psychiatry in internal medicine

1. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
INTRODUCTION
● Disturbance of eating that impairs health or psychosocial functioning
● Include
○ anorexia nervosa
○ avoidant/restrictive food intake disorder
○ binge eating disorder
○ bulimia nervosa
○ Pica
○ Rumination disorder
SCREENING
● SCOFF questionnaire >=2 ‘Yes’
○ Do you make yourself ​S​ick because you feel uncomfortably full?
○ Do you worry you have lost ​C​ontrol over how much you eat?
○ Have you recently lost more than ​O​ne stone (14 pounds or 6.35 kg) in a
three-month period?
○ Do you believe yourself to be ​F​at when others say you are too thin?
○ Would you say that ​F​ood dominates your life?
ANOREXIA NERVOSA
● Epidemiology
○ Young adults
○ F>M
○ Prevalence = 1-2%
● Diagnosis (DSM-5) = all 3 of the following
○ Restriction of energy intake that leads to a low body weight
○ Intense fear of gaining weight or becoming fat, or persistent behavior that
prevents weight gain, despite being underweight
○ Distorted perception of body weight and shape
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

2. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
● Amenorrhea commonly occurs
● DSM-5 eliminated amenorrhea as a criterion
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER
● Epidemiology
○ Onset in early childhood
○ Prevalence = ?
● Diagnosis = DSM-5
○ Avoiding or restricting food intake, which may be based upon lack of interest in
food, the sensory characteristics of food, or a conditioned negative response
associated with food intake
○ The eating behavior leads to a persistent failure to meet nutritional and/or energy
needs, manifested by at least one of the following
■ Clinically significant weight loss
■ poor growth or failure to achieve expected weight gain
■ Nutritional deficiency
■ Supplementary enteral feeding or oral nutritional supplements are
required
■ Impaired psychosocial functioning
○ Not due to lack of available food or associated with a culturally sanctioned
practice
○ Does not occur solely in the course of anorexia nervosa or bulimia nervosa
○ Not due to a general medical condition (eg, GI disease, food allergies, or occult
malignancy) or another mental disorder
BINGE EATING DISORDER
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

3. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
● Epidemiology
○ Young adults
○ F>M
○ a/w
■ Phobia
■ Depression
■ PTSD
■ Obesity
■ DM
■ Alcoholism
● When to suspect
○ Greater than expected weight dissatisfaction
○ Large weight fluctuations
○ Depressive symptoms
● Diagnosis = DSM-5
○ Episodes of binge eating
■ Eating more rapidly than normal
■ Eating until feeling uncomfortably full
■ Eating large amounts of food when not feeling physically hungry
■ Eating alone because of embarrassment by the amount of food
consumed
■ Feeling disgusted with oneself, depressed, or guilty after overeating
○ No inappropriate compensatory behaviors (eg, purging, fasting, or excessive
exercise) as are seen in bulimia nervosa
○ Binge eating does not occur solely during the course of bulimia nervosa or
anorexia nervosa.
BULIMIA NERVOSA
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

4. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
● Epidemiology
○ F>M
○ Young adults
PICA
● Epidemiology
○ Childhood
○ Can occur during adolescence or adulthood
● Diagnosis = DSM-5
○ Repeated eating of nonfood substances for >= 1 month
○ The eating behavior is inappropriate to the patient’s developmental level, and is
not culturally supported or socially normal
● Pica may be a clinical manifestation of iron deficiency anemia
RUMINATION DISORDER
● Epidemiology
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

5. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
○ Young adults
○ Can be found in adults
○ Prevalence ?
● Diagnosis = DSM-5
○ Repeated regurgitation of food, which may be rechewed, reswallowed, or spit out
○ Occurs for >= 1 month
○ Not due to a general medical condition, such as gastroesophageal reflux disease
or pyloric stenosis
○ does not occur solely during the course of avoidant/restrictive food intake
disorder, anorexia nervosa, binge eating disorder, or bulimia nervosa.
Mx
● Interdisciplinary care
○ mental health clinician
○ Dietitian
○ Physician
● Criteria for hospitalization
○ Medically unstable
○ medical complications
● Reducing stigma
○ The stigma of eating disorders = a/w dysfunctional thoughts
○ may interfere with treatment
● PREVENTION
○ Education
■ Idealization of thinness
■ Body dissatisfaction
■ Dieting
■ Negative affect (dysphoria)
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava

6. “People who see life as anything more than pure entertainment are missing the point.”
― George Carlin
TREATMENT
● Psychotherapy
○ Cognitive-behavioral therapy (CBT)
■ CBT encourages patients to change the dysfunctional
● cognitions = Thoughts and beliefs about body weight and shape
● Behavioral disturbances = excessive food restriction
○ Psychodynamic psychotherapy
■ Time-limited psychodynamic psychotherapy addresses conscious and
unconscious meanings of eating disorder symptoms, the effects of
symptoms upon current relationships and the patient’s relationship with
the therapist
■ Does not advise patients about eating behaviors.
○ Motivational interviewing
■ motivate patients with anorexia nervosa to gain weight by eliciting both
their reasons to do so, and their ambivalence about change
○ Family therapy
■ places parents in charge of making decisions about appropriate eating
and related behaviors
● Pharmacotherapy
Non nobis solum nati sumus
(​Not for ourselves alone are we born​)
-Dr. Eashan Srivastava