psychiatry in internal medicine

1. INTRODUCTION
● Disordes of eating behavior
● deriving primarily from an overvaluation of the
desirability of wt loss that result in functional, medical
psychological&social impairment.
● more common since 1970 & are now frequently
encountered in clinical practice
● Significant mortality

2. CLASSIFICATION & DEFINITION
1. Anorexia nervosa –deliberate, self imposed
starvation owing to a relentless pursuit of thinness
& fear of fatness, leading to varying degrees of
emaciation
2. Bulimia nervosa – episodic patterns of binge eating
accompanied by a sense of loss of control,& efforts
to control body weight such as through self induced
vomiting or use of laxatives
BOTH ARE PATHOLOGICALLY PRE OCCUPIED WITH
WEIGHT & SHAPE AND HAVE A STRONG DESIRE FOR A
THINNER BODY SIZE
3. Eating disorder not otherwise specified

3. EPIDEMIOLOGICAL FACTORS
● Cultural: Societal endorsement of weight loss and
dieting
● Gender: Women > men
●
● Age: Peaks occur at early and late teen years
● Prevalence: Anorexia nervosa, approximately 1% of
young women; bulimia nervosa, 2–4% of young
women
● Family disorders: Eating disorders, affective
disorders, obesity

4. EPIDEMIOLOGICAL FACTORS
● Socioeconomic class: Anorexia, possibly ↑ with social class;
bulimia, independent of social class
● Personality role: ↑ probability of a personality disorder;
anorexia, ↑ with Cluster C; bulimia, ↑ with Cluster B
● Prior psychiatric disturbance: Childhood and
early-adolescent anxiety, mood, and obsessive-compulsive
disorders
● Pubertal age: ↑ with early puberty, especially pubertal obesity,
for girls
● Rural vs. urban: ↑ with move from rural to urban setting

5. EPIDEMIOLOGICAL FACTORS
● Prior physical, emotional, or sexual abuse: Nonspecific ↑ in
all psychiatric disorders, not specifically eating disorders
● Premature mortality: 0–19% on 10- to 20-yr follow-up after
hospitalization (medical causes, closely followed by suicide);
anorexia nervosa plus insulin-dependent diabetes mellitus ↑
mortality 10 times either anorexia or diabetes alone
● Vocational, avocational risks: Ballet, modeling, amateur
wrestling, visual media roles, appearance sports (female
gymnastics, figure skating), thinness sports (jockey,
cross-country running, lightweight crew)

6. ANOREXIA NERVOSA
● DIAGNOSTIC CRITERIA
BY DSM- IV
A. Refusal to maintain body wt at or above a
minimally normal wt for the age & Ht
B. Intense fear of gaining wt or becoming fat,
even though underweight
c. Disturbance in the way in which once body
weight or shape is experienced

7. D. In post menarchal females,amenorrhea,i.e.
absence of at least three consecutive
menstrual cycles
●

8. CLINICAL FEATURES
● Exaggerated desire for thinness & associated
conviction that the persons body wt is too
large
● Dieting is c/b resetting wt goals downward as
old goals are achieved
● Increased physical activity
● Diminished social contacts
● Believing themselves to be fat even in stages
of advanced emaciation

9. CLINICAL FEATURES
● Obsessional system of rules regarding their
daily activities & food
● Poor concentration
● Cognitive pattern extends beyond issues of
food & wt to intrapsychic & interpersonal
beliefs
● Other features like constipation, edema,
weakness, leg cramps, amenorrhea,
depression or anxiety

10. Differential diagnosis
WEIGHT LOSS
● Medical illness
Malignancy, Chrons disease, Hyperthyroidism,
Addison's & Diabetes
● Psychiatric illness
Depression, schizophrenia, conversion disorder
with psychogenic vomiting

11. MANAGEMENT
● Out / in patient basis
● Multidisciplinary approach
● Behavioral, family, interpretive,& pharmacological(SSRI)
● Promote an average wt gain of 1-2 kg / wk
● Can begin 1500cal & increase in blocks of 300 as daily
caloric intake
● When a person is not able to complete a meal as
served, a high caloric liquid supplement can be offered
● Individual psychotherapy
● Supportive, cognative,interpretive elements

