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1956 SECTION 24: Psychosocial Disorders The central theme of the somatic type, and a potential trigger for an ED visit, is a preoccupation with health and organ function. For example, individuals may be convinced that they have an infestation of insects on their skin or that a part of their body is not functioning. Schizoaffective disorder is about one third as prevalent as schizophrenia. 36 It is characterized by Criterion A of schizophrenia (see Table 290-5) occurring concurrently with a major mood episode (major depressive or manic). Patients with schizophrenia and schizoaf fective disorder have a 5% lifetime risk of suicide, with higher risk in patients with depressive symptoms. Catatonia may occur in the context of various conditions. Medical conditions associated with catatonia include encephalitis, head trauma, hepatic encephalopathy, and neoplasms. The acute presentation of catatonia often includes stupor, and therefore, patients often have their first clinical contact in the ED. It is therefore important to recognize that catatonia is frequently associated with an organic cause. REFERENCES The complete reference list is available online at www.TintinalliEM.com. with anorexia nervosa.8 MRI studies detect differences in brain behavior and structure, and some implicate brain regions involved in reward processing.9-12 CLINICAL FEATURES  HISTORY Patients with eating disorders often present to the ED with vague signs and symptoms such as weakness, fatigue, pallor, dizziness, syncope, confusion, bloating, edema, or persistent nausea. 13 Complaints may otherwise be due to medical complications, such as chest pain and hematemesis caused by a Mallory-Weiss tear from purging; palpitations from dysrhythmias; dysmenorrhea from disruption of the hypothalamicpituitary axis; or fractures from osteoporosis. Depression, anxiety, substance abuse, self-injurious behavior, or suicidality may coexist. 14,15 Therefore, if an eating disorder is suspected, consider screening for depression and suicidality. If clinical suspicion is raised for an eating disorder based on com plaint cluster, physical examination, or family report, explore a more focused history. Important data points to elicit include eating and dieting behavior; desire for weight loss; typical daily dietary intake; presence of calorie counting; compensatory exercise behavior; guilt patterns fol lowing eating; menstruation pattern; and use of over-the-counter dietary supplements or laxative agents. Certain sensitive history points may be difficult to elicit in the ED, such as early childhood GI issues or picky eating or obesity, self-esteem issues, societal thinness pressures, teas ing, propensity toward perfectionism, or sexual abuse. Certain physi cal activities raise risk for eating disorders, such as gymnastics, ballet and other dance, wrestling, swimming, and cross-country running. 16-18 Because eating disorders are characterized by denial of symptoms and behaviors, take a nonjudgmental approach to encourage trust and truthful disclosure.  PHYSICAL EXAMINATION Patients with anorexia are typically easily identifiable based on a very thin body habitus. Other signs include hypotension (resting or ortho static), bradycardia or tachydysrhythmia, heart murmur and S 2 “click” of mitral valve prolapse, or hypothermia.

o encourage trust and truthful disclosure.  PHYSICAL EXAMINATION Patients with anorexia are typically easily identifiable based on a very thin body habitus. Other signs include hypotension (resting or ortho static), bradycardia or tachydysrhythmia, heart murmur and S 2 “click” of mitral valve prolapse, or hypothermia. Patients may also exhibit signs of vitamin deficiencies such as brittle, flaking, or ridged nails (nonspe cific malnutrition); stomatitis or cheilitis (B vitamin deficiency); or perifollicular petechiae (scurvy). They may also develop fine, long hair on the arms and face, acral cyanosis (impaired thermoregulation), and/or pretibial edema secondary to malnutrition. 14 Nonsuicidal self-injury is also common, and stigmata of cutting, picking, burning, or bruising may be present. Patients with bulimia or binge eating disorder can be difficult to detect in the ED because they tend to be normal weight or over weight. Consider eating disorder diagnoses in the presence of other physical indicators, even in normal weight or overweight patients. Self-induced vomiting can cause painless hypertrophy of the parotid glands (sialadenosis), dental erosion, and trauma or callus formation to the dorsal hands (Russell’s sign), 20 as well as pharyngeal erythema or abrasions, gingivitis, facial petechiae or subconjunctival hemorrhage, and halitosis. Laxative abuse may cause peripheral edema, anal fissures, hemorrhoids, perianal dermatitis, and rectal bleeding. Patients with binge eating disorder will likely have no abnormalities apparent on physical examination.  