Eating Disorders21 November 2013
Krissy Schwerin, MDChild and Adolescent PsychiatristCanterbury District Health BoardSouth Island Eating Disorders ServiceChild Adolescent & Family Rural Service
Overview
Anorexia Nervosa (AN) Bulemia Nervosa (BN) Binge Eating disorder (BED) Unspecified Feeding or Eating Disorder (UFED) Other Eating/Feeding problems
Diagnosis Epidemiology Medical risks Etiology Treatment Prognosis
Misconceptions
Myth: White, upper-middle class females in metropolitan areas of the western world
Eating disorders are increasing in prevalence in males, younger children, older adults, and other ethnic groups.
Our field needs to do a better job screening and treating…
Case Vignette #1 - CarlaCarla is a 13 year-old female who presented to
the ER with a grand-mal seizure from hyponatremia. She had been binging on water in order to fend off hunger. Carla had always been a happy child and great student, but had recently become obsessed with her schoolwork and isolated from her friends and close-knit family.
Carla began losing weight after her PMD told her she was overweight. This coincided with a family trip to parents’ country of origin where Carla didn’t like the food. She lost >40 pounds and stopped getting her period
Anorexia Nervosa (AN) - DSM V- Persistent restriction of energy intake leading low
weight (lower than minimally expected for age/sex)- Intense fear of gaining weight or becoming fat, or
behaviour that interferes with weight gain- Disturbance in body image, undue influence of
shape/weight on self-evaluation, lack of recognition of seriousness of low body weight
- Restricting sub-type- Binge-eating/purging sub-type
**DSM-IV: 1. “refusal” to maintain weight 2. <85 percentile weight 3. amnorrhea was required
Anorexia Nervosa: chief complaint…- Family or school is concerned about eating
habits or personality change- Physical symptoms- Other psychological concerns – depression,
anxiety, obsessive- “unintentional” weight loss- Amenorrhea
- Patient: “I’m fine!”
Anorexia Nervosa:Risk Factors, Precipitating Factors, & Traits
Perfectionism Early Puberty Failed attempts to lose weight Antecedent illness with weight loss Athletics Beginning a diet Family history of eating disorder Life/family stressors
Anorexia Nervosa: Epidemiology
Lifetime prevalence 0.5-1% Females:Males 10:1 Usually arises during adolescence or
young adulthood Increased risk in 1st degree biological
relatives with AN 1/3 will develop bulimia nervosa Long-term mortality 10-20%
Physical Risks Death (suicide, starvation, sudden cardiac death) Hypometabolic state (bradycardia, hypotension, hypothermia) Orthostasis Dehydration Arrhythmia, heart failure, liver failure Bone marrow suppression Malnourishment Bone loss Lanugo Peripheral edema Stunted growth Delayed sexual maturity Hair loss, brittle hair Cognitive impairment Water intoxication Re-feeding syndrome
Neurological Effects
• Cerebral Atrophy• Associated with
weight loss but not necessarily with lowest BMI
• May improve but do not necessarily return to normal
Katzman D et al, Journal of Pediatrics 1996
Anorexia Nervosa: Medical Workup
- Vitals (w/ temperature)- ECG (look for long QTc)- Lytes, CBC, LFTs, ESR, TFTs, CK- β-HCG, LH, FSH, prolactin, estradiol if indicated- Bone density
(don’t be fooled by normal bloods!!!)
Etiology
From Silber et.al.
Anorexia Nervosa: Treatment Determine level of care
Inpatient medical stabilization Inpatient eating disorders service Outpatient treatment
1st: weight restoration 2nd: psychological 3rd: maintenance (long-term)
Multidisciplinary Team Approach! (psychiatrist, PCP, nurse, psychologist, family therapist, social worker, occupational therapist, dietician)
Considering Medical Admission
<75% ideal body weight Hypothermia T<35.5 C Bradycardia HR<50 (peds) or HR <40 (adults) Orthostasis-drop in sbp >10, increase in HR>35 Dehydration Potassium < 2.5 or other electrolyte abnormality Acute medical complication Delirium Re-feeding syndrome Severe depression/suicidality– psychiatric admit
Anorexia Nervosa: Treatment
No evidence-based psychotherapy for Anorexia Nervosa in adults!
No evidence-based pharmacologic treatments in any age!
