The Diagnosis & Treatment of Eating Disorders

Dr. Clare Roscoe

Staff Psychiatrist

Regional Eating Disorder Program

Children’s Hospital of Eastern Ontario

Eating Disorders Overview

• Epidemiology

• Diagnosis

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Types of Eating Disorders

1. Anorexia Nervosa – restricting or – binge-eating/purging subtype

2. Bulimia Nervosa 3. Eating Disorder Not Otherwise

Specified

4. Binge Eating Disorder5. Childhood Eating Disorders

Epidemiology:• Prevalence

A.N. 0.5-1% adol. & young adult ♀B.N. 1-3% adol. & young adult ♀EDNOS </= 10% adol. & young adult ♀ (“disordered eating” in 30% of children sampled)

• ♀ : ♂ 5-10 : 1• Onset

– A.N.: 13-20 yrs (peaks at 14 and 18 yrs)– B.N.: 16.5-19 yrs old

Eating Disorders Overview

• Epidemiology

• Diagnosis

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Definitions: Anorexia NervosaA. 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

Bulimia NervosaA. 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.

Specify: Purging vs. Non-Purging

Restriction

Binge

Purge

RestrictPurging is the result of: - Fear of weight gain - stomach discomfort - Shame

Severe Weight Loss

Eating Disorder (EDNOS)

Patient does not meet all the criteria for an eating disorder. For example:

– A.N. with normal periods– A.N. with the psychological criteria but is

above 85%ile for weight– Frequent purging but no bingeing and

above 85%ile for weight– Binge Eating Disorder will likely be a new

diagnostic category in the next DSM

Binge Eating Disorder

• Recurrent episodes of binge eating

• No compensatory behaviours

Eating Disorders Overview

• Epidemiology

• Diagnosis

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Etiology and Risk Factors

• 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?

Risk Factors for A.N. or B.N.

• Developed countries

• Female

• Adolescent

• Caucasian

Risk Factors for ANIndividual Family CulturalPerfectionism / Obsessionality

Family History of ED / Mood disorder

Idealization of thinness

Inflexibility / feeling out of control

? Family dysfunction /high expectations

“normative discontent” for female body image

Low self-esteem /

Eagerness to please

Self worth= appearance

Predisposition to thinness

Gay males

Comorbid: Anxiety, OCD, Social Phobia, Depression

Involved in activity where thinness = success e.g. modeling / acting

Puberty / Adverse life experience

Competitive sports with emphasis on thinness: e.g.. gymnastics / ballet

Risk Factors for BNIndividual Family CulturalHx of obesity Family Hx of obesity Idealization of

thinness

Impulsivity / risk taking/ mood swings

Critical comments re. weight / shape / eating

Self worth = appearance

Low self-esteem Family Hx of Mood / ED / or substance abuse

Overweight = lack of control

Comorbid: anxiety and depression; substance abuse

Verbal, physical or sexual abuse

Volatile / conflicted family environments

What Keeps the Illness Going?i.e. Makes the ED so Strong?

• Starvation

• The meaning it has /

how helpful it is

• Stuck in an “addiction”

Starvation

• Keys study– WWII, 36 men of “superior psychobiological

stamina” , put on severe diet, then gradually re-fed

– Developed symptoms of eating disorders including; food rituals, prolonged time eating, withdrawal, isolation, extreme mood swings, outbursts of anger, hospitalization, episodes of bingeing and vomiting when given access to food

What is the Meaning of the Illness?

• Eating Disorders are about feeling “not good enough”

• The ED makes a person feel “good enough”

• EDs are associated with low self-worth; depression; anxiety; guilt; feeling ‘bad’

• The ED helps push away/numb/replace the bad feelings

What is the Meaning of the Illness?

• Not eating allows all my other worries to go away. This is all I have to focus on

• Not eating allows me to feel in complete control of my life

• This makes me feel that I can do what no one else can; makes me feel special, competent

• I need to punish myself by not eating.• The eating disorder is who I am.• I don’t want to grow up (fear)

Co-Morbidity of A.N.:

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

GAD, and Social Phobia)

• Perfectionism• “Pathological Compliance”• Cluster ‘C’ P.D. traits, e.g.. OCPD

(rigidity, restraint, obsessiveness)

Comorbidity of B.N.:

• Depression #1 comorbidity • Anxiety in >50% (esp. GAD

• Impulsivity/risk-taking behaviors• Borderline Personality Disorder traits • Bipolar Spectrum disorders

