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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 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 1 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 2 4/24/2013 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 3 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… 4 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 5 4/24/2013 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 6 4/24/2013 Complications 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 7 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 8 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 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” Electrolyte disturbances (decr PO4, K, Mg) Fluid imbalances Vitamin deficiencies Hyperglycemia 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?) 9 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 Higher prevalence Able to manage outpatient setting/ medically fragile Initially used antidepressants (high incidence of depression sxs in BN): 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 10 4/24/2013 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 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 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 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 11 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