PSYCHIATRY AND BEHAVIOR COURSE: Eating

Disorders Dr. Satu Michele Repo-Hendsbee

Psychiatrist

Regional Mental Health Care London

455-5110 extension 47417

OBJECTIVES

• 1. Know the general criteria for anorexia nervosa, bulimia nervosa and binge eating disorder

• 2. List predisposing factors for each of these disorders

• 3. Know the usual course and prognosis of each disorder

• 4. Know the complications of each disorder.• 5. Describe the management

(assessment/treatment/follow-up) for each disorder.

WHY STUDY EATING (DIETING ) DISORDERS?

• The most lethal of all psychiatric disorders

• Significant source of mortality and morbidity (interferes with normal growth and development)

• Significant number of patients struggle chronically

EPIDEMIOLOGY

• Lifetime prevalence of AN is 0.5% for females & 0.05% for males

• Lifetime prevalence of BN is 1-3% for females & 1/10th of that for males

• Incidence of AN appears to have increased in last few decades

• Up to 1/3 of those seeking obesity treatment in hospital settings have binge eating disorder

ETIOLOGIC THEORIES

• In general: multiple biopsychosocial determinants

• BIOLOGICAL: genetics, dieting/restriction

• PSYCHOLOGICAL: affect regulation; avoidance; control

• SOCIAL: family pressure; cultural norms

ANOREXIA NERVOSA CRITERIA (the short version)

• A. refusal to maintain weight at a normal level

• B. intense fear of being fat

• C. Preoccupation/misperception/lack of insight as related to weight and shape

• D. Amenorrrhea

• May be restricting or binge/purge type

ANOREXIA NERVOSA – associated psychiatric features

• 1. Ego syntonic symptoms

• 2. Lack of motivation

• 3. Lack of insight (denial)

• 4. Ambivalence

ANOREXIA NERVOSA- associated bps factors

• BIOLOGICAL: first degree relatives with AN, history of obesity, dieting

• PSYCHOLOGICAL: negatives feelings about the body, perfectionism, eager to please, difficulty expressing feelings verbally, difficulty resolving conflicts, maturation fears

• SOCIAL: female, Caucasian, middle to upper-class, industrialized societies, certain sports, maternal preoccupation with diets, compliments for losing weight

ANOREXIA NERVOSA – Course and Prognosis

• ONSET - usually between 14 & 18• GENERAL OUTCOME – up to 50% develop BN,

66% still preoccupied with food and weight; 44% weight restored within normal limits; after 10-15 years 12% remain anorexic

• MORTALITY – 5% mortality over 10 years (metabolic complications/suicide) and 10% of those admitted to university hospitals

ANOREXIA NERVOSA – Complications/Associations

• Vitals: bradycardia, hypothermia, hypotension

• Psychiatric: depression, anxiety, irritability, depression/dysthymia (20%), 25% of those with OCD, cluster C personality disorders, social isolation

• ENT: dental erosion (p), parotid hypertrophy

ANOREXIA NERVOSA – Complications/Associations (2)

• CVS: bradycardia, QT proongation, arrhythmias

• GI: delayed gastric emptying, constipation, abdominal pain, malabsorptio9n

• GU: peripheral edema• OB/GYN: premature births• MSK: osteopenia, stunting of growth

osteoporosis, pathological fractures

ANOREXIA NERVOSA – Compliations/Associations (3)

• Derm: lanugo, dry hair, dry skin, carotenemia, Russell’s sign, acrocyanosis

• Metabolic: hypochloremia and hypokalemia (p), low phosphate, low magnesium

• Heme: anemia, leukopenia• Endocrine: low FSH, low LH, low libido,

infertility, increased cholesterol, increased cortisol

ANOREXIA NERVOSA – Management (1)

• Scare tactics are futile

• Emotional Impact on physicians can be significant

• Studies are generally based on treatments of 6-12 weeks duration; results have to extrapolated in the treatment of this often chronic condition

ANOREXIA NERVOSA – Management Goals

• Biological: weight restoration, restore ovulatory function/hormone levels and sex drive, treat co-morbid conditions

