1. EATING DISORDERS Review Course in Psychiatry University of Ottawa 2012 Dr. Wendy Spettigue, Associate Professor and Dr. Clare Roscoe, Assistant Professor University of Ottawa wspettigue@cheo.on.ca

2. Eating Disorders Overview Epidemiology Diagnosis Understanding Eating Disorders – Etiology, Risk Factors, and Power Medical Complications Principles of Treatment Outcome

3. Epidemiology: Prevalence A.N. 0.5-1%(for strictly defined) B.N. 1-3% EDNOS 3-10% ♀ : ♂ 10 : 1 Onset –A.N.: 13-20 yrs (peaks at 14 and 18 yrs) : 5% present after 20 years of age –B.N.: 16.5-19 yrs old

4. Types of Eating Disorders 1.Anorexia Nervosa –Restricting Type –Binge-Eating/Purging Type 2.Bulimia Nervosa − Purging Type − Nonpurging Type 3.Eating Disorder NOS

5. Definitions: Anorexia Nervosa A. Refusal to maintain body weight 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

6. Common Symptoms of A.N.: Restricting intake Exercising Standing, moving, restlessness Self-induced vomiting Diet pills, laxatives

7. Anorexia Nervosa cont’d Specify: –Restricting Type –Binge-Eating / Purging Type Purging - Vomiting - Laxatives - Diuretics - Enemas

8. Bulimia Nervosa A. 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…)

9. 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.

10. Bulimia Nervosa Cont.. Specify: –Purging Type –Nonpurging Type

11. The Bulimic Cycle A binge is almost always the result of dieting and food restriction. Purging is the result of: –Fear of weight gain –The perception of stomach discomfort –Shame caused by the loss of control over eating Restrict Binge Purge

12. Eating Disorder NOS (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 binge-eating and above 85%ile for weight –Binge Eating Disorder will be a new diagnostic category in the next DSM

13. Understanding Eating Disorders Rates of body dissatisfaction are > 85% in females, and 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?

14. Eating Disorders: Eating disorders are not a fad or phase, and not the same as dieting Eating disorders are severe mental illnesses with significant medical risks Eating disorders are not the fault of the parents or the child

15. The Development of an ED Vulnerable Youth -Risk factors -Comorbidities -Low self-esteem Stressors Need to Gain Control / Feel Better Dieting Sense of Achievement Increased Dieting Snowballing of behaviours Eating Disorder

16. Risk Factors for AN IndividualFamilyCultural Female GenderFamily History of ED / Anxiety / Mood disorder / OCPD Idealization of thinness, “normative discontent” for female body image Perfectionism / Obsessionality/ “harm avoidance” Early life: “high concern parenting” Gay males Low self-esteem / Sense of ineffectiveness Lack of family mealsActivity where thinness = success e.g. modeling / acting Eagerness to please / High sensitivity/ self- consciousness Competitive sports with emphasis on thinness: e.g.. gymnastics / ballet PubertyPeer group that over- values appearances

17. Risk Factors for BN IndividualFamilyCultural FemaleFamily Hx of obesityIdealization of thinness Low self-esteem / Sense of ineffectiveness Family Hx of Mood /Anxiety / ED / or Substance Abuse / Cluster B PD Specific sports / activities as AN Critical comments re. weight / shape / eating Hx of sexual abuse Volatile / conflicted family environments

18. Co-Morbidity of A.N.: 50-65% Depression (i.e. #1 comorbidity) >50% Anxiety Disorders (esp. GAD, Social Phobia and OCD) Perfectionism “Cluster ‘C’ P.D. traits, e.g.. OCPD (rigidity, restraint, obsessiveness)

19. Comorbidity of B.N.: Depression 50-65%, #1 comorbidity Anxiety in >50% (esp. GAD and Social Phobia) Substance Abuse Impulsivity/risk-taking behaviors Borderline Personality Disorder traits PTSD Bipolar Spectrum disorders

20. E.D. Spectrum A.N.-------------A.N./B-P--------------B.N. Perfectionistic Chaotic Compliant Unstable moods Anxious Substance abuse Sensitive Impulsive Possible OCPD Possible BPD

21. Understanding Eating Disorders:

22. Eating Disorders come from: Feeling “not good enough” Feeling worried or stressed Feeling “out of control” Feeling you don’t deserve good things Feeling like you should keep your problems to yourself / not burden others Wanting to be accepted and liked Not wanting to give others something to criticize or tease you about

23. The Development of an ED Vulnerable Youth -Risk factors -Comorbidities -Low self-esteem Stressors Need to Gain Control / Feel Better Dieting Sense of Achievement Increased Dieting Snowballing of behaviours Powerful Eating Disorder

24. i.e. What makes an Eating Disorder so Strong?

