eating disorders in children and adolescents nervosa binge eating disorder other/unspecified feeding...
TRANSCRIPT
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EATING DISORDERS
IN CHILDREN AND
ADOLESCENTS
Kristina Sowar MD UNM Dept Child and Adolescent Psychiatry
10/20/2015
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INTRODUCTIONS
Thank you:
UNM Department of Psychiatry
Eating Disorder Treatment Center of Albuquerque
Disclosures: none
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INTRODUCTION
EATING DISORDERS
Definitions/Diagnoses
Signs and Symptoms
Etiology
Treatment
Resources
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BACKGROUND
Experiences with Eating Disorders
clinical
personal/family
Questions / Topics to Address?
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INTRODUCTIONS
What do we think of when we hear “eating disorders?”
Reactions?
Stigma?
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EATING DISORDERS
DSMV: “characterized by a persistent disturbance of eating or
eating related behavior that results in altered
consumption or absorption of food, and that
significantly impairs physical health or
psychosocial functioning.”
Extreme emotions, attitudes, and behaviors surrounding
weight and food issues
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SUBTYPES - DSMV
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder
Other/Unspecified Feeding or Eating Disorder
Pica
Rumination Disorder
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ANOREXIA NERVOSA
Restriction of energy intake relative to requirements ->
significantly low body weight
less than minimally expected, or failure to meet growth
trajectory
intense fear of gaining weight / becoming fat
disturbance in the way one’s body weight or shape is
experienced, undue influence of body weight on
self-evaluation
lack of recognition of seriousness of current body weight
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ANOREXIA NERVOSA
Restricting Type vs Binge-eating/purging type
Severity specified on BMI
global body image versus specific
Prevalence: 0.4% amongst females,
10:1 female: male
CMR: 5% per decade
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ANOREXIA WARNING SIGNS
Behaviors:
preoccupation with food, calories, dieting, cooking
refusing to eat/restricting certain foods or groups
comments about feeling fat or anxiety about body
denial of hunger
development of food rituals (small pieces, slow, order)
avoiding mealtimes, situations involving food
social withdrawal
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HEALTH CONSEQUENCES
Affects multiple organ systems:
CV: Bradycardia, heart failure, low blood pressure
decreased bone density
muscle loss/weakness
dehydration, peripheral edema
depressive signs (can be physiological)
dry skin, hair, lanuga
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LAB FINDINGS
CBC: leukopenia
Chemistries:
elevated cholesterol/LFT
low phosphate, magnesium
alterations in Cl/K if vomiting
Endocrine
low sex hormones
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ETIOLOGY
genetics (ED, mood sx)
obsessive-compulsive tendencies, anxiety
onset
life stressor
initial weight loss (diet, virus) -> -> -> spirals
societal/cultural
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SAMPLE CASES
14 yo female, started dieting last year - received compliments
so continued to lose weight, restrict food,
increased exercise. Down to 500 calories/day,
BMI 14, admitted for pericardial effusion.
Stabilized inpatient and transitioned to outpt.
14 yo female, lost 10 pounds viral illness, continued to lose to
BMI 16. Anxiety, BPAD, home schooled - in outpt,
improved with medications.
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BULIMIA NERVOSA
eating in a discrete period of time, amount of food larger than
most would eat in that time/circumstance
lack of control over eating during the episodes
recurrent inappropriate compensatory behavior to prevent
weight gain
at least once/week for 3 months
self evaluation unduly influence by body shape and weight
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BULIMIA NERVOSA
Cycles of binging and compensatory behavior (purging)
binge: eating relatively large amount of food in short period of
time (2 hours,) “out of control”
purging: vomiting, laxatives, exercise
Near normal or above body weight
severity based on number of episodes/week
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BULIMIA WARNING SIGNS
Disappearance of large amounts of food
Frequent trips to bathroom after meals, evidence of laxative
use
excessive exercise routines
swelling of cheeks (parotid glands)
calluses on hands from vomiting
discoloration of teeth
social withdrawal
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BULIMIA COMPLICATIONS
Electrolyte disturbance
Inflammation/rupture of the esophagus
Dental issues
Chronic irregular bowel movements
Gastric rupture
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ETIOLOGY/PREDISPOSING FACTORS
Temperament (weight concerns, low self-esteem, social
anxiety)
hx of abuse (physical or sexual)
childhood obesity and pubertal maturation
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BULIMIA FACTOIDS
about 80% female/ 20% male
onset before puberty or after 40, unusual
often accompanies mood dysregulation, trauma/abuse,
borderline personality traits
crossover from bulimia <-> anorexia
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SAMPLE CASE
16 yo Hispanic female
presents to ICU severely hypokalemic
recently withdrew from school
reports purging when upset, when feeling full, or worried
about weight.
