Download Eating Disorders - Contemporary Forums

4/24/2013
“12yo Julia”
Eating Disorders
Age
0-6 yrs
Diane M. Straub, M.D., M.P.H.
Department of Pediatrics and
Adolescent Medicine, University of
South Florida
History
Toilet training problems
“Picky eater”
7-10 yrs Food rituals
“Obsessive”
Parents-no limit setting
Mom dieting constantly
“Julia”
“Julia”
History
Parents’ difficult divorce
Increased food avoidances
Anger outbursts at parents
“A’s” in school
12 yrs
Weight loss, doctor’s appts, GI
evaluation for constipation; admit
to hospital-severe malnutrition
FHx: Mom – nurse, h/o depressive episodes,
controlling; Dad – consultant, frequently away,
emotionally distant
• Vitals:
Eating Disorders - Epidemiology
Eating Disorders - Epidemiology
Age
11 yrs

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Anorexia Nervosa (AN)
 0.5% point prevalence in adolescent/young
adult women
Bulimia Nervosa (BN)
 1.3% to 10.1% of North American women
 1% adolescent/young adult women (APA)
Binge-Eating Disorder
 ? but estimated as more than AN/BN
combined
•
•
lying:
BP 80/50, HR 38; T 35.1
standing: BP 60/30, HR 82
PE: Subdued, cachectic, dry skin,
lanugo hair, cold extremities,
peripheral cyanosis, poor cap
refill, systolic murmur
BMI:
WT 67 lb, HT 59,” BMI 13.2
 Eating
Disorder NOS
Up to 20% adolescent girls with
“disordered eating”
 Approx. 3% of young women with
“diagnosis”; twice as many with clinically
important variants
 Typically in young women, but 5-15% AN
and 10-40% BN occur in males

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4/24/2013
Updates to DSM-5 - rationale
 Many
clinically significant problems do not
meet criteria for DSM-IV (eg, EDNOS)



Frustration for patients
Difficulty in conducting research
Lack of insurance coverage for treatment
Updates to DSM-5 - rationale
 Lifespan

 Obesity?



Updates to DSM-5 - changes
 Changes
to AN and BN criteria, and formally
adding binge-eating disorder
 EDNOS renamed: “Feeding and Eating
Conditions Not Elsewhere Classified,” with
sub-threshold and inadequately studied but
clinically important problems represented
 Pica, rumination disorder, “avoidant/ restrictive
food intake disorder”
 Obesity not added as mental health d/o
Projected publication May, 2013
approach:
Many psych d/o develop early in life, but
manifestations change over time – may not be
recognized or come to clinical attention until
much later
Huge public health problem
Clear associations b/t weight gain and
emotional problems
Possible impact of commonly used psych
medications on weight gain
Diagnostic Criteria – AN (DSM-IV)
1.
2.
3.
4.
Refusal to maintain body weight at or above
normal weight for age and height.
Intense fear of gaining weight or becoming
fat, even though underweight.
Disturbance in the way in which one’s body
weight or shape is experienced, undue
influence of body weight or shape on selfevaluation, or denial of the seriousness of
the current low body weight.
In postmenarcheal females, amenorrhea.
Diagnostic Criteria – AN (DSM-IV)
Types:
 Restricting:

the person has not regularly engaged
in binge-eating or purging behavior
 Binge-Eating/Purging:

the person has regularly engaged in
binge-eating or purging behavior
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Diagnostic Criteria – BN
As defined by DSM-IV
1.
2.
3.
4.
5.
Recurrent binge eating*
Engaging in a method to prevent weight gain
(i.e., purging; excessive exercise; fasting;
misuse of laxatives, diuretics, enemas, etc.)*
Behaviors* occur, on average, at least two
times per week for three months
Excessive concern about body weight or
shape
Absence of AN
Diagnostic Criteria –
Binge-Eating Disorder
As defined by DSM-IV
1.
2.
3.
Recurrent binge eating (at least two days per
week for six months)
Marked distress with at least three of the
following:

