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Overview of Eating Disorders

Seda Ebrahimi Ph.D.Founder and Director of the Cambridge Eating Disorder Center Instructor, Department of Psychiatry, Harvard University

+THE PREVALENCE OF EATING DISORDERS

An estimated 8 million Americans suffer from eating disorders 7 Million Women 1 Million Men

1 in 200 women in America suffer from anorexia

2-3% of American women suffer from bulimia

Nearly 50% of all Americans know someone suffering from an Eating Disorder

10-15% of those suffering from anorexia or bulimia are males

+CHILDREN AND EATING DISORDERS

42% of third grade girls wish to be thinner

50% of 11-13 girls view themselves as “overweight”

Obesity rates have tripled in children ages 2-19 since the 1980s32% are overweight17% are obese

Caucasian:10% boys, 15% girlsAfrican American: 17% boys, 23% girlsHispanic: 24% boys, 17% girls

+DIFFERENT TYPES OF EATING

DISORDERSAnorexia Nervosa

Restricting typeBinging/Purging Type

Bulimia Nervosa

Binge Eating disorder

Other Specified Feeding or Eating Disorder

Unspecified Feeding or Eating Disorder

+ANOREXIA NERVOSA Persistent restriction of energy intake leading to

significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health) .

Either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain (even though significantly low weight).

Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

Subtypes: Restricting type Binge-eating/purging type

+ANOREXIA NERVOSA(CONTINUED)

Specify if: In partial remission: After full criteria of anorexia nervosa were

previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B or Criterion C is still met. In full remission: After full criteria of anorexia nervosa were previously met,none of the criteria have been met for a sustained period of time.

Specify current severity: The minimum level of severity is based, for adults, on current body

mass index (BMI) (see below) or, for children and adolescents, on BMI percentile.

The ranges below are derived from World Health Organization categoriesfor thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased toreflect clinical symptoms, the degree of functional disability, and the need for supervision.

Mild: BMI > 17 kg/m2 Moderate: BMI 16-16.99 kg/m2 Severe: BMI 15-15.99 kg/m2 Extreme: BMI < 15 kg/m2

+ANOREXIA NERVOSA WARNING SIGNS Low Weight

Avoidance of Food

Food rituals

Excessive/compulsive exercise

Body checking

Body distortion and dissatisfaction

Calorie counting

Obsessional weighing

If binging eating/purging: Laxative or diuretic ues Diet pills Binge eating Self induced vomitting

+BULIMIA NERVOSA

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g. within any 2-hour period), 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 over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

+BULIMIA NERVOSA WARNING SIGNS Cognitive distortions and irrational beliefs around, weight

and appearance

Body image distortions

Body loathing

May have food rituals

Hiding or sneaking food

Discomfort/avoidance of eating in public

Obsessive weighing

Body checking

Frequent/Compulsive exercise

Dieting/calorie counting

+BINGE EATING DISORDER (BED) Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following: Eating, in a discrete period of time (e.g. within any 2-hour period), 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 over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

The binge eating episodes are associated with three 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 feeling embarrassed by how much one is eating feeling disgusted with oneself, depressed or very guilty afterward

Marked distress regarding binge eating is present

Binge eating occurs, on average, at least once a week for three months

Binge eating not associated with the recurrent use of inappropriate compensatory behaviours as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa, or Anorexia Nervosa methods to compensate for overeating, such as self-induced vomiting.

+Other Specified Feeding or Eating Disorder (OSFED) A diagnosis might then be allocated that specifies a specific reason why the

presentation does not meet the specifics of another disorder (e.g. Bulimia Nervosa- low frequency). The following are further examples for OSFED:

Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.

Binge Eating Disorder (of low frequency and/or limited duration): All of the criteria for BED are met, except at a lower frequency and/or for less than three months.

Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behavior occurs at a lower frequency and/or for less than three months.

Purging Disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating

Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. BED).

+COMMON EATING DISORDER WARNING SIGNS

Preoccupations with body or weight

Obsession with calories, food or nutrition

Constant dieting even when thin

Rapid unexplained weight loss or weight gain

Taking laxatives or diet pills

Compulsive exercising

Making excuses to get out of eating

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Avoiding social situations involving food

Going to the bathroom right after meals

Eating alone, at night or in secret

Hoarding high-calorie food

Fainting

Wearing many layers of clothing

Redness on backs of hands

Chipmunk cheeks

Dental problems

COMMON EATING DISORDER WARNING SIGNS (CONTINUED)

+RECURRING WARNING SIGNS Excessive talk of exercise

Lots of “food/diet talk”

