Download Integrative Approaches to Eating Disorders

Integrative Medicine
Approaches to Eating Disorders
Carolyn Ross, MD, MPH
Eating Disorder and Integrative Medicine Consultant
1855 S. Pearl St.
Denver, CO 80210
520-440-0079
[email protected]
www.carolynrossmd.com
Objectives
1. Participants will be able to list two common
characteristics between all eating disorder
diagnoses
2. Participants will be able to name one
medication studied in the treatment of eating
disorders
3. Participants will be able to understand
American Psychiatric Association
recommendations for Anorexia or Bulimia
2
Eating Disorders

7 million females



.5-3.7% of females have AN
1.1-4.2 % have BN
2-5% - B.E.D.

1 million males with AN

10-25% of those with AN will die as
a direct result of the disease

19% of college-aged females are
bulimic

35% of US population is obese
Eating Disorders

Have one of the highest mortality rates of all
psychiatric diagnoses




SMR = 11.6 for anorexia; 1.3 for bulimia
SMR for suicide in anorexia = 56.9
Severity of alcohol use was associated with increased risk
for mortality
Hospitalization for an affective disorder was protective from
mortality

Keel PK, et al. Arch of Gen Psych. 2/2003;60(2)
DSM-IV Criteria for Anorexia Nervosa





Refusal to maintain body weight at or above a minimally normal weight for
age and height (e.g. weight reduction less than 85% of expected or failure to
gain weight during growth to less than 85% of expected)
Unrealistic fear of gaining weight or becoming fat
Unrealistic appraisal of body weight or shape or denial of seriousness of
current low body weight.
In postmenarcheal females, amenorrhea (i.e. absence of at least 3
consecutive menstrual cycles.)
May be binge-purge type of restricting type
DSM-IV Criteria for Bulimia Nervosa





Note: may be purging type (selfinduced vomiting or using laxatives) or
nonpurging type (exercise or fasting)
Inappropriate behavior to compensate for
overeating (e.g. self-induced vomiting,
laxatives, diuretics, fasting
Eating and compensation at least twice a
week for 3 months
Self-evaluation is unduly influenced by
body shape and weight
Recurrent episodes of binge eating
 Eating, in a discrete period of time (e.g.
up to two hours) an amount of food that is
definitely larger than most people would
eat during a similar period of time and
under similar circumstances.
 A sense of lack of control during the
episode
DSM-IV Criteria for B.E.D. or C.E.
Recurrent episodes of binge eating. An episode is characterized by:
n
Eating a larger amount of food than normal during a short period of time
(within any two hour period)
n
Lack of control over eating during the binge episode (i.e. the feeling that
one cannot stop eating).
1. Binge eating episodes are associated with three or more of the following:.
1. Eating until feeling uncomfortably full
Eating large amounts of food when not physically hungry
2. Eating much more rapidly than normal
3. Eating alone because you are embarrassed by how much you're eating
4. Feeling disgusted, depressed, or guilty after overeating
5. Marked distress regarding binge eating is present

2. Binge eating occurs, on average, at least 2 days a week for six months
3. The binge eating is not associated with the regular use of inappropriate
compensatory behavior (i.e. purging, excessive exercise, etc.) and does not
occur exclusively during the course of bulimia nervosa or anorexia nervosa
Definitions of Eating Disorders


Weight preoccupation and excessive selfevaluation of weight and shape
50-64% of anorexics develop bulimic
behaviors / bulimics often begin to restrict
Common Co-Morbidities

Major Depressive Disorder
 Lifetime risk in Anorexics = 80%

Anxiety Disorders, ADHD, OCD, Panic
 OCD prevalence= 30% in patients with eating disorders

Personality Disorders - 21-97%
 Cluster B most common with bulimia (dramatic/erratic)
 Cluster C most common with anorexia (avoidant/anxious)

Social Phobias

Substance Use Disorders
 Prevalence in anorexia = 12-18%
 Prevalence in bulimia = 30-70%

PTSD
Integrative Approach to ED
1st SUPERFICIAL LEVEL OF BEHAVIORS: Eating Disorders, Substance Use,
Depression, Anxiety, Sexual Compulsivity, others
2nd EMOTIONAL SOUP: Shame, Fear, Anger, Joy, Guilt – Emotions in control of
the person. Emotions are the fuel for behaviors.
3rd SENSATE LEVEL: The body sensations associated with emotions
4th CORE BELIEFS: Beliefs formed in the midst of intense emotion, often
forgotten but unconsciously these beliefs continue to shape and drive
behaviors
5th Deeper Urges of the Soul: The authentic or true self which caismouflaged by
all of the above, Passion or Bliss. Your soul’s desires
Screening for Eating Disorders

SCOFF Questions*
Do
you make yourself Sick (induce vomiting) because you feel uncomfortably full?
Do
you worry that you have lost Control over how much you eat?
Have
Do
you recently lost more than One stone (14 lb [6.4 kg]) in a three-month period?
you think you are too Fat, even though others say you are too thin?
Would
you say that Food dominates your life?
One
point for every yes answer; a score >= 2 indicates a likely case of anorexia nervosa or bulimia nervosa
(sensitivity: 100 percent; specificity: 87.5 percent).
Morgan
JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders.
BMJ 1999; 319:1467.
*12.5%
False positive rate
11
Screening for Eating Disorders

TABLE 4
Suggested Screening Questions for Anorexia Nervosa and Bulimia Nervosa

How many diets have you been on in the past year?

Do you think you should be dieting?

Are you dissatisfied with your body size?

Does your weight affect the way you think about yourself?

A positive response to any of these questions warrants further evaluation.

Information from Anstine D, Grinenko D. Rapid screening for disordered eating in college-aged females in the
primary care setting. J Adolesc Health 2000;26:338-42.
12
Newer Pieces to the Puzzle

SPECT scans in anorexics show decreased
cerebral blood flow in multiple areas of the
brain associated with




Emotional stability, social function, Learning and
memory (temporal)
Impulsivity and Attentiveness (prefrontal cortex)
Worry and Obsessiveness (cingulate system)
Scans showed improvement with weight
restoration
This is your brain on STRESS:
HPA Axis, ED, SUD and Trauma

Hypothalamus ----------------- Pituitary ------------ Target
organ
Hormone
production

Thyroid: TRH 

CRH/CRF ACTH & Beta endorphins

Sex Hormones: GnRH 


TSH

FSH and LH
T3 and T4
Cortisol
 Estrogen/Testoster
Serotonin decreased  self-mutilation, impulsiveness, cravings
No consistent serotonin findings in ED/CD/SUD
Obesity and Stress

Acute stress associated with severe, yet
reversible, form of insulin resistance


Brandi LS, et al. Clin Sci 1993;85:525-35
Psychosocial stress associated with insulin
resistance


Raikkonen K, et al. Metabolism 1996; 45:1533-38
Nilsson PM, et al. J Intern Med 1995; 237:479-86
ED and Stress



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Bulimics may have a complex and poorly
understood dysregulation of the HPA axis
associated with the disease.[1]
A study in patients with night eating
syndrome also demonstrated dysregulation
of the HPA axis with blunting of the CRHinduced ACTH and cortisol response.[2]
1] Birketvedt GS, Drivenes E, Agledahl I, et al. Bulimia nervosa – a primary defect in
the hypothalamic-pituitary-adrenal axis? Appetite. 2006 Mar;46(2):164-7. Epub 2006
Feb 24.
[2] Krupa D. www.the-aps.org/press/journal/release2-7-02-4.htm. [
Genetics

Twin studies show:



a substantial contribution to AN and BN and traits
associated with both
Unique environmental influences (trauma, sports
that emphasize thinness) > shared environmental
influences (SES, religion, parenting style)
Those with a mother or sister with AN are:


12 X more likely to develop AN
4 X more likely to develop BN
17
Genetics

Binge Eating Disorder



Binge-eating disorder is a familial disorder caused
in part by factors distinct from other familial factors
for obesity
Hereditability estimated at 57% (Javaras KN, et al. 2007)
Obesity / Compulsive Overeating

Hereditability estimated at between 40-70%
18
Causes of Eating Disorders
Causes of eating disorders





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Family history of eating disorder or chemical
dependency
Early onset puberty
Increased BMI prior to onset
Mood disorder history
Highly competitive academic/social
environments
Enmeshed or disengaged family system
20
Precipitating factors

Internal or external sense of loss of control




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Puberty and attendant weight gain
Major life transitions:
separation/individuation/identity
Traumatic events: abuse / rejection / failure
Family issues: divorce
Innocent weight loss
Onset of co-morbid illness
21
Eating Disorders
n
Influence of the culture
QuickTi me™ and a
TIFF ( Uncompressed) decompressor
are needed to see thi s pi ctur e.

Ana Carolina Reston


Brazilian Model
Died at age 21 after prolonged hospitalization for





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Anorexia
Bulimia
Kidney Failure
Septicemia
BMI 13.5
Weight 88 lbs.
QuickTi me™ and a
TIFF ( Uncompressed) decompressor
are needed to see thi s pi ctur e.
“There were times I felt fat. I
had a distorted image of
myself”
Ana Carolina Reston (19852006)
23
Eating Disorders
Haven’t you had enough
calories?
Parents divorced at age 9, no
longer “Daddy’s little girl” or gifted
student
Julie and
Morticia
One-quarter of what you eat keeps you alive.
The other three-quarters keeps your doctor
alive. (Hieroglyph found in an ancient Egyptian tomb)
The doctor of the future will no longer treat the
human frame with drugs, but rather will cure
and prevent disease with nutrition. Thomas Edison
Nutrition and Eating Disorders: “It’s
not just about food”


Keys 1950’s study
Signs of under/malnutrition



mood disorders
obsession with food
bizarre food rituals
27
“Let they food be thy medicine, and let
thy medicine be food.”



Protein
Nutrient Density
Sugar
Dietary Supplements
Dietary Supplements

Depression

Longer remission
with Omega-3 FA
supplementation


Cott J, 2004
Populations with
high depression
have low EFAs

Eating Disorders

Levels of EFAs
decreased in AN


EFAs effect zinc
absorption
Zinc necessary for
EFA metabolism
Omega 3 FA

Suicide Risk

Low DHA% and Low
Omega-3:6 ratio
predicted risk in
depressed patients
over 2 year period


Borderline
personality disorder

Omega 3 FA
decrease anger and
aggression

BMJ 3/05
Am J Psychiatry,
Sublette M, et al.
2006
31
Dietary Supplements

Calcium, Magnesium,
Vitamin D

Food sources of zinc:
Oysters
Fortified breakfast cereal
Lean meats
Yogurt
Beans
Nuts and seeds
Supplements

Digestion & Absorption:
 Enzymes: Thorne or
Tyler
 Probiotics: Lactobacillus
GG

Deficient in patients with
chronic constipation


With fiber  decreased
constipation and bloating


Hongisto, 2005
Khalif, 2005
IBS

Kajander, 2005
Supplements for Depression

5-HTP: Serotonin precursor

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Treatment for refractory depression
Insomnia



Cowan 1996
Cangiano C, 1992
Cochrane Database
34
Supplements for Anxiety

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L-Theanine
Valerian Root

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Benzodiazepine
withdrawal
Sleep




Anxiety



Morin CM, 2005
Shinomiya K, 2005
Kohnen R, 1988
Andreatini R, 2003
Kava-Kava

Yager, et al. (1999) –
patient on Prozac (20
mg/day) for alcoholinduced mood disorder. Hx
ETOH hepatitis. Pt. took 2
gelcaps of Valerian root
and felt like “I’m on acid.”
Mc Gregor, et al. (1989)
reported 4 cases of
hepatotoxicity with
combined preparations
containing valerian root.
Chan (1995) Cases of
ingestion of 15-20 grams
of valerian root caused
headache, excitability,
uneasiness, cardiac
disturbances but no signs
35
of hepatitis
St. John’s Wort

SIDE EFFECTS





Dosage: 300 mg three
times a day
SAD, ADHD, OCD,
Anxiety, Depression
Study done on (PerikaNature’s Way):


Extract WS5572: 3%
hyperforin
300 mg three times
daily







Reduces effect of digitalis
May increase effects and side
effects of products that
increase serotonin (5-HTP,
SAMe, SSRI’s)
May increase the effect of
Xanax, Coumadin,
Immunosuppresive agents
Robitussin DM  increase
serotonin
May decrease effectiveness of
OCP’s
May increase metabolism of
Dilantin
May reduce levels of
Zocor(not Pravacol or Lescol)
/ ?Lipitor/Mevacor
Other: may induce mania in
bipolar patients
Other: high doses may cause
sunburn-like reaction
36
St. John’s Wort Case Report

Yager, et al. – Patient with long-standing
GAD with panic attacks. Patient began
taking St. John’s wort and reported reduction
in panic attacks from 3-4/day to 3-4/week.
Patient also taking passionflower and wild oat
and in CBT.
37
Patient comments about supplements


“The nutritional supplements made it easier for me to begin
eating again. I didn’t have the bloating and stomach pain I had
when I went through this process in my last treatment.”
“I never thought I could sleep without my sleep medications. I
feel much more well rested and not as groggy as when I took the
sleep medicines.”
38
Anorexia Nervosa /Bulimia Nervosa / Binge Eating Disorder
History and
Sx
Amenorrhea,
Constipation,
headaches, fainting,
cold intolerance
Bloating, fullness,
Constipation, GERD,
lethargy, GERD,
fatigue, abnormal
abdominal pain, sore
menses, PCOS
throat, abn menses
Physical
findings
Cachexia,
acrocyanosis, dry
skin, hair loss,
bradycardia,
orthostatic
hypotension,
hypothermia, loss of
muscle mass and sq
fat, lanugo
Knuckle calluses,
dental enamel
erosion, salivary
gland enlargement,
Overweight or obese
cardiomegaly (ipecac
toxicity). Can be
normal or sl overwt.
Laboratory
findings
Hypoglycemia,
leukopenia, elevated
liver enzymes,
euthyroid sick
syndrome (low TSH,
normal T3, T4),
OSTEOPENIA
Hypochloremic,
hypokalemic or
metabolic acidosis
(from vomiting),
hypokalemia (from
laxatives / diuretics,
inc. amylase
Hyperlipidemia,
hyperglycemia,
Insulin resistance
Elevated androgens
ECG
findings
Low voltage,
prolonged QT
interval, bradycardia
Low voltage,
prolonged QT
interval, bradycardia
Variable
39
Medications used in the Treatment of
Eating Disorders

Topamax - decreased binge eating behavior, BMI and
weight in Binge eating disorder (BED) Mc Elroy, et al. Biol Psych 2007
May 1;61(9)

In one study, the use of Clozapine/olanzapine may
worsen symptoms of binge eating Gebhart, et al. J Neural Transm 2007 Aug;
114(8)

Sertraline - decrease in Night Eating Syndrome
behaviors: nighttime hyperphagia, awakenings,
nocturnal ingestions and Beck Depression scores
AJ, et al. J Clin Psych 2006 Oct; 67(10)
40
Stunkard
Medications for ED

Medications tried for AN have been
disappointing and / or studies hampered by
small size



None have a significant impact on weight gain
Tricyclics show improvement in mood only
High drop-out rates limit ability to draw
conclusions
41
Medications for ED

Bulimia

Trials with Prozac (60 mg/day) for up to 18 weeks





Reduce binging and purging
Reduce psychological symptoms
Trials with Luvox and Trazadone - small studies
show some efficacy
Preliminary study on Zofran (Ondansetron) - an
antiemetic and 5HT3 Antagonist decreased binging
and purging when patients self-administered prn
cravings
Medication only trials show abstinence in only a
minority of patients.
42
Medications for Binge Eating
Disorder

Trial of Prozac vs. placebo



Overall, in short term studies, SSRI’s lead to
reduction in binging, decrease in weight and severity
of illness and decrease in psychological symptoms




Decrease in binging, depression
Abstinence rates, high drop-out rates and long-term followup not reported - conclusions ?
Long-term follow up is lacking
No data on abstinence from binging
Topamax and Sibutramine - decrease in binging. No
long term data
High placebo response in all trials is noteworthy
43
Mind-Body Therapies
Mind-Body Treatments of Mental Illness



Restoring the mind-body connection
Stress reduction
Research shows efficacy for:







ADD and ADHD
Insomnia
Memory improvements after head trauma
Panic disorder
Chronic Pain
Eating Disorders
Mind-Body Therapies



Guided Imagery
Self-hypnosis
Relaxation Therapies


Breath work, Meditation, PMR
Mindful Practices for



Eating
Exercising
Self-soothing
Research on Yoga







Berger (1992): Yoga & Swimming – decreased anger, confusion, tension
and depression more than aerobic training
Shannahoff-Khalsa (1996): Yogic techniques used to treat OCD
 Y-BOCS group mean improvement was +54%; improvement on
Perceived Stress Scale; 3/5 stopped fluoxetine, 2/5 decreased dose
Woolery, et al (2004): Iyengar yoga effective in decreasing symptoms in
subjects with mild depression.
Yoga in ED patients produced increased body contentment, self-confidence
and general emotional maturation
Yoga has been effective in treatment of drug addiction in India and US
Hatha yoga found equal to group therapy for reducing drug use and
criminal activities in patients on methadone maintenance
SKY yoga breathing in patients with HAM-D >17 (n=45): remission rates
were equal for yoga and imipramine but lower than remission rates for ECT.
CASES


Julia’s depression
Thom - from Obesity to Anorexia
48
Thom – “no reason to live”






40 y.o. WM – Hx of morbid obesity  now
severely anorexic
S/P Gastric bypass surgery
Neuromuscular scoliosis
Diet consisted of ¼ grilled cheese
sandwich/day + 10-15 Reese’s PB cups
Wheelchair
Day in the Life
History of Thom




“I don’t know how I got here..”
Adult child of alcoholic  silent eater since
age 9 / “Mother locked up the cabinets”
Youngest of 5 children “I could do whatever I
wanted and not get punished”
The loss of his “sons”
Thom



Medical:
 Difficulties with solid food  EGD
 Osteoporosis- Why?
 Spectracell
EDI-3
CAM
 Acupuncture: pulse very deficient  wiry pulse
 Somatics: collapse of his core
 Chiropractic  increase height/ pain decreased
 Massage
 Reiki  low energy along left side
 Zero Balancing – felt body soaking up energy
Upper endoscopy
showing marked
stenosis at site of
anastomosis of gastric
bypass surgery.
Thom K – 3/06
Weight 183 lbs.
Height 5’8”
Loves dogs
Moved to board and care
home
Relapsed with ETOH
within 3 months
Resources
Healing – D.H. Lawrence




I am not a mechanism, an assembly of various
sections.
And it is not because the mechanism is working
wrongly that I am ill.
I am ill because of wounds to the soul, to the deep
emotional self and wounds to the soul take a long,
long time, only time can help and patience, and a
certain difficult repentance, long, difficult
repentance, realization of life’s mistake, and the
freeing oneself
From the endless repetition of the mistake which
mankind at large has chosen to sanctify.
References
1.
2.
3.
4.
5.
6.
7.
Kaye Wh, et al. Comorbidity of anxiety disorders with anorexia and bulimia
nervosa. AM J Psychiatry, 2004 Dec; 161(12):2215-21.
Latner JD, Wilson GT. Binge eating and satiety in bulimia nervosa and binge eating
disorder: effects of macronutrient intake. Int J Eat Disord. 2004 Dec;36(4):402-15.
Dalvit-McPhillips S. A dietary approach to bulimia treatment. Physiol Behav
33(5):769-75, 1984.
Blouin AG, et al. A double-blind placebo-controlled glucose challenge in bulimia
nervosa: psychological effects. Biol Psychiatry 33(3):160-8, 1993.
Ward NI. Assessment of zinc status & oral supplementation in anorexia nervosa. J
Nutr Med 1:171-7, 1990.
Yamaguchi H, et al. Anorexia nervosa responding to zinc supplementation: a case
report. Gastroenterol Jpn. 1992 Aug;27(4):554-8.
Cowan PJ, et al. Moderate dieting causes 5HT2Cr eceptor supersensitivity.
Psychol Med 26(6):1155-9, 1996.
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17. The Rhodiola Revolution. Richard Brown, MD & Pat Garberger, MD