Eating Disorders and Excessively Low BMI Table 4-1
Anorexia Nervosa Bulimia Nervosa
Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2)
Fear of appearing fat
Frequently starving but in denial;
lacking insight
Often brought in by family members May present as failure to make
expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men
Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido
Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics
Biologic complications
●Neuroendocrine changes:
amenorrhea, hormonal alterations
●Cardiovascular disorders:
bradycardia, hypotension, dysrhythmias, cardiomyopathy
●Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema
Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, osteoporosis
Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise Often with normal weight Overeating at least twice a
week during 3-month period; large amounts of food consumed in short period (∼2 hrs) Preoccupation with eating;
craving and compulsion to eat; lack of control over eating; alternating with periods of starvation Dread of fatness but may be
obese Subtypes of
●Purging: bulimic episodes accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas
●Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, exercise without purging
Biologic complications; see changes listed for anorexia nervosa.
Sources: World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC:
American Psychiatric Association, 2000. Halmi KA: Eating disorders: In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 7th ed. Philadelphia:
Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia nervosa.
N Engl J Med 2003;349(9):875–880.
Table 4-2 Nutrition Screening Checklist I have an illness or condition that made
me change the kind and/or amount of food I eat.
Yes (2 pts) _________
I eat fewer than 2 meals per day. Yes (3 pts) _________
I eat few fruits or vegetables, or milk products.
Yes (2 pts) _________
I have 3 or more drinks of beer, liquor, or wine almost every day.
Yes (2 pts) _________
I have tooth or mouth problems that make it hard for me to eat.
Yes (2 pts) _________
I don’t always have enough money to buy the food I need.
Yes (4 pts) _________
I eat alone most of the time. Yes (1 pt) _________
I take 3 or more different prescribed or over-the-counter drugs each day.
Yes (1 pt) _________
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
Yes (2 pts) _________
I am not always physically able to shop, cook, and/or feed myself.
Yes (2 pts) _________
TOTAL _________
Instructions: Check “yes” for each condition that applies, then total the nutritional score. For total scores between 3 and 5 points (moderate risk) or ≥6 points (high risk), further evaluation is needed (especially for the elderly).
Source: American Academy of Family Physicians. The Nutrition Screening Initiative.
Available at: www.aafp.org/PreBuilt/NSI_DETERMINE.pdf. Accessed January 23, 2008.
Table 4-3 Nutrition Counseling: Sources of Nutrients Nutrient Food Source
Calcium Dairy foods such as milk, natural cheeses, and yogurt
Calcium-fortified cereals, fruit juice, soy milk, and tofu
Dark green leafy vegetables like collard, turnip, and mustard greens; bok choy Sardines Iron Lean meat, dark turkey meat, liver
Clams, mussels, oysters, sardines, anchovies Iron-fortified cereals
Enriched and whole grain bread
Spinach, peas, lentil, turnip greens, peas, and artichokes
Dried prunes and raisins Folate Cooked dried beans and peas
Oranges, orange juice Liver
Black-eyed peas, lentils, okra, chick peas, peanuts Folate-fortified cereals
Vitamin D Vitamin D–fortified milk
Cod liver oil; salmon, mackerel, tuna Egg yolks, butter, margarine Vitamin D–fortified cereals
Source: Adapted from: Dietary Guidelines Committee, 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000; Choose MyPlate.gov.
Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011;
Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/.
Accessed June 24, 2011.
Table 4-4
Patients With Hypertension:
Recommended Changes in Diet
Dietary Change Food Source Increase foods high
in potassium
Baked white or sweet potatoes
White beans, beet greens, soybeans, spinach, lentils, kidney beans
Bananas, plantains, many dried fruits, orange juice
Tomato sauce, juice, and paste Decrease foods high
in sodium
Canned foods (soups, tuna fish) Pretzels, potato chips, pickles, olives
Many processed foods (frozen dinners, ketchup, mustard)
Batter-fried foods
Table salt, including for cooking
Source: Adapted from Dietary Guidelines Committee. 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000. Choose MyPlate.gov.
Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011;
Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/.
Accessed June 24, 2011.
Table 4-5
Abnormalities in Rate and Rhythm of Breathing
Normal. In adults, 14–20 per min; in infants, up to 44 per min.
Rapid Shallow Breathing (Tachypnea).
