1. Eating Disorders (EDs)

2. Anorexia Nervosa (AN) Refusal to maintain 85% of ideal body weight
Intense fear of gaining weight or becoming fat
Disturbed perception of the shape or size of the body
Denial of the seriousness of the problem
Amenorrhea—3 months without period

3. Subtypes of AN Restricting Binge-eating/Purging
Lose weight primarily through dieting, fasting, or excessive exercise
Binge-eating/Purging
Person regularly engages in binge eating or purging
Purging is self-induced vomiting, misuse of laxatives, diuretics, or enemas

4. Bulimia Nerovsa (BN)
Recurrent episodes of binge eating (eating a large amount of food given the context with an associated sense of loss of control)
Recurrent inappropriate compensatory behavior (purging, fasting, excessive, exercise)
Binge eating and compensatory behavior occur at least 2 times per week
Clients are usually normal body weight or overweight

5. Subtypes of BN Purging type Non-purging type
Person regularly engages in self-induced vomiting or the misuse of laxatives, diuretics, or enemas
Non-purging type
Person regularly engages in other inappropriate compensatory behavior—fasting or excessive exercise

6. Who’s at Risk for AN and BN?
Adolescents
Athletes
Appearance focused professionals

7. Demographic Factors Females comprise 95% of those with EDs
Onset of AN ranges from pre-puberty to the 30s, but generally occurs between 12-18
Onset of BN typically begins during late adolescence or early adulthood

8. Statistical Data 10-18% mortality rate
Highest mortality rate of any of the psychiatric disorders
Death most frequently occurs by starvation, electrolyte disturbances, or suicide
People who have had the disease greater than 20 years have a 20-25% increased mortality rate
Long term data—no more than 50% recover completely

9. Statistical Data (cont)
Prevalence rates of 0.5-1% among females in late adolescence and early adulthood who meet full criteria for AN
1-3% with BN

10. Risk Factors

11. Psychological Factors
Low self-esteem
Perfectionism and unrealistically high standards
Difficulties in self-soothing and mood modulation

12. Biological Factors 8 times the risk if family member has ED
50% concordance in monozygotic twins, 15% for dizygotic
A family history of mood or anxiety disorders or OCD increases the risk of EDs

13. Biological Factors Many neurochemical changes occur with EDs
Low NE levels are seen in clients during periods of restricted intake
High levels of 5-HT and its precursor tryptophan have been linked to satiety
Low levels of 5-HT have been found in clients with BN and the binge-purge subtype of AN

14. Family Factors AN BN Family is rigid about values and rules
Overprotective
Unable to deal with conflict BN
Family is chaotic with loose boundaries
Perceived as less caring
Unrealistic expectations for achievement
Parental concerns with weight

15. Sociocultural Factors
Cultural ideal of being thin
Media focus on beauty, thinness, and fitness
Chronic dieting, particularly among young women

16. Comorbid Illnesses

17. Comorbid Illnesses AN Depression Dysthymia OCD/OCPD Anxiety Disorders
Avoidant PD

18. Comorbid Illnesses BN Depression Dysthymia Substance abuse BAD BPD
Avoidant PD

19. Medical Complications of EDs Related to Weight Loss

20. Dermatologic Complications
Dry skin
Lanugo-like hair
Alopecia
Brittle nails
Pale skin
Cyanosis

21. Cardiac Complications
Low heat rate—30-40s common
Low BP
Decrease in heart size
CHF—biggest risk factor for death MI
Arrhythmias
Death

22. Respiratory Complications
Decrease in the number of breaths per minute
Decrease in respiratory muscle tone

23. Gastrointestinal Complications
Delayed gastric emptying
Bloating
Constipation
Abdominal pain
Gas
Diarrhea

24. Musculoskeletal Complications
Loss of muscle mass
Loss of fat
Osteoporosis
Pathologic fractures

25. Hematologic Complications
Leukopenia
Anemia
Thrombocytopenia
Hypercholesterolemia
Hypercarotonemia

26. Neuropsychiatric Complications
Abnormal taste sensation
Apathetic depression
Mild organic mental sx
Sleep disturbances

27. Medical Complications of EDs Related to Purging

28. Metabolic Complications
Electrolyte abnormalities
Particularly hypokalemia and hypomagnesemia
Elevated BUN

29. GI Complications Salivary gland enlargement
Pancreatic inflammation with elevated serum amylase
Esophageal irritation
Gastric erosion

30. Dental Complications
Erosion of dental enamel

31. Neuropsychiatric Complications
Seizures
Mild neuropathies
Fatigue
Weakness
Mild organic mental sx

32. Laboratory Abnormalities

33. Labs
Routine labs include:
CBC
Electrolytes
Serum glucose levels

34. Labs (cont) RBCs—low WBCs—low
Hgb and Hct elevated due to hemoconcentration
WBCs—low
Na, K, Cl—low in purging, diuretic, or laxative use
Serum glucose—low

35. Treatment of EDs

36. Rx
Cognitive behavioral therapy
Pharmacologic therapy

37. CBT
Use strategies designed to change the client’s thinking (cognition) and actions (behaviors) about food
Focus on:
Interrupting the cycle of dieting, binging, and purging
Altering dysfunctional thoughts and beliefs about food, weight, and body image

38. Pharmacology
SSRIs have shown success with weight maintenance and treatment resistant AN
Prozac and Celexa
Zyprexa—being researched to treat low weight and rx resistant individuals with high levels of anxiety
May need meds to treat co-morbid illness
WB--contraindicated

39. Refeeding Calorie calculation
25-35 kcl x current weight
Increase calories by kcl every 2-3 days (1-2 lb gain/week)
Fluid intake of at least 1500cc/day
Daily weights

40. Refeeding Syndrome
Greatest risk of cardiac complication is within the 1st two weeks of refeeding
The myocardium is less able to withstand the stress of increased metabolic demands because left ventricular mass and contractility have been reduced
Hypophosphatemia—causes decreased cardiac stroke volume
Electrolyte abnormalities

41. Recovery Long-term study of AN 50% fully recovered
25% had intermediate outcomes
10% still met criteria for AN
15% had died of causes r/t AN
Best indicator for recovery is return of menses

42. Recovery 50 % recover fully 20% continue to meet criteria for BN
30% have episodic bouts
Death rate with BN is estimated to be 0-3%