Rosen & Barkin's 5-Minute Emergency Medicine Consult (231 page)

333.72 Acute dystonia due to drugs

BASICS

• Restriction of intake, leading to markedly low body weight for age, height, and/or developmental trajectory
  
• Intense fear of gaining weight or becoming fat, or behavior that prevents weight gain
  
• Severe body image disturbance, undue influence of body weight and shape on self-evaluation, or denial of seriousness of low body weight
  
• Lifetime prevalence: 0.5% of females in US
  
• Typical age of onset for AN is bimodal at 13–14 yr and 17–18 yr
  

• Recurrent episodes of binge eating characterized by:
  
  • Eating an unusually large amount of food in a discrete period of time
    
  • A sense of loss of control over eating during the episode
    
• Recurrent inappropriate compensatory behaviors used to prevent weight gain:
  
  • Self-induced vomiting
    
  • Misuse of laxatives or enemas
    
  • Diuretics
    
  • Diet pills
    
  • Fasting
    
  • Excessive exercise
    
• Bingeing and compensation occur on average at least once a week for 3 mo
  
• Self-evaluation that is excessively influenced by weight or body shape
  
• Lifetime prevalence: 2% of females in US
  
• Commonly onset in late adolescence or early adulthood.
  

• Recurrent episodes of binge eating characterized by:
  
  • Eating a larger than usual amount of food in a discrete period of time
    
  • A sense of loss of control over eating during the episode
    
• Binge eating episodes associated with 3 or more of the following:
  
  • Eating much more rapidly than normal
    
  • Eating until feeling uncomfortably full
    
  • Eating large amounts of food when not feeling physically hungry
    
  • Eating alone because of embarrassment about how much one is eating
    
  • Feeling disgusted with oneself, depressed, or very guilty after overeating
    
• Marked distress over binge eating
  
• Occurs on average at least once a week for 3 mo
  
• No compensatory behavior
  
• Lifetime prevalence: 3.5% of females and 2% males in US
  
• Onset in late adolescence or early adulthood.
  

• Twin studies have supported a strong genetic component.
  
• Cultural emphasis on thinness as a valued attribute has been implicated
  
• Temperament or personality attributes of perfectionism, anxiety, and behavioral rigidity have been described
  
• Family conflict or stress is a frequent element
  
• Neurochemical (serotonin) and neuroendocrinologic (leptin, HPA axis) abnormalities have been reported
  
• Dieting is a frequent immediate precipitant
  

DIAGNOSIS

• Rapid or sustained weight loss
  
• Typical detailed day’s eating pattern shows restricting and/or bingeing behavior
  
• Purging (vomiting, laxatives, diuretics, enemas)
  
• Excessive exercise
  
• Dizziness, syncope
  
• Bloating (gastroparesis), constipation, abdominal pain
  
• Fatigue, lethargy
  
• Palpitations
  
• Cold intolerance
  
• Amenorrhea, loss of libido
  
• Family history of eating disorders and obesity
  
• Comorbid psychiatric disorder (e.g., mood disorder, substance abuse, personality disorder)
  

• Weight <85% IBW or BMI <17.5 for AN
  
• Hypothermia
  
• Hypotension, orthostasis
  
• Bradycardia, arrhythmia
  
• Skin: Dry skin, lanugo (soft downy body hair on chest and arms), carotenoderma
  
• Breast atrophy
  
• Parotid swelling, submandibular swelling
  
• Abnormal dentition
  
• Abrasions of dorsum of hand
  
• Skin breakdown, poor wound healing
  
• Peripheral edema
  
• Muscle weakness
  

• History
  
• Physical exam
  
• Lab testing
  
• Nutritional assessment
  
• Psychiatric interview:
  
  • Concurrent psychiatric illness
    
  • Suicide risk assessment
    
  • Explore psychosocial context
    
• Family evaluation when patient lives with his or her family
  

• CBC (anemia, leukopenia, thrombocytopenia)
  