Many causes, including restrictive lung disease, pleural chest pain, and an elevated diaphragm.
Rapid Deep Breathing (Hyperpnea, Hyperventilation). Many causes, including exercise, anxiety, metabolic acidosis, brainstem injury. Kussmaul breathing, due to metabolic acidosis, is deep, but rate may be fast, slow, or normal.
Slow Breathing (Bradypnea). May be secondary to diabetic coma, drug- induced respiratory depression, increased intracranial pressure.
Cheyne-Stokes Breathing. Rhythmically alternating periods of hyperpnea and apnea. In infants and the aged, may be normal during sleep; also accompanies brain damage, heart failure, uremia, drug-induced respiratory depression.
Ataxic (Biot’s) Breathing. Unpredictable irregularity of depth and rate. Causes include brain damage and respiratory depression.
Sighing Breathing. Breathing punctuated by frequent sighs. When associated with other symptoms, it suggests the hyperventilation syndrome. Occasional sighs are normal.
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Behavior and Mental Status 5
Empathic listening, careful observation, and skilled history tak- ing help patients to reveal their deepest concerns and experiences.
Clinicians often miss clues to trauma, mental illness, and harmful dysfunctional behaviors. The prevalence of mental health disorders in the U.S. population is 30%, yet only approximately 20% of affected patients receive treatment. Even for patients who obtain care, evi- dence suggests that adherence to treatment guidelines in primary care offices is <50%.
Often, patients have health symptoms that mirror medical illnesses.
Thirty percent of symptoms last more than 6 weeks and are “medically unexplained,” masking anxiety, depression, or even somatoform disorders. See Table 5-1, Somatoform Disorders: Types and Approach, pp. 76–78. Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Difficult patients” are frequently those with multiple unexplained symptoms and underlying psychiatric conditions that are amenable to therapy. Without better “dual diagnosis,” patient health, function, and quality of life are at risk.
Mental Health Disorders and Unexplained Symptoms in Primary Care Settings
Mental Health Disorders in Primary Care
◗Approximately 20% of primary care outpatients have mental disorders, but up to 50% to 75% of these disorders are undetected and untreated.
◗Prevalence of mental disorders in primary care settings is roughly:
◗Anxiety—20%
◗Mood disorders including dysthymia, depressive, and bipolar disorders—25%
◗Depression—10%
◗Somatoform disorder—10% to 15%
◗Alcohol and substance abuse—15% to 20%
(continued)
For unexplained conditions lasting beyond 6 weeks, experts recom- mend brief screening questions with high sensitivity and specificity, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety.
Mental Health Disorders and Unexplained Symptoms in Primary Care Settings (continued)
Explained and Unexplained Symptoms
◗Physical symptoms account for approximately 50% of office visits.
◗Roughly one-third of physical symptoms are unexplained; in 20% to 25% of patients, physical symptoms become chronic or recurring.
◗In patients with unexplained symptoms, the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical symptoms, making detection and “dual diagnosis” important clinical goals.
Common Functional Syndromes
◗Co-occurrence rates for common functional syndromes such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity reach 30% to 90%, depending on the dis- orders compared.
◗The prevalence of symptom overlap is high in the common functional syn- dromes: namely, complaints of fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems.
◗The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy.
Patient Identifiers for Mental Health Screening
◗Medically unexplained physical symptoms—more than half have a depressive or anxiety disorder
◗Multiple physical or somatic symptoms or “high symptom count”
◗High severity of the presenting somatic symptom
◗Chronic pain
◗Symptoms for more than 6 weeks
◗Physician rating as a “difficult encounter”
◗Recent stress
◗Low self-rating of overall health
◗High use of health care services
◗Substance abuse
The Health History
Common or Concerning Symptoms
◗Changes in attention, mood, or speech
◗Changes in insight, orientation, or memory
◗Anxiety, panic, ritualistic behavior, and phobias
◗Delirium or dementia
Your assessment of mental status begins with the patient’s first words.
As you gather the health history, you will quickly observe the patient’s level of alertness and orientation, mood, attention, and memory. You will learn about the patient’s insight and judgment, as well as any recurring or unusual thoughts or perceptions. For some, you will need to conduct a more formal evaluation of mental status.
Many of the terms used to describe the mental status examination are familiar to you from social conversation. Take the time to learn their precise meanings in the context of the formal evaluation of mental status (see below).