Eating Disorders in the Primary Care Setting

Educational Objectives

The goal of this program is to improve the management of eating disorders (EDs) and emergency treatment in the pediatric population. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the signs and symptoms of anorexia.

2. Distinguish between anorexia and bulimia.

3. Counsel patients with EDs about the importance of seeking treatment.

Summary

Overview: no consensus exists on core psychopathology involved in eating disorders (EDs); requires biopsychosocial approach to treatment; patients with ED typically do not seek psychiatric treatment voluntarily

Etiology: no universally accepted theory accounts for EDs; multiple converging factors (biologic, psychological, and environmental) may be involved in understanding EDs

Biologic explanations: Kaye et al (2009) theorized that individuals with anxious, perfectionistic, or obsessive-compulsive traits engage in pathologic eating during puberty, which leads to neurobiologic changes that result in increased dysphoria, denial, perfectionism, and obsessionality; once ED established, secondary changes in brain chemistry (eg, serotonin system) may occur; mood disorders — EDs may be variant of mood disorder, as many patients have comorbid major depression, dysthymic disorder, or bipolar disorder; increased prevalence of mood disorders found in relatives of patients with EDs; obsessive-compulsive disorder — many patients with anorexia have obsessive thoughts and compulsive rituals

Genetic explanations: no equivocal findings exist; studies show rate of heritability as high as 83% in patients with bulimia

Psychological explanations: Bruch suggested that EDs result from problems with body image, self-esteem, and interoceptive awareness (eg, patient with ED self-identifying aversive emotional state as “feeling fat”; these patients more likely to restrict diet further or, conversely, binge and purge to lessen intensity of aversive feelings); help patients identify and cope with aversive feelings in lieu of maladaptive eating

Sequence of events in bulimia: biological factors (decreased serotonin levels, altered gut hormones), poor eating habits (delaying eating until excessively hungry, avoidance of food), and aversive emotional states result in episodes of binge eating; fullness and bloating equate to “feeling fat”; compensatory strategy involves vomiting, which reduces fear of gaining weight and thus negatively reinforces behavior

Sequence of events in anorexia: event such as social function elicits aversive emotional state; patient compensates with behavior such as body checking, restrictive dieting, excessive exercise, and/or avoidance of social function; these strategies decrease anxiety and allow patient to avoid aversive feelings, which in turn reinforces behavior

Cultural explanations: thin body type considered ideal by society; 330,000 adolescents underwent plastic surgery in 2007; many pro-ED websites available that teach patients how to artificially inflate their weight to mislead their doctors

Diagnostic criteria: anorexia — restriction of energy intake resulting in excessively low weight (ie, weight less than minimally normal [body mass index <18.5] or, in children and adolescents, less than minimally expected [<5th percentile]); intense fear of gaining weight and denial of seriousness of low body weight; menstrual irregularity removed from criteria in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition); subtypes of anorexia include restricting type and binge-eating and purging type; binge eating — defined as consumption of amount of food larger than that consumed by most individuals in similar (discrete) period of time; differentiated from overeating by lack of control; binge-eating disorder — eating more rapidly than normal, eating until uncomfortably full, eating large amounts of food when not feeling physically hungry, and eating alone because of embarrassment or shame; patients may experience guilt or shame afterward

Common mimics: rumination disorder — repeated regurgitation not attributable to associated gastrointestinal or other medical condition; food commonly rechewed and reswallowed; cyclic vomiting syndrome — possible precursor to migraine headaches; characterized by distinct pattern of intense vomiting not attributable to organic cause; most commonly diagnosed in school-age children; most common in whites and and girls; diagnosis of exclusion; often incapacitating in morning hours; nearly constant vomiting can lead to severe dehydration; attacks often correlated with stressors (eg, infections, menstruation, sleep deprivation, parental discord, difficulties in school, impending deadlines; cyclic vomiting often regresses as children age (patients may develop migraine headaches in adolescence); asymptomatic periods may occur between episodic periods; avoidant or restrictive food intake disorder — persistent failure to meet appropriate nutritional and/or energy needs; associated with significant weight loss or nutritional deficiency; characterized by lack of interest in food and concern about aversive consequences of eating; selective ED — affected children typically eat only 1 or 2 foods; develops when parents give children complete control over foods eaten; Wilson disease — symptoms similar to those of anorexia nervosa; look for Kayser-Fleischer ring and test for copper in patients who appear anorexic; pica — ingestion of nonnutritive substances

Other conditions: prevalence of EDs higher in patients with insulin-dependent diabetes, hypothyroidism, cystic fibrosis, and Crohn disease; prevalence of bulimia higher in pregnant patients

Epidemiology and comorbidities: ≈1% of population falls into anorexia category, whereas 1% to 4.2% have bulimia; slightly higher proportion have other specified EDs; prevalence increases in certain populations (eg, college students); binge eating present in 70% of attendees at Overeater’s Anonymous meetings; common comorbid diagnoses include borderline, histrionic, and narcissistic personality disorder; other comorbidities may include perfectionism, low self-esteem, poor interoceptive awareness, social problems, mood swings, and irritability; many patients with ED have history of unwanted sexual experiences or sexual trauma; girls and women primarily at risk (but boys and men may be underrepresented because they tend not to seek treatment)

