The Eating DisordersA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1Kendall L. Stewart, MD, MBA, DLFAPAFebruary 15, 2013

1 This presentation will focus on the most serious Eating Disorder, Anorexia Nervosa.

Why is this important?

• These are common, serious disorders.

• Anorexia Nervosa affects up to 2.1% of women.

• Up to 15% of patients are male.• Only about 40% of these

patients recover completely.• The reported mortality rate is as

high as 22%.

• After mastering the information in this presentation, you will be able to– Describe how patients with

Anorexia Nervosa often present,– Detail the diagnostic criteria,– Describe some of the associated

features,– List some differential diagnoses,– Identify some of the common

clinical problems– Write a preliminary treatment plan,

and– Identify some of the frequent

treatment challenges.1

1 Families are not always as helpful as you would wish. I asked a patient to tell her mother about purging.

What specific diagnoses are included here?

• Eating Disorders1,2

– Anorexia nervosa• Restricting type• Binge-eating /Purging type

– Bulimia nervosa• Purging type• Nonpurging type

– Eating Disorder NOS• Explore one of the best health and fitness sites on the Web here.• In DSM-5, this category will likely be renamed

Feeding and Eating Disorders, and several new diagnoses will be added.

1 Obesity is not a mental disorder, but it is an epidemic and you should consider making it a priority.2 Begin by making permanent changes in your own life.

How might a patient with anorexia nervosa present?• This is a17-year-old high school

senior.• “I started dieting last year to lose

a few pounds, but I’m still fat.”• “There’s nothing wrong with

me.”• “She’s too thin, and she’s

obsessed with food and exercise.”

• “She won’t believe that she’s too thin, and she resents our comments.”

• “She used to be a sweet girl, but now she’s sullen and hostile.”

• “I’m cold all the time.”• “I can’t concentrate; I’m in a fog.”• “I’m afraid to leave home to go

away to college, but no one stays in this town after high school.”

• “My parents fight all the time; they may get a divorce when I leave home.”

• “I can’t make friends.”• “People don’t like me because I’m

fat.”1

• You can view some of their stories here.

1 These patients regularly post videos on YouTube™.

What are the diagnostic criteria1 for anorexia nervosa?

• Refusal to maintain normal body weight leading to body weight less than 85% of what would be expected

• Intense fear of gaining weight or becoming fat

• Disturbance of body image• In postmenarchal females, amenorrhea

1 Specify whether the diagnosis is Restricting Type or Binge-Eating/Purging Type.

What other diagnoses might you include in your differential?

• Normal dieting– Thinness is holy grail for most women.

• Another eating disorder– In Bulimia Nervosa, normal body weight is maintained.

• Weight loss secondary to a general medical condition– GI disease– Brain tumors– Occult malignancies– AIDS

• Substance-induced weight loss– Stimulants

• Weight loss secondary to other psychiatric disorders– Depression and others1,2

1 A woman presented with severe depression and weight gain.2 I was consulted to see a paranoid patient who believed that her food was poisoned.

What associated features might you see?

• About two-thirds of these patients also have a mood disorder.

• Anxiety disorders are also very common.• Personality disorders are common.• These patients are at increased risk for substance

abuse disorders.• Starvation also produces psychiatric symptoms

including– Dysphoria– Anxiety– Obsessiveness– Hyperactivity

1 Physical findings in Anorexia Nervosa include lanugo, dry skin, emaciation, cold intolerance, hair loss,sunken eyes, bradycardia, hypotension, edema and hypothermia.

What are some treatment challenges you can expect?

1 Those who do best decide to maintain a healthy weight in spite of how they feel.2 The weight at which their menstrual flow changed is a good target weight.

• These patients are often sullen, resistant and noncompliant.

• Their families often minimize the problem.• The patient may have trouble building and

sustaining a therapeutic relationship.• Medication is not helpful for the disorder itself,

but when used for comorbid problems, these patients may be very sensitive to drug side effects.

• They may refuse medication for fear of weight gain.

• They will want to talk about food and weight and avoid the painful feelings that trouble them.1,2

What might a typical treatment plan look like?• Medical Complications

– Dehydration– Electrolyte imbalance

• Hospitalization– Fainting– CHF– Bradycardia– Cognitive impairment– Failure of outpatient treatment

• Laboratory investigation– Initial evaluation should be

extensive.• Nutritional Balance

– Behavior modification– Consider medication with weight

gain as a side effect

• Other comorbid disorders– Diagnose and treat these conditions

vigorously.• Maladaptive attitudes and behaviors

– Acceptance– Consider cognitive behavioral

psychotherapy (CBT)• Education and self help

– Provide educational resources.– Recommend a daily exercise

regimen.– Recommend a healthy diet.– Suggest healthy distractions.– Recommend online resources.– Recommend self help groups with

caution.

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any additional

questions I may have.• Make a follow up appointment.• Communicate with my other physicians.

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of my problems and

concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

How can you access the OU-HCOM psychiatry flash card online?

• Go to Quizlet.• Create a free account.• When you receive a confirmatory email, click on the link

to activate your new account.• With your activated account open in another browser

window, click on this link to join the class.• You can download the free Quizlet app to your iPhone or

import these learning sets to the more robust Flashcards Deluxe app.

• Enjoy. I hope you find these cards helpful.• Please post your feedback or suggestions on the Quizlet

site.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008.

You can read this text online here.• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition,

March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

Are there other questions?

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