMetabolic AlkalosisDehydrationHyponatremia
Neurological and mental status
Neurocognitive deficitDiminished muscle strengthPeripheral neuropathyMovement disorderSeizures- hyponatremia Suicidal ideation, comorbid psychiatric disorders
Suicidal ideation, comorbid psychiatric disorders
Initial work up
What initial investigations would you complete?
Initial work up
Plot height and weight on growth chart, assess trend
Calculate ideal body weight/ BMICBCElectrolytes, extended lytesLiver enzymes/ function testsUrea/ CreatinineThyroid function tests (TSH, T4)LH/ FSH/ estradiol/prolactinECGBone density studies- DEXA in those patients who
have amenorrhea ≥ 6-12 monthsVitamin studies generally not ordered
Treatment Continuum
Most patients will be treated as an outpatient collaborative outpatient care by a multidisciplinary team
Medical stabilization and nutritional rehabilitation are essential for correcting cognitive deficits to allow for effective mental health interventions
Oral refeeding preferred modality- but may need supplements/ NG feeding
Treatment -Nutritional rehabilitation
Refeeding syndrome: rapid refeeding of patients who are severely malnourished (hospitalized, more than 30-35% below IBW) can lead to: Shifts of phosphate from extracellular to intracellular
spaces in the setting of total body phosphorus depletion
Hypophosphatemia- can result in major complications such as cardiac failure, stupor, coma…
Cautious refeeding, monitoring electrolytes, low threshold for phosphorus supplementation
Unusual after first 2 weeks of treatment
Treatment Continuum
Collaborative outpatient careFamily-based (“Maudsley”) therapyDay-treatment programsHospital-based treatmentPharmacotherapy
Treatment Continuum
Family-based (“Maudsley”) therapy Work originally performed at Maudsley Hospital in
London 3 phases:
1. Parents supported by therapist take responsibility to make sure adolescent is eating adequately and limiting pathologic weight control behaviours
2. Substantial weight recovery has occurred, and the adolescent is helped to gradually resume responsibility for own eating
3. Weight restored, therapy shifts to address the more general issues of adolescent
Treatment Continuum
Day-treatment Programs Intermediate level of care for patients who require
more than outpatient care but less than 24 hour hospital care
Prevent need for hospitalization, “step down” from inpatient to outpatient
Typically involves 8-10hrs of care (including meals, therapy, groups, other activities) by a multidisciplinary staff 5 days/week
Treatment Continuum
Hospital-based Treatment
Criteria?
Treatment Continuum
Treatment Continuum
Pharmacotherapy- Anorexia Nervosa: No medication has been approved by FDA for treatment of AN. If prescribed typically targeted at comorbid symptoms of
anxiety and depression. SSRIs most often used but may not be effective in severely
malnourished patients. In recent case reports and open label trials- olanzapine shown
to improve weight gain & dysfunctional thinking in patients with AN. Further evaluation needed.
Hormonal supplementation although capable of restoring menstruation has not been shown to improve bone mineral density
American Academy of Pediatrics. Clinical Report- Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251
Treatment Continuum
Pharmacotherapy- Bulimia Nervosa: Fluoxetine approved by FDA Other SSRIs, SNRIs and TCAs have been shown to
decrease binge-eating and purging in BN Topiramate has been shown to significantly decrease
binge-eating
American Academy of Pediatrics. Clinical Report- Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251
Prognosis
Prognosis varies widely in the literatureIn AN: approximately 50% of patients do well
overtime, 30% do reasonable well and 20% do poorly
High rates of residual psychiatric disorders even after full recovery from AN
Mortality rates for AN- 5-10% due to medical complications or suicide
Thanks!
References:1. American Academy of Pediatrics. Clinical Report-
Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126 (6): 1240-1251
2. American Academy of Pediatrics. Committee on Adolescence. Identifying and treating eating disorders. Pediatrics. 2003;111: 204–211
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994
4. The BMJ Publishing group, Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319(7223):467-8.
5. Goldstein,M, Dechant, E & Beresin, E. Eating disorders. Pediatrics in Review. 2011; 32 (12) 508-520.
6. Fisher, M. Treatment of eating disorders in children, adolescents, and young adults. Pediatrics in Review. 2006; 27(1) 5-16.