DISEASE COMPLICATIONS Eating disorders can be life threatening. Death by suicide is six and four times more common in patients with anorexia and bulimia, respectively, than in the general population. 21 Medical complications are typically more severe in anorexia than in bulimia or binge eating. Complications of anorexia are generally directly due to malnutrition 22 and can account for a large proportion of deaths. 23 Bulimia medical complications are usually related to method and frequency of purging and are often the result of chemical derangements or structural damage to the GI tract. 24 Patients with binge eating disorder describe significantly CHAPTER Eating Disorders Gemma C.L. Bornick INTRODUCTION AND EPIDEMIOLOGY Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, are psychological conditions characterized by a pathologic relationship with food that adversely affects psychosocial functioning. Eating disorders can be challenging in the ED because physical manifestations may be subtle and historical features may not be elicited unless a disorder is suspected from medical complications. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders refines the diagnostic criteria of eating disorders from the previous edi tion (Table 291-1). There are two subtypes of anorexia nervosa: restrictive and binge/ purge, with crossover between the two. 2 Restrictive patients minimize their food intake, whereas those with bingeing/purging make up for unacceptable food intake with diuretics, laxatives, enemas, or vomiting. There are also two subtypes of bulimia: purging and nonpurging. Those who purge do so by the above methods; those classified as nonpurging use other compensatory methods such as fasting or excessive exercise. Up to 50% of anorexia patients develop bulimia. 3 Binge eating disorder is characterized by habitual, recurrent binge consumption episodes that cause significant distress. This is distinct from simple episodic overeating and must be both independent of anorexia or bulimia and free of compensatory mechanisms.

exercise. Up to 50% of anorexia patients develop bulimia. 3 Binge eating disorder is characterized by habitual, recurrent binge consumption episodes that cause significant distress. This is distinct from simple episodic overeating and must be both independent of anorexia or bulimia and free of compensatory mechanisms. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, also defines avoidant/restrictive food intake disorder, pica, and rumination disorder, which are not addressed here. Anorexia nervosa has an estimated lifetime prevalence of 0.9% in women and 0.3% in men, and median age of onset is 18 years old. 4,5 Bulimia nervosa has an estimated lifetime prevalence of 1.5% in women and 0.5% in men, and median age at onset is also 18 years old. 5 Binge eating disorder is more common in older individuals and males than both anorexia and bulimia, with a lifetime prevalence of 3.5% in women and 2.0% in men. 4,5 PATHOPHYSIOLOGY There is evidence that eating disorders run in families, possibly due to both genetic influences and similar underlying temperaments and behaviors. 6,7 For example, genetic locus (rs4622308) on chromosome 12 is associated Tintinalli_Sec24_p1933-1966.indd 1956 8/2/19 5:19 PM

in women and 2.0% in men. 4,5 PATHOPHYSIOLOGY There is evidence that eating disorders run in families, possibly due to both genetic influences and similar underlying temperaments and behaviors. 6,7 For example, genetic locus (rs4622308) on chromosome 12 is associated Tintinalli_Sec24_p1933-1966.indd 1956 8/2/19 5:19 PM CHAPTER 291:  Eating Disorders      1957 more somatic symptoms than the general population, but true medical complications are rare.25 Cardiopulmonary Complications Among the most deadly of the eating disorder complications in anorexia are structural and functional changes to the cardiovascular system. 26 Malnutrition causes decreased cardiac muscle mass and increased vagal tone. This leads to decreased contractility and cardiac output and, therefore, results in hypotension, bradycardia, and orthostasis. Relative decreases in cardiac muscle mass can lead to the development of mitral valve prolapse. 27 Rarely, patients with anorexia nervosa can develop myocardial fibrosis 28 or pericardial effusion, which in a few cases has led to cardiac tamponade requiring pericardiocentesis. 29 Syrup of ipecac, used as an emetogenic, is directly cardiotoxic and can cause an irreversible cardiomyopathy. Prolongation of the QT interval on ECG has been described, but this is rare in the absence of electrolyte disturbance or congenital long QT syndrome and should prompt evaluation for these conditions. 