HM – Anorexia: binge/purge type - PowerPoint Presentation

HM – Anorexia: binge/purge type
HM – Anorexia: binge/purge type

HM – Anorexia: binge/purge type - Description

Shelby Boxell DI Clinical Case Study Anorexia Eating disorder characterized by weight loss difficulty maintaining appropriate weight and distorted body image Weight loss is achieved through calorie restriction ID: 908934 Download Presentation


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HM – Anorexia: binge/purge type

Shelby Boxell

DI Clinical Case Study



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.

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is the 3


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

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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



Poor wound healing

*HM had all bolded signs and symptoms at time of appt.



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



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




- 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


Family Dynamic






Individual Temperament


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


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


HM – Initial Assessment


: 65”


: 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


HM - Plan


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





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