• Psychological: enhance motivation, provide education, correct maladaptive thoughts and behaviors, relapse prevention

• Social – improve family functioning, improve peer relationships, expand activities

ANOREXIA NERVOSA – Management Setting

• Setting: based on nature and severity of symptoms, medical status, motivational status, treatment history, logistic considerations

• Inpatient criteria: medically and/or psychiatrically unstable, less than 75% of IBW, outpatient failure, inappropriate home environment

ANOREXIA NERVOSA – Setting continued

• Day treatment: transition from inpatient to outpatient, supportive home environment

• Outpatient: weight close to 85% of ideal, motivated and reliable

ANOREXIA NERVOSA – Management (Assessment)

• Biological: history, physical, growth charts, dieting history, blood work, ECG, bone studies, rule out diff. Diagnosis

• Psychological: mental status exam, dietary and exercise history, assess motivation, patient goals and expectations, self-portrait

• Social: family and couple’s assessment, collateral history from school/work/sports

ANOREXIA NERVOSA – Management (Assessment)

• Sample questions:– How would your life be different if you were at

your ideal weight? If you were “overweight”?– How does gaining weight influence your

thoughts/feelings? How does losing weight influence those areas?

– What would it mean if you were overweight? If you were skinny?

ANOREXIA NERVOSA - Treatment

• Biological: nutritional rehabilitation, medical stabilization, SSRIs, atypical antipsychotics, activity limitations

• Psychological: therapeutic alliance, motivational interviewing, supportive psychotherapy, cognitive behavioral therapy, dialectical behavior therapy,

• Social: skill based group therapy, family therapy

ANOREXIA NERVOSA – follow-up

• Therapy often needs to continue beyond the restoration of weight

• Regular medical check-ups

• Relapse prevention through ongoing group/individual support

BULIMIA CRITERIA – (the short version)

• A. Binge eating

• B. Unhealthy attempts to get rid of “extra” food/weight

• C. at least 2x/week for 3 months

• D. Self-esteem based on weight and shape

• E. It’s not anorexia nervosa

• Types: Purging or non-purging

BULIMIA NERVOSA – associated psychiatric features

• Ego dystonic

• Increased insight and shame

• Impulsivity

• Sexual promiscuity

• Substance abuse

• Self-harm behavior

BULIMIA NERVOSA – Associated bps factors

• Biological: first degree relatives with BN, dieting, anorexia nervosa

• Psychological: low self-esteem, interpersonal sensitivity, impulsivity, history of sexual abuse

• Social: negative comments from family, encouragement to diet, cultural emphasis on slimness, bullying by peers

BULIMIA NERVOSA – Course and prognosis

• Disturbed eating generally persists for years• @ 6 years: 60% had a “good” outcome, 29%

intermediate, 10% poor and 1% deceased• Meta-analysis over 5-10 years showed that 50%

fully recovered but 20% fully bulimic• Approximately 30% relapse 1-4 years after full

recovery• Worse if inpatient care, multiple purges, low

functioning,

BULIMIA NERVOSA – complications and associations

• Vitals: hypotensive

• Psychiatric: 30% have substance abuse, 50-75% have depression/dysthymia, increased incidence of borderline personality diosrder

• ENT: parotid hypertrophy, dental decay

• CVS: ipecac cardiomyopathy, arrhythmia

BULIMIA NERVOSA – complications and associations

• GI: hematemesis, Mallory-Weiss tear, GERD, uncontrolled vomiting, gastritis, esophagitis, colonic dysmotility

• GYNE: infertility, irregular periods

• Metabolic: hypokalemia, hypochloremia

• Derm: Russell’s sign

Bulimia Nervosa – Management Goals

• Biological: reduce binge eating and purging (usually requires reduction in restriction and dieting), treatment of co-morbid medical conditions

• Psychological: reduce cognitive distortions, “peace of mind” treatment of co-morbid conditions

• Social: improved family functioning and understanding, improved occupational/ social/education functioning

BULIMIA NERVOSA – Management (Setting)

• Inpatient: failure of outpatient treatment, symptom interruption beds, medical/ psychiatric instabilty, substance abuse

