Priority Topic: Eating Disorders

Key Feature 3: In a patient with an eating disorder, rule out co-existing psychiatric conditions (ex: depression, personality disorder, obsessive-compulsive disorder, anxiety disorder).
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 4: When managing a patient with an eating disorder, use a multidisciplinary approach (ex: work with a psychiatrist, a psychologist, a dietitian).
Skill: Clinical Reasoning, Professionalism
Phase: Treatment, Referral

Key Feature 5: When assessing a patient presenting with a problem that has defied diagnosis (ex: arrhythmias without cardiac disease, an electrolyte imbalance without drug use or renal impairment, amenorrhea without pregnancy), include “complication of an eating disorder” in the differential diagnosis.
Skill: Clinical Reasoning
​Phase: Hypothesis generation

Today I had the opportunity to spend time with the multidisciplinary* Eating Disorders Program at St Paul's Hospital, which included the opportunity to perform an initial consultation on a patient with an eating disorder. The attending psychiatrist let me lead the interview, and provided me with super useful feedback afterward, specifically regarding screening for comorbid psychiatric conditions. He suggested that rather than ask about typical symptoms of comorbid conditions, if I know specifically what diagnoses I'm trying to rule out, I can simply pick the "Criterion A" symptom to ask about per each of their DSM 5 diagnostic criteria; if they don't have the A criterion, they don't have the condition. Straightforward and obvious after having this pointed out, I will never forget it, and this will make my future screening for psychiatric conditions so much more efficient. Excellent! 

What are the comorbid psychiatric conditions to rule out in a patient with an eating disorder? And what are their associated A criteria? (Note that in my blog posts, the A criteria are listed as the first criteria - the Weebly website creator I use doesn't give me the option to make lists with anything other than numbers or bullet points.)

1. Depression: See this blog post
2. Personality disorder: See this blog post
3. Obsessive-compulsive disorder (OCD): See below
4. Anxiety disorder: See this blog post

I have yet to talk about OCD in previous blog posts. The DSM 5 diagnostic criteria for this diagnosis are as follows:

1. ​Presence of obsessions, compulsions, or both. 
   1. Obsessions are defined by (1) and (2):
      1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
      2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
   2. Compulsions are defined by (1) and (2):
      1. Repetitive behaviors (ex: hand washing, ordering, checking) or mental acts (ex: praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
      2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
2. The obsessions or compulsions are time-consuming (ex: take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition.
4. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

• With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
• With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
• With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:

• Tic-related: The individual has a current or past history of a tic disorder.

*The St Paul's Hospital Eating Disorders Program inpatient and outpatient clinical teams include Psychiatrists, Psychologists, and Dieticians. During my day spent with the Program, I interviewed and observed outpatient interviews with a Psychiatrist, I watched as a Psychologist delivered a Cognitive Behavioural Therapy session to inpatients, and I learned about how a team Dietician with experience in the management of eating disorders helps to create meal plans and coach around making tolerable dietary changes. Eating disorders are very often chronic, pervasive, and refractory to therapy, and so an intensive team approach is thought to provide the best possible chance for recovery.

The inpatient program at SPH is an intensive program that is capable of supporting people who suffer from complications associated with their eating disorder, of which there are many physical let alone psychological and emotional ones.

The UpToDate article, "Medical complications of anorexia nervosa" provides a succinct but long table of possible complications that can occur secondary to this disorder:

The medical complications associated with bulimia nervosa include: 

System	Complications
Gastrointestinal	Gastrointestinal complications include parotid and submandibular gland hypertrophy; loss of gag reflex; abdominal pain, bloating and dilatation; Mallory-Weiss syndrome, gastroesophageal reflux disease (GERD); diarrhea and malabsorption; constipation; and colonic dysmotility.
Renal & electrolytes	The most common renal and electrolyte complications include dehydration, hypokalemia, hypochloremia, and metabolic alkalosis.
Cardiac	Cardiac complications are rare. Complications observed in patients with bulimia nervosa include hypotension and orthostasis, sinus tachycardia, palpitations, edema, electrocardiogram changes, and arrhythmia.
Ipecac-induced	Ipecac is used by some patients with bulimia nervosa to induce vomiting, and chronic abuse may cause cardiomyopathy and damage skeletal muscle.
Endocrine	Endocrine complications of bulimia nervosa involve the reproductive and skeletal systems, and there may be an association between bulimia nervosa and diabetes.
Dental	Dental complications of bulimia nervosa include erosion of dental enamel, decalcification and discoloration of the teeth, caries, and gum disease.
Skin	Dermatologic complications include scarring or calluses on the dorsum of the hand (Russell’s sign), xerosis, poor skin turgor, petechia, telogen effluvium, and acne. In addition, patients with self-injurious behavior will show acute or chronic signs of trauma from cuts or burns.

Of the above complications, according to the UpToDate article, "Bulimia nervosa and binge eating disorder in adults: Medical complications and their management," "​The most common medical symptoms of bulimia nervosa are lethargy, irregular menses, abdominal pain and bloating, and constipation."