25. What an Eating Disorder does…. Complete preoccupation with food and weight Isolation Give up or dramatically alter relationships with family and friends Effects on school / work Effects on sports / hobbies

26. Why so powerful? Understanding the Eating Disorder Effects of starvation The Meaning of the Eating Disorder An illness by nature that creates denial / poor insight

27. Effects of Starvation Ancel Keys, University of Minnesota, during WWII Psychologically “Normal” men, with superior “psychobiological stamina”  Semi-starvation (lost 25% body weight)

28. Effects of Starvation Change of Eating Habits –Started to eat in silence, prolonged time, unusual mixing of food Social Changes –Men became withdrawn, decrease wish to socialize, lack of interest in sex or intimacy –Less humour Cognitive Changes –Impaired concentration –Impaired comprehension and judgment

29. Effects of Starvation Emotional Changes –Depression –Irritability –Frequent outbursts of anger –Extreme mood swings –Social withdrawal –High levels of anxiety (including nail biting) –Almost 20% experienced extreme emotional deterioration, even psychosis (some hospitalized) –Most changes persisted through refeeding, became worse for some

30. Sadness Shame Guilt Fear Emptiness Powerless FAT Weight control Powerful The Power of an Eating Disorder:

31. The Meaning of the Eating Disorder The Eating Disorder is one thing I am good at Not eating pushes my other worries away The Eating Disorder makes me feel powerful, special and in control The Eating Disorder means I don’t have to grow up Eating means I am weak and a failure The Eating disorder is who I am

32. Medical Complications of Eating Disorders

33. Eating Disorders affect the whole body Brain, thinking, cognitions Hair Dental Disease Heart Fluids/ electrolytes Muscles, bones Kidneys GI system Hormones Skin

34. Eating Disorders can..… Result in heart arrhythmias which, in severe cases can be fatal. Result in structural brain changes Cause osteoporosis (poor bone health) Delay puberty Stop/ Stunt Growth Interfere with pregnancy

35. Medical Complications of Eating Disorders SystemStarvationPurge CVLow BP, low HR, small heart, QTc prolongation, cardiac arrest Arrhythmias (K), cardiac arrest Metabolic / HemeHypothermia, Anemia, Leukopenia, poor immunity Metabolic alkalosis, hypokalemia

36. Electrocardiograms (EKGs) QTc NormalMalnourishment

37. Medical Complications SystemStarvationPurge Reprod.Amenorrhea, Infertility, complications in pregnancy Amenorrhea (or oligomenorrhea), infertility DermDry skin and hair, lanugo hair Russell’s sign, enlarged parotid glands, perioral skin irritation, periocular petechiae GIConstipationHematemesis, esophagitis, reflux, poor muscle tone in colon (laxative abuse)

38. Medical Complications SystemStarvationPurge MSKMuscle wasting, Osteoporosis, short stature Dental erosion, muscle cramps (low K) RenalPre-Renal failure (dehydration) Pre-Renal failure (dehydration) CNS  concentration, severe mood changes,  white & gray matter  concentration, severe mood changes

39. Osteoporosis Resorption (losing) > Deposition (gaining) Absolute Bone Mineral Density Low

40. Structural brain changes MRI Findings - Katzman et al, 1996 Adolescent Females Controls 14 years 15 years 16 years Adolescent Females With AN

41. Labs in Eating Disorders:  BUN (dehydration) Amylase (vomiting) Cholesterol (starvation)  Na, K, CL (vomiting/laxatives) LH, FSH, estrogen (starvation) RBCs (starvation) WBCs (starvation) T3

42. Refeeding Syndrome May occur within 4 days, in severely malnourished pts (<70% IBW) During starvation: There is a an intracellular loss of electrolytes, in particular phosphate. With feeding, insulin is secreted This stimulates cellular uptake of phosphate (and other electrolytes), which can lead to profound hypophosphataemia.

43. Refeeding Syndrome  Phosphate < 0.50 mmol/l (normal range 0.85-1.40 mmol/l) –rhabdomyolysis, leukocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death Therefore initial feeding must be slow and gradual, with careful medical monitoring, and possible phosphate supplementation

44. Clinical features of a Patient at Higher Risk of Death 1.Very low weight at admission 2.Bradycardia 3.No medical follow-up 4.Longer duration of illness 5.Multiple purging methods 6.Chronic self-harm or suicide attempts 7.Amphetamine or cocaine use 8.Severe alcohol abuse

45. Eating Disorders Overview Epidemiology Diagnosis Understanding Eating Disorders – Etiology, Risk Factors, and Power Medical Complications Principles of Treatment Outcome

46. Principles of Treatment for Eating Disorders

47. Key Treatment Principