3MisconceptionsMyth: White, upper-middle class females in metropolitan areas of the western worldEating 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…
4Case 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
5Anorexia 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 gainDisturbance in body image, undue influence of shape/weight on self-evaluation, lack of recognition of seriousness of low body weightRestricting sub-typeBinge-eating/purging sub-type**DSM-IV: 1. “refusal” to maintain weight 2. <85 percentile weight3. amnorrhea was required
7Anorexia Nervosa: chief complaint… Family or school is concerned about eating habits or personality changePhysical symptomsOther psychological concerns – depression, anxiety, obsessive“unintentional” weight lossAmenorrheaPatient: “I’m fine!”
8Anorexia Nervosa: Risk Factors, Precipitating Factors, & Traits PerfectionismEarly PubertyFailed attempts to lose weightAntecedent illness with weight lossAthleticsBeginning a dietFamily history of eating disorderLife/family stressors
9Anorexia Nervosa: Epidemiology Lifetime prevalence 0.5-1%Females:Males 10:1Usually arises during adolescence or young adulthoodIncreased risk in 1st degree biological relatives with AN1/3 will develop bulimia nervosaLong-term mortality 10-20%
10Physical Risks Death (suicide, starvation, sudden cardiac death) Hypometabolic state (bradycardia, hypotension, hypothermia)OrthostasisDehydrationArrhythmia, heart failure, liver failureBone marrow suppressionMalnourishmentBone lossLanugoPeripheral edemaStunted growthDelayed sexual maturityHair loss, brittle hairCognitive impairmentWater intoxicationRe-feeding syndrome
11Neurological Effects Cerebral Atrophy Associated with weight loss but not necessarily with lowest BMIMay improve but do not necessarily return to normalKatzman D et al, Journal of Pediatrics 1996
12Anorexia Nervosa: Medical Workup Vitals (w/ temperature)ECG (look for long QTc)Lytes, CBC, LFTs, ESR, TFTs, CKβ-HCG, LH, FSH, prolactin, estradiol if indicatedBone density(don’t be fooled by normal bloods!!!)
14Anorexia Nervosa: Treatment Determine level of careInpatient medical stabilizationInpatient eating disorders serviceOutpatient treatment1st: weight restoration2nd: psychological3rd: maintenance (long-term)Multidisciplinary Team Approach! (psychiatrist, PCP, nurse, psychologist, family therapist, social worker, occupational therapist, dietician)
15Considering Medical Admission <75% ideal body weightHypothermia T<35.5 CBradycardia HR<50 (peds) or HR <40 (adults)Orthostasis-drop in sbp >10, increase in HR>35DehydrationPotassium < 2.5 or other electrolyte abnormalityAcute medical complicationDeliriumRe-feeding syndromeSevere depression/suicidality– psychiatric admit
16Anorexia Nervosa: Treatment No evidence-based psychotherapy for Anorexia Nervosa in adults!No evidence-based pharmacologic treatments in any age!
17Psychological Treatments: Adolescents with AN Family Based Treatment (FBT) (aka “Maudsley Approach”)no-blame approach, family did not cause anorexiafamily is the best resource to help her/him get betterEmpower 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 anorexiaFamily Meal (Session #2)Focus on weight restoration firstthen explore the family dynamics and psychological issues that may get in the way of maintaining weight
18Psychological Treatments: Adults with AN None are “evidence-based”We use…Motivational InterviewingCognitive Behavioural Therapy (CBT)Supportive PsychotherapyMetacognitive TherapyCouples or Family Therapy, or family involvementPsychodynamic TherapyInterpersonal Therapy (IPT)Group Therapy
19Anorexia Nervosa: Medications No approved medication treatments for Anorexia NervosaFluoxetine (or other SSRI) for co-morbid depression or anxietyGrowing evidence for low-dose atypical antipsychotics (Olanzapine) for obsessive ruminations and possibly weight gain (still off-label)
20Re-feeding SyndromeMetabolic abnormalities as a result of reinstating nutrition to patients who are malnourishedPotentially fatalLow phosphateEdemaTachycardiaHypoglycemia (hyperinsulinemic response)Treatmentadmitreplace phosphatehigher protein: carbohydrate ratio
21Anorexia Nervosa: Prognosis 1/3 recover1/3 continue with milder course1/3 chronic severeYoung age of onset, short time since onset of illness: very good prognosis>7 years of illness, very unlikely recovery (but not zero!!!)
22Case 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.
23Bulemia 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 monthsSelf-evaluation is unduly influenced by body shape or weightDoes not occur exclusively during episodes of Anorexia Nervosa**DSM-IV: compensatory episodes had to be 2x/week
24Bulemia Nervosa: Risk Factors, Precipitating Factors, & Traits Often normal weight or overweight (easy to forget to screen for eating disorders!)Shame and guiltHistory of sexual abuse not uncommonImpulsivity, risk-taking behavioursDepression/anxiety, emotional dysregulation, self-harmLess denial compared to AN, but may go to great lengths to keep symptoms secret
25Bulemia Nervosa: Epidemiology Lifetime Prevalence1.5% women0.5% menPrevalence of binge-purge behaviors:13% girls7% boysSlightly older average age of onset compared to Anorexia NervosaPurging extremely rare in children
27Medical Risks Electrolyte abnormalities (hypokalemia, ketosis) Dental – loss of enamel, chipped teeth, cavitiesParotid hypertrophyConjunctival hemorrhagesCalluses on dorsal side of hand (Russell’s sign)Esophagitis, Mallory-weiss tears, Barrett esophagushematemesisLatxative-dependent: cathartic colon, melena, rectal prolapseElevated CK or other injuries (over-exercising)Poor nutrition (if severe purging)Edema upon cessation of purging
28Bulemia Nervosa: Treatment Again, multidisciplinary team!!!Adults:Best evidence: Cognitive Behavioural Therapy (CBT) + Antidepressant (SSRI)AdolescentsEvidence for adolescents is sparse; we extrapolate from the evidence for adult treatmentCBT + SSRIor Family-Based Treatment (FBT) modified for BN (good evidence, but not as good as for AN)
29Bulemia 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 -> purgeDialectical Behavioral Therapy (DBT)Chain analysis, mindfulness, emotion-regulation skillsthoughtfeelingbehaviorFelt angryCalled friend,She was tooBusy to talkFelt lonelyBingeFight withmom
30Bulemia: Other Therapies Family Therapy and/or family involvementInterpersonal 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
31Bulemia Nervosa: Medications High-dose Fluoxetine (SSRI) – very good evidence!Sertraline (SSRI) – some good evidenceTopiramate (mood stabalizer, promotes weight loss) – some good evidence, but use with caution especially if low-weightRemember: Buproprion (other antidepressant) is contraindicated! (risk of seizures if history of purging)
32Bulemia: Prognosis 33% remit every year But another 33% relapse into full criteriaAdolescent-onset better prognosis than adult-onsetDeath-rate = 1%
33Case 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.
34Binge Eating Disorder (BED) – DSM V Recurrent episodes of binge eatingEating definitely more than most people would eat in discrete 2-hour period of timeSense of lack of control during the episodeThree or more of the following:Eating much more rapidly than normalEating until uncomfortably fullEating large amounts when not physically hungryEating alone because embarrassed by how much eatingFeeling disgusted, depressed, or guilty afterwardsMarked distress regarding binge eatingOn average at least once a week for 3 monthsNo compensatory behaviours such as in bulemia nervosa**DSM IV: Binge-eating disorder was only in the appendix, frequency of binge episodes was >2x/week
35Binge Eating Disorder vs. Obesity Binge Eating Disorder: may be overweight, but not required for diagnosisBinge Eating Disorder: more subjective distress about episodes of over-eating compared to obese non-BED
36Binge Eating Disorder: Epidemiology Most common eating disorderLifetime prevalence:3.5% women2% men
38Binge Eating Disorder: Treatment (Medication) SSRIhigh dose reduces binge behavior short-termbut doesn’t help weight lossTopiramate, Zonisamide (anticonvulsants, mild mood stabalizer)Helps binge reductionHelps weight lossCaution for adverse effects, high discontinuation rates
39Binge Eating Disorder: Treatment (Therapy) Therapies either prioritize…Weight lossBinge-reductionNeither (ie. relationships, depression etc)Group psychotherapyThere is little evidence that obese individuals who binge should receive different therapy than obese individuals who do not binge
40Binge Eating Disorder: Psychosocial Support Family may need help with co-dependencyAttachment approach, particularly with youthWeight loss programs12-step self-help groups (addressing the problem as an addiction)Food Addicts in Recovery Anonymous
41Case 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.
42Other Eating/Feeding Disorders DSM V Pica- eating non-nutritive substancesRumination Disorder- chewing/spitting, re-chewing, regurgitatingAvoidant/Restrictive Food Intake Disorder- failure to meet energy/nutritive needs, dependence on enteral feeding or supplements
43Unspecified Feeding or Eating Disorder (UFED) Formerly Eating Disorder NOS (EDNOS) Clinically significant distress/impairment but do not meet criteria for other eating disordersMay 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.)
45Eating 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 etiologyMultidisciplinary treatment approachInvolve the family in treatment whenever you canYoung patient with new AN cannot afford to wait for FBTPrevalent in teens, but much less research to guide us in their treatmentLittle evidence for medications in EDs: this is why psychiatrists need to be more than med-managers!
46ReferencesHay et.al. “Psychological Treatments for Bulemia Nervosa and Bingeing” The Cochrane Library 2010Lock, J., “Evaluation of Family Treatment Models for Eating Disorders” Current Opinion in Psychiatry 2011Lock & LeGrange Treatment Manual for Anorexia Nervosa, Second Edition 2013Rosen et.al. “Identification and Management of Eating Disorders in Children and Adolescents” Pediatrics 2010Treasure et.al. “Eating Disorders” Lancet 2010Vocks et.al. “Meta-Analysis of the Effectiveness of Psychological and Pharmacological Treatments for Binge Eating Disorder” International Journal for Eating Disorders 2010Feeding and Eating Disorders Fact Sheet, American Psychiatric Association 2013