Child Psych Eating Disorders 1

49問 • 11ヶ月前

問題一覧

-Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month. -The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual. -The eating behavior is not part of a culturally supported or socially normative practice. -If the eating behavior occurs in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder], autism spectrum disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to warrant additional clinical attention.

Pica

-Prevalence unclear and unknown; among individuals with intellectual disabilities it increases with severity -Can occur at any age, most common with childhood onset -Minimum age of 2 for diagnoses -May occur in pregnancy; diagnoses only considered if posing a medial risk

Epidemiology: PIca

-Possible vitamin deficiencies (e.g., zinc and iron) -Insufficient stimulation/parent-child difficulties -Cultural traditions, do not warrant diagnosis (Criterion C) -No specific biological abnormalities noted -Most are brought to clinical attention as a result of general medical complications -Bowel problems -Obstructions -Toxoplasmosis/toxocariasis poisoning

Etiology: PIca

When treating patients for pica, what blood lead levels require consultation and treatment?

> 4 mcg/dl

-Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out. -The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis). -The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder. -If the symptoms occur in the context of another mental disorder (e.g., intellectual disability [intellectual developmental disorder] or another neurodevelopmental disorder), they are sufficiently severe to warrant additional clinical attention.

DSM-5 Criteria: Rumination Disorder

Prevalence data are inconclusive; although the disorder is commonly reported to be higher in individuals with intellectual disabilities Etiology is unknown; however there are some presumptive causes Lack of external sources of gratification (in infants) Understimulating or overstimulating environment can contribute to the appearance of the disorder Highly associated with gastroesophageal reflux

Epidemiology and Etiology: Rumination Disorder

-Onset can occur in infancy, childhood, adolescence, or adulthood -Infancy: Occurs during 1st year; resolves by 2nd year -Can be fatal in infancy -Adolescence: Often accompanied with anxiety, depression or eating disorders -Resolves with treatment of underlying disorders -Individuals with intellectual disabilities -Regurgitation and rumination behaviors may be self soothing

Course: Rumination Disorder

-Tooth decay -Failure to thrive -Dehydration -Electrolyte imbalance -Malnutrition

Prognosis/Complications: Rumination disorder

-Recommend a behavioral consultation -Infants: Parent training focused on behavioral techniques -Positive attention/interaction (i.e., cuddling, playing before, during, and after meals) reduces social deprivation and withdrawal -Negative reinforcement (ignoring) + rewards for not doing the behavior (parental attention) can be used in outpatient treatment Adolescents: -Habit reversal training (HRT) -Diaphragmatic breathing -biofeedback

Treatment: Rumination Disorder

-Consider hospitalization if significant malnutrition -Benefits of hospitalization: -Provides partial separation from child and primary caregiver -Provides alternative feeding environment for the child (to “decondition” the symptoms) -Provides respite for the parent -Continued treatment -Facilitates attachment -Assists in monitoring psychosocial environment at home -Provides a support system

Treatment: Rumination Disorder

-An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following: -Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). Significant nutritional deficiency. -Dependence on enteral feeding or oral nutritional supplements. -Marked interference with psychosocial functioning. -The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. -The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

DSM-5 Criteria: Avoidant/Restrictive Food Intake Disorder (ARFID)

-DO NOT have a fear of gaining weight as motivation to restrict food intact -Behaviors to restrict or avoid foods may result from: -Lack of interest in eating -Sensory sensitivities -Fear of choking -History of traumatic experiences (i.e., forceful feeding)

Clinical Description: Avoidant/Restrictive Food Intake Disorder (ARFID)

In eating disorders clinics (8-18y) -14% prevalence -Younger than typical AN, BN patients -Males>Females -Comorbid medical or anxiety disorder -Body weight % between that of pts with AN and BN

Epidemiology: Avoidant/Restrictive Food Intake Disorder (ARFID)

-History of picking eating -Lack of interest in food -Sensory issues -Traumatic/aversive experiences

Etiology: Avoidant/Restrictive Food Intake Disorder (ARFID)

Screening tool for Avoidant/Restrictive Food Intake Disorder (ARFID)

Administer the Eating Disturbances in Youth-Questionnaire (EDY-Q)

-Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. -Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. -Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

DSM-5 Criteria: Anorexia Nervosa (AN)

What BMI is mild anorexia?