• Electrolytes, BUN, creatinine, glucose (hyponatremia, hypokalemia, hypoglycemia, dehydration, metabolic alkalosis)
  
• Calcium, magnesium, phosphorus, albumin (hypocalcemia, hypomagnesemia, hypophosphatemia, hypoalbuminemia)
  
• LFTs (hepatic dysfunction)
  
• UA including specific gravity
  
• Toxic screen
  
• β-hCG
  
• Amylase (salivary hyperamylasemia if vomiting, pancreatitis)
  
• Lipase (more accurate than amylase in predicting pancreatitis)
  
• Consider checking thyroid-stimulating hormone.
  

Specific tests may be useful in making differential diagnoses, e.g., MRI (rule out brain tumor), abdominal CT (rule out obstruction)

• ECG (QTc prolongation, arrhythmia)
  
• Consider cardiac echo if substantial weight loss (cardiomyopathy from AN or ipecac)
  
• Bone mineral density (osteoporosis)
  

• Medical conditions:
  
  • GI disease (e.g., Crohn's Disease, IBD, celiac disease)
    
  • Endocrine disorder (e.g., DM, thyroid disorder, adrenal insufficiency)
    
  • Cancer
    
• Psychiatric conditions
  
  • Borderline personality disorder
    
  • Mood disorders
    
  • Obsessive-compulsive disorder
    
  • Substance abuse
    

TREATMENT

• ABCs
  
• Careful fluid resuscitation for dehydration to avoid precipitating peripheral or pulmonary edema
  
• Replete phosphate and thiamine since both may drop with refeeding
  
• Correct hypokalemia, hypomagnesemia, hypocalcemia
  
• Correct hypoglycemia
  
• Warming blankets for severe hypothermia
  

• Initial workup
  
• Medical stabilization
  
• Psychiatric consultation (including assessment of suicide risk and psychiatric comorbidities)
  

• No medication has been demonstrated to be of benefit for AN per se
  
  • Small trials have suggested possible benefit from atypical antipsychotics, particularly olanzapine 2.5–10 mg PO QD
    
  • It may be helpful to treat psychiatric comorbidities
    
• Only fluoxetine 20–60 mg PO QD has FDA indication for the treatment of BN, though other SSRIs are frequently used. There is also evidence for tricyclic antidepressants as well as topiramate
  
• There is evidence for imipramine, sertaline, citalopram/escitalopram, and topiramate for BED
  

FOLLOW-UP

• Medical risk:
  
  • Extremely low weight (<75% IBW)
    
  • Rapid weight loss
    
  • Serum electrolyte imbalance (K <3, glucose <60)
    
  • Bradycardia <40
    
  • BP <90/60
    
  • Orthostasis (>20 bpm or >20 mm Hg/10 mm Hg)
    
  • Hypothermia <97°F
    
  • Arrhythmia or heart failure
    
  • Hepatic or renal dysfunction
    
• Psychiatric risk:
  
  • Severe depression, psychosis, or other comorbid psychiatric diagnosis
    
  • Suicidality
    
  • Lack of motivation or cooperation with treatment
    
  • Failure of outpatient treatment
    
  • Severe impairment in functioning
    
  • Toxic family environment
    

• Medically and psychologically safe enough to be managed on an outpatient basis
  
• Multimodal, multidisciplinary team in place to manage medical, nutritional, and psychological issues
  

• Outpatient treatment requires a team approach composed of a:
  
  • Psychiatrist and/or psychologist
    
  • Nutritionist, preferably one who specializes in eating disorders
    
  • Pediatrician or internist
    
  • Family therapist
    
  • Group therapist
    
  • Dentist
    
• Prognosis:
  
  • AN and BN:
    
    • 20% chronic course
      
    • 30% improve
      
    • 50% recover
      
  • Mortality rate 5.6% per decade for AN
    
  • Outcomes improved with early diagnosis and treatment