Assessment: interdisciplinary approach recommended

Questions for patients suspected of having ED: Do you make yourself sick (ie, induce vomiting) because you feel uncomfortably full? Do you worry that you have lost control over how much you eat? Have you recently lost >14 lb in a 3-mo period? Do you think you are too fat even though others say you are too thin? Would you say that food dominates your life?; ask about tasting, chewing, and spitting behaviors; ask about exercise habits

Common signs and symptoms: often more apparent in patients with anorexia than in patients with bulimia; include dry skin, lanugo (especially on chin and neck), low body temperature, elevated liver function tests, increased bruising, hypercholesterolemia, amenorrhea, hypotension, and yellowish skin; abnormalities on electrocardiography common; laboratory findings include elevated serum urea nitrogen, hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis and/or acidosis, and abnormal thyroid function; gastrointestinal complications include delayed stomach emptying, which causes feeling of fullness; endocrine and skeletal abnormalities, decreased resting metabolic rate, and neurologic changes also occur; refeeding syndrome — induction of hypophosphatemia in response to rapid reinstitution of nutrients in undernourished patients; can be lethal

Findings in patients with bulimia: overlap with those in anorexia; additional changes associated with purging; signs include skin lesions on dorsum of fingers, erosion of tooth enamel, sores in corners of mouth, Mallory-Weiss tears, and inflammation of salivary (parotid) glands; electrolyte disturbances may also occur; studies indicate 89% of patients with bulimia shown signs of tooth erosion after only 6 mo of vomiting

Treatment: brochures and information sheets should be readily available; gain familiarity with local and regional resources, including specialists in EDs; schedule convenient time after examination for discussion with patient; begin discussion by mentioning notable abnormalities on examination or laboratory findings, and gently introduce possibility of ED (do not be judgmental or accusatory); request permission for appropriate referral; if resistance encountered, have patient sign minimum-weight contract and inform him or her that referral imminent if weight falls below certain level; obtain appropriate laboratory tests to confirm medical stability

Inpatient treatment: indications — patient considered danger to self (ie, unable to provide adequate self-care); inability of parents to provide adequate supervision; failure to comply with minimum-weight contract; orthostasis, bradycardia, or life-threatening electrolyte imbalances

Nutrition: supplemental feeding with liquids indicated in patients who cannot eat properly; nasogastric feeding, jejunostomy, or gastrotomy may be required

Pharmacotherapy: psychopharmacologic treatment for anorexia generally not effective, partly because medications fat soluble; antidepressants more effective when patient reaches 85% of ideal body weight; selective serotonin reuptake inhibitors appear to be most effective; use tricyclic antidepressants with caution because of potential cardiac complications; mirtazapine (Remeron) has shown promising results but may be too sedating for adolescents; olanzapine (Zyprexa) effective (speaker uses it frequently in conjunction with antidepressant for patients with restricting-type anorexia until goal of 85% of ideal body weight reached; contraindicated if patient has binge-eating problem); pharmacotherapy most effective in patients with bulimia when used in combination with cognitive behavioral therapy; fluoxetine approved by Food and Drug Administration for treatment of bulimia; bupropion contraindicated for treatment of bulimia because of potential to increase seizure activity

Readings

Kaye WH et al: New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci 2009 Aug;10(8):573-84; Bayless JD et al: Neuropsychological characteristics of patients in a hospital-based eating disorder program. Ann Clin Psychiatry 2002 Dec;14(4):203-7; Brown NJ et al: Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014 Feb;133(2):e299-304; Freedman SB et al: Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr 2014 Jan;164(1):83-88; Kaye WH et al: New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci 2009 Aug;10(8):573-84; Lemmon CR, Josephson AM: Family therapy for eating disorders. Child Adolesc Psychiatr Clin N Am 2001 Jul;10(3):519-42; Little JW: Eating disorders: dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002 Feb;93(2):138-43; Mazzeo SE, Bulik CM: Environmental and genetic risk factors for eating disorders: what the clinician needs to know. Child Adolesc Psychiatr Clin N Am 2009 Jan;18(1):67-82; Morgan JF et al: The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999 Dec 4;319(7223):1467-8; Thompson M et al: Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013 Dec 11;347:f7027; Wagner A et al: Normal brain tissue volumes after long-term recovery in anorexia and bulimia nervosa. Biol Psychiatry 2006 Feb 1;59(3):291-3.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose. In his lecture, Dr. Lemmon presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Lemmon was recorded at the UF Primary Care, Pain Medicine, and Addiction Conference, held October 30 to November 1, 2014, at Ponte Vedra Beach, FL, and sponsored by the University of Florida College of Medicine. For information about upcoming CME activities from the University of Florida College of Medicine, please visit http://cme.ufl.edu/. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

FP631901

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.