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Amy B. Middleman, MD, MSEd, MPH
Professor of Pediatrics, Chief - Section of Adolescent Medicine
University of Oklahoma Health Sciences Center
Oklahoma City, OK
I serve as a section editor for UpToDate.com.
the DSM 5 diagnostic criteria of the major eating disorders
current treatment strategies for eating disorders
how to determine if a patient has an eating
disorder
At the end of this session, learners will understand:
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Restriction of energy intake relative to requirements, leading to a significantly low body weight (less than minimally normal or expected) in the context of age, sex, developmental trajectory, and physical health
Intense fear of gaining weight or becoming fat, or behavior that interferes with weight gain, even though less than minimally expected
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of weight/shape on self-evaluation, or lack of recognition of the seriousness of low body weight
DSM V
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Subtypes:
◦ Restricting type
◦ Binge-eating/purging type
Specify:
◦ Partial Remission
◦ Full remission
Severity:
◦ Mild – BMI > 17 kg/m2
◦ Moderate – BMI 16-16.99 kg/m2
◦ Severe – BMI 15-15.99 kg/m2
◦ Extreme – BMI < 15 kg/m2
Recurrent episodes of binge eating (amount;control)
Recurrent inappropriate compensatory behavior to prevent weight gain
Both binge eating/purging behaviors occur, on average, at least ONCE a week for 3 months
Self-evaluation is unduly influenced by body shape/weight
The disturbance does not occur exclusively during episodes of anorexia nervosa
Specify: ◦ Partial Remission
◦ Full remission
Severity: ◦ Mild – An average of 1-3 episodes/week
◦ Moderate – An average of 4-7 episodes/week
◦ Severe – An average of 8-13 episodes/week
◦ Extreme – An average of 14 or more episodes/week
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Recurrent episodes of binge-eating (~1x/wk;3 mo)
Binges must have 3 of 5 criteria: ◦ Eating more rapidly than normal
◦ Eating until uncomfortably full
◦ Eating large amounts when not hungry
◦ Eating alone because of embarrassment
◦ Feeling disgusted, depressed or guilty afterward
Marked distress recurrent binge eating is present
No inappropriate compensatory behavior; no diagnosis of AN or BN
Specify: ◦ Partial remission
◦ Full remission
Severity: ◦ Mild – An average of 1-3 binge episodes/week
◦ Moderate – An average of 4-7 binge episodes/week
◦ Severe – An average of 8-13 binge episodes/week
◦ Extreme – An average of 14 or more binge
episodes/week
Eating/feeding disturbance (e.g. lack of interest in food, avoidance based on sensory characteristics of food, concern for aversive consequences to eating) manifested as failure to meet appropriate nutritional needs
Not better explained by lack of food, cultural practice
Does not occur in context of AN or BN – no evidence of body image disturbance
Not attributable to another medical/mental health condition
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Disordered eating behaviors that do not meet the more strict criteria of a specific eating disorder.
Based on DSM IV Criteria Adult Females *AN – .9% BN – 1.5% BED – 3.5% Adult Males *AN - .3% BN - .5% BED – 2.0%
Hudson JI. Biol Psychiatry. 61:348-58, 2007.
*Estimates likely doubled for DSM 5 AN diagnosis
Puberty represents change that challenges rigidity,
exacerbates serotonin dysregulation
Reduced dietary intake modulates serotonin and
alleviates dysphoric mood
Malnutrition and weight loss, however,
exaggerates dysphoric mood
Functional MRIs implicate interaction of pathways
regulating appetite and emotion
Genetics - twin studies suggest 50-80% genetic
contribution to liability – similar to bipolar
Kaye W. Physiology and Behavior. 2008;94:121-135
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Attempting control at time of change
Separation and individuation
Identity formation: disorder defines self
Family/social dysfunction or stressors
Pressure to achieve
Conducted by Ancel Keys from 1944-1945
36 healthy, male volunteers
University of Minnesota – subjects lived in dorms
Experiment ◦ Control period – 12 weeks
◦ Starvation period – 24 weeks – 1570 calories on avg
◦ Rehabilitation period – 12 weeks
Psychological effects of starvation
Depression
Irritability
Preoccupation with food
Social introversion
Decreased libido
Decreased attention and problem solving (cognitive slowing)
Physical effects of starvation
Post-starvation hyperphagia
Abundant calories required for recovery
With recovery, preferential fat to the abdominal region/triceps
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PATIENT PRESENTATION
Susan is an 18 year old female with a history of obesity as a child here now for cold intolerance and a low heart rate noted by her pediatrician. Patient was overweight as a child. Her highest weight was 260 pounds by age 12 years. Her lowest weight was 130 pounds last month. Over the past several years, Susan has lost weight by becoming a vegetarian and exercising.
