Presentation on theme: "HM – Anorexia: binge/purge type"— Presentation transcript
Slide1
HM – Anorexia: binge/purge type
Shelby Boxell
DI Clinical Case Study
Slide2
Anorexia
Eating disorder characterized by weight loss, difficulty maintaining appropriate weight and distorted body image
- Weight loss is achieved through calorie restriction
- Some will use methods of purging (emesis, laxative, compulsive exercise)Diagnosing criteria per DSM-V:Restriction of energy intake relative to requirements leading to a significant low body weight in the context of age, sex, developmental trajectory and physical healthIntense fear of gaining weight or becoming fat, despite being underweightDisturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation or denial of the seriousness of the current low body weight* Serious ED can be present despite dx, due to not meeting all criteria.
Image from: https
://clinicalgate.com/anorexia-nervosa-bulimia-nervosa-and-other-eating-disorders/
Slide3
Anorexia
is the 3
rd
most common chronic disease in
adolescents, behind asthma and type I diabetesAdolescents, age 15-24, with anorexia are 10x more likely to die than their healthy peersEating disorder behaviors are nearly as common in males as females*males are less likely to seek treatment, and are therefore at higher risk of deathThe fastest growing prevalence is in females, age 15-24, all other groups have stayed steady over the last 50 years – according to an ongoing study in Minnesota
Image by: http
://www.dailymail.co.uk/health/article-2080191/Children-suffering-anorexia-three.html
Slide4
Signs/Symptoms
Dramatic weight loss
Preoccupied with weight, food, and/or calories
Restricting foods/food groups
Constipation, stomach painFatigueFood ritualsCooks without eatingAggressive exercise routineIrregular or loss of menstrual styleInflexible thinking
Difficulty concentrating
↓ thyroid
↓ potassium
↓ blood count (anemia)
↓ heart rate (pulse) and blood pressure
Dizziness or fainting
Being cold, excess hair growth (lanugo)
Dental problems
Swollen salivary glands
Sleep
disturbances
Poor wound healing
*HM had all bolded signs and symptoms at time of appt.
Slide5
Pathophysiology
Cardiovascular System
Body begins to break down muscle to get energy
Blood pressure and pulse decreases
Purging depletes body of important electrolytes (potassium, sodium, chloride)Can lead to irregular heart beat, possibility of cardiac arrest, fainting and dizzinessGI SystemLack of oral intake with consistent purging leads to GI distress gastroparesis, malabsorption, stomach pain, bloating, blood glucose fluctuations, constipation (blockages d/t undigested food), bacterial infection, esophageal irritation and erosion, swollen parotid glands (from emesis), pancreatitis
Slide6
Pathophysiology
Neurologic System
1/5 of total kcal from daily intake are used to run the CNS
Lack of oral intake means no fuel for the brain, leading to constant food thoughts, difficulty sleeping and concentrating
Lack of fat intake can lead to decrease nerve myelination, causing numbness in extremities Muscle cramps and seizures due to electrolyte imbalancesEndocrine SystemDietary fat and cholesterol are main components of hormone production (estrogen, testosterone, thyroid), without adequate intake hormone production slowsAmenorrhea Bone loss/osteopenia/osteoporosisBinges can lead to insulin resistance (DMII), ↑ triglycerides, ↑ LDL, ↑ cholesterolHypothermia
Slide7
Etiology
Biological
- Research is being done to determine if there is a genetic component
Psychological- Certain personality traits make people more vulnerable – obsessive compulsive tendencies, perfectionism, and anxietyEnvironmental- Western culture places an emphasize on being thin, relating attractiveness, self-worth and success to looking a certain way*often people have a disorder of trauma or abuse prior to development of disorder
Genetic
Family Dynamic
Cultural
B
iological
M
edia
Individual Temperament
Slide8
Prognosis → Treatment
Anorexia has the highest mortality rate among psychiatric conditions
20% mortality
High prevalence of comorbid substance use disorder
