The Anxiety Disorders Some Practical Questions

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The Anorexic PatientA Patient-Centered,
Evidence-Based Diagnostic and Treatment Process
A Presentation for SOMC Medical Education
Kendall L. Stewart, M.D. November 21, 2008
1I intend to provide practice information that
will actually assist you in diagnosing and
treating these patients. 2Please let me know
whether I succeeded on your evaluation forms.
2
Why is this important?

• This is a common, serious disorder.1
• It affects up to 2.1 of women.
• Up to 15 of patients are male.
• Only about 40 of these patients recover
  completely.
• The reported mortality rate is as high as 22.

• After mastering the information in this
  presentation, you will be able to
• Describe how patients with Anorexia Nervosa often
  present,
• Detail the diagnostic criteria,
• Describe some of the associated features,
• List some differential diagnoses,
• Identify effective treatment strategies, and
• Write a preliminary treatment plan.2.3

1These patients have the highest death rate of
any psychiatric disorder. They also have high
hospital utilization rates. 2Of course,
treatment does not always proceed according to
your plan. 3A patient demanded a bedpan.
3
What diagnoses are included in this category?

• Eating Disorders
• Anorexia nervosa
• Restricting type
• Binge eating type
• Purging type
• Bulimia nervosa
• Purging type
• Nonpurging type
• Eating Disorder NOS1,2

1Obesity is not an eating disorder. 2Binge Eating
Disorder is being considered for inclusion in
this section.
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What is the biological basis of Anorexia Nervosa?1

• Biological Factors
• Endogenous opioids may contribute to the denial
  of hunger.
• Starvation
• Increases cortisol,
• Decreases thyroid function
• Amenorrhea with accompanying hormonal changes
• Increased CSF spaces on CT
• Increased caudate nucleus metabolism on PET
  during starvation
• Some have proposed a hypothalamic-pituitary axis
  dysfunction because of many neuroendocrine
  abnormalities (probably an affect not a cause)

1 Kaplan Sadock, 2003
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How do these patients present?

• This is a17-year-old high school senior.
• I started dieting last year to lose a few
  pounds, but Im still fat.1
• Theres nothing wrong with me.
• Shes too thin, and shes obsessed with food and
  exercise.1,2
• She wont believe that shes too thin, and she
  resents our comments.
• She used to be a sweet girl, but now shes
  sullen and hostile.

• Im cold all the time.
• I cant concentrate Im in a fog.
• Im afraid to leave home a go away to college,
  but no one stays in this town after high school.
• My parents fight all the time they may get a
  divorce when I leave home.
• I cant make friends.
• People dont like me because Im fat.

1These patients often self-induce vomiting to
lose weight. 2I once insisted that a patient
inform her mother.
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What are the diagnostic criteria for Anorexia
Nervosa (AN)?

• Refusal to maintain normal body weight leading to
  body weight less than 85 of what would be
  expected
• Intense fear of gaining weight or becoming fat
• Disturbance of body image
• In postmenarchal females, amenorrhea1

1The patients weight when her menses become
light is an excellent indicator of her minimal
healthy weight.
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What associated features might your see?

• About two-thirds of these patients also have a
  mood disorder.1
• Anxiety disorders are also very common.2
• Personality disorders are common.
• These patients are at increased risk for
  substance abuse disorders.
• Starvation also produces psychiatric symptoms
  including
• Dysphoria
• Anxiety
• Obsessive preoccupation
• Hyperactivity

1The intensity of depression will often demand a
therapeutic trial of antidepressant
medication. 265 have depression. 34 have Social
Phobia. 26 have OCD. 3These patients are all
over YouTube.
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What might you include in the differential
diagnosis?

• Weight loss from a general medical illness
• The history and physical exam reveal the
  underlying illness and these people dont feel
  fat or dread gaining weight.1
• Weight loss associated with other psychiatric
  disorders such as schizophrenia or mood disorders
• These patients are not preoccupied with caloric
  intake
• Patients with Bulimia nervosa are not underweight

1I once treated a man with weight loss and
intense anxiety who became incapacitated with a
low dose of benzodiazepine. 2He turned out to
have ALS.
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What might a typical treatment plan look like?

