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					  EATING DISORDERS
    Unit III Lecture, 2011



Dr. Clare Roscoe
Assistant Professor
University of Ottawa
croscoe@cheo.on.ca
Eating Disorders
Overview
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical Complications
• Principles of Treatment
• Outcome
  Epidemiology:
• Prevalence
  A.N.           0.5-1%
  B.N.           1-3%
  EDNOS          3-10%


•♀:♂       10 : 1

• Onset
  – A.N.   : 13-20 yrs (peaks at 14 and 18 yrs)
           : 5% present after 20 years of age
  – B.N.   : 16.5-19 yrs old
Eating Disorders
Overview
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical Complications
• Principles of Treatment
• Outcome
Types of Eating Disorders
1. Anorexia Nervosa
  – Restricting Type
  – Binge-Eating/Purging Type

2. Bulimia Nervosa
  − Purging Type
  − Nonpurging Type

3. Eating Disorder NOS
Set Point
• BMI 18.5 – 25
• Body Mass Index kg/m²
Definitions: Anorexia
Nervosa A. Refusal to maintain body weight
                    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



                         Purging   -   Vomiting
                                   -   Laxatives
                                   -   Diuretics
                                   -   Enemas
  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.
The Bulimic Cycle
• A binge is almost always
  the result of dieting and
  food restriction.                Restrict
• Purging is the result of:
   – Fear of weight gain                      Binge
   – The perception of
     stomach discomfort
   – Shame caused by the            Purge
     loss of control over eating
Bulimia Nervosa Cont..

• Specify:
  – Purging Type
  – Nonpurging Type



                      Purging   -   Vomiting
                                -   Laxatives
                                -   Diuretics
                                -   Enemas
Eating Disorder NOS (EDNOS)
 Patient does not meet all the criteria for
 an eating disorder. For example:

   – A.N. with normal periods
   – Frequent purging but no binge-eating and
     above 85%ile for weight
Eating Disorders
Overview
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical Complications
• Principles of Treatment
• Outcome
Understanding Eating
Disorders
• 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?
 The Development of an ED
                                Need to Gain Control / Feel
                                Better
                   Stressors         Dieting


                               Sense of Achievement


                                Increased Dieting


Vulnerable Youth         Snowballing of behaviours

-Risk factors
-Comorbidities
-Low self-esteem
                               Eating Disorder
    Risk Factors for AN
Cultural                  Family                   Individual
Idealization of           Family History of ED /  Female Gender
thinness, “normative      Anxiety / Mood disorder
discontent” for female    / OCPD
body image
Gay males                 Early life               Perfectionism /
                          “overprotective / high   Obsessionality
                          concern parenting”
Activity where thinness                            Low self-esteem /
= success e.g.                                     Sense of
modeling / acting                                  ineffectiveness
Competitive sports                                 Eagerness to please /
with emphasis on                                   High sensitivity
thinness: e.g..
gymnastics / ballet
                                                   Puberty
Risk Factors for BN
Cultural            Family                  Individual
Idealization of     Family Hx of obesity    Female
thinness
Specific sports /   Family Hx of Mood       Low self-esteem /
activities as AN    /Anxiety / ED / or      Sense of
                    Substance Abuse /       ineffectiveness
                    Cluster B PD
                    Critical comments re.
                    weight / shape /
                    eating
                    Hx of sexual abuse

                    Volatile / conflicted
                    family environments
Co-Morbidity of A.N.:

• >50% Depression (i.e. #1 comorbidity)
• 50% Anxiety Disorders (esp. OCD, GAD,
  and Social Phobia)

• Perfectionism
• “Cluster ‘C’ P.D. traits, e.g.. OCPD (rigidity,
  restraint, obsessiveness)
Comorbidity of B.N.:
• Depression >50%, #1 comorbidity
• Anxiety in >50% (esp. GAD and Social Phobia)

•   Impulsivity/risk-taking behaviors
•   Substance Abuse
•   Borderline Personality Disorder traits
•   PTSD
•   Bipolar Spectrum disorders
E.D. Spectrum
• A.N.-------------A.N./B-P--------------B.N.
• Perfectionistic            Chaotic
• Compliant                   Unstable moods
• Anxious                    Substance abuse
• Sensitive                   Impulsive
• Possible OCPD               Possible BPD
Eating Disorders come
from:
• Feeling “not good enough”
• Feeling worried or stressed
• Feeling emotions that are
  “out of control”
• Feeling like you should keep your
  problems to yourself / not burden others
• Wanting to be liked and fit in - Not
  wanting to give others something to
  criticize or tease you about
The Development of an ED
                                Need to Gain Control / Feel Better

                                        Dieting
                   Stressors

                                Sense of Achievement


                                  Increased Dieting


                               Snowballing of behaviours
Vulnerable Youth

-Risk factors            Powerful Eating Disorder
-Comorbidities
-Low self-esteem
i.e. What makes
an Eating
Disorder so
Strong?