Susan recently started college. She counts calories and eats approximately 2700 calories per day. She exercises daily at her gym for two hours and runs 4 miles per day. Recently, she was asked not to return to her gym.
She denies laxatives, diet pills, diuretics, Ipecac, vomiting. Her last menstrual period was 9 months prior to the visit.
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Susan had a fear of becoming obese again.
She was experiencing increased weakness, cold intolerance, constipation, occasional chest pain, hair loss. She denied muscle cramps, growth delay, syncope.
Susan was stretching during the interview. When asked, she indicated she thinks about food or weight 90% of her waking hours.
Hair loss
Abdominal pain
Constipation
Weakness and fainting
Coarse, yellow skin
Short stature and/or delayed puberty
Muscle cramps
Chest pain
Moodiness and irritability
Low self-esteem
Perfectionism
Social withdrawal and intolerance of others
Overly sensitive to criticism
Extreme concern about appearance
Change in food choices; vegetarianism
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Do you think you are too thin, too heavy, or just right?
Have you had difficulty maintaining your weight recently?
Have you ever felt you had to vomit or diet to keep your weight stable? Recent dietary changes?
Have you ever used laxatives, diuretics, diet pills or Ipecac?
Do you drink a lot of caffeine?
Do you smoke cigarettes?
How often/for how long do you exercise? (remember to ask about night-time exercise)
When was your last menstrual period?
Have your periods been irregular?
Are you cold when others in the room seem comfortable?
Have you had any bone fractures?
Patient appears jittery and nervous
HR – 33 beats per minute
BP – 90/60
Temperature – 96.7 degrees F
Lying/Standing – 33 bpm/42 bpm; 90/50 lying and 90/55 standing
UA – no abnormalities
Urine pregnancy test - negative
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Renal effect/fluids and electrolytes
Cardiovascular
Gastrointestinal
Endocrine
Reproductive
Hematologic
Skeletal*
Dermatologic
Neurologic*
* potentially irreversible effects
Golden NH. JAH, 2015;56:370.
Multiple studies have revealed no improvement in
bone with use of combination hormone pills
High estrogen dose in OCPs suppresses IGF-1,
a bone trophic hormone
Use of patch (100 µg 17β-estradiol patch twice
weekly with cyclic progesterone) or physiologic
doses of estrogen (for those with BA<15 years)
preserve bone
Misra M et al. JBMR 2011;26:2430-38.
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Chui HT. Pediatrics. 2008;122:e426-e437.
Additional Advantages to Estrogen Replacement
Performance on the WJ-III according to menstrual function. aP < .05 compared with control subjects; bP< .01 compared with control subjects; cP < .05 compared with irregular or absent menses AN.
Eating Disorder
Inflammatory bowel disease
Achalasia
Celiac disease
Primary endocrine disorder
Diabetes mellitus
Addison’s disease
Depression or other psychiatric disease
Malignancy including CNS tumor
Pregnancy
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An interdisciplinary team approach is ideal
Medical care by providers trained in eating disorders
Nutritional support
Psychological treatment with age appropriate family support
Teamwork and alliance with family prevents the patient’s disorder from dictating treatment
Treatment takes many months to years
Focus on health – not weight
When patient stable, more autonomy and choice can be therapeutic and developmentally appropriate
Treatment approach from all team members including family must be consistently supportive versus punitive/shaming
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Severe malnutrition –less than 75% median body mass index for age and sex
Dehydration or electrolyte imbalance
Cardiac arrhythmias; EKG abnormalities
Physiologic instability severe bradycardia hypotension (<90/45 mm Hg) hypothermia (<96 F) severe orthostatic changes
Arrested growth and development
Failure of outpatient treatment (three visits)
Acute food refusal
Uncontrolled binge eating and purging
Acute complications of malnutrition (syncope,
seizures, pancreatitis, etc.)