• Malnutrition
• Behavioral intervention including hospitalization
  if necessary
• Consider olanzapine1
• Electrolyte disturbances
• Appropriate repletion under primary care
  physicians supervision
• Depression
• Consider fluoxetine 10mg daily

• Anxiety
• Consider buspirone 15 mg twice per day
• Maladaptive attitudes and behaviors
• Cognitive behavioral psychotherapy2,3
• Education
• Assigned homework

1Barbarich NC, et al, J Clin Psychiatry
2004651480-1482. This was an open-label trial
with 17 inpatients. 2The EBM rating for the
treatments of Anorexia Nervosa are of Unknown
Effectiveness 3Only 25 of current
recommendations in medicine are EBM-rated as
Beneficial.
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What are some of the challenges you can expect?

• These patients are often sullen, resistant and
  noncompliant.
• Their families often minimize the problem.
• The patient may have trouble building and
  sustaining a therapeutic relationship.1,2
• Medication is not helpful for the disorder
  itself, but when used for comorbid problems,
  these patients may be very sensitive to drug side
  effects.
• They may refuse medication for fear of weight
  gain.
• They will want to talk about food and weight and
  avoid the painful feelings that trouble them.

1When the therapeutic relationship emerges, most
of the talk will be about their maladaptive
patterns of interpersonal behavior. 2I monitor
these patients weight, but I dont tell them
what they weigh.
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Anorexia NervosaA Patient-Centered,
Evidence-Based Diagnostic and Therapeutic Process

• Introduce yourself.
• Sit down.
• Make me comfortable by asking some routine
  demographic questions.
• Ask me to list all of problems and concerns.
• Using my problem list as a guide, ask me
  clarifying questions about my current
  illness(es).
• Using evidence-based diagnostic criteria, make
  accurate preliminary diagnoses.
• Ask about my past psychiatric history.
• Ask about my family and social histories.
• Clarify my pertinent medical history.
• Perform an appropriate mental status examination.

• Review my laboratory data and other available
  records.
• Tell me what diagnoses you have made.
• Reassure me.
• Outline your recommended treatment plan while
  making sure that I understand.
• Repeatedly invite my clarifying questions.
• Be patient with me.
• Provide me with the appropriate educational
  resources.
• Invite me to call you with any additional
  questions I may have.
• Make a follow up appointment.
• Communicate with my other physicians.

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Where can you learn more?

• American Psychiatric Association, Diagnostic and
  Statistical Manual of Mental Disorders, Fourth
  Edition, Text Revision, 2000
• Goldman HH, Review of General Psychiatry, Sixth
  Edition, July 20081
• Flaherty, AH, and Rost, NS, The Massachusetts
  Handbook of Neurology, April 20072
• Kaplan HI, Sadock BJ, Synopsis of Psychiatry,
  Tenth Edition, 2007
• Jacobson JL and Jacobson AM, Psychiatric Secrets,
  Second Edition, 2001
• Stahl SM, Essential Psychopharmacology
  Neuroscientific Basis and Practical Applications,
  Third Edition, March 2008
• Stewart KL, Dealing With Anxiety A Practical
  Approach to Nervous Patients and an Overview of
  the Objectives in the Anxiety Module in the OUCOM
  Psychiatry Block, 2000

1,2Please note that you must master all of the
information in a basic neurology textbook and a
basic psychiatry textbook to do well on the
comprehensive, standardized final examination.
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Where can you find evidence-based information
about mental disorders?1

• Explore the site maintained by the organization
  where evidence-based medicine began at McMaster
  University, http//hsl.mcmaster.ca/resources/ebpra
  ctice.htm.
• Sign up for the Medscape Best Evidence
  Newsletters in the specialties of your choice at
  http//profreg.medscape.com/px/newsletter.do.
• Subscribe to Evidence-Based Mental Health at
  http//ebmh.bmj.com/.
• Search a database at the National Registry of
  Evidence-Based Programs and Practices maintained
  by the Substance Abuse and Mental Health Services
  Administration at http//ebmh.bmj.com/.
• Explore a limited but useful database of mental
  health practices that have been "blessed" as
  evidence-based by various academic,
  administrative and advocacy groups collected by
  the Iowa Consortium for Mental Health at
  http//www.medicine.uiowa.edu/ICMH/evidence/.

1Please visit www.KendallLStewartMD.com to
download related White Papers and presentations.
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How can you contact me?1
Kendall L. Stewart, M.D. VPMA and Chief Medical
Officer Southern Ohio Medical Center President
CEO The SOMC Medical Care Foundation, Inc. 1805
27th Street Waller Building Suite B01 Portsmouth,
Ohio 45662 740.356.8153 StewartK_at_somc.org
KendallLStewartMD_at_yahoo.com www.somc.org www.Kend
allLStewartMD.com
1All speaking and consultation fees benefit the
SOMC Endowment Fund.
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Kevin Kammler, DO OUCOM 1993