• Substance Abuse• PTSD

Eating Disorders Overview

• Epidemiology

• Diagnosis

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Physiologic Complications of Eating Disorders

• Starvation– Body shutting down one system at a time

• Bingeing and Purging

Physiologic Complications of Eating Disorders

System Starvation Binge/ purge

CV Low BP, low HR, cardiac arrest, pedal edema (low albumin)

Arrhythmias, cardio-myopathy, sudden death

Metabolic / Heme Anemia, poor immunity

Metabolic alkalosis, hypokalemia

Resp Aspiration pneumonia

Physiologic Complications of Eating Disorders

System Starvation Binge/ purge

Reprod. Infertility

Derm Dry skin and hair, lanugo hair

Russell’s sign, enlarged parotid glands, perioral skin irritation, periocular petechiae

GI Constipation Hematemesis, esophagitis, reflux, poor muscle tone in colon from laxative abuse

Physiologic Complications of Eating Disorders

System Starvation Binge/ purge

MSK osteoporosis Dental erosion, muscle cramps (low K)

Renal Pre-Renal failure

(dehydration)

General / other Low temp, short stature

Dehydration, weight fluctuations

Labs in Eating Disorders:

INCREASED

• BUN (dehydration)

• Amylase (vomiting)

• Cholesterol

(starvation)

DECREASED

• Na, K, CL (vomiting/laxatives)

• LH, FSH, estrogen

(starvation)

• RBCs (starvation)

• WBCs (starvation)

Clinical features of a Patient at High Risk of Death

1. Very low weight

2. Multiple purging methods

3. No medical follow-up

4. Ipecac use

5. Chronic self-harm or suicide attempts

6. Bradycardia

7. Amphetamine or cocaine use

Checklist of Visible Characteristics for AN Siegel et al., 1997

Behavioural Signs:• restricted eating: severe

diet or fasting• odd food rituals• intense fear of

becoming fat• rigid exercise regime• dressing in layers• Mood shifts• Withdrawal from others

Physiological:• weight loss• menses stopped/ no

start• paleness• always cold• dizziness, fainting spells

Checklist visible signs of Bulimia Siegel et al, 1997

Behavioural Signs:• secretive eating• missing food• constant talk about

food and body• self-critical when too

much eaten• bathroom visits after

meals

• rigid/harsh exercise routine

• Severe mood shifts• Severe self-criticism

Checklist Bulimia continued

Physiological Signs• swollen glands, puffiness cheeks, broken blood

vessels under eyes• complaints of sore throats• fatigue, muscle ache• tooth decay• weight fluctuations

Eating Disorders Overview

• Epidemiology

• Diagnosis

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Principles of Treatment for E.D.’s:

1. Start with a thorough assessmenta. Biopsychosocial formulation

2. Specialized, multidisciplinary treatment team (physician, dietician, therapist…)a. A psychological illness with medical and nutritional

consequencesb. Importance of medical and psychological aspects of

treatment together

3. Importance of Education

Treatment of Anorexia Nervosa:

• Medical and Nutritional:– “food is the medicine”– reversal of the effects of starvation;

re-feeding– meal plan, “mechanical eating”– 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– Family Therapy for Children and

Adolescents (evidence based)– CBT; IPT; motivational therapy; groups– externalizing the illness; challenging the

E.D.– importance of alliance with therapist– psychoeducation e.g. re. effects of

starvation

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 Difficulties

• Symptoms are ego syntonic (i.e. wanted)

• Defensive / difficult families

• Malnutrition may preclude effective psychotherapy

• Chronicity

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

• Etiology and Risk Factors

• Physiologic Complications

• Principles of Treatment

• Outcome

Outcome for Anorexia Nervosa:

• High morbidity and mortality (among highest of all psychiatric illnesses)

• Mortality: 5-20% (50% suicide, 50% medical complications)

• 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

• 10-15% continue to do poorly

• 15-20% intermediate outcome

A.N. B.N.

• 50% of Anorexics develop B.N.

• Within 2 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

Quiz…

1. What is the prevalence of Anorexia Nervosa in young women (age 15-40)?

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. Trueb. False

Quiz…

3. First line treatment for Anorexia Nervosa in the weight restoration phase is:

a. an SSRIb. an appetite stimulant

c. none of the above

4. First line treatment for Bulimia Nervosa includes:a. an SSRIb. CBTc. all of the above