integrative medicine approaches to eating disorders carolyn ross, md, mph eating disorder and...

Integrative Medicine Approaches to Eating Disorders

Carolyn Ross, MD, MPHEating Disorder and Integrative Medicine Consultant1855 S. Pearl St.Denver, CO 80210520-440-0079Crossmd@mac.comwww.carolynrossmd.com

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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

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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 (self-

induced 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:.• Eating until feeling uncomfortably full

Eating large amounts of food when not physically hungry• Eating much more rapidly than normal • Eating alone because you are embarrassed by how much you're eating• Feeling disgusted, depressed, or guilty after overeating • Marked distress regarding binge eating is present

2. Binge eating occurs, on average, at least 2 days a week for six months3. 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 self-

evaluation 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

4th CORE BELIEFS: Beliefs formed in the midst of intense emotion, often forgotten but unconsciously these beliefs continue to shape and drive behaviors

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

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

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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 you recently lost more than One stone (14 lb [6.4 kg]) in a three-month period?

Do 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

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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.

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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 TSH T3 and T4

CRH/CRF ACTH & Beta endorphins Cortisol

Sex Hormones: GnRH FSH and LH 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

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 CRH-induced 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. [

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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

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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%

Causes of Eating Disorders

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Causes of eating disorders

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

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Precipitating factors

Internal or external sense of loss of control 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

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Eating Disorders n Influence of the culture

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

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Ana Carolina Reston Brazilian Model Died at age 21 after prolonged hospitalization for

Anorexia Bulimia Kidney Failure Septicemia BMI 13.5 Weight 88 lbs.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

“There were times I felt fat. I had a distorted image of myself” Ana Carolina Reston (1985-2006)

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

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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

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“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

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Omega 3 FA

Suicide Risk Low DHA% and Low

Omega-3:6 ratio predicted risk in depressed patients over 2 year period

Am J Psychiatry, Sublette M, et al. 2006

Borderline personality disorder Omega 3 FA

decrease anger and aggression

BMJ 3/05

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 Hongisto, 2005

With fiber decreased constipation and bloating

Khalif, 2005 IBS

Kajander, 2005

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Supplements for Depression

5-HTP: Serotonin precursor Treatment for refractory depression Insomnia

Cowan 1996 Cangiano C, 1992 Cochrane Database

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Supplements for Anxiety

L-Theanine Valerian Root

Benzodiazepine withdrawal

Sleep Morin CM, 2005 Shinomiya K, 2005

Anxiety Kohnen R, 1988 Andreatini R, 2003

Kava-Kava

Yager, et al. (1999) – patient on Prozac (20 mg/day) for alcohol-induced 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 of hepatitis

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St. John’s Wort

Dosage: 300 mg three times a day

SAD, ADHD, OCD, Anxiety, Depression

Study done on (Perika-Nature’s Way):

Extract WS5572: 3% hyperforin

300 mg three times daily

SIDE EFFECTS 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

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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.

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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.”

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History and Sx

Amenorrhea, Constipation, headaches, fainting, cold intolerance

Bloating, fullness, lethargy, GERD, abdominal pain, sore throat, abn menses

Constipation, GERD, fatigue, abnormal menses, PCOS

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, cardiomegaly (ipecac toxicity). Can be normal or sl overwt.

Overweight or obese

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 resistanceElevated androgens

ECG findings

Low voltage, prolonged QT interval, bradycardia

Low voltage, prolonged QT interval, bradycardia

Variable

Anorexia Nervosa /Bulimia Nervosa / Binge Eating Disorder

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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 Stunkard

AJ, et al. J Clin Psych 2006 Oct; 67(10)

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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

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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.

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Medications for Binge Eating Disorder Trial of Prozac vs. placebo

Decrease in binging, depression Abstinence rates, high drop-out rates and long-term follow-

up not reported - conclusions ?

Overall, in short term studies, SSRI’s lead to reduction in binging, decrease in weight and severity of illness and decrease in psychological symptoms 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

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.

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CASES

Julia’s depression Thom - from Obesity to Anorexia

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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.

References1. Kaye Wh, et al. Comorbidity of anxiety disorders with anorexia and bulimia

nervosa. AM J Psychiatry, 2004 Dec; 161(12):2215-21.

2. 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.

3. Dalvit-McPhillips S. A dietary approach to bulimia treatment. Physiol Behav 33(5):769-75, 1984.

4. Blouin AG, et al. A double-blind placebo-controlled glucose challenge in bulimia nervosa: psychological effects. Biol Psychiatry 33(3):160-8, 1993.

5. Ward NI. Assessment of zinc status & oral supplementation in anorexia nervosa. J Nutr Med 1:171-7, 1990.

6. Yamaguchi H, et al. Anorexia nervosa responding to zinc supplementation: a case report. Gastroenterol Jpn. 1992 Aug;27(4):554-8.

7. Cowan PJ, et al. Moderate dieting causes 5HT2Cr eceptor supersensitivity. Psychol Med 26(6):1155-9, 1996.

References 8. Misra M, et al. Alternations in cortisol secretory dynamics in

adolescent girls with anorexia nervosa and effects on bone metabolism. J Clin Endocrinol Metab. 2004 Oct; 89(10):4972-80.

9. Guinn B, et al. J Sch Health 1997 Mar; 67(3):112-5. 10. Ferron C. Adolescence 1997 Fall; 32(127):735-45 11. Laessle RG, et al. A comparison of nutritional management

with stress management in the treatment of bulimia nervosa. Br J Psychiatry. 1991 Aug;159:250-61.

12. Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Pediatr Int. 2000 Feb;42(1):76-81.

13. Cangiano C, et al. Am J Clin Nutr. 1992 Nov;56(5):863-7. 14. Bressa GM, S-adenosyl-l-methionine (SAMe) as

antidepressant: meta-analysis of clinical studies. Acta Neurol Scand Suppl. 1994;154:7-14.

15. Friedel HA, et al. SAMe. A review of its pharmacological properties and therapeutic potential in liver dysfunction and affective disorders in relation to its physiological role in cell metabolism. Drugs. 1989 Sep;38(3):39-416.

• SAMe for treatment of depression, osteoarthritis and liver disease. www.ahrq.gov/clinic/epcsums/samesum.htm

17. The Rhodiola Revolution. Richard Brown, MD & Pat Garberger, MD