22 Increased QT dispersion (difference between maximum and minimum QT intervals seen in each lead of a single ECG) indicates heterogeneous ventricular depolarization and is a marker for increased arrhythmic risk. 30 QT derangements as a result of eating disorders are reversed by adequate refeeding. QT resolution is associated with normalization of heart rate, heart rate variability, and exercise tolerance 31 and, therefore, has been used as a marker to guide rehabilitation. 32 Most other cardiac sequelae are also reversible with appropriate weight gain, but there is increased risk of cardiac complications during the first week of refeeding after severe nutrient depletion. 31,33 Cardiac complications are only rarely seen in patients with bulimia nervosa or binge eating disorder.24,34 Pulmonary Complications Anorexia can lead to weakness of respi ratory muscles, decreased pulmonary and aerobic capacity, 35,36 and aspiration due to pharyngeal muscle weakness. Aspiration pneumonitis and subsequent pneumonia can occur as a result of pharyngeal muscle weakness and from chronic purging. 37 There are case reports of pneu mothorax and pneumomediastinum.38 Patients with bulimia and binge eating disorder are often smokers and may have pulmonary complications related to smoking. GI Complications Patients with anorexia are at increased risk of con stipation, gastroparesis, acute gastric dilatation, gastroesophageal reflux, and acute pancreatitis. 14,40,41 Gastroesophageal reflux and laryngopha ryngeal reflux commonly occur in patients with bulimia or purging-type anorexia and may result in hoarseness or dysphagia. 14,42 Forceful vomiting can result in Mallory-Weiss tears or, rarely, Boerhaave syndrome. 34 Chronic stimulant laxative abuse can lead to development of ileus, rectal prolapse, melanosis coli, or the cathartic colon syndrome. 43-45 Nutritional Complications The proportion of eating disorder patients with vitamin deficiencies is difficult to determine because many take supplements. Decreased bone mineral density and skeletal fragility are common but are not associated with decreased vitamin D levels. Iron and vitamin B 12 deficiencies can lead to anemia in severely foodrestrictive patients but are uncommon. Skin erythema and pruritus with sun exposure, glossitis, epidermal desquamation, and diarrhea should raise suspicion of pellagra.

etal fragility are common but are not associated with decreased vitamin D levels. Iron and vitamin B 12 deficiencies can lead to anemia in severely foodrestrictive patients but are uncommon. Skin erythema and pruritus with sun exposure, glossitis, epidermal desquamation, and diarrhea should raise suspicion of pellagra. 47 Confusion, confabulation, ataxia, ophthal moplegia, and/or nystagmus suggest Wernicke-Korsakoff encephalopathy. Other vitamin deficiencies reported in association with eating disorders include wet beriberi and scurvy, although these are extremely rare. 48,49 Poor nutritional state can result in hypoplastic or aplastic bone marrow50 and resultant cytopenias.51 Renal and Electrolyte Complications Electrolyte derangements and other lab abnormalities are more common in purging-type eating dis orders. Patients with restrictive-type anorexia may not demonstrate any laboratory abnormalities. Frequent vomiting can result in metabolic alkalosis, hyponatremia, and hypochloremia. Laxative and diuretic abuse and vomiting can lead to potassium and magnesium deple tion. Hyponatremia may also develop in patients who abuse diuretics. Signs of starvation ketosis may be evident. In patients with very severe anorexia, hypoglycemia and hypophosphatemia can develop. 14,22,52,53 Refeeding following prolonged nutrient depletion can also cause electrolyte abnormalities, most commonly hypokalemia, hypophosphatemia, and hypomagnesemia, due to redistribution of electrolytes from the extracellular to the intracellular space triggered by insulin release and from depletion of phosphorus during protein synthesis. This can lead to arrhythmias, congestive heart failure, pericardial effusions, and cardiac arrest. Endocrine Complications Profound food restriction affects the hypothalamic-pituitary axis. Low levels of gonadotropins, loss of the normal pulsatile waves of luteinizing hormone, and estrogen deficiency lead to hypothalamic amenorrhea. 54 Anorexia is also associated with the “euthyroid sick syndrome” in which thyroid-stimulating hormone is normal or slightly low, T 3 is low, and sometimes T 4 levels are also decreased. Thyroid deficiencies likely contribute to the bradycardia, orthostasis, and hypothermia in anorexia. High cortisol levels and low levels of insulin-like growth factor 1 (somatomedin C), T 3, estradiol, and testosterone contribute to loss of bone mass. 55 Refeeding and recovery from illness do not fully return bone mass to normal levels, and patients with anorexia remain at an increased risk of fracture for many years following initial diagnosis. 56 The endocrine effects of bulimia and binge eating disorder are less well studied.