What an Eating Disorder
does….
• Give up or dramatically alter relationships
  with family and friends
• Give up school / work
• Give up sports / hobbies
Why so powerful?
Understanding the Eating
Disorder
• Effects of starvation
• The Meaning of the Eating Disorder
• An illness by nature that creates denial /
 poor insight
Effects of Starvation
• Ancel Keys, University of Minnesota,
 during WWII

• Psychologically “Normal” men, with
 superior “psychobiological stamina”
              
          Semi-starvation
    (lost 25% body weight)
Effects of Starvation
• Change of Eating Habits
  – Started to eat in silence, prolonged time, unusual
    mixing of food


• Social Changes
  – Men became withdrawn, decrease wish to socialize
  – Less humour


• Cognitive Changes
  – Impaired concentration
  – Impaired comprehension and judgment
Effects of Starvation
• Emotional Changes
  –   Depression,
  –   Irritability,
  –   Frequent outbursts of anger,
  –   Extreme mood swings,
  –   High levels of anxiety (including nail biting),
  –   Almost 20% experienced extreme emotional
      deterioration (some hospitalized),

  – Most changes persisted through refeeding, became
    worse for some
The Meaning of the
Eating Disorder
Attempt to loose weight     Eating
  (way to feel accepted      Disorder
     by others)
                                 
                          New
                          Meaning
                          & Importance
The Meaning of the Eating
Disorder
 • The Eating Disorder is one thing I am good at
 • Not eating allows me to feel in control of my
     life
 •   Not eating allows all my other worries to go
     away
 •   The Eating Disorder makes me feel powerful,
     special and in control
 •   The Eating Disorder means I don’t have to
     grow up
 •   Eating means I am weak and a failure
 •   The Eating disorder is who I am
Poor Insight and Denial
Eating Disorders
Overview
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical Complications
• Principles of Treatment
• Outcome
Medical Complications of
Eating Disorders
• Starvation
  – Body shutting down one system at a time


• Purging
Medical Complications of
Eating Disorders
System             Starvation         Purge

CV                 Low BP, low HR,    Arrhythmias (K),
                   small heart, QTc   cardiac arrest
                   prolongation,
                   cardiac arrest
Metabolic / Heme   Hypothermia,       Metabolic
                   Anemia,            alkalosis,
                   Leukopenia, poor   hypokalemia
                   immunity
  Medical Complications
System Starvation                    Purge
Reprod.   Amenorrhea, Infertility,   Amenorrhea (or
          complications in           oligomenorrhea),
          pregnancy                  infertility
Derm      Dry skin and hair,         Russell’s sign, enlarged
          lanugo hair                parotid glands, perioral
                                     skin irritation,
                                     periocular petechiae
GI        Constipation               Hematemesis,
                                     esophagitis, reflux, poor
                                     muscle tone in colon
                                     (laxative abuse)
Medical Complications
System   Starvation          Purge

MSK      Muscle wasting,     Dental erosion,
         Osteoporosis,       muscle cramps
         short stature       (low K)
Renal    Pre-Renal failure   Pre-Renal failure
         (dehydration)       (dehydration)
CNS       concentration,     concentration,
         severe mood         severe mood
         changes, white     changes
         & gray matter
 Labs in Eating Disorders:

                      
• BUN (dehydration)    • Na, K, CL (vomiting/laxatives)
• Amylase (vomiting)   • LH, FSH, estrogen
• Cholesterol           (starvation)
      (starvation)     • RBCs (starvation)
                       • WBCs (starvation)
                       • T3
Clinical features of a Patient
at Higher Risk of Death
1.   Very low weight at admission
2.   Bradycardia
3.   No medical follow-up
4.   Longer duration of illness
5.   Multiple purging methods
6.   Chronic self-harm or suicide attempts
7.   Amphetamine or cocaine use
8.   Severe alcohol abuse
Eating Disorders
Overview
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical 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”
  – meal plan, “mechanical eating”
  – reversal of the effects of starvation;
    re-feeding
  – 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
  • Therapeutic Alliance
  • Supportive, compassionate, empathic
  • Understanding the illness, education
  • Externalize the illness, lift blame and
    shame, challenging ED
  • Motivational techniques; exploring pros
    and cons, comparing to OCD
  • Exploring and treating co-morbidities
Treatment of A.N.
cont’d:
 – Family Therapy for Children and Adolescents
   (evidence based)

 – CBT; IPT; motivational therapy; groups
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 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
• Epidemiology
• Diagnosis
• Understanding Eating Disorders
  – Etiology, Risk Factors, and Power
• Medical Complications
• Principles of Treatment
• Outcome
Outcome for AN
• High morbidity and mortality (among
 highest of all psychiatric illnesses)

• Mortality: 5-20%
  – 50% suicide
  – 50% medical complications
Outcome for AN
• Prognosis in Adolescents:
  – 50-70% full recovery in 5 years
  – 10-20% develop chronic AN

• 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
• 15-20% intermediate outcome
• 10-15% continue to do poorly
A.N.  B.N.

• 50% of AN-R develop bulimic symptoms
 within 5 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
References
• APA Guidelines, Practice Guideline for the
 Treatment of Patients with Eating Disorders,
 Third Edition, 2006
 http://www.psychiatryonline.com/pracGuide
 /pracGuideTopic_12.aspx
References
• Klump K et al, Academy for Eating Disorders
    Position Paper: Eating Disorders are Serious
    Mental Illnesses, International Journal of Eating
    Disorders, 42:2, p97-103, 2009.
•   Le Grange D et al, Academy for Eating Disorders
    Position Paper: The Role of the Family in Eating
    Disorders, International Journal of Eating
    Disorders, 43:1, p1-5, 2010.
•   Rosen, David, Identification and Management of
    Eating Disorders in Children and Adolescents,
    Pediatrics, Vol. 126 No. 6 December 2010, pp.
    1240-1253
1. What is the prevalence of Anorexia Nervosa in
   women?
    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
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

				
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