Eating Disorders: Anorexia Nervosa, Bulimia Nervosa

University of Massachusetts, AmherstNursing 690MDonna Petko, MSN, RN, APN, FNP-BCApril 17, 2015

Objective

• prevalence• diagnostic criteria• development• functional

consequences• cultural issues

• measurements• diagnostic features• specifiers• severity levels• differential diagnoses• ICD-10 coding

To increase understanding of Anorexia Nervosa & Bulimia Nervosa in the DSM-5 (APA, 2013):

Eating Disorders: Anorexia Nervosa & Bulimia Nervosa

Anorexia

Prevalence (APA, 2013):• 12 month prevalence among young females 0.4%• Less common in males• 10:1 female-to-male ratio

Anorexia Cont.

Diagnostic Criteria & Features (APA, 2013): • Criterion A

▫ Maintains body weight that is below minimally normal level for age, sex, developmental trajectory, and physical health

• Criterion B▫ Display intense fear of gaining weight or becoming

fat• Criterion C

▫ Experience and significance of body weight and shape are distorted

Anorexia Cont.

Diagnostic Criteria & Features Cont. (APA, 2013):• 3 Features:

▫ Persistent energy intake restriction▫ Intense fear of gaining weight or becoming fat or

persistent behavior that interferes w/ weight gain▫ Disturbance in self-perceived weight or shape

Anorexia Cont.

Development & Course (APA, 2013): • Typically begins in adolescence/young adulthood• Rarely begins before puberty or after age 40

▫ Early and late onset are possible• Onset often associated with a stressful life event• Course/outcome are highly variable

Anorexia Cont.

Functional Consequences (APA, 2013):• May exhibit a range of functional limitations

▫ Some individuals may remain active in social/professional functioning

▫ Others may demonstrate significant social isolation and/or failure to fulfill academic or career potential

Anorexia Cont.

Cultural Considerations (APA, 2013):• Occurs across culturally and socially diverse

populations• Cross-cultural variation in occurrence and

presentation• Prevalent in post-industrialized, high income

countries:▫ US, Europe, Australia, New Zealand, Japan

• Low among Latinos, African Americans, and Asians

Anorexia Cont.

Measurements (APA, 2013):• The SCOFF questionnaire:

▫ Screens for eating disorders using 5 simple, easy-to-remember questions

▫ An eating disorder can be suspected with 84.6% sensitivity and 89.6% specificity if a patient responds positively to 2 or more questions.

▫ The negative predictive value is 99.3% for the SCOFF questionnaire

Anorexia Cont.

Measurements Cont.(APA, 2013):• The SCOFF questions:

▫ Do you make yourself Sick because you feel uncomfortably full?

▫ Do you worry that you have lost Control over how much you eat?

▫ Have you recently lost more than One stone (14 lb) in a 3-month period?

▫ Do you believe yourself to be Fat when others say you are too thin?

▫ Would you say that Food dominates your life?

Anorexia Cont.

Specifiers (APA, 2013):• Specify whether:

▫ (F50.01) Restricting type: During last 3 months, individual did not engage in binge

eating/purging

▫ (F50.02) Binge-eating/purging type: During last 3 months, individual has engaged in binging

eating/purging

Anorexia Cont.

Specifiers Cont. • Specify if:

▫ In partial remission: After full criteria for AN were previously met, Criterion A (low body wt) has not been met, but B (fear of gaining wt) & C (disturbance in perception of wt/shape) is still met

▫ In full remission: After full criteria for AN were previously met, none of the criteria have been met for a sustained time

Anorexia Cont.

Specifiers Cont. (APA, 2013): • Specify Current Severity:

▫ Mild: BMI ≥ 17 kg/m²▫ Moderate: BMI 16-16.99 kg/m²▫ Severe: BMI 15-15.99 kg/m²▫ Extreme: BMI < 15 kg/m²

ICD 10 Coding & Severity (APA, 2013): •307.1

Anorexia Cont.

Differential Diagnosis (APA, 2013):• Medical conditions (e.g., GI disease, hyperthyroid, occult malignancies, AIDS)• Major depressive disorder• Schizophrenia• Substance use disorders• Social anxiety disorder, obsessive-compulsive disorder, body dysmoric disorder•Bulimia Nervosa•Avoidant/restrictive food intake disorder

Anorexia Cont.