Acute psychiatric emergencies
Very little data pertaining to adolescents
Fluoxetine most commonly studied:
◦ No effect on eating behaviors or weight maintenance for AN; use for antecedent depression/anxiety/OCD+
or after weight restoration
◦ Decreases vomiting/binge-eating behaviors for BN
60 mg per day produced greater effects than 20 mg per day, especially among those with depression*
American Psychiatric Association: medications are not recommended as sole or primary treatment for eating disorders
+Couturier J et al. J Can Acad Child Adolesc Psychiatry. 2007;16:173-176.
*Goldstein DJ et al. Int J Eat Disord. 1999;25:19-27.
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Challenges rigid, distorted thoughts about food
and body image; does not investigate the “why”
Psychoeducation that challenges ED thinking
comes from all team members
Ego-syntonic nature of AN can make CBT difficult
CBT is the treatment of choice for BN
With progress, focus moves beyond food and
weight
Dialectical behavior therapy – teaches skills to replace maladaptive coping (Federici A. Int J Eating Disorders. 2013)
Acceptance and commitment therapy (ACT) – focus on mindfulness work, experiential avoidance
Interpersonal therapy – investigates how relationships may be causing/maintaining ED (Fairburn C, APA Press. 1993)
Psychodynamic therapy – creates insight into later effects of earlier experiences/relationships
Supportive psychotherapy – seeks resolution of underlying issues
More data are needed; only 2 RCT with adolescent EDs
“Th
ird W
ave”
CB
T
Family-based therapy (FBT) is increasingly popular (“Maudsley Method”) for AN
Maudsley Model = Intense family involvement
◦ Phase 1 – weight gain through refeeding with high family involvement (rewards system) ◦ Phase 2 – transfer control back to patient ◦ Phase 3 – individual therapy for the patient
Most FBT is not truly Maudsley; Maudsley has no interdisciplinary team
Varchol L et al. Curr Opin Pediatr. 2009;21:457-464.
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Most effective for younger patients with
shorter duration of illness
Variations in method yield similar results;
parental involvement may be key element
Smith A, Cook-Cottone C. J Clin Psychol Med Settings 2011;18:323-34.
OU Disordered Eating Program
In-hospital treatment
◦ Individual and family (CBT structural, communication-
based) therapy
◦ Daily medical visits; dietitian daily, then as needed
◦ Physical therapy; child life
◦ Daily interdisciplinary team consultation
Discharge to timely outpatient follow-up
◦ Same medical doctor
◦ Same individual therapist
◦ Same family therapist
◦ Weekly interdisciplinary team meeting
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OUTPATIENT TREATMENT
The patient is expected to:
Gain weight (as appropriate)
Eat three balanced meals per day
Decrease frequency of disordered behaviors
including: vomiting, hyperexercise, diet pill or
laxative use, diuretic use, restriction
Work toward therapy goals including improved
communication and coping strategies
Weigh after voiding (look at SG), in a gown only,
no hair accessories or jewelry
Remaining vital signs after lying for 3 minutes;
again after standing for 5 minutes
Screen for 24 diet history, exercise history, eating
behavior history (binge/purge), related symptoms
(dizziness, fatigue, chest pain, palpitations)
Assess mood
Patients followed as needed
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INPATIENT TREATMENT (primarily for malnutrition)
The patient is expected to:
Achieve 85% MEBW/MEBMI
Maintain stable vital signs with a resting heart rate
of at least 50 beats per minute
Eat three unobserved meals per day and continue
to make progress
Desist from disordered eating behaviors
Establish and begin work on individual and family
therapy goals to support patient as an outpatient
Video monitoring/bathroom restrictions initially and as needed
Bedrest as needed
Point system (nutritional intake)
Behavioral plan (includes use of cells, computers, off-the-floor privileges)
Individual therapy at least 3x per week
Family therapy at least 1x per week
Physical therapy daily
Child life daily
Chaplain services on request
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No IVs unless specified
Weights in gown only, no hair accessories or jewelry, post-void and pre-breakfast
Specific gravity checked qAM
Provide nutrition orally; meals and post-meal time observed
Avoid NG or parenteral feeding when possible (psychological/medical complications)
Reintroduction of carbohydrate releases insulin
Phosphorus, potassium, magnesium shift to intracellular space; fluid imbalance
Neutra-Phos-K; labs qOD for 8 days
Multivitamin provides any needed thiamine
New data – safe to refeed more quickly than in the past
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Start out low and move slowly!