Psychological Treatments:Adolescents with AN
Family Based Treatment (FBT) (aka “Maudsley Approach”) no-blame approach, family did not cause anorexia family is the best resource to help her/him get better Empower parents to get the young person to eat in order to save
his/her life: “intense scene” Align siblings with the patient for support “Externalize” the anorexia Family Meal (Session #2) Focus on weight restoration first then explore the family dynamics and psychological issues that
may get in the way of maintaining weight
Psychological Treatments:Adults with ANNone are “evidence-based”We use…Motivational InterviewingCognitive Behavioural Therapy (CBT)Supportive PsychotherapyMetacognitive TherapyCouples or Family Therapy, or family involvementPsychodynamic Therapy Interpersonal Therapy (IPT)Group Therapy
Anorexia Nervosa: Medications No approved medication treatments for Anorexia
Nervosa
Fluoxetine (or other SSRI) for co-morbid depression or anxiety
Growing evidence for low-dose atypical antipsychotics (Olanzapine) for obsessive ruminations and possibly weight gain (still off-label)
Re-feeding Syndrome Metabolic abnormalities as a result of reinstating
nutrition to patients who are malnourished Potentially fatal Low phosphate Edema Tachycardia Hypoglycemia (hyperinsulinemic response) Treatment
admit replace phosphate higher protein: carbohydrate ratio
Anorexia Nervosa: Prognosis
1/3 recover 1/3 continue with milder course 1/3 chronic severe
Young age of onset, short time since onset of illness: very good prognosis
>7 years of illness, very unlikely recovery (but not zero!!!)
Case Vignette #2: KatieKatie is a 20 year-old University student who had been in
therapy for anxiety, self-harm, and a prior trauma that occurred in early adolescence. One session Katie revealed to her therapist that she had an embarrassing secret that she wanted to disclose. She had been bingeing and purging multiple time per week throughout the course of treatment. For years she had gone to great lengths to hide this from roomates/family, going to extents of hiding bags of vomit in the outside rubbish. She finally decided to tell her therapist and ask for help, because after years of being under 130 pounds, her weight has now increased to 134 pounds and she thinks her body is “disgusting”. Current BMI is 22.
Bulemia Nervosa (BN)– DSM V Recurrent episodes of binge eating (eating larger
amounts of food than others would eat in a discrete- 2 hour- period of time, with a sense of lack of control)
recurrent episodes of compensatory behavior (vomiting, laxatives, diuretics, excessive exercise)
Both occur at least 1x/week for 3 months Self-evaluation is unduly influenced by body shape or
weight Does not occur exclusively during episodes of Anorexia
Nervosa
**DSM-IV: compensatory episodes had to be 2x/week
Bulemia Nervosa: Risk Factors, Precipitating Factors, & Traits
Often normal weight or overweight (easy to forget to screen for eating disorders!)
Shame and guilt History of sexual abuse not uncommon Impulsivity, risk-taking behaviours Depression/anxiety, emotional dysregulation, self-harm Less denial compared to AN, but may go to great lengths
to keep symptoms secret
Bulemia Nervosa: Epidemiology Lifetime Prevalence
1.5% women 0.5% men
Prevalence of binge-purge behaviors: 13% girls 7% boys
Slightly older average age of onset compared to Anorexia Nervosa
Purging extremely rare in children
Bulemia: Etiology
Multifactorial!!!
Media factors
genetic
Individual Temperament(ie. impulsive)
biological
Family dynamics
Societal, cultural
Medical Risks Electrolyte abnormalities (hypokalemia, ketosis) Dental – loss of enamel, chipped teeth, cavities Parotid hypertrophy Conjunctival hemorrhages Calluses on dorsal side of hand (Russell’s sign) Esophagitis, Mallory-weiss tears, Barrett esophagus hematemesis Latxative-dependent: cathartic colon, melena, rectal
prolapse Elevated CK or other injuries (over-exercising) Poor nutrition (if severe purging) Edema upon cessation of purging
Bulemia Nervosa: Treatment Again, multidisciplinary team!!! Adults:
Best evidence: Cognitive Behavioural Therapy (CBT) + Antidepressant (SSRI)
Adolescents Evidence for adolescents is sparse; we extrapolate
from the evidence for adult treatment CBT + SSRI or Family-Based Treatment (FBT) modified for BN
(good evidence, but not as good as for AN)
Bulemia Nervosa: CBT or DBT Best evidence is for CBT or DBT (good outcomes, but
outcomes are short-term) Cognitive Behavioral Therapy (CBT)
Thought Challenging: “I will gain weight if I eat normal amounts of food.” Break the cycle of: “dieting” -> feel hungry/deprived -> binge -> guilt -> purge
Dialectical Behavioral Therapy (DBT)Chain analysis, mindfulness, emotion-regulation skills
Felt angryCalled friend, She was too Busy to talk
Felt lonely BingeFight with mom
thought
feeling behavior
Bulemia: Other Therapies Family Therapy and/or family involvement Interpersonal therapy (IPT) (short-term
treatment focused on life transitions) Psychodynamic Psychotherapy (good for
long-term results in people with chronic depressive and personality symptoms)
Psychotherapy for comorbidities
Bulemia Nervosa: Medications High-dose Fluoxetine (SSRI) – very good
evidence! Sertraline (SSRI) – some good evidence Topiramate (mood stabalizer, promotes weight
loss) – some good evidence, but use with caution especially if low-weight
Remember: Buproprion (other antidepressant) is contraindicated! (risk of seizures if history of purging)
Bulemia: Prognosis
33% remit every year But another 33% relapse into full criteria Adolescent-onset better prognosis than
adult-onset Death-rate = 1%
Case Vignette #3 - LauraLaura is a 47 year-old divorced female in treatment for
depression. She has suffered from morbid obesity ever since she stopped using cocaine 13 years ago. When Laura’s teenage son (who is involved in an inner-city gang) does not come home on time, or when she feels empty and lonely about not having a romantic relationship, she eats excessive amounts of food, despite her mindset and efforts throughout the rest of the day to watch her diet. Laura visits multiple different fast-food restaurants in succession and in neighborhoods far from home, so that this behavior will not get noticed by others. Laura one of 7 siblings. She is always identified as the “strong” one in the family who will take care of others who are ailing.
