Download Eating Disorders Dr.Roscoe 2010

The Diagnosis & Treatment of
Eating Disorders
Dr. Clare Roscoe
Staff Psychiatrist
Regional Eating Disorder Program
Children’s Hospital of Eastern Ontario
Eating Disorders Overview
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Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Types of Eating Disorders
1. Anorexia Nervosa
– restricting or
– binge-eating/purging subtype
2. Bulimia Nervosa
3. Eating Disorder Not Otherwise
Specified
4. Binge Eating Disorder
5. Childhood Eating Disorders
Epidemiology:
• Prevalence
A.N.
0.5-1%
adol. & young adult ♀
B.N.
1-3%
adol. & young adult ♀
EDNOS </= 10% adol. & young adult ♀
(“disordered eating” in 30% of children sampled)
• ♀:♂
5-10 : 1
• Onset
– A.N.: 13-20 yrs (peaks at 14 and 18 yrs)
– B.N.: 16.5-19 yrs old
Eating Disorders Overview
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Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Definitions: Anorexia Nervosa
A. Body weight <85% of expected
B. Intense fear of gaining weight
C. Distorted body image
- or Undue influence of
weight on self-worth,
- or Denial of seriousness of
the low weight
D. Amenorrhea: the absence of at least 3
consecutive menstrual cycles
Anorexia Nervosa cont’d
• Specify:
– Restricting Type
– Binge-Eating / Purging Type
Bulimia Nervosa
A. Recurrent Binge Eating:
1. Eating a very large amount
of food in a discrete period
of time
2. Lack of control during the
episode
B. Recurrent Compensatory behavior
to prevent weight gain
(vomiting, laxatives, fasting,
over-exercising…)
Bulimia Nervosa
C. A. and B. occur at least:
• 2x / week for 3 months
D. Self-worth unduly influenced by shape
and weight
E. Not A.N.
Specify: Purging vs. Non-Purging
Restriction
Severe Weight Loss
Binge
Purge
Restrict
Purging is the result of:
- Fear of weight gain
- stomach discomfort
- Shame
Eating Disorder (EDNOS)
Patient does not meet all the criteria for
an eating disorder. For example:
– A.N. with normal periods
– A.N. with the psychological criteria but is
above 85%ile for weight
– Frequent purging but no bingeing and
above 85%ile for weight
– Binge Eating Disorder will likely be a new
diagnostic category in the next DSM
Binge Eating Disorder
• Recurrent episodes of binge eating
• No compensatory behaviours
Eating Disorders Overview
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•
•
•
•
•
Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Etiology and Risk Factors
• Up to 90% of teenage girls will go on a
diet. What happens to the 5%, (and the
boys), that go on to develop Eating
Disorders?
Risk Factors for A.N. or B.N.
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Developed countries
Female
Adolescent
Caucasian
Risk Factors for AN
Individual
Family
Cultural
Perfectionism /
Obsessionality
Family History of ED /
Mood disorder
Idealization of thinness
Inflexibility / feeling out
of control
? Family dysfunction
/high expectations
“normative discontent”
for female body image
Low self-esteem /
Eagerness to please
Self worth= appearance
Predisposition to
thinness
Gay males
Comorbid: Anxiety,
OCD, Social Phobia,
Depression
Involved in activity
where thinness =
success e.g. modeling /
acting
Puberty / Adverse life
experience
Competitive sports with
emphasis on thinness:
e.g.. gymnastics / ballet
Risk Factors for BN
Individual
Family
Cultural
Hx of obesity
Family Hx of obesity
Idealization of
thinness
Impulsivity / risk
taking/ mood swings
Critical comments re. Self worth =
weight / shape /
appearance
eating
Low self-esteem
Family Hx of Mood /
ED / or substance
abuse
Comorbid: anxiety
and depression;
substance abuse
Verbal, physical or
sexual abuse
Volatile / conflicted
family environments
Overweight = lack of
control
What Keeps the Illness Going?
i.e. Makes the ED so
Strong?