rone contribute to loss of bone mass. 55 Refeeding and recovery from illness do not fully return bone mass to normal levels, and patients with anorexia remain at an increased risk of fracture for many years following initial diagnosis. 56 The endocrine effects of bulimia and binge eating disorder are less well studied. Bulimia is associated with both TABLE 291-1 Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, Criteria for Eating Disorders Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Restriction of caloric intake relative to requirements, leading to a lower than expected body weight in the context of age, sex, development, and physical health (<85% predicted) Recurrent episodes of binge eating characterized by both: •   Eating in a discrete time period an amount of food that is larger than most people would eat in the same period under the same circumstance •   A feeling of lack of control over eating during an episode Recurrent episodes of binge eating characterized by both: •   Eating in a discrete time period an amount of food that is larger than most people would eat in the same period of time under the same circumstance •   A feeling of lack of control over eating during an episode Fear of weight gain or becoming fat, despite lower than predicted body weight Recurrent, inappropriate compensatory behaviors to prevent weight gain including self-induced emesis; abuse of laxatives, diuretics, or other medications; caloric restriction; or excessive exercise The episodes are associated with three of the following: •   Eating much more quickly than normal •   Eating until feeling uncomfortably full or overfull •   Eating large amounts of food even when not feeling hungry •   Eating alone because of embarrassment about how much one is eating •   Feeling disgusted, depressed, or guilty afterward Derangement in the way the patient’s body weight or appearance is experienced, undue effects of body weight on self-evaluation, or denial of the dangerousness of the current low body weight Bingeing and purging at least 1 time a week for 3 weeks The patient exhibits marked distress regarding binge eating. Self-evaluation is unduly influenced by body weight and appearance The binge eating occurs at least 1 time a week for 3 months. The disturbance does not occur exclusively during episodes of anorexia The binge eating is not associated with inappropriate compensatory behavior and does not occur exclusively during the course of anorexia, bulimia, or avoidant/restrictive food intake disorder. Source: Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5 , 5th ed. Washington, DC: American Psychiatric Association; 2013. Tintinalli_Sec24_p1933-1966.indd 1957 8/2/19 5:19 PM

ly during the course of anorexia, bulimia, or avoidant/restrictive food intake disorder. Source: Data from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5 , 5th ed. Washington, DC: American Psychiatric Association; 2013. Tintinalli_Sec24_p1933-1966.indd 1957 8/2/19 5:19 PM 1958 SECTION 24: Psychosocial Disorders TABLE 291-2 SCOFF Questionnaire • Do you make yourself sick because you feel uncomfortably full? • Do you worry you have lost control over how much you eat? • Have you recently lost more than 1 stone (14 lb) in a 3-month period? • Do you believe yourself to be fat when others say you are too thin? • Would you say that food dominates your life? Note: A score of 2 or more indicates a probable eating disorder with a sensitivity of 84.6% and a specificity of 89.6%. Source: Reproduced with permission from Morgan JF, Reid F, Lacey JH: The SCOFF questionnaire: a new screening tool for eating disorders. West J Med 2000;172(3):164-165. TABLE 291-3 Differential Diagnosis of New-Onset Eating Disorders Endocrine Adrenal insufficiency Hyperthyroidism Diabetes GI Hepatitis Pancreatitis Celiac disease Inflammatory bowel disease Superior mesenteric artery syndrome Infectious disease Mononucleosis Human immunodeficiency virus Tuberculosis Cancer Nervous system malignancy Ovarian malignancy Intra-abdominal malignancy Pregnancy Hyperemesis gravidarum Psychiatric Substance abuse Major depressive disorder Bipolar disorder Schizophrenia Inborn error of metabolism Mitochondrial disorders Enzyme deficiency TABLE 291-4 Society of Adolescent Medicine Criteria for Hospital Admission Anorexia Nervosa Bulimia Nervosa Body weight <75% of ideal for age, sex, and height