1. The Anorexic Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DLFAPA February 17, 2012 1 I intend to provide practice information that will actually assist you in diagnosing and treating these patients. 2 Please let me know whether I succeeded on your evaluation forms.

2. Why is this important? After listening to this presentation, you will be able to answer the following questions: –Why is this important? –How do these patients present? –What are the diagnostic criteria? –What is the differential diagnosis? –What is the treatment? –What are some of the treatment challenges? 1 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%. 1 These patients have the highest death rate of any psychiatric disorder. They also have high hospital utilization rates. 2 Of course, treatment does not always proceed according to your plan. 3 A patient demanded a bedpan.

3. What diagnoses are included in this category? Eating Disorders –Anorexia nervosaAnorexia nervosa Restricting type Binge eating type Purging type –Bulimia nervosaBulimia nervosa Purging type Nonpurging type –Eating Disorder NOS 1,2 1 Obesity is not an eating disorder. 2 Binge Eating Disorder is being considered for inclusion in this section.

4. How do these patients present? This is a17-year-old high school senior. “I started dieting last year to lose a few pounds, but I’m still fat.” 1 “There’s nothing wrong with me.” “She’s too thin, and she’s obsessed with food and exercise.” 1,2 “She won’t believe that she’s too thin, and she resents our comments.” “She used to be a sweet girl, but now she’s sullen and hostile.” “I’m cold all the time.” “I can’t concentrate; I’m in a fog.” “I’m 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 can’t make friends.” “People don’t like me because I’m fat.”People don’t like me because I’m fat 1 These patients often self-induce vomiting to lose weight. 2 I once insisted that a patient inform her mother.

5. What are the diagnostic criteria? 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 fatfear of gaining weight Disturbance of body image In postmenarchal females, amenorrhea 1 amenorrhea 1 The patient’s weight when her menses become light is an excellent indicator of her minimal healthy weight.

6. What is the differential diagnosis? Weight loss from a general medical illness –The history and physical exam reveal the underlying illness and these people don’t feel fat or dread gaining weight. 1,2 Weight loss associated with other psychiatric disorders such as schizophrenia or mood disorders schizophreniamood disorders –These patients are not preoccupied with caloric intake Patients with Bulimia nervosa are not underweight 1 I once treated a man with weight loss and intense anxiety who became incapacitated with a low dose of benzodiazepine. 2 He turned out to have ALS.

7. What associated features might you see? About two-thirds of these patients also have a mood disorder. 1 Anxiety disorders are also very common. 2Anxiety disorders Personality disorders are common.Personality disorders These patients are at increased risk for substance abuse disorders. substance abuse disorders Starvation also produces psychiatric symptoms includingStarvation –Dysphoria –Anxiety –Obsessive preoccupation –Hyperactivity 1 The intensity of depression will often demand a therapeutic trial of antidepressant medication. 2 65% have depression. 34% have Social Phobia. 26% have OCD. 3 These patients are all over YouTube.™

8. What is the treatment? Malnutrition –Behavioral intervention including hospitalization if necessary –Consider olanzapine 1olanzapine Electrolyte disturbances –Appropriate repletion under primary care physician’s supervision Depression –Consider fluoxetine 10mg dailyfluoxetine Anxiety –Consider buspirone 15 mg twice per daybuspirone Maladaptive attitudes and behaviors –Cognitive behavioral psychotherapy 2,3Cognitive behavioral psychotherapy Education –Assigned homework 1 Barbarich NC, et al, J Clin Psychiatry 2004;65;1480-1482. This was an open-label trial with 17 inpatients. 2 The EBM rating for the treatments of Anorexia Nervosa are of “Unknown Effectiveness” 3 Only 25% of current recommendations in medicine are EBM-rated as “Beneficial.”

9. What are some of the treatment challenges? 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. 1,2therapeutic relationship 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. 1 When the therapeutic relationship emerges, most of the talk will be about their maladaptive patterns of interpersonal behavior. 2 I monitor these patients’ weight, but I don’t tell them what they weigh.

10. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1.AIDET 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. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

11. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

12. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here 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 here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

13. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

14.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Justin Greenlee, DO Phillip Roberts, DO