Initial Tests (Epocrates, 2015):• CBC• Serum chemistry• TFTs• LFTs• Urinalysis• Urine pregnancy test• ECG

Anorexia Cont.

Treatment (Epocrates, 2015): • Structured eating plan with oral nutrition• Psychotherapy• In-patient admission:

▫ Oral, enteral, parental nutrition▫ Fluid intake correction▫ Potassium repletion▫ Magnesium repletion▫ Calcium repletion▫ Sodium repletion

• SSRIs

Bulimia

Prevalence (APA, 2013):• 12 month prevalence among young females is 1-1.5%• Highest among young adults

▫ Peaks in adolescence • Less common in makes• 10:1 female-to-male ratio

Bulimia Cont.

Diagnostic Criteria & Features (APA, 2013):• Criterion A

▫Recurrent episodes of binge eating: Eating, in a discrete period of time, an amount of food that is larger than most individual would consume in a similar period of time Sense of lack of control over eating during the episode

• Criterion B▫Recurrent inappropriate compensatory behaviors in order to prevent weight gain:

Vomiting, laxative use, diuretics, other meds, fasting, excessive exercise

Bulimia Cont.

Diagnostic Criteria & Features (APA, 2013):• Criterion C

▫ Binge eating and inappropriate compensatory behaviors occur, on average, at least once a week for 3 months

• Criterion D▫ Self-evaluation is unduly influenced by body

shape/weight• Criterion E

▫ The disturbance does not occur exclusive during episodes of AN

Bulimia Cont.

Diagnostic Criteria & Features Cont. (APA, 2013):

• 3 Features:▫ Recurrent episodes of binge eating▫ Recurrent inappropriate compensatory behaviors to

prevent weight gain▫ Self-evaluation that is unduly influenced by body

shape/weight• To qualify for diagnosis, behavior must occur, on

average, at least once a week for 3 months

Bulimia Cont.

Development & Course (APA, 2013):• Commonly begins in adolescence or young adulthood• Onset before puberty or after age 40 uncommon• Frequently begins during or after a dieting episode• Experiencing multiple stressful life events can precipitate onset• Behavior may persist for several years • Elevated risk for mortality• Diagnostic cross-over from BM to AN occurs in minority of cases (10-15%)

Bulimia Cont.

Functional Consequences (APA, 2013):• May exhibit a range of functional limitations • Some report severe role impairment

▫Social-life domain likely to be affected

Bulimia Cont.

Cultural Considerations (APA, 2013):• Similar frequencies in most industrialized

countries▫ US, Canada, Europe, Australia, Japan, New

Zealand, South Africa▫ Individuals presenting in US predominately white

• Occurs in other ethnic groups with prevalence comparable to estimated prevalence in white samples

Bulimia Cont.

Measurements Cont.(APA, 2013):• The SCOFF questionnaire:

▫ Screens for eating disorders using 5 simple, easy-to-remember questions.

▫ An eating disorder can be suspected with 84.6% sensitivity and 89.6% specificity if a patient responds positively to 2 or more questions.

▫ The negative predictive value is 99.3% for the SCOFF questionnaire

Bulimia Cont.

Measurements Cont.(APA, 2013):• The SCOFF questions:

▫ Do you make yourself Sick because you feel uncomfortably full?

▫ Do you worry that you have lost Control over how much you eat?

▫ Have you recently lost more than One stone (14 lb) in a 3-month period?

▫ Do you believe yourself to be Fat when others say you are too thin?

▫ Would you say that Food dominates your life?

Bulimia Cont.

Specifiers (APA, 2013): • Specify if:

▫ In partial remission: After full criteria for BN were previously met, some, but not all, criteria have been met for a sustained time

▫ In full remission: After full criteria for BN were previously met, none of the criteria have been met for a sustained time

Bulimia Cont.

Specifiers (APA, 2013): • Specify current severity:

▫ Mild: Average of 1-3 episodes of inappropriate compensatory behaviors per week

▫ Moderate: 4-7 episodes▫ Severe: 8-13 episodes ▫ Extreme: 14 or more episodes

Bulimia Cont.

ICD-10 Coding & Severity (APA, 2013): • 307.51 (F50.2)

Bulimia Cont.

Differential Diagnosis (APA, 2013):• Anorexia

▫binge-eating/purging type • Binge-eating disorder• Kleine-Levin syndrome• Major depressive disorder

▫w/ atypical features• Borderline personality disorder

Bulimia Cont.