50% ED dx with SUD~42% relapse rateOn average 7 treatment attempts before sustained recoveryInpatient, Intensive Outpatient, OutpatientAll will have a therapy + nutritional support componentSeverity of malnutrition and willingness of patient will determine location of treatmentTreatment GoalsWeight restorationNormalizing eating behaviors
Addressing trauma/family dynamic in therapy
Slide9
HM – Patient Profile
39 y/o female presenting for anorexia nervosa
No current medications, drinking 1 Boost a week
Hawaiian, engaged to fiancé – have been dating for over 20 years
1 prior hospitalization d/t starvation when she was in high school Extensive history of SUD (heroin, alcohol, marijuana, cocaine, hallucinogens, benzos), was in prison for 2 years d/t heroin use, last use 10+ years agoFamily history of alcoholismLives with fiancé and dog, working 35-40 hours a week at a local dry cleaner, in the summer additional work as a landscaperRecent visit with PCP reveal: ↑ triglycerides, ↑cholesterol, ↓ vitamin D, malnutrition/starvation EKG and DEXA scan ordered, referral for outpatient MNT
Slide10
HM – Initial Assessment
Height
: 65”
Weight
: 82# BMI: 13Weight history: lowest – 68# Highest – 115# (during inpatient ED treatment)Sexual assault by a family member from age 3-11. Restricting began at 8 y/o, first diagnosis of anorexia at 15Appearance: lanugo, thinning hair, visible collar bone/cheek bones, sunken temple region24 Hour Recall: binging/purging 2-3 times a dayFalling asleep around 2400 – 0100, waking at 0200 for binge/purge, sleep, waking up around 0500-0600 eating 1 packet of oatmeal, running 2-3 miles (20-25 minutes) or elliptical for 45 minutes and yoga for 20 minutes 7 days a week, working from 1100 – 1800 eating “safe snacks” (no more than 100 kcal), coming home engaging in 1-2 binge/purge sessions Binge: oatmeal, 1 bag of pasta or instant potatoes, chips, 3-4 egg sandwiches (2 pieces of bread, 7-9 eggs with cheese), yogurt, 16-20oz chocolate milk or milk shake – each binge/purge takes 2-4 hours in total Previous MNT: 4 inpatient ED treatment facilities + 1 hospitalization, reports being forced to go and therefore not gaining anything – “going through the motions to get out”, always on weight restoration programs, outpatient MNT in middle school – college
Current motivation
: tired of the daily fight, wanting something more out of life
Slide11
HM - Plan
PES:
Disordered eating pattern
related to
weight regulation/preoccupation significantly influences self-esteem and familial, societal, biological/genetic, and/or environmental-related obsessive desire to be thin as evidenced by abnormal lipid profile, BMI of 13, severely depleted adipose and somatic protein stores, lanugo, damaged tooth enamel, skeletal muscle loss, impaired healing of 3rd finger on right hand (infection), self-report of inability to concentrate, decreased BP and pulse, self-report avoidance of food, excessive physical activity, inflexibility with food choices, and amenorrheaLevel of Risk: moderate – highClient not currently willing to engage with inpatient or treatment centerDiet Order: Regular Diet/Regular TextureNeeds: 1800 – 2200 kcal/day (MSJ – AF 1.5 – weight gain)Current meal plan will not reach necessary calories – immediate goal is to increase intake using safe foods, get through 24 hours without binge/purgePlan
: mechanical eating - every 3 hours (continuing through the night since she is not sleeping more than 3 hours at a time), each feeding will consist of 1 protein + 1 carbohydrate – using safe foods, decrease physical activity to yoga 20 minutes a day, no more than 3 days of cardio for no more than 20 minutes, continue attending weekly therapy session
Client safe foods: oatmeal, tofu, veggie patties, 35 calorie bread, fruit and vegetables, seaweed, yogurt, cottage cheese, string cheese, eggs, pretzels
Goals were established using MI with patient – follow up in 7 days, will re-evaluate weight/need for more intensive treatment
Slide12
Resources
https://
www.nationaleatingdisorders.org/anorexia-nervosa
https://
www.mayoclinic.org/diseases-conditions/anorexia/symptoms-causes/syc-20353591