Binge Eating Disorder (BED) – DSM V Recurrent episodes of binge eating
Eating definitely more than most people would eat in discrete 2-hour period of time
Sense of lack of control during the episode Three or more of the following:
Eating much more rapidly than normal Eating until uncomfortably full Eating large amounts when not physically hungry Eating alone because embarrassed by how much eating Feeling disgusted, depressed, or guilty afterwards
Marked distress regarding binge eating On average at least once a week for 3 months No compensatory behaviours such as in bulemia nervosa
**DSM IV: Binge-eating disorder was only in the appendix, frequency of binge episodes was >2x/week
Binge Eating Disorder vs. Obesity
Binge Eating Disorder: may be overweight, but not required for diagnosis
Binge Eating Disorder: more subjective distress about episodes of over-eating compared to obese non-BED
Binge Eating Disorder:Epidemiology Most common eating disorder Lifetime prevalence:
3.5% women2% men
Binge Eating Disorder: Etiology
Multifactorial!!!
Media factors
genetic
Individual Temperament(ie. impulsive)
biological
Family dynamics
Societal, cultural
Binge Eating Disorder:Treatment (Medication) SSRI
high dose reduces binge behavior short-term but doesn’t help weight loss
Topiramate, Zonisamide (anticonvulsants, mild mood stabalizer) Helps binge reduction Helps weight loss Caution for adverse effects, high discontinuation rates
Binge Eating Disorder:Treatment (Therapy) Therapies either prioritize…
Weight loss Binge-reduction Neither (ie. relationships, depression etc)
Group psychotherapy There is little evidence that obese individuals
who binge should receive different therapy than obese individuals who do not binge
Binge Eating Disorder:Psychosocial Support
Family may need help with co-dependency Attachment approach, particularly with youth
Weight loss programs 12-step self-help groups (addressing the
problem as an addiction) Food Addicts in Recovery Anonymous
Case Vignette #4: AlisaAlisa is an 8 year-old girl who was admitted to the hospital
for malnutrition. She had stopped eating due to a subjective sense of stomach pain every time she ate. Nasogastric feedings were initiated, and Alisa underwent a complete GI workup which was negative for a medical cause for her pain. Her parents had difficulty accepting that there may be a psychological component to her illness. Parents were divorced, with a high level of post-divorce conflict. Alisa’s older brother had low-functioning Autistic Spectrum Disorder with behavior/aggression problems, and the family were always impressed with Alisa’s resilience. Alisa denied body image distortion or desire for weight loss.
Other Eating/Feeding DisordersDSM V Pica- eating non-nutritive substances Rumination Disorder- chewing/spitting,
re-chewing, regurgitating Avoidant/Restrictive Food Intake
Disorder- failure to meet energy/nutritive needs, dependence on enteral feeding or supplements
Unspecified Feeding or Eating Disorder (UFED) Formerly Eating Disorder NOS (EDNOS)
Clinically significant distress/impairment but do not meet criteria for other eating disorders
May be used when not enough clinical information (ie. emergency room settings)
Atypical presentations
** Overall changes in eating disorders are meant to limit the use of this “unspecified” category, which was too large in DSM-IV. (ED-NOS was more common than AN or BN, and actually represented a very “sick” group.)
Other Feeding Problems in Infancy/Childhood (non-DSM) Selective Eating Food Phobias Pervasive Food Refusal Food Avoidance Emotional Disorder
Eating Disorders: Take Home Points Great need for provider-awareness (both in mental
health and non-mental health) Very medically risky!!! Need intense psychological AND
medical management! Multifactorial etiology Multidisciplinary treatment approach Involve the family in treatment whenever you can Young patient with new AN cannot afford to wait for FBT Prevalent in teens, but much less research to guide us in
their treatment Little evidence for medications in EDs: this is why
psychiatrists need to be more than med-managers!
References Hay et.al. “Psychological Treatments for Bulemia Nervosa and
Bingeing” The Cochrane Library 2010 Lock, J., “Evaluation of Family Treatment Models for Eating
Disorders” Current Opinion in Psychiatry 2011 Lock & LeGrange Treatment Manual for Anorexia Nervosa, Second
Edition 2013 Rosen et.al. “Identification and Management of Eating Disorders in
Children and Adolescents” Pediatrics 2010 Treasure et.al. “Eating Disorders” Lancet 2010 Vocks et.al. “Meta-Analysis of the Effectiveness of Psychological
and Pharmacological Treatments for Binge Eating Disorder” International Journal for Eating Disorders 2010
www.dsm5.org Feeding and Eating Disorders Fact Sheet, American Psychiatric Association 2013