Psychiatry and Behavioral Health Rotation

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

Treatment:

• 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

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

Treatment:

• 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