Psychiatry and Behavioral Health Rotation

Psychiatry: Feeding or Eating Disorders (Pearls)

Anorexia nervosa
Patient will present as → a 19-year-old female who has lost 40 pounds over the last 6 months. Her body mass index is 16. When asked about her most recent meal, the patient reports that she ate an apple the previous morning.

Patient who refuses to eat due to fear of being overweight

  • Intense fear of becoming fat, even though underweight. Frequent weight checks and denial of emaciated state.
  • Weight < 85% of ideal body weight
  • Anorexia nervosa can be distinguished from bulimia nervosa by body mass index < 17 or bodyweight < 85% of ideal body weight.
  • The highest suicide rate of eating disorders.

Two types

  • Binging/purging
    • Laxatives/diuretics abuse
    • Excessive exercise
  • Restricting
    • Eat very little
    • Exercise to excess


  • Restore nutritional state
  • Hospitalization - if weight is < 75% expected body weight
  • Psychotherapy - behavioral therapy
  • Pharmacologic - SSRIs;
    • Have added benefit of causing weight gain
    • Have not been proven to be effective in anorexia nervosa
    • Have some efficacy in bulimia nervosa
Bulimia nervosa
Patient will present as → a 14-year-old is female who is brought to your clinic by her mother who claims to hear the child vomiting after dinner in the evenings. The patient reportedly denies vomiting and feels fine. On physical exam, you notice petechial hemorrhages of the soft palate and conjunctiva. Further exam reveals scars on her knuckles, swollen parotid glands,  dental erosions. Her weight is normal. Lab tests reveal hypochloremia and hypokalemia.

Patient who has episodes of mass eating followed by self-induced vomiting or intense exercise

Frequent binge eating with or without purging

  • Purging commonly performed by self-induced vomiting resulting in - metabolic alkalosis, urinary chloride < 20mEq, and volume depletion
    • May abuse laxatives/diuretics
    • May exercise excessively
  • Patients are disturbed by their behavior
  • Binging and compensatory behaviors occur at least once a week for 3 months.
  • On the exam look for these classic physical findings: scars on knuckles, swollen parotid glands + dental erosions + normal weight +hypokalemia


  • First, you must restore the nutritional state.
  • Fluoxetine 60 mg PO once/day is recommended (this dose is higher than that typically used for depression). SSRIs used alone often reduce the frequency of binge eating and vomiting.
  • Second-line medications: TCAs, MAOIs
  • Behavioral/family/group therapy
Psychiatry EOR: Schizotypal personality disorder (Lecture) (Prev Lesson)
(Next Lesson) Psychiatry EOR: Anorexia nervosa (ReelDx + Lecture)
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