≥ 17 kg/m2

What BMI is moderate anorexia?

16–16.99 kg/m2

What BMI is severe anorexia?

15–15.99 kg/m2

What BMI is considered extreme anorexia?

< 15 kg/m2

Estimated prevalence: 0.3-0.7% of adolescent girls within the U.S. Lifetime prevalence -Women: 1.4% (0.1-3.6%) -Men: 0.2% (0-0.3%) 12-month prevalence -Women: 0.5% (0-0.8%) -Men: 0.1% (0-0.2%) Common in Western industrialized nations Prevalence in boys, minority population and non-Western countries lower, but increasing

Epidemiology: Anorexia Nervosa (AN)

Biological -Genetic/neurophysiological mechanisms -1st degree relatives 6-10x more likely to have an eating disorder -Disturbance of hypothalamic function Psychological -Perfectionistic -Cognitively rigid -Detail oriented -Obsessive and conflict avoidant personality style

Etiology: Anorexia Nervosa (AN)

Family dynamics -Parental over-involvement -Lack of appropriate boundaries (enmeshment or disengaged) -Insufficient autonomy -Strict parenting -Maternal preoccupation with weight -Alcoholism in 1st degree relative

Etiology: Anorexia Nervosa (AN)

Onset: Between ages 14 and 18 Less common in prepubertal children; however, can develop AN or problem eating behaviors -Avoidance -body image disturbance -Inappropriate dieting -Overeating -Ritualistic behavior during meals -Selective eating Body dissatisfaction may lead to preoccupation with dieting After 5 years: 1/3 recovered, 1/3 improved, 1/3 not improved After 10-20 years: 50% recovered, 30% improved, 10% chronic, 10% mortality

Course and Prognosis: Anorexia Nervosa (AN)

Labs: CBC, CMP, TSH, T4, LFTs, ECG, Fasting glucose, total protein, albumin, DEXA scan (to evaluate for osteoporosis) -Hypoglycemia is a particularly poor prognostic sign -Dehydration can lead to elevations in blood urea nitrogen, liver function test values, and serum cholesterol levels -Infections may be masked by leukopenia and hypothermia -Abnormal thyroid function studies are classified as “sick-euthyroid syndrome,” with normal to low levels of thyroxine (T4) and free T4 and variable levels of thyroid-stimulating hormone.

Evaluation: Anorexia Nervosa (AN)

Goal: Weight Restoration Restore patients to the ideal healthy range of weight for age, height, and gender Patients above 70 percent of healthy weight can start at 1,500 calories per day -Can be increased 500 calories per day every 4 days during inpatient or partial hospital treatment or each week in outpatient care Caloric requirements -Women: maximum of 3,500 calories per day (typically) -Men: may need 4,000 calories or more

Treatment: Anorexia Nervosa (AN)

-Treatment consists of three phases which occur over a period of 6-12 months, directed by a family-based therapist, and which involve the entire family in weekly sessions. -Phase I – Weight Restoration: In Phase I, a professionally trained therapist concentrates on the various effects associated with anorexia nervosa, particularly physiological, cognitive, and emotional. -A major focus of this phase is the restoration of the patient’s weight and the “re-feeding” component. A crucial psychological feature of this primary phase is substantiating the illness. -Phase II – Returning control over eating to the adolescent: Phase II encompasses the patient learning to progressively regain control over their individual eating habits again. This typically commences when the patient’s weight has reached approximately 87% of their ideal body weight. -Phase III – Establishing healthy identity: This phase is initiated when the patient is sufficiently able to sustain their weight above 95% of ideal body weight independently and refrains from engaging in restrictive eating behaviors. Focuses of treatments are primarily on the psychological consequences the eating disorder has had on the patient and the establishment of a healthier identity.

Family Based Treatment: Maudsley Approach

-Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: -Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. -A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). -Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. -The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. -Self-evaluation is unduly influenced by body shape and weight.

