Anorexia nervosa - Eating Disorder - Comment
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Information covered in this presentation slides: 1. Christopher Nirmal 2. - Definition: Anorexia nervosa is an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain as well as a distorted body self-perception. - It typically involves excessive weight loss and is diagnosed approximately nine times more often in females than in males 3. - A DSM-5 diagnosis of anorexia nervosa requires each of the following criteria : - ●Restriction of energy intake that leads to a low body weight, given the patient’s age, sex, developmental trajectory, and physical health - ●Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight - Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s low body weight 4. - ●Mild – BMI 17 to 18.49 kg/m2 - ●Moderate – BMI 16 to 16.99 kg/m2 - ●Severe – BMI 15 to 15.99 kg/m2 - ●Extreme – BMI < 15 kg/m2 5. - Anxiety disorders - Obsessive-compulsive disorder - Body dysmorphic disorder - Posttraumatic stress disorder - Mood disorders - Substance use disorders - Disruptive, impulse control, and conduct disorders 6. - ●Obsessive-compulsive - (15 percent of patients with anorexia nervosa) - ●Avoidant (14 percent) - ●Dependent (7 percent) - ●Narcissistic (6 percent) - ●Paranoid (4 percent) - ●Borderline (3 percent) 7. - ●Perfectionism – pursuing unrealistically high standards despite the occurrence of adverse consequences - ●Compulsivity – insisting upon order, symmetry, exactness, and control - ●Narcissism – craving admiration and external validation from others; excessive concern with physical appearance 8. - ●Amenorrhea - ●Infertility - ●Exertional fatigue - ●Weakness - ●Cold intolerance - ●Palpitations - ●Dizziness - ●Abdominal pain and bloating - ●Early satiety - ●Constipation - ●Swelling of the feet - Irritability is often present as well. 9. - ●Low body mass index (< 17.5 kg/m2) - ●Emaciation (body weight less than 70 percent of ideal body weight) - ●Hypothermia (core temperature < 35°C or 95°F) - ●Bradycardia (pulse < 60 beats per minute) - ●Hypotension (systolic blood pressure < 90 mmHg and/or a diastolic blood pressure < 50 mmHg) - ●Hypoactive bowel sounds - ●Xerosis (dry, scaly skin) - ●Brittle hair and hair loss 10. - ●Serum electrolytes - ●Blood urea nitrogen - ●Serum creatinine - ●Serum glucose - ●Serum calcium, phosphorous, and magnesium - ●Serum albumin and prealbumin - ●Liver function tests (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase) 11. - ●Internationalized Normalized Ratio (INR) - ●Complete blood count (CBC) including differential - ●Thyroid stimulating hormone (TSH) - ●20-OH Vitamin D - ●Electrocardiogram (ECG) - ●Urinalysis for specific gravity 12. - ●Neoplasm - ●Chronic infections (eg, tuberculosis or acquired immunodeficiency syndrome) - ●Uncontrolled diabetes mellitus - ●Hyperthyroidism - ●Malabsorption syndromes (eg, celiac disease) - ●Inflammatory bowel disease (eg, Crohn disease) - ●Pregnancy - ●Primary ovarian failure - ●Polycystic ovary disease - ●Pituitary prolactinoma 13. -Cardiovascular (structural) - Decreased cardiac mass - Decreased cardiac chamber volumes - Mitral valve prolapse (20%) - Myocardial fibrosis - Pericardial effusion - Improve with weight gain 14. -Cardiovascular (functional) : - Bradycardia - Hypotension - QT dispersion - Occasionally QT prolongation - Decreased heart rate variability - ST,T changes AV block Vent.arrhythmias 15. - Gastroparesis with bloating - Constipation - Severe pancreatitis - Mild rise in LFTS - Superior mesentric artery syndrome (rare) 16. - Anaemia 83% - Leucopenia 79% - Thrombocytopenia 25% -Bone marrow: - Normal 11% - Aplastic or Hypoplastic 39% - Gelatinous degeneration with serous fat atrophy 50% 17. -Decreased GFR -Decreased concentration -Electrolyte abnormalities - (Purging > Restrictive) 18. - Dyspnoea - (weakness and wasting of resp. muscles) - Pneumothorax /Pneumomediastinum - (weakening of alveolar walls) - Aspiration pneumonia - PFTS: - decreased maximal inspiratory pressures (59% of predicted) - expiratory pressures (35%), and - increased residual volume (162%). - Diffusion capacity (98.1 +/- 16.2%) and transfer coefficient (98.4 +/- 16.2%) were also normal 19. - Hypoglycemia - Hypothalamus and pituitary: - Decreased GRH - Increased activation of HPA axis> Raised Cortisol - Increased GH and decreased IGF-1 - Decreased ADH levels - Abnormalities of thermoregulation - Osteoporosis: In 30% (multifactorial) - (BMI < 15 and Amenorrhoea > 6months) 20. - Euthyroid hypothyroxinemia may develop in anorexia nervosa, marked by - normal to decreased serum levels of thyroxine (T4) and triiodothyronine (T3) levels, - - a normal level of thyroid stimulating hormone (TSH), - and an increased level of reverse T3 21. - ●Xerosis (dry, scaly skin) - ●Lanugo-like body hair (fine, downy, dark hair) - ●Telogen effluvium (hair loss) - ●Carotenoderma (yellowing) - ●Acne - ●Hyperpigmentation - ●Seborrheic dermatitis (erythema and greasy scales) - ●Acrocyanosis (cold, blue, and occasionally sweaty hands or feet) 22. - ●Perniosis (painful or