Eating very rapidly, until uncomfortably full,
when not hungry, and alone

Feeling disgusted or guilty after a binge
No associated inappropriate compensatory
mechanisms
Other (atypical) eating disorders
Clinically important
 disordered eating,
 inappropriate weight control, or
 excessive concern about body weight or
shape
that does not meet all the criteria for AN,
BN, or binge-eating disorder
= “EDNOS”
Young Children with Eating
Disorders
 Atypical
patterns
 Fluid restriction
 Failure to maintain position on growth
curve
 Prevalence increasing
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4/24/2013
Males with Eating Disorders
proportion with medical abnormalities
due to difficulties in establishing diagnosis
and delay in seeking treatment
 ?Different psychopathology: physical
effectiveness (vs. physical attractiveness)
predicts self-concept/ self esteem
 ?More unconventional sexual development
and gender identity issues
Abnormalities that may indicate an
Eating Disorder - Behavioral
 Higher
 Change
in eating habits
eating in social settings
 Reluctance to be weighed
 Depression
 Social withdrawal
 Absence from school or work
 Deceptive or secretive behavior
 Excessive exercise
 Difficulty
Abnormalities that may indicate an
Eating Disorder - Somatic
Risk Factors –
Cultural
 Arrested
 Marked
growth
change or frequent fluctuation in
weight
 Inability
to gain weight
 Fatigue
 Constipation
or diarrhea
to fractures
 Delayed menarche or menstrual disturbance
 Hypokalemia, hyperphosphatemia, metabolic
acidosis or alkalosis, or high serum amylase
levels
 Susceptibility
 Equating
thinness with both beauty and
happiness
 Emphasis on self and body
 Capability of disseminating these values
and styles through visual media
More Media Images…
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4/24/2013
“Self-perception of the average
teen female”
Risk Factors - Family
 Achievement-oriented
 Intrusive,
enmeshed, overprotective, rigid,
and unable to resolve conflicts
 Frugal with support, nurturance, and
encouragement
 Over-invested in food, diet, weight,
appearance, or physical fitness
 Other family members with a history of an
eating disorder or an affective disorder
Risk Factors - Individual
 Female
 Adolescent
 Slightly
overweight
of low self-esteem or
ineffectiveness
 Conflicts and doubts about sense of
personal identity and autonomy
 Perceptual disturbances regarding body
 Sense of personal competitiveness with
peers or family members
 Obsessional style
 Feelings
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Evaluation
 Detailed
eating history
 Psychosocial history, including family
history
 Problem-based review of systems to
evaluate for concurrent or etiological
organic illness
 Physical Assessment
 Laboratory studies
Detailed Eating History









H/o feeding difficulties, “picky eater”
Weight history
Subjective ideal weight
Preoccupation with fears of being fat
Restricting
Bingeing, purging
Use of ipecac, laxatives, enemas, diuretics,
anorexic drugs, caffeine, or other stimulants
Dietary recall
Exercise history
Psychosocial History
• Features of depression, anxiety, and
obsessional thoughts
• Low self-esteem
• Perfectionistic attitude
• High achiever / family expectations
• Drop in school performance
• Social anxiety and withdrawal
Additional Red Flags:
• Fat and food obsessions / rituals
• Out-of-control eating
• Uncomfortable eating with others
• Preoccupation with food intake
• Para-eating behaviors
• Frequent self-weighing
Psychosocial, Family History
 Significant






life events/stressors:
Physical or sexual abuse
Recent move, new school
Teasing
Relationship break-up
Divorce of parents
Illness or death
 Abnormal
family eating patterns,
psychiatric illness
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Complications

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
Problem-Based Review of
Systems:
General complaints:
• Weak, tired
• Dizzy, h/o fainting
• Cold hands and feet
• Poor concentration
• Dry skin, hair loss
Cardiovascular: sinus bradycardia,
sinus arrhythmia, hypotension,
ventricular dysrrhythmias, reduced
myocardial contractility, prolonged QT
interval, sudden death, ipecac
cardiomyopathy, mitral valve prolapse,
congestive heart failure, pericardial
effusion
Renal: renal calculi, edema,
hypokalemia, renal concentrating
defect, increased BUN, decreased
glomerular filtration rate, ketonuria
GI: delayed gastric emptying, superior
mesenteric artery syndrome,
constipation, elevated LFTs, gastric
dilation, necrotizing colitis, pancreatitis,
parotid gland enlargement, esopagitis,
Mallory-Weiss lesions, paralytic ileus,
cathartic colon, esophageal or gastric
rupture, perforation/rupture of
stomach, Barrett esophagus,
gallstones
Dermatologic: acrocyanosis,
hypercarotenemia, brittle hair and
nails, lanugo hair, hair loss, Russell
sign (calluses over the knuckles)
 Missed
 Early
satiety (feels full before or soon after
starting to eat)
 Nausea,
vomiting, chronic abdominal pain




> 3 periods in a row
 Delayed
 Growth
menarche
stopped / slowed
 Delayed
/ interrupted puberty
Skeletal History
 Stress
diarrhea

