View source for WBR0604

 {{WBRQuestion
|QuestionAuthor= {{AO}}
|ExamType=USMLE Step 2 CK
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|MainCategory=Psychiatry
|MainCategory=Psychiatry
|SubCategory=Psychiatry
|Prompt=A 45-year-old Caucasian female, non-smoker, single woman with a past medical history of amenorrhea and depression came to the clinic for a routine hospital visit.  She had been a runway model for the past 29 years.  This is the first time she is coming to the hospital.  Her physical examination showed marked malnutrition and paleness.  Her body mass index was 16.42 (height: 1.58 m; weight: 41 kg).  On further questioning, she admitted to severely restricting her diet due to thoughts about actually being fat even whenever she sees herself in the mirror.  She also confessed to occasional binge eating and abuse of laxatives.

Which of the following is the diagnosis in this woman?






|Explanation=Anorexia nervosa is a psychiatric eating disorder characterized by abnormal eating behavior, severe self-induced weight loss, and psychiatric co-morbidities.
Criteria for diagnosis include:
* Refusal to maintain body weight at or above a minimally normal weight for age and height: Weight loss leading to maintenance of body weight <85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected
* Intense fear of gaining weight or becoming fat, even though under weight
* Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight
* Amenorrhea (at least three consecutive cycles) in post-menarchal girls and women. Amenorrhea is defined as periods occurring only following hormone (e.g., estrogen) administration.

People with anorexia have an intense preoccupation with thoughts of being fat, extreme fear of gaining weight, which causes them to try to maintain a very low weight. They will do almost anything to avoid gaining weight, including starving themselves or exercising too much. People with anorexia also have a distorted body image – they think they are fat when they are indeed extremely thin.

There are two types of anorexia nervosa:
* Restricting type: No binge-eating or purging behavior (self-induced vomiting or misuse of laxatives, diuretics, or enemas).
* Binge-eating–purging type: The person regularly engages in binge-eating or purging behavior (self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Individuals with anorexia nervosa and bulimia nervosa share many similar features.  In fact, the binge-eating-purging type of anorexia may be difficult to distinguish from bulimia nervosa.  Some patients constantly cycle back and forth between the two disorders.  In both disorders, individuals have an obsession with weight loss, an intense fear of weight gain, and over-concern with body weight and image.  Both disorders can have self-imposed caloric restriction, food binging and purging.  Anorexic individuals restrict their food intake far more than bulimic individuals do; thus anorexics are pathologically thin, whereas many bulimics have a normal weight.  Bulimic individuals binge more than anorexic individuals.

Educational Objective: Anorexia nervosa is a psychiatric condition characterized by abnormal eating behavior, conscious restriction of food due to distorted body image of being fat.  It it’s different from bulimia by the food restriction and distorted body image.  Bulimic patients have uncontrolled eating habits which drives them into purging thereafter.  The most common cause of death in anorexia nervosa is ventricular arrhythmias. 

|AnswerA=Weight loss syndrome
|AnswerAExp=Incorrect.  Weight loss syndrome is characterized by loss of weight, loss of appetite, overall decline in quality of life, and shortened survival in patients with advanced incurable cancer, AIDS or any incurable chronic condition.
|AnswerB=Anorexia nervosa
|AnswerBExp=Correct.  Anorexia nervosa is a psychiatric eating disorder characterized by abnormal eating behavior, severe self-induced weight loss, and psychiatric co-morbidities
|AnswerC=Bulimia nervosa
|AnswerCExp=Incorrect.  Bulimia nervosa is a psychiatric eating disorder characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives, laxatives, diuretics, enemas, or in some instances, over-exercising.  It is common among teen females and women, but boys and men could also have it also.

Diagnostic Criteria – According to the American Psychiatric Association, a diagnosis of bulimia must meet all the following criteria:
                  
* 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 most people would eat during a similar period of time and 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 behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

* The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

* Self-evaluation is unduly influenced by body shape and weight.

* The disturbance does not occur exclusively during episodes of anorexia nervosa.

The management of bulimia involves the combination of cognitive behavioral therapy, SSRIs such as fluoxetine, as well as patient and family support groups, are effective.

|AnswerD=Binge eating disorder
|AnswerDExp=Incorrect.  Binge eating disorder (BED) is characterized by compulsive overeating in which an individual consumes huge amounts of food as a mechanism to cope with stress or an unwanted emotion.  
The key features of binge eating disorder include:
* Frequent episodes of uncontrollable binge eating
* Feeling extremely distressed or upset during or after binge eating
* No purging behavior (vomiting, fasting, laxatives, diuretics, or over-exercising)
* People with binge eating disorder struggle with feelings of guilt, disgust, and depression after a bingeing episode 

|AnswerE=Food avoidance emotional disorder
|AnswerEExp=Incorrect.  Food avoidance emotional disorder (FAED) is a childhood emotional disorder in which food avoidance is the prominent feature, resulting in weight loss. This is primarily a mood, rather than food, disturbance. Children with FAED tend to be younger than those with early onset anorexia nervosa.  FAED is more common in boys than girls.
|RightAnswer=B
|WBRKeyword=Anorexia nervosa, binge eating disorder, food avoidance emotional disorder,  weight loss syndrome, eating disorders 
|Approved=No
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