From: Subject: Best Dx/Best Rx: The Eating Disorders Date: Wed, 3 Jun 2009 21:52:31 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0279_01C9E495.9822FE60" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_0279_01C9E495.9822FE60 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx1309.htm Best Dx/Best Rx: The Eating Disorders



Anorexia=20 Nervosa

Bulimia=20 Nervosa and Binge Eating

Anorexia Nervosa

W. Stewart Agras, M.D.
Stanford University = School of=20 Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition

  • A chronic disorder of severe dietary = restriction=20 occurring predominantly in women=20
  • Frequent psychiatric comorbidity, leading to = chronic=20 starvation
3D""=20=20 bac= k to=20 top

Key Clinical Features

  • Symptoms=20
    • Severe dietary restriction=20
    • Marked weight loss=20
    • Amenorrhea=20
    • Depression
  • Features=20
    • Distortion of body-image perception=20
    • Excessive exercise=20
    • Obsessive thinking and behavior regarding = food=20
    • Intense fear of gaining weight=20
3D""=20=20 bac= k to=20 top

Differential Diagnosis

  • Hypopituitarism=20
  • Schizophrenia
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Best=20 Tests

  • Physical exam=20
    • Marked emaciation=20
      • ≥ 15% reduction in ideal body = weight
    • Dry skin that may be covered with = lanugo=20
    • Cold, cyanotic extremities sometimes = accompanied by=20 the following=20
      • Peripheral edema
      • Bradycardia=20
      • Hypotension
  • Psychological exam=20
    • Depressive symptoms=20
    • Anxiety disorders
    • Cognitive impairment=20
      • Poor concentration
      • Poor memory=20
      • Poor judgment
  • Lab findings=20
    • Anemia=20
    • Leukopenia=20
    • Elevated cholesterol and = β-carotene=20
    • Osteoporosis=20
    • Abnormal hormonal findings caused by = starvation=20
      • Significantly decreased plasma = gonadotropin=20 levels=20
      • 24-hr luteinizing hormone pattern = resembles that of=20 prepubertal girl=20
      • Low FSH and estrogen=20
      • Elevated growth hormone=20
      • Low total serum thyroxine=20
      • Low triiodothyronine=20
      • Elevated resting plasma cortisol=20
      • Decreased metabolic clearance of = cortisol=20
3D""=20=20 bac= k to=20 top

Best=20 Therapy

  • Patient weighs 75=9690% of ideal body = weight=20
    • If weight loss is caused by self-starvation, = refer for=20 psychotherapy
  • Patient weighs < 70=9675% of ideal body = weight=20
    • Hospitalize for medical stabilization, = weight=20 restoration=20
    • If weight loss is caused by = self-starvation=20
      • Restore weight to at least 90% of ideal = body=20 weight=20
      • Refer for psychotherapy=20
      • Follow up =

Psychological Therapy

  • Positive reinforcement for small and continued = weight=20 gains=20
  • Cognitive-behavioral therapy, including = family, after=20 some weight has been gained=20
  • Family therapy for younger patients =

Pharmacologic Therapy

  • SSRIs for patients with obsessive-compulsive=20 disorder
3D""=20=20 bac= k to=20 top

Best References

Dare, et al: Br J Psychiatry 178:216, = 2001

Kaye, et al: Biol Psychiatry 49:644, = 2001

Strober, et al: Am J Psychiatry 157:393, 2000 =

July=20 2004

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Bulimia=20 Nervosa and Binge Eating

W. Stewart Agras, M.D.
Stanford University = School of=20 Medicine

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best= =20 References

Definition/Key Clinical Features

  • Chronic conditions accompanied by an increased = risk of=20 psychiatric illness=20
  • Female predominance=20
  • Bulimia nervosa=20
    • Binge eating followed by purging or other = compensatory=20 behavior=20
      • Self-induced vomiting=20
      • Laxative abuse=20
      • Excessive exercise=20
      • Fasting
    • Symptoms=20
      • Fatigue=20
      • Decreased energy=20
      • Abdominal pain=20
      • Amenorrhea=20
      • Depression
    • Weight and shape concerns less extreme than = in=20 anorexia nervosa=20
    • Past episode of anorexia nervosa in = one-quarter of=20 patients=20
    • May be associated with type 1 diabetes = mellitus in=20 adolescents
  • Binge eating=20
    • Episodic, without compensatory = purging=20
    • Periods of dietary restriction alternating = with=20 binges=20
    • Overweight or obesity common =
3D""bac= k to=20 top

Differential Diagnosis

  • Bulimia=20
    • Causes of spontaneous vomiting =
  • Binge eating=20
    • Brain injury (rare) =
3D""bac= k to=20 top

Best=20 Tests

Bulimia = Nervosa=20
  • Diagnostic criteria=20
    • Binge eating and purging on average ≥ = 2 times/wk for 3=20 mo
  • Physical examination=20
    • Dry skin=20
    • Evidence of dehydration=20
    • Fluctuant salivary gland hypertrophy=20
    • Tooth decay, periodontal disease =
  • Psychological examination=20
    • Major depression (positive history in > = 50%)=20
    • Anxiety disorders=20
    • Alcohol or drug dependency or abuse =
  • Laboratory tests=20
    • Elevated serum amylase=20
    • Metabolic alkalosis=20
    • Elevated serum bicarbonate=20
    • Hypochloremia=20
    • Hypokalemia (uncommon) =
Binge Eating=20
  • Diagnostic criteria=20
    • Binge eating ≥ 2 days/wk for 6 = mo
  • History and physical examination=20
    • Overweight or obese=20
    • Sizable weight gain or marked weight = cycling=20
    • Major depression=20
    • Anxiety disorders=20
    • Personality disorders =
    3D""bac= k to=20 top

    Best=20 Therapy

    Psychotherapy=20
    • Binge eating and/or purging twice a week or = more=20
      • Outpatient cognitive-behavioral therapy = (CBT) =B1=20 antidepressants
    • Binge eating and/or purging once a wk=20
      • Self-help manual=20
      • If treatment fails, institute outpatient = CBT=20
    Pharmacologic = Therapy=20
    • Antidepressants=20
      • Tricyclic antidepressants (e.g., = desipramine, 150=96300=20 mg/day)=20
      • Selective serotonin reuptake inhibitors = (e.g.,=20 fluoxetine, 60 mg/day)
    • Topiramate=20
      • Dose: Up to 600 mg/day=20
        • Cost/mo: $522.75 =
    3D""bac= k to=20 top

    Best = References

    American Psychiatric Association: Am J Psychiatry = 157(1=20 suppl):1, 2000 [PMID 10642782]

    Hay PJ, et al: Cochrane Database Syst Rev = (3):CD000562,=20 2004 [PMID 15266434]

    Hoopes SP, et al: J Clin Psychiatry 64:1335, 2003 = [PMID=20 14658948]

    McElroy SL, et al: J Clin Psychiatry 65:1463, = 2004 [PMID=20 15554757]

    Strober M, et al: Am J Psychiatry 157:393, 2000 = [PMID=20 10698815]

    September=20 2006

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