Hematologic: anemia, leukopenia,
thrombocytopenia, decreased C3 and
ESR
Endocrine and metabolic: elevated
cholesterol, amenorrhea,
osteoporosis, decreased somatomedin
C, short stature, partial diabetes
insipidis, abnormal temperature
regulation, metabolic alkalosis,
hyponatremia, hypokalemia,
decreased magnesium with resultant
muscle cramps, weakness, and
restlessness
Neuromuscular: generalized muscle
weakness, seizures, peripheral
neuropathies, myopathy due to ipecac
abuse, syncope, diplopia, movement
disorders, cortical atrophy
Correlates of sudden death:
prolonged QT interval, decreased
serum phosphate, ipecac myopathy,
weight loss more than or equal to 35%
ideal body weight, suicide
Dental: dental and enamel erosions,
caries, periodontal disease
Pulmonary: aspiration pneumonia,
pneumomediastinum
Endocrine/Menstrual History
GI History
 Constipation,

fractures
 Osteopenia
 Calcium

intake
Important for bone growth and helping to
achieve peak bone mass during
adolescence
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4/24/2013
Differential Diagnosis:
 Hyperthyroidism
or hypothyroidism
 Malabsorptive states
 Inflammatory bowel disease
 Diabetes mellitus
 Brain tumors (especially 4th ventricle)
 Collagen vascular disease
 Addison’s disease
Physical Assessment
Health Parameters:
 HT,
WT (inappropriate loss/no gain)
 BMI (Kg / M2), %tile for age
 Tº < 36.3º
 HR < 50
 Orthostatics (lying down to standing):


Physical Exam Findings:
HR  > 20-35 beats/ min (stand)
BP  > 10 mm (stand)
Dental Changes…
 General:
cachexia
dry skin, hypercarotenemia, lanugo
hair, acrocyanosis, Russell sign, edema
 HEENT: parotid and submandibular
gland enlargement, abnormal dentition,
perimolysis
 Heart: hemodynamic instability, mitral
regurgitation murmur due to MVP
 GI: signs c/w constipation
 Skin:
Laboratory Abnormalities
 Endocrine:
“sick euthyroid,” low
gonadotropins, abnl ACTH response, DI
 Chemistry: Increased BUN, LFTs,
cholesterol, carotene; decreased PO4,
Mg, Ca, Vitamin A, Zn, Cu
 Hematologic: leukopenia, anemia,
thrombocytopenia, decreased C3 and
ESR
Laboratory Abnormalities – Cont’d
 Cardiac:
bradycardia, low-voltage
changes, T-wave inversions, ST segment
depression; decreased cardiac size and
left ventricular wall thickness; increased
prevalence of MVP
 GI: Hypomotility
 Renal and metabolic: Decreased GFR
and maximum concentration ability,
elevated BUN, metabolic alkalosis
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4/24/2013
Laboratory Studies
CBC and ESR
BUN, creatinine
 Urinalysis
 Serum electrolytes and LFTs
 Ca, Mg, PO4, Zn
 Albumin, total protein
 Thyroid function test(s)
 ECG
Optional: CXR, stool studies, UGIS, Ba enema,
head CT/MRI
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
Medical Treatment
 Weight
gain is primary goal in treatment of
AN – “Food is MEDICINE!”
 Monitoring of weight, vital signs (HR, BP,
T), and serum electrolytes
 Education about nutrition, adjustment of
caloric and nutritional intake (in
conjunction with a nutritionist), and
limitations on exercise and other
modifications of behavior
 Enteral/parenteral nutrition reserved for
severe undernutrition refractory to
conservative treatment
Indications for Hospitalization,
Cont’d
Indications for Hospitalization
Any one or more of the following:
 Severe malnutrition (weight <75% ideal
body weight)
 Dehydration
 Electrolyte disturbances
 Cardiac dysrrhythmias
 Physiological instability (T, HR, BP,
orthostatic changes)
 Arrested growth and development
 Failure of outpatient treatment
Any one or more of the following:
 Acute food refusal
 Uncontrollable bingeing and purging
 Acute medical complication of malnutrition
(i.e., syncope, seizures, cardiac failure,
pancreatitis)
 Acute psychiatric emergencies (i.e.,
suicidal ideation, acute psychosis)
 Comorbid diagnosis that interferes with
treatment (i.e, OCD, severe family
dysfunction)
Refeeding
Prevention and Treatment
 Weight

 Can

gain requires careful supervision
lead to gastric bloating, edema, and
rarely congestive heart failure
 “Refeeding Syndrome”
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


Electrolyte disturbances (decr PO4, K, Mg)
Fluid imbalances
Vitamin deficiencies
Hyperglycemia
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Goal: GO SLOW!!!
Volume and nutritional repletion must begin with
less than full restoration of metabolic needs;
advance fluid volume and calories SLOWLY
Closely monitor electrolytes, urine production,
and cardiovascular integrity
Identify high risk patients (<70% ideal body
weight)
Electrolyte and vitamin supplements as needed
(empiric phos?)
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4/24/2013
Other management points:
 ECG:
hypokalemia, palpitations,
prolonged QT
 Alleviation of severe constipation: stoolsofteners and bulk-forming laxatives
 No intervention if euthyroid sick syndrome;
thyroid function returns to normal with
weight gain
 Dental care for induced vomiting
 Osteopenia: Vitamin supplementation (Ca
1,000-1,500 mg/d, multivitamin with 400
IU/d Vitamin D); estrogen replacement
(controversial)
Psychopharmacology - AN
Psychiatric Treatment
 Few
 Combination
of individual, group, and
family Tx beneficial
 Early-onset, non-chronic AN – family Tx
 BN: cognitive-behavioral therapy,
interpersonal Tx
 Psychodynamic Tx and behavioral
strategies helpful
 Family Tx, education
Psychopharmacology - BN
AN, many effective therapies, both
pharmacologic and therapeutic
 Easier to study


RCTs
Patient medically compromised, ambivalent
about tx, few parents grant consent
Little compelling data
 TCAs
– modest benefits, significant SEs
 SSRIs
– benefit in weight-recovered pts,
use for relapse prevention
 Atypical
anti-psychotics – low-weight pts c
mood disturbance, OCD, tx failure
Psychopharmacology - BN
 Unlike
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
Higher prevalence
Able to manage outpatient setting/ medically
fragile
 Initially
used antidepressants (high incidence
of depression sxs in BN):
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
Significant short-term decrease in BN, purging
Effective in depressed and non-depressed
patients
 TCAs
(6 RCTs), MAOIs (5), SSRIs (5),
other classes (3) – equal efficacy vs
placebo:

remission of binge episodes = 0.87 (95% CI

“clinical improvement” = 0.63
0.81-0.93; p<0,001)
 Fluoxetine
(95% CI 0.55-0.74)
– FDA-approved, dose-
response
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AN Outcomes/Prognosis
Combo Tx:
Cochrane Review
 Remission



rates:
Rx vs Tx (5): 20 vs 39% RR 1.28 (0.98, 1.67)
Combo vs Rx (5): 42 vs 23% RR 1.38 (0.98, 1.93)
Tx vs Combo (7): 36 vs 49% RR 1.21 (1.02, 1.45)
appeared to be more
acceptable to subjects

Morbidity and mortality are amongst the highest of all
functional psychiatric disorders due to malnutrition,
purging behavior and suicide.
 Mortality: 5% (1.4-7.8%) = up to 18x increase
(Steinhausen, 2002, Sullivan, 1995, Nielsen, 1998)

 Psychotherapy


57% more likely to commit suicide than age/race
matched controls
Mortality: 5-10% within 10yrs, 18-20% within 20
yrs; only 30-40% fully recover
20% of people suffering from anorexia will
prematurely die from complications related to their
eating disorder, including suicide and heart
problems
AN Outcomes/Prognosis
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Average time to first recovery 6 yrs
Frequent weight fluctuations
50% may develop BN
Increased depression, anxiety disorder, alcohol
dependence
45% never marry
Predictors of outcome:


Good: purging subtype, short duration of illness,
higher weight at discharge
Bad: low BMI at diagnosis, long duration of illness,
high creatinine, compulsion to exercise, disturbed
family relations
BN Outcomes/ Prognosis
 Mortality:
5.6%
achieve full recovery in 2 yrs
 Frequent relapses
 20-46% may have symptoms 6yrs after tx
 55% diagnosed with mood disorders
 42% diagnosed with substance abuse
disorders
 50%
Anti-anorexia campaigns:
Prevention
Cochrane review
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

Media literacy and advocacy (2): significant
decrease in internalization or acceptance of
societal ideals
Eating attitudes and behaviors (5) and selfesteem (2): insufficient evidence to support
No evidence of harm from any of the programs
 Star
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Models –
Modeling agency based in Brazil
Ads: picture of a model in a fashion design
sketch (with the exaggerated proportions and
long lines typical of fashion illustration) and a
picture of a "real" model (depicted with the
exact same proportions)
Tagline; "You are not a sketch. Say no to
anorexia."
Models airbrushed to mimic the unrealistic
sketches, but closely resemble actual runway
models
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4/24/2013
Stars speaking out
 Isabelle
Caro, Italian model, died in 2007
at 28yo – “shock” ad campaign.
 Demi Lovato, Amanda Beard, etc
 Ashley Judd
Questions?
12