• Starvation
• The meaning it has /
how helpful it is
• Stuck in an “addiction”
Starvation
• Keys study
– WWII, 36 men of “superior psychobiological
stamina” , put on severe diet, then gradually
re-fed
– Developed symptoms of eating disorders
including; food rituals, prolonged time eating,
withdrawal, isolation, extreme mood swings,
outbursts of anger, hospitalization, episodes
of bingeing and vomiting when given access
to food
What is the Meaning of the
Illness?
• Eating Disorders are about feeling “not
good enough”
• The ED makes a person feel “good
enough”
• EDs are associated with low self-worth;
depression; anxiety; guilt; feeling ‘bad’
• The ED helps push away/numb/replace
the bad feelings
What is the Meaning of the
Illness?
• Not eating allows all my other worries to go
away. This is all I have to focus on
• Not eating allows me to feel in complete
control of my life
• This makes me feel that I can do what no one
else can; makes me feel special, competent
• I need to punish myself by not eating.
• The eating disorder is who I am.
• I don’t want to grow up (fear)
Co-Morbidity of A.N.:
• >50% Depression (i.e. #1 comorbidity)
• 50% Anxiety Disorders (esp. OCD,
GAD, and Social Phobia)
• Perfectionism
• “Pathological Compliance”
• Cluster ‘C’ P.D. traits, e.g.. OCPD
(rigidity, restraint, obsessiveness)
Comorbidity of B.N.:
• Depression #1 comorbidity
• Anxiety in >50% (esp. GAD
• Impulsivity/risk-taking behaviors
• Borderline Personality Disorder traits
• Bipolar Spectrum disorders
• Substance Abuse
• PTSD
Eating Disorders Overview
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Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Physiologic Complications of
Eating Disorders
• Starvation
– Body shutting down one system at a time
• Bingeing and Purging
Physiologic Complications
of Eating Disorders
System
Starvation
Binge/ purge
CV
Low BP, low HR,
cardiac arrest,
pedal edema (low
albumin)
Anemia, poor
immunity
Arrhythmias,
cardio-myopathy,
sudden death
Metabolic / Heme
Resp
Metabolic
alkalosis,
hypokalemia
Aspiration
pneumonia
Physiologic Complications
of Eating Disorders
System
Starvation
Reprod.
Infertility
Derm
Dry skin and
hair, lanugo hair
GI
Constipation
Binge/ purge
Russell’s sign, enlarged
parotid glands, perioral
skin irritation, periocular
petechiae
Hematemesis,
esophagitis, reflux, poor
muscle tone in colon
from laxative abuse
Physiologic Complications
of Eating Disorders
System
Starvation
Binge/ purge
MSK
osteoporosis
Dental erosion,
muscle cramps
(low K)
Renal
Pre-Renal failure
(dehydration)
General / other
Low temp, short
stature
Dehydration,
weight
fluctuations
Labs in Eating Disorders:
INCREASED
DECREASED
• BUN (dehydration)
• Na, K, CL (vomiting/laxatives)
• Amylase (vomiting)
• LH, FSH, estrogen
• Cholesterol
(starvation)
(starvation)
• RBCs (starvation)
• WBCs (starvation)
Clinical features of a Patient
at High Risk of Death
1.
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Very low weight
Multiple purging methods
No medical follow-up
Ipecac use
Chronic self-harm or suicide attempts
Bradycardia
Amphetamine or cocaine use
Checklist of Visible
Characteristics for AN
Siegel et al., 1997
Behavioural Signs:
Physiological:
• restricted eating: severe
diet or fasting
• odd food rituals
• intense fear of
becoming fat
• rigid exercise regime
• dressing in layers
• Mood shifts
• Withdrawal from others
• weight loss
• menses stopped/ no
start
• paleness
• always cold
• dizziness, fainting spells
Checklist visible signs of
Bulimia
Siegel et al, 1997
Behavioural Signs:
• secretive eating
• missing food
• constant talk about
food and body
• self-critical when too
much eaten
• bathroom visits after
meals
• rigid/harsh exercise
routine
• Severe mood shifts
• Severe self-criticism
Checklist Bulimia continued
Physiological Signs
• swollen glands, puffiness cheeks, broken blood
vessels under eyes
• complaints of sore throats
• fatigue, muscle ache
• tooth decay
• weight fluctuations
Eating Disorders Overview
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Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Principles of Treatment for
E.D.’s:
1. Start with a thorough assessment
a. Biopsychosocial formulation
2. Specialized, multidisciplinary treatment team
(physician, dietician, therapist…)
a. A psychological illness with medical and
nutritional consequences
b. Importance of medical and psychological aspects
of treatment together
3. Importance of Education
Treatment of Anorexia
Nervosa:
• Medical and Nutritional:
– “food is the medicine”
– reversal of the effects of starvation;
re-feeding
– meal plan, “mechanical eating”
– medical management and weighing
– No medication found to be effective;
(recent use of atypical antipsychotics);
SSRI’s not effective at low weight
Treatment of A.N. cont’d:
• Psychological
– Family Therapy for Children and
Adolescents (evidence based)
– CBT; IPT; motivational therapy; groups
– externalizing the illness; challenging the
E.D.
– importance of alliance with therapist
– psychoeducation e.g. re. effects of
starvation
Treatment of A.N. cont’d:
• Inpatient vs. Day Treatment Programs
vs. Outpatient (stepped-care approach)
• Treatment of co-morbidities e.g..
anxiety, depression
Treatment Difficulties
• Symptoms are ego syntonic (i.e.
wanted)
• Defensive / difficult families
• Malnutrition may preclude effective
psychotherapy
• Chronicity
Treatment of Bulimia Nervosa:
• Use of high-dose SSRIs (Prozac)
• CBT (manualized); IPT; Groups
• Importance of a meal plan
• Psychoeducation
• Treatment of co-morbidities, e.g..
substance abuse, PTSD...
Eating Disorders Overview
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Epidemiology
Diagnosis
Etiology and Risk Factors
Physiologic Complications
Principles of Treatment
Outcome
Outcome for Anorexia
Nervosa:
• High morbidity and mortality (among highest
of all psychiatric illnesses)
• Mortality: 5-20% (50% suicide, 50% medical
complications)
• Prognosis in Adults:
– 50% “recover”
– 25% intermediate outcome
– 25% poor outcome
Outcome for B.N.
• Better treatment outcomes compared to
A.N.
• Up to 70% recover with treatment
• 10-15% continue to do poorly
• 15-20% intermediate outcome
A.N.  B.N.
• 50% of Anorexics develop B.N.
• Within 2 years of weight recovery
• (Crossover from B.N.  A.N. is rare)
Outcome cont’d:
• Better prognosis associated with:
– onset (and treatment) before age 15 yrs
– treatment within 3 years of onset of illness
– weight recovery within 2 years of treatment
• Worse Prognosis associated with:
– later age of onset, longer duration of
illness, previous hospitalizations, greater
individual and family disturbance
Outcome cont’d (A.N. and
B.N.)
• Higher rates of Major Depression
• Higher rates of Anxiety (esp. OCD and
GAD)
• Higher rates of Substance Abuse for
those with history of B.N.
www. nedic.ca
Quiz…
1. What is the prevalence of Anorexia Nervosa
in young women (age 15-40)?
a. 0.1 – 0.2%
b. 0.5-1%
c. 5%
2. To have a diagnosis of Bulimia Nervosa, the
compensatory behaviour must include
vomiting.
a. True
b. False
Quiz…
3. First line treatment for Anorexia Nervosa in
the weight restoration phase is:
a. an SSRI
b. an appetite stimulant
c. none of the above
4. First line treatment for Bulimia Nervosa
includes:
a. an SSRI
b. CBT
c. all of the above