pruritic erythema) - ●Petechiae - ●Livedo reticularis (reddish-cyanotic circular patches) - ●Paronychia (inflamed lateral and posterior nail folds) - ●Pruritus - ●Striae distensae (erythematous or hypopigmented linear patches) - ●Slower wound healing 23. - Nutritional rehabilitation - Psychotherapy - Nutritional rehabilitation: - Supervised meals - Proscribing binge eating and purging - Expected weight gain: 0.9 to 1.4 kg/week (in pts) - 0.2 to 0.5kg/week (out pts) - 1000 to 1600 kcal /day gradually stepped up - ( 30 to 40 kcal/kg) 24. -Psychotherapy: - Cognitive Behavioural Therapy - Specialist supportive clinical management - Motivational interviewing - Family therapy - Maintenance Psychotherapy 25. -Pharmacotherapy: - Olanzapine (2.5 to 10mg/day) - Lorazepam 0.5mg/day - SSRIs - Deep Brain Stimulation for chronic and treatment refractory Anorexia nervosa - (Sub callosal singulate gyrus) - DBS was associated with improvements in mood, anxiety, affective regulation, and anorexia nervosa-related obsessions and compulsions. Seems to be safe 26. - American Psychiatric Association suggest hospitalization for adults, adolescents, and children who meet one or more of the following criteria - ●Medical instability (eg, bradycardia near 40 beats per minute; blood pressure < 80/50 mmHg; dehydration; or compromised cardiac, hepatic, or renal functioning) - ●Weight < 85 percent normal body weight, or rapid weight decline with food refusal despite outpatient treatment or partial hospitalization - ●Suicidal ideation with high lethality plan or suicide attempt - ●Poor motivation that necessitates supervision with meals, or cooperation with treatment that is contingent upon a highly structured environment - ●Comorbid psychiatric conditions (eg, depressive, substance use, or anxiety disorders) that require hospitalization 27. - Practice guidelines from the Society for Adolescent Medicine suggest hospitalization for adolescents with eating disorders who meet one or more of the following criteria : - ●Failure of outpatient or partial hospital treatment - ●Acute food refusal - ●Uncontrollable binging and purging - ●Severe malnutrition (eg, rapid weight loss and/or weight at a medically concerning level) - ●Dehydration - ●Cardiac dysrrhythmia 28. - ●Vital signs unstable - •Severe bradycardia (eg, heart rate < 50 beats per minute during the day or < 45 at night) - •Hypotension (eg, blood pressure < 90/50 mmHg) - •Hypothermia (eg, < 96ºF) - •Orthostatic changes in pulse (> 20 beats per minute) or blood pressure (> 10 mmHg) - Electrolyte disturbances (hypokalemia, hyponatremia, or hypophosphatemia) 29. - Acute medical complication of malnutrition (eg, syncope, seizures, cardiac failure, or pancreatitis) - ●Arrested growth and development - ●Acute psychiatric emergencies (eg, suicidal ideation or behavior, or acute psychosis) - ●Comorbid diagnosis that interferes with the treatment of eating disorders (eg, moderate to severe depression, obsessive compulsive disorder, concurrent substance abuse, or family dysfunction) 30. - The refeeding syndrome is defined as the clinical complications that occur as a result of fluid and electrolyte shifts during nutritional rehabilitation of malnourished patients - ●Hypophosphatemia - ●Hypokalemia - ●Vitamin (eg, thiamine) deficiencies - ●Congestive heart failure - ●Peripheral oedema 31. - Cardiovascular: Heart failure / Arrhythmias - Pulmonary : Dyspnoea and impaired respiratory function - Muscular: Myalgia / Weakness / Tetany - Gastrointestinal: Impaired LFTS / Nausea, vomiting, diarrhoea - Neurological: Tremors / Paraesthesias / Delirium / Seizures 32. - ●Available dietary and nutritional support staff should be consulted to determine the initial daily calories to be ingested - ●Patients should be fed according to a standard protocol that includes a limited intake of sodium and fluids. The amount of daily calories should be raised by 300 to 400 kcal every three to four days. - Electrolyte deficiencies that are present in patients with anorexia nervosa should be corrected prior to initiating the refeeding process - The goal for weight gain should be limited to one kilogram per week. - ●Vital signs and weight should be monitored each day - ●The daily physical examination should focus upon the cardiovascular and pulmonary systems, and upon signs of edema 33. - Reduce nutritional support - Correct hypophosphatemia, hypokalemia, and hypomagnesemia. - Moderately to severely ill patients with marked edema or a low serum phosphate level should be hospitalized to intravenously correct electrolyte deficiencies and for close monitoring. - Continuous telemetry may be needed to monitor cardiopulmonary physiology. 34. - Anorexia is a serious, potentially life threatening mental illness. - A person with Anorexia Nervosa has not made a ‘lifestyle choice’, they are actually very unwell and need help. 35. - Thank you |
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| Posted by : peter88 | Post date : 2020-10-19 22:37 | ||
| Category : Health & Medicine | Views : 342 | ||
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