Potassium <3.2 mmol/L Daytime heart rate <50 beats/min or nighttime heart rate <45 beats/min Chloride <88 mmol/L Body fat <10% of body weight Esophageal trauma and hematemesis Dehydration Vomiting unresponsive to antiemetics Cardiac arrhythmia including QT prolongation Dehydration Temperature <96°F Cardiac arrhythmia including QT prolongation Orthostasis and syncope Temperature <96°F Acute psychiatric emergencies such as hallucinations or suicidality Orthostasis and syncope Systolic blood pressure <90 mm Hg Acute psychiatric emergencies such as hallucinations or suicidality Ongoing weight loss despite outpatient treatment Ongoing purging despite outpatient treatment TABLE 291-5 American Psychiatric Association Criteria for Hospital Admission Medical status Adults: heart rate <40 beats/min, blood pressure <90/60 mm Hg, glucose <60 milligrams/dL (<3.3 mmol/L), potassium <3 mEq/L, temperature <97.0°F, end-organ compromise requiring acute treatment, poorly controlled diabetes Children: heart rate near 40 beats/min, orthostasis, blood pressure <80/50 mm Hg, hypokalemia, hypophosphatemia, hypomagnesemia Suicidality Specific plan with high lethality or intent Weight Generally <85% of ideal body weight or acute weight change with food refusal Motivation to recover Very poor motivation; patient preoccupied with intrusive repetitive thoughts and/or uncooperative with treatment Comorbid disorders Any existing psychiatric disorder requiring hospitalization Structure required Needs supervision to ensure caloric intake, prevention of exercise, or prevention of purging behaviors Environmental Severe family conflict or absence of family, absence of appropriate outpatient resources in patient’s geographic region type 1 and type 2 diabetes mellitus. There is some evidence to support an increased risk of dyslipidemia, glucose dysregulation, and diabetes in binge eating disorder. 25,57 Repeated vomiting can lead to metabolic alkalosis, hypokalemia, and increased aldosterone secretion—a cluster described as pseudo-Bartter syndrome.

ype 1 and type 2 diabetes mellitus. There is some evidence to support an increased risk of dyslipidemia, glucose dysregulation, and diabetes in binge eating disorder. 25,57 Repeated vomiting can lead to metabolic alkalosis, hypokalemia, and increased aldosterone secretion—a cluster described as pseudo-Bartter syndrome. DIAGNOSIS Diagnostic criteria are outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, but screening tools are more practical for presumptive diagnosis in the ED. The SCOFF Questionnaire (Table 291-2) is useful for screening for anorexia and bulimia in a brief encounter and can be remembered by its acronym: Sick, Control, One stone, Fat, Food. 59 Other screening tools, such as the Eating Disor der Diagnostic Scale or the Eating Attitudes Test, are more extensive and are more useful in a primary care setting. 60,61 The Questionnaire on Eating and Weight Patterns–Revised is specific for binge eating disorder.62 It is very important to search for, diagnose, and treat organic pathol ogy as part of the assessment of a patient with a potential eating disorder (Table 291-3).  LABORATORY TESTING Initial testing should include an ECG and a full chemistry panel including magnesium, calcium, and phosphorus; CBC; urinalysis; pregnancy test; hepatic function panel; serum albumin; lipase and amylase; and thyroid-stimulating hormone.  IMAGING Obtain imaging only to rule out an underlying organic cause of presenting symptoms or to exclude medical complications. Nonspecific radio graphic findings in patients with anorexia may include decreased muscle mass, paucity of subcutaneous fat, mild small bowel dilatation, 63 and osteoporosis.65 There are no specific radiographic findings diagnostic of binge eating disorder or bulimia, but a swallowed toothbrush or similar item suggests purging by induced vomiting. TREATMENT AND DISPOSITION The ED treatment of eating disorders is limited to stabilization of urgent medical complications, followed by hospital admission or out patient referral to a mental health specialist. Tables 291-4 and 291-5 list guidelines for hospital admission. 63,67 Most medical complications of anorexia nervosa can be treated in an outpatient setting if the patient’s weight is >70% of ideal body weight or body mass index is >15 kg/m 2.52 Tintinalli_Sec24_p1933-1966.indd 1958 8/2/19 5:19 PM