12. BULIMIA NERVOSA
DIAGNOSTIC CRITERIA
BY DSM- IV
A. Recurrent episodes of binge eating.
1. eating, in a discrete period of time , an amount of food
i.e., larger than most people would eat
2. A sense of lack of control over eating during the episode
B. Recurrent inappropriate behavior in order to
prevent wt gain
– self induced vomiting, misuse of laxatives, diuretics,
enemas or other medications
– Fasting and excessive exercise

13. BULIMIA NERVOSA
DIAGNOSTIC CRITERIA
BY DSM- IV
C.The binge eating & inapropriate compensatory
behaviors both occur, on average, at least twice a
wk for 3 months
D.Self evaluation is unduly influenced by body shape
and weight
E.The disturbance does not occur exclusively during
episodes of anorexia nervosa

14. BULIMIA NERVOSA
clinical features
● More frequent in person – previously obese, substance use,
an episode of anorexia nervosa
● Self loathing and disgusted with the body
● Binges may occur habitually or may be triggered by
unpleasant feelings, guilt and dysphoria are common
afterwards
● Binges are fallowed by efforts to prevent wt gain
● Minority reports impulsive stealing of food or money to buy
food
● Social isolation & impaired professional functioning
● Other features – depression, pts are more eager to be rid of
their symptoms , thus seeks help

15. Constitution/whole body
Cachexia and low body mass index
Arrested growth
Hypothermia
Cardiovascular
Myocardial atrophy
Mitral valve prolapse
Pericardial effusion
Bradycardia, heart blocks
Arrhythmia - SCD
Electrocardiogram (ECG) changes
ST-T wave abnormalities
Hypotension

16. Gynecologic and reproductive
Amenorrhea
Unplanned pregnancy and neonatal complications
Endocrine
Osteoporosis and pathologic stress fractures
Euthyroid sick syndrome
Hypercortisolemia
Hypoglycemia
Neurogenic diabetes insipidus
Poor diabetes control

17. Gastrointestinal
Gastroparesis (delayed gastric emptying)
Constipation
Gastric dilatation
Increased colonic transit time
Hepatitis
Superior mesenteric artery syndrome
Diarrhea

18. Renal and electrolytes
Decreased glomerular filtration rate
Renal calculi
Impaired concentration of urine
Dehydration
Hypokalemia
Hypomagnesemia
Hypovolemic nephropathy
Pulmonary
Pulmonary muscle wasting
Decreased pulmonary capacity
Respiratory failure

19. Hematologic
Anemia (normocytic, microcytic, or macrocytic)
Leukopenia
Thrombycytopenia
Neurologic
Cerebral atrophy (decreased gray and white matter)
Enlarged ventricles
Cognitive impairment
Peripheral neuropathy
Seizures

20. Dermatologic
Xerosis (dry skin)
Lanugo hair (fine, downy, dark hair)
Telogen effluvium (hair loss)
Carotenoderma (yellowing)
Scars from self-injurious behavior (cuts and burns)
Muscular
Muscle wasting
Vitamin deficiencies
Refeeding syndrome

21. INVESTIGATIONS
● CBC(anemia is frequent)
● S/E
● KFT
● LFT
● TFT
● ECG
● CXR
● Total protein and prealbumin
● Amylase

22. BULIMIA NERVOSA
MANAGEMENT
● Out patient – normal wt patients
- initiating normal eating pattern
without vomiting or purgative
misuse
● Psychiatric hospitalization –necessary to break the cycle in
– 1) who are unable to halt dangerous sequence of dieting
binging & purging,
– 2) repeated failure to respond to competent outpatient
treatment, suicidality, and the presence of complicating
comorbidities, especially borderline personality disorder,
substance abuse, and mood disorder

23. BULIMIA NERVOSA
MANAGEMENT
● Pharmacotherapy
● antidepressants
- Anticonvulsants
- Opiate antagonists – naltrexone
• Psychotherapy
• CBT
● Multiimpulsive bulimia nervosa
● dialectical behavioral therapy,+ intensive
psychotherapies, +medications