• Day Hospital: ability to work in a group program, structured and supportive environment outside of hospital

• Outpatient: medical stability, supportive environment, work/school obligations

BULIMIA NERVOSA – Management (Assessment)

• Biological: history and physical exam, blood work, ECG

• Psychological; mental status exam, diet/exercise history, goals and expectations, motivational assessment, identify cognitive distortions

• Social: family and couples assessment, collateral from school/work

BULIMIA NERVOSA – Management (Treatment)

• Biological: nutritional counseling, SSRIs

• Psychological: motivational interviewing, psychoeducation, individual therapy (CBT, DBT, interpersonal therapy), bibliotherapy, self-help manuals (www. Gurze.com)

• Social: family therapy, couples therapy, group therapy

BULIMIA NERVOSA – Management (Follow-up)

• Monitor for high risk situation and prepare proactively (pregnancy, marriage, moves, schooling, jobs changes)

• Relapse prevention through group and individual therapy

EATING DISORDERS - NOS

• Binge eating disorder

• Orthorexia Nervosa

• Compulsive Exercise

• Disordered Eating

• Obesity:

OBESITY

• “Simple obesity does not appear in the DSM-IV because it has not been established that it is consistently associated with a psychological or behavioral syndrome.” (DSM-IV)

• “One can say with confidence that there is little relationship between obesity and gross psychologic abnormalities.” (Medical Clinics of North American, 2000)

BINGE EATING DISORDER CRITERIA (the short version)

• Binge eating

• Absence of significant attempts to get rid of weight/food by vomiting/exercise/diuretics etc.

BINGE EATING DISORDER – associated bps factors

• Biological: dieting, past history of bulimia

• Psychological: judgmental stance towards self, low self-efficacy, childhood abuse

• Social: negative judgments or comments from friends/family, cultural endorsements of dieting, bullying by peers

BINGE EATING DISORDER – course and prognosis

• 30% of those in weight control programs

• Females 1.5 times the rate of males

• Approximately 2% of community samples

• Chronic, relapsing condition

BINGE EATING DISORDER – associations and complications

• Vitals: hypertension

• Psychiatric: depression

• RESP: sleep apnea, SOB

• CVS: cardiac risk factor

• GI: hiatus hernia, gallbladder disease, colon cancer

• GU: stress incontinence

BINGE EATING DISORDER – associations and complications

• Gyne: endometrial cancer, breast cancer, PCOD

• MSK: osteoarthritis

• Endocrine: type II diabetes, hyperandrogeneic states infertility

• Metabolic: dyslipedemias

• Derm: hirsutism, venous stasis

BINGE EATING DISORDER – Management (Goals)

• Biological: normalization of eating, decreased binge eating, improved physical health.

• Psychological: improved emotional health: improved self-esteem and self-confidence

• Social: Improved family understanding of disorder, improved social, occupational and educational functioning

BINGE EATING DISORDER – Management (Setting)

• Inpatient: symptoms interruption bed

• Day Treatment: Frequent relapses

• Outpatient: almost 100% of the time

BINGE EATING DISORDER – Management (Assessment)

• Biological: history and physical exam, blood work, ECG

• Psychological: mental status exam, dieting and exercise history, motivational assessment, goals and expectations determined, cognitive distortions identified, assess coping mechanisms

• Social: family & marital assessment, collateral history

BINGE EATING DISORDER – Management (Treatment)

• Biological: SSRIS, naltrexone, topiramate

• Psychological: CBT, BT, non-dieting philosophy, self-help (TOPS)

• Social: group therapy, family and couples therapy

BINGE EATING DISORDER – Management (Follow-up)

• Ongoing support and treatment needed by many patients

• Reduce follow-up visits as remission extends in length

EATING DISORDERS - Summary

• 1. Disordered eating comes in many forms, each of which can be extremely destructive to physical, emotional and social functioning

• 2. Chronicity of disorder often mandates long-term treatment

• 3. Team management is often crucial to avoid clinician burn-out

• 4. Can be very satisfying when results are achieved.