DSM-5 Criteria: Bulimia Nervosa

Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week. Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week

Bulimia nervosa (BN)

Biological and Genetics -More common in first-degree, biological relatives of the disease -Family history of the disorder, mood disorders, substance abuse/dependence or obesity at higher risk -Delayed gastric emptying -Enlarged stomach capacity Neurobiological disturbances -Reduced secretion of cholecystokinin (CCK), a peptide hormone released by the small intestine that helps to signal satiety during food consumption Abnormal levels of serotonin, Brain-Derived Neurotrophic Factor (BDNF) Linked to specific area of chromosome 10p There is an association with polymorphisms in the ERβ (estrogen receptor β)

Etiology: Bulimia Nervosa (BN)

Labs: CBC, CMP, TSH, T4, LFTs, ECG, Fasting glucose, total protein, albumin Diagnostic Lab abnormalities Hematology – Leukopenia, mild anemia, thrombocytopenia Serum Chemistry – F/E imbalance, dehydration, hypochloremia, hyponatremia (may develop SIADH), metabolic alkalosis (inc. bicarb), hypokalemia (cardiac arrythmias), metabolic acidosis (laxative use), mildly elevated serum amylase Endocrine – T4 levels usually low normal, T3 (decreased), low serum estrogen ECG – Prolonged QTc, sinus brady

Evaluation: Bulimia Nervosa (BN)

Anorexia nervosa, binge-eating/purging type Binge-eating disorder Kleine-Levin syndrome Major depressive disorder, atypical features Borderline personality disorder

Differential Diagnoses: Bulimia Nervosa (BN)

Phase 1: Focuses on educating patients, helping them to increase the regularity of eating and resist urges to binge or purge Phase 2: Uses various structured procedures and homework assignments to help patients broaden their food choices and identify and correct dysfunctional attitudes and beliefs Phase 3: Patients are taught to identify interpersonal stressors and deal more effectively with them by employing more adaptive coping styles Phase 4: Relapse prevention strategies are used to reduce the likelihood of relapses in the future

CBT: Bulimia Nervosa (BN)

Name the meds that can be used to treat bulimia and the med that is contraindicated

-Fluoxetine, TCAs, and MAOIs -Bupropion contraindicated

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: -Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances. -A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). The binge-eating episodes are associated with three (or more) of the following: -Eating much more rapidly than normal. -Eating until feeling uncomfortably full. -Eating large amounts of food when not feeling physically hungry. -Eating alone because of feeling embarrassed by how much one is eating. -Feeling disgusted with oneself, depressed, or very guilty afterward. Marked distress regarding binge eating is present. The binge eating occurs, on average, at least once a week for 3 months. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa

DSM-5 Criteria: Binge-Eating Disorder

Most common eating disorder and the least gender divided Lifetime prevalence in U.S. -Women: 3.6% -Men: 2.1% Lifetime prevalence -Women: 2.8% (0.6-5.8%) -Men: 1.0% (0.3-2.0%) 12-month prevalence -Women: 1.4% (0.5-3%) -Men: 0.6% (0-1.2%) Higher rates in overweight or obese individuals

Epidemiology: Binge-eating disorder (BED)

Differential Diagnoses Binge-Eating Disorder (BED)

-Bulimia nervosa -Obesity -Bipolar and depressive disorders -Borderline personality disorder

FDA approved for short-term treatment of BED

Lisdexamfetamine

Most children achieve bowel and bladder continence by the age of ______.

4 years

How old does a child have to be before diagnosing them with enuresis?

5 years old

Explain the role of genetics and enuresis

Children with enuretic fathers are more likely to have problems vs those with previously enuretic mothers

Explain the role of genetics an nocturnal enuresis

Heterogenous disorder, and while having a enuretic mother significantly increases the chance of the child developing the disorder, having a enuretic father is associated with the highest chance.

What is associated with causing osmotic diuresis?

Milk

How old must a chlld be before disagnosing encopresis?

4 years old

What is the duration on encopresis before making a diagnosis?

Once a month for at least 3 months

Besides narcotics, what other medications can cause constipation?

Anticonvulsants and cough suppressants

A distant father and neurotic mother will increase the chances of a child developing?

Encopresis

Which disorder is most closely associated with poverty?

Primary encopresis

This form may be associated with oppositional defiant disorder, conduct disorder, or large anal insertions

Non-retentive encopresis

Patho Renal

Two Clean Queens · 100問 · 2年前

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