1. EATING DISORDERS ANDREW P. LEVIN, MD SAINT VINCENT’S WESTCHESTER HARRISON, NY

2. Essential Features of Eating Disorders Disturbance in perception of body weight, size, or shape Behavioral efforts to control or lose weight in response to perceptions of body.

3. Associated Features of Eating Disorders Mood and anxiety symptoms Distorted Cognitions Emotional and physical developmental delays Physical complications Relationship to trauma

4. Mechanisms of Appetite and Satiety Cephalic phase Central control areas Termination of eating Eating disorder –Uncoupling of eating behavior and motivation. –Uncoupling of eating behavior and plasma Endogenous opiate system Serotonin system

5. Eating Disorder History Weight history Daily eating pattern Self-appraisal Loss of control Use of eating/binging/purging diary

6. Anorexia Nervosa in DSM-IV Refusal to maintain weight at 85% of minimum for height and age. Intense fear of gaining weight or becoming fat, even though underweight. Disturbance in body perception Amenorrhea in postmenarchy

8. Anorexia Nervosa in DSM-IV (con’t) Subtypes: – Restricting (low intake only) –Binge-Eating/Purging Type (these new in DSM-IV)

9. Associated features of Anorexia Nervosa Epidemiology Associated psychiatric conditions – Perfectionistic style –Major depressive disorder –Obsessive-compulsive disorder –Starvation syndrome

10. Associated features of Anorexia Nervosa (con’t) Family Dynamics – Enmeshment –Overprotection –Conflict avoidance –Rigidity –Conflict Detouring

13. Associated features of Anorexia Nervosa (con’t) Medical Complications –Gasterointestinal –Cardiovascular –Renal –Endocrine –Systemic Longterm outcome--mortality rate approximately 10%

15. Principles of Treatment in Anorexia Nervosa Medical evaluation and stabilization Laboratory evaluation Physical exam with focus on hydration Rehydrate and correct electrolytes

16. Principles of Treatment in Anorexia Nervosa (con’t) Refeeding-- “food is the best medicine” –Inpatient--controlled eating environment –Outpatient--difficulty in maintaining eating –Try to minimize cues Individual and family therapies Psychopharmacologic interventions –Appetite stimulants –Antidepressants –Benzodiazepines and neuroleptics

17. Bulimia Nervosa in DSM-IV Recurrent episodes of binge eating Recurrent inappropriate compensatory behavior (maintain wt. above 85% IBW) Binge/compensation cycle at least twice per week Self-evaluation by body weight and shape Types: –Purging--vomiting, laxative, diuretics, enemas. –Non-purging--exercise or fasting

18. Associated features of Bulimia Nervosa Epidemiology –Onset--late adolescence or early adulthood, learned from peers. –Premorbid obesity –Industrialized countries –Female:Male 9:1

22. Associated features of Bulimia Nervosa (con’t) Psychiatric Complications –Incidence of Major depressive disorder –Substance abuse 20-30%. –Labile, low frustration tolerance, poor self- soothing, high anxiety

23. Associated features of Bulimia Nervosa (con’t) Medical complications –Gastrointestinal –Dental –Electrolyte abnormalities –Endocrine

24. Principles of treatment in Bulimia Nervosa Similar to Anorexia Nervosa in terms of medical evaluation. Dietary normalization stresses control of intake Cognitive behavioral therapy is guiding principle Individual and family therapy

25. Principles of treatment in Bulimia Nervosa (con’t) Careful attention to substance abuse issues. 12-step groups such as Over Eaters Anonymous Pharmacotherapy

26. Eating Disorder NOS Features of Eating Disorder without full criteria Binge Eating Disorder Trauma related eating disorder Obesity