Start with approximately 30-40 kcal/kg
(1000-1600 cal/day)
Increase calories by approximately 200
calories every 1-2 days
Goal = 2-3 pound gain/wk in the hospital;
1 pound gain/wk as an outpatient
35 subjects; mean age – 16.2 yrs
Controlled environment
Calories increased from 1205 to 2668 per refeeding guidelines
83% of subjects initially lost weight (Minnesota)
Higher calories assigned at presentation associated with:
◦ Faster weight gain
◦ Shorter length of stay
Garber et al. JAH 2012;50:24-29.
1-year retrospective review – 46 admissions
Mean age – 15.7 yr; %MBW – 72.9%
61% of admissions started on 1900 kcal/d
28% started on 2200 kcal/day
Intake increased to 2700 kcal/d by day 5; up 300 cal/d thereafter as needed
No patient developed moderate or severe hypophosphatemia (HP); 38% mild HP
Whitelaw M et al. JAH 2010;46:577-82.
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Benefits of moving more quickly are not clear
◦ Biologically (e.g., fat distribution)
◦ Psychologically (e.g., increased stress of rapid change,
decreased patient autonomy versus improved cognition)
Refeeding quickly requires greater monitoring;
some suggest lower carbs/continuous NG to
obviate insulin shifts and decrease risk
Requires study incorporating psychological
consequences
212 patients hospitalized with AN in Europe
Variables on logistic regression independently
associated with BMI>17.5 at follow-up (~8 yr)
were:
◦ Pre-morbid BMI – OR=1.31, p=0.02
◦ BMI at first discharge – OR=1.39, p=0.04
◦ Age at admission – OR=0.70, p=0.02
Keep patients until 85% MBW
◦ Repeat hospitalization rates 13% at TCH (Houston)
◦ Repeat hospitalization rates in literature 45%
(European data; patient stays shorter)
Unpublished data for TCH; Steinhausen et al. Int J Eat Disord 2008;41:29-36.
Steinhausen et al. Int J Eat Disord 2009;42:19-25.
Fourteen adolescent medicine academic disordered eating programs
1 year follow-up of 700 patients ◦ 54% AN
◦ 34% atypical AN
◦ 12% ARFID
Higher intake %MBMI predicted weight recovery (no psychological parameters studied) ◦ Atypical AN>AN>ARFID odds of weight recovery
No treatment strategy significantly associated with higher odds of weight recovery (FBT approached significance)
Forman S et al. JAH 2014; 55:750
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Meta-analysis 1920-80 (not adolescent-specific) – mortality is 0.56% per year
10-fold increase in mortality compared to age-matched controls; 6-fold increase overall (approx 2-fold for BN/BED)
Cause of death:
◦ Complications of the AN – 54% ◦ Suicide – 27%
Prognosis is good; specific data sparse; approximately 70% recovery rate.
Sullivan PF. Am J Psychiatry. 1995;153:1073.
Smink F. Curr Psych Rep. 2012; 14:406.
Eating disorders are primarily psychological diseases with relatively high mortality rates
An interdisciplinary team approach is ideal
Medical complications require inpatient stay with follow-up outpatient care
Data are sparse regarding optimal inpatient and outpatient protocols for care; data collection is ongoing
The goal is to determine best practices to help patients achieve emotional and physical health as quickly as possible
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Golden NH, Katzman D, et al. Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults. J Adol Health 2015; 56:121.
Misra M, Katzman D, et al. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. JBMR 2011; 26:2430-38.
Kaye W. Neurobiology of anorexia and bulimia nervosa. Physiology and Behavior 2008; 94:121-135.
Attia E, Walsh BT. Behavioral management for anorexia nervosa. NEJM 2009; 360:500-506.
Kohn MR, Madden S, Clarke SD. Refeeding in anorexia nervosa: increased safety and efficiency through understanding the pathophysiology of protein calorie malnutrition. Curr Opin Pediatr 2011;23:390-94.
Smith A, Cook-Cottone C. A review of family therapy as an effective intervention for anorexia nervosa in adolescents. J Clin Psychol Med Settings 2011;18:323-34.
Strober M, Johnson C. The need for complex ideas in anorexia nervosa…Int J Eat Disord 2012;45:155-78.
