1. 1 One Size Does Not Fit All: An Overview of Eating Disorders Kristin Grasso, Psy.D. Clinical Psychologist and College Liaison

2. 2 Spectrum of Eating Disorders Diagnosable Disorder Disordered Eating “Normative Discontent”

3. 3 Risk Factors Female gender Female gender Ethnicity Ethnicity Weight and Shape factors Weight and Shape factors Psychiatric history Psychiatric history Genetic predispositions Genetic predispositions Participation in activities that promote thinness Participation in activities that promote thinness Certain personality traits Certain personality traits

4. What’s the risk of dieting? The more severely girls diet, the more likely they are to drink frequently and heavily, as well as to use marijuana and other illicit drugs Adolescent girls who engage in dieting have a 324% greater risk for obesity than those who do not diet (Stice et al., 1999). 95% of all dieters will regain their lost weight in 1- 5 years (Grodstein, 1996). 35% of "normal dieters" progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders. (Shisslak & Crago, 1995).

5. 5 Anorexia Nervosa Refusal to maintain minimum body weight Refusal to maintain minimum body weight Intense fear of gaining weight or becoming fat, even though underweight Intense fear of gaining weight or becoming fat, even though underweight Disturbance in experience of weight or shape, undue importance of weight or shape, or denial of seriousness of problem Disturbance in experience of weight or shape, undue importance of weight or shape, or denial of seriousness of problem Amenorrhea Amenorrhea

6. 6 Subtypes of AN Restricting Type: Restricting Type: –person does not engage in binge eating or purge behavior Binge Eating/Purging Type: Binge Eating/Purging Type: –person regularly engages in binge eating or purging (self-induced vomiting or misuse of laxatives, diuretics, or enemas)

7. 7 Bulimia Nervosa Recurrent episodes of binge eating Recurrent episodes of binge eating –Eating a large amount of food given the context –An associated sense of loss of control Recurrent inappropriate compensatory behavior Recurrent inappropriate compensatory behavior –E.g., purging, fasting, excessive exercise –Diuretics and laxatives

8. 8 BN cont’d Binge eating and compensatory behavior occur at least twice per week for 3 months Binge eating and compensatory behavior occur at least twice per week for 3 months Self-evaluation is unduly influenced by body shape and weight Self-evaluation is unduly influenced by body shape and weight Disturbance does not occur exclusively during episodes of anorexia nervosa Disturbance does not occur exclusively during episodes of anorexia nervosa

9. 9 Subtypes of BN Purging Type: Purging Type: –Regularly engages in self-induced vomiting, or the misuse of laxatives, diuretics, or enemas Non-Purging Type: Non-Purging Type: –Regularly engages in other inappropriate compensatory behaviors, i.e. fasting or excessive exercise, but has not regularly engaged in the above stated purging behavior

10. 10 ED-NOS Most common Most common Patient has clinically significant disorder, BUT does not meet AN or BN criteria Patient has clinically significant disorder, BUT does not meet AN or BN criteria Comparably severe in relation to AN and BN Comparably severe in relation to AN and BN

11. 11 Binge Eating Disorder Recurrent episodes of binge eating Recurrent episodes of binge eating Episodes are associated with 3 or more of the following: Episodes are associated with 3 or more of the following: –Eating more rapidly than normal –Eating until uncomfortably full –Eating large amounts when not hungry –Eating alone because of embarrassment about how much one is eating –Feeling disgusted with self, depressed, or guilty after overeating

12. 12 BED cont’d Marked distress regarding binge eating Marked distress regarding binge eating Binge eating occurs at least two days a week for 6 months Binge eating occurs at least two days a week for 6 months Binge eating is not associated with regular inappropriate compensatory behavior, and does not occur exclusively in course of AN or BN Binge eating is not associated with regular inappropriate compensatory behavior, and does not occur exclusively in course of AN or BN

13. 13 What’s the difference? AN trumps BN AN trumps BN Presentation of AN vs. BN Presentation of AN vs. BN The dieting factor The dieting factor Binge Eating Disorder and obesity Binge Eating Disorder and obesity

14. “Drunkorexia” and other terms to be aware of…

15. 15 Prevalence Anorexia:.5-1% Anorexia:.5-1% Bulimia: 1-3% Bulimia: 1-3% Binge Eating Disorder:.7-4% Binge Eating Disorder:.7-4%

16. 16Etiology The etiology of eating disorders is multi- factorial, with importance of specific factors varying with each individual The etiology of eating disorders is multi- factorial, with importance of specific factors varying with each individual

17. 17 Men and Eating Disorders 10% of eating disordered 10% of eating disordered individuals are male individuals are male There is a greater stigma There is a greater stigma for males than females for males than females Eating disorder behavior Eating disorder behavior can present differently can present differently in males in males

18. 18 Beyond Food… Beyond Food… Eating disorders appear to be all about food…they are not. Eating disorders appear to be all about food…they are not. Simply eating more/less will not make things better and often, when someone begins to eat, things get harder Simply eating more/less will not make things better and often, when someone begins to eat, things get harder Issues related to control, coping with emotions, self- esteem, guilt and shame, etc will become MORE intense as someone stabilizes Issues related to control, coping with emotions, self- esteem, guilt and shame, etc will become MORE intense as someone stabilizes

19. 19 Common Comorbid Disorders Major Depressive Disorder or Dysthymia Major Depressive Disorder or Dysthymia –50-75% Anxiety Disorders Anxiety Disorders –64% Sexual Abuse Sexual Abuse –20-50% Obsessive-Compulsive Disorder Obsessive-Compulsive Disorder –25% (AN); 41% overall Substance Abuse Substance Abuse –12-18% (AN); 30-37% (BN) Bipolar Disorder Bipolar Disorder –4-13%

20. 2020 Health Consequences Anorexia Anorexia –Abnormally slow heart rate & blood pressure –Reduction of bone density –Muscle loss, weakness –Severe dehydration –Anemia, Leukopenia –Reproductive consequences –5-20% mortality rate PHYSICAL SIGNS: lanugo, headaches, feeling cold, tingling in extremities, feeling faint, dry skin, hair loss

21. 2121 Health Consequences Bulimia Bulimia –Electrolyte Imbalances –Esophageal tears –Ulcers –Salivary gland enlargement –Dental Disease PHYSICAL SIGNS: headaches, fatigue, tingling in extremities, feeling faint, sore throat and swollen glands, Russell’s sign, dental problems

22. 22 Health Consequences BED BED –High blood pressure –High cholesterol levels –Heart disease as a result of elevated triglyceride levels –Secondary diabetes –Gallbladder disease PHYSICAL SIGNS: temperature irregularities, joint pain, decreased endurance and fatigue

23. 23 Treatment: Anorexia Psychopharmacoloy: Psychopharmacoloy:  interventions typically recommended after weight restoration  Medication can begin earlier with focus on maintaining weight and normalizing eating Psychological Psychological  Insufficient evidence regarding psychological interventions  CBT, IPT, Family Therapy 23

24. 24 Treatment: Bulimia Psychopharmacology Psychopharmacology  reduce frequency of disturbed eating behaviors.  FDA approved medication for BN: fluoxetine (Prozac)  Bupropion (Wellbutrin) has been associated with seizures in purging bulimic patients and its use is not recommended. Psychological Psychological  First line is CBT  IPT and DBT 24

25. 25 General Treatment Issues Require multidisciplinary approach Require multidisciplinary approach  Nutritional counseling and medication must not be sole treatment Psychotherapy will generally require at least 1 year and most likely longer Psychotherapy will generally require at least 1 year and most likely longer Specialist in Eating Disorders preferred over general practitioner Specialist in Eating Disorders preferred over general practitioner 25

26. 26 Levels of Care Inpatient Inpatient Partial Hospitalization Partial Hospitalization Intensive Outpatient Intensive Outpatient Outpatient Outpatient

27. 27 Indicators for Hospitalization In general: In general: –individual is below estimated healthy weight –Rapid, persistent decline in oral intake or weight and/or or uncontrollable purging –weight at which physical instability is likely to occur –Serious medical abnormalities –Comorbid psychiatric issues that warrant increased support 27

28. 28 Prognosis Anorexia Anorexia –50% recover –33% improve somewhat –20% remain chronically ill **mortality is 6x peers without anorexia and is the highest of any psychiatric illness!! Bulimia Bulimia –50% recover –18-30% improve somewhat –20% continue to meet full criteria

29. 29 References Deshmukh, R. & Franco, K. (2003). Eating Disorders. Retrieved December 9, 2006, http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating. htm Deshmukh, R. & Franco, K. (2003). Eating Disorders. Retrieved December 9, 2006, http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating. htm http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating. htm http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating. htm Grodstein, F., Levine, R., Spencer, T., Colditz, G.A., Stampfer, M. J. (1996). Three- year follow-up of participants in a commercial weight loss program: can you keep it off? Archives of Internal Medicine. 156 (12), 1302. National Eating Disorders Association's Information website: www.NationalEatingDisorders.org Practice Guideline for the Treatment of Patients with Eating Disorders (3 rd Edition) http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisord ers3ePG_04-28-06 Practice Guideline for the Treatment of Patients with Eating Disorders (3 rd Edition) http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisord ers3ePG_04-28-06 http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisord ers3ePG_04-28-06 http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisord ers3ePG_04-28-06 Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209-219. Stice, E., Cameron, R., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight reduction efforts prospectively predict growth in relative weight and onset of obesity among female adolescents. Journal of Consulting and Clinical Psychology, 67, 967-974.

30. 30 For More Information: http://www.nationaleatingdisorders.org http://www.nationaleatingdisorders.org http://www.nationaleatingdisorders.org –NEDA Educator Toolkit http://www.eatingdisorders.org http://www.eatingdisorders.org http://www.eatingdisorders.org –The Center for Eating Disorders at Sheppard Pratt http://www.something-fishy.org http://www.something-fishy.org http://www.something-fishy.org Handbook of Treatment for Eating Disorders: 2 nd Edition by David Garner Ph.D. and Paul E. Garfinkel, M.D. Handbook of Treatment for Eating Disorders: 2 nd Edition by David Garner Ph.D. and Paul E. Garfinkel, M.D.