normal weight
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BINGE EATING DISORDER
Recurrent episodes of binge eating that must occur, at least
once/week for 3 months
“binge” - eating in a discrete (~2 hours) period of time, that is
definitely larger than most people would eat in a similar
period of time under similar circumstances
with marked distress
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BINGE EATING DISORDER
Recurrent Episodes of Binge Eating
>3:
eating more rapidly than normal
until uncomfortably full
large amounts when not feeling hungry
alone because of embarrassment
feeling disgusted with oneself/guilty
Marked distress re: binge eating
at least once/week for 3 months
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BINGE EATING DISORDER
Severity: based on number of episodes/week
occurs with both “normal” and overweight individuals
12 month prevalence: 1.6% females, 0.8% males
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BINGE EATING COMPLICATIONS
metabolic issues
elevations in blood sugar, cholesterol, BP
gastric complications
obesity and weight related issues
self esteem and shame complications
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UNSPECIFIED EATING DISORDER
not meeting full criteria for another diagnosis, but still cause
clinically significant distress or impairment in
social, occupational, or other important areas of
functioning
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HOW TO HELP?
Awareness in assessing / evaluating warning signs
Working within degree of insight and family systems
Coordinating interventions
Creating Supportive Environments
Preventative Care
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TREATMENTS
Multidisciplinary:
Therapy (CBT, DBT, Family)
Nutrition/Dietician
Physician / Psychiatrist
Intensive Outpatient
Inpatient (Medical vs Residential)
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FAMILY WORK
age of patient re: privacy/disclosure of information
family member feelings about illness
attempts to intervene
awareness of “identified patient”
control vs safety
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NUTRITIONAL ASSESSMENT daily intake
restrictions/avoidants
calories and nutritional breakdown
assessing for re-feeding syndrome
expenditure
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TREATMENT
Medical Interventions:
Weight/BMI
Labs
CBC/Chemistries/LFT/Lipids
Celiac?
EKG
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TREATMENT
Medications
antidepressants
SSRI’s, mirtazapine
weight dependent
anxiety remedies
antipsychotics (Olanzapine)
Stimulants (Vyvanse)
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LEVEL OF CARE DECISIONS
Outpatient Therapy / Nutrition
Intensive Outpatient Programs
Partial Hospitalization
Residential
Inpatient
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DETERMINING LEVEL OF CARE …
safety (suicidal ideation? self harm?)
supervision/monitoring
ability to eat/maintain weight at lower levels of care
other life stressors, activities
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RISK FACTORS/ETIOLOGY
Genetics (women with mothers with eating disorders -
much higher rates)
altered leptin/ghrelin, cholesterol receptors
Family Factors (control, stress)
Societal Pressures
Media Exposure
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TARGET POPULATIONS
Males
LBGTQ
College Students
Mid-Life
Diabetes / Chronic Illness
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RESOURCES
Local:
Eating Disorder Treatment Center of Albuquerque
Eating Disorders Institute of New Mexico
UNM / Dept of Psychiatry
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REGIONAL RESOURCES
Rosewood Inpatient (Wickenberg)
Remuda (Wickenberg)
University of Colorado - Denver Health
Denver Center for Eating Disorder
Mirasol (Arizona)
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COST OF CARE / INSURANCE
many insurance companies do not cover various levels of
care
advocacy
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SOCIAL/MEDIA EXPOSURE
Airbrushing
Pro-ANA websites
comments/feedback on photos/body preoccupation
Focus on fitness
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WEBSITES
National Eating Disorders Website
Something Fishy