Initial Tests (Epocrates, 2015):• CBC• Serum electrolytes• Serum creatinine• Serum magnesium• Urine pregnancy test• Serum LFTs• Serum CK• Urinalysis• ECG

Bulimia Cont.

Treatment (Epocrates, 2015):• Cognitive Behavioral Therapy• Nutritional/meal support• SSRIs, SNRIs• Other types of psychological therapies• Referral for specialist evaluation or emergency

department assistance• Glycemic control

Case StudyA 21-year-old woman is brought into an outpatient clinic by her mother, who complains that her daughter has been demonstrating unusual eating patterns since she moved back home 6 months ago. Her mother observes her to eat large amounts of food, such as desserts, when she is alone, often finding food wrappers hidden in her daughter’s room. She is worried that her daughter may be engaging in vomiting after these episodes of heavy eating. She often isolates herself in the bathroom for 10-20 minutes after a large meal.

When the patient was asked about her eating habits, she admitted to a “loss of control.” She described feeling deep remorse when she eats more than she would like. Furthermore, she described feeling so laden with guilt about her eating binges that she purposefully induces vomiting at least once every other day. This act gives her tremendous relief. She admits that she is unhappy with her overall appearance, and feels that she is “fat” and “out of shape.” She is preoccupied with her appearance and says that she compares herself to other women “all day long.” She also admits to feeling sad most days. She endorses experiencing occasional missed menstrual periods, low libido, low energy, and intermittent sore throat. (Yager & Bienenfield, 2013,

para. 1)

Case Study Cont.Historically, the patient has memories of a chaotic childhood. She is an only child whose parents fought often and finally divorced when she was 9 years old. The patient remembers the first time she induced vomiting at 10 years old, after she felt “too full after a large meal.” The mother describes her daughter as having few friends and as tending to isolate herself. However, the mother describes her as very bright; in fact, she was valedictorian of her high school.

On physical examination, the patient’s blood pressure is 90/60, heart rate is 100, and BMI is 19. Her oropharynx appears injected without areas of erosion, and multiple dental caries are seen. Bilateral parotid enlargement with minor tenderness is present. The patient is tachycardic and bowel sounds are hyperactive. The abdomen is soft, nontender, and nondistended. Skin turgor is poor.

(Yager & Bienenfield, 2013, para. 1)

Case Study Cont.On mental status examination, the patient presents as a young Caucasian woman with average body habitus and pale skin. She is meticulously dressed and groomed. She answers questions curtly, makes poor eye contact, and demonstrates mild foot tapping throughout the interview. Her mood is anxious and her affect is mood congruent but restricted to negative emotionality. She is highly articulate. Thought process is linear and goal directed. Methodical about her statements, she often takes time to clarify what she “really means.”

Thought content displays themes of shame, guilt, and self-reproach. No active delusions or hallucinations are present. Her cognition is grossly intact. She denies suicidal thoughts, but sometimes wishes she was “invisible.” She has no violent or homicidal thoughts. Insight is limited regarding her ability to acknowledge her psychiatric illness. Her judgment is impaired considering her inability to recognize the potential negative health consequences of her eating behaviors.

(Yager & Bienenfield, 2013, para. 1)

Case Study Cont. Prior to entering your office, laboratory assessment obtained at the

suggestionof her primary care doctor reveals a serum potassium level of 3.8 Meq/L andserum amylase level of 140 Units/L.

▫ Take home points: The differential diagnosis of bulimia nervosa includes depression,

anxiety and age-appropriate developmental problems (e.g., lack of esteem). These issues are common co-occurrences.

A biopsychosocial treatment plan will be necessary to provide her the care she needs.

Collaboration with primary care providers is often necessary for short-term and sometimes long-term.

(Yager & Bienenfield, 2013, para. 1)

ReferencesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington

D.C.: Author. Yager, J. & Bienenfield, D. (2014). Bulimia Nervosa clinical presentation. Retrieved from http://emedicine. medscape.com/article/286485-clinicalEpocrates. (2015). Anorexia Nervosa. Retrieved from https://online.epocrates.com/u/2942440/Anorexia+nervosa/Treatment/Tx+DetailsEpocrates. (2015). Bulimia Nervosa. Retrieved from https://online.epocrates.com/noFrame/showPage?method=diseases&MonographId=441&ActiveSectionId=42Rushing, J.M., Jones, L.E., Carney, C.P. (2003). Bulimia Nervosa: A primary care review. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419300/