“Fat Talk”

Negative body image

Low self-esteem

Self-deprecating

Complaints of constipation (laxative use)

Amenorrhea/menstrual irregularity

+MEDICAL COMPLICATIONS

Fatigue

Weakness

Sleep disturbances

Dizziness/fainting

Chest pain

Osteoporosis/Osteoperia

Amenorrhea

Cold Intolerance

Brittle hair/nails

Abdominal pain

Constipation/diarrhea

Hair loss

Anemia

Brady Cardia

Hypotension

Hypothermia

Chest pain

Edema

Amenorrhea

Swollen Parotid Glands

Dental Erosions

Knuckle scarring

Electrolyte imbalance

Sore Throat

+Common Comorbidities

Depression

Generalized Anxiety

Social Anxiety

OCD

Alcohol/substance abuse

Borderline Personality Disorder

Trauma History

Self-harming behaviors

+Multidisciplinary Treatment Team Approach

Medical Stability

Medication Management

Nutritional Rehabilitation

Psychotherapy

+Eating Disorders and Nutrition

Normalization of eating

Weight Restoration

Re-feeding Issues

Activity Level

+Goals of Treatment

Restoration of weight

Normalization of eating

Significant changes in thoughts and behaviors

Relapse prevention

+Behavioral warning signs Focus on low-fat or “heathy foods”

Diet drinks Energy bars Supplements

Counting calories and grams of fat Becoming vegetarian/vegan Fasting Obsessive thinking about food Skipping meals/refusal to eat Avoiding food in social situations Wearing oversized clothing Complaining of food allergies Excessive exercise Reading fitness/health magazines Checking weight several times daily Body checking Spending excessive amounts of time in front of the mirror

+Psychological Signs of at-risk Individuals Perfectionism

Competitiveness

Overly responsible

Critical of self/others

Conformity

Approval seeking

Low self-esteem

Mood swings

Rigid “black and white” thinking

Difficulty expressing emotions

Complaining of “feeling fat”

+SOCIAL SIGNS OF AN AT RISK INDIVIDUAL

Isolation

Avoidance of social/recreational activiesDieting scheduleExercise regimen

+HOW TO ADDRESS AN AT-RISK INDIVIDUAL

Early intervention is crucial to recovery

Show support and concern

Express empathy and understanding

Be truthful in addressing denial and resistance

Be aware of local resources and make appropriate referrals for assessment and treatment

+TREATMENT Creating the Treatment Team

Building the Treatment Contract

Psycho-education

Building trust and rapport

Different Therapeutic Methods Cognitive Behavioral Therapy (CBT) Dialectical Behavior Therapy (DBT) Family-Based Treatment (FBT/Maudsley

Method) Psychodynamic Therapy

+TREATMENT LEVELS OF CARE

Outpatient

Intensive Outpatient

Partial Hospitalization (Day Treatment)

Transitional Living

Residential

Inpatient (Acute Hospitalization)

+CRITERIA FOR INPATIENT TREATMENT Low weight (severity, rapidity)

Alterations in vital signs (postural hypotension, Bradycardia)

Low Serum Potassium level (fatal arrhythmia)

Low Mood (Suicidal thoughts or intents)

Presence of Formal Thought Disorder

Presence and severity of associated Impulsivity Control Problems (e.g. sexual promiscuity, shoplifting, financial difficulties, alcohol/drug abuse, self injurious behaviors)

Level of disruption to daily functions Job difficulties/loss of job Withdrawal from school Isolation

Failure of outpatient treatment

+Treatment Contract Certain amount of weight loss leading to higher

level of care

Not gaining weight leading to a higher level of care

Frequency of weight checks, blood work, etc.

Activity level specifications

Frequency of binge/purge may require a higher level of care

One person is identified as the leader of the team; generally the individual therapist

Splitting can be a major problem Frequent communication is a must

+ TREATMENT AT CAMBRIDGE EATING DISORDER CENTER

Specialized Multidisciplinary Eating Disorder Treatment Including: Individual therapy Family therapy Group therapy Nutritional Support/education CBT/DBT/FBT Medication management Expressive arts therapy Yoga

Levels of Care include: Residential Partial Hospitalization Intensive Outpatient Outpatient Transitional Living

Teaching Facility: Harvard University Psychiatry Massachusetts General Hospital

+Seda Ebrahimi

Director, Cambridge Eating Disorder CenterCambridge Eating Disorder Center (CEDC)3 Bow Street | Cambridge, MA 02138

617-547-2255 ext. 222seda@cedcmail.com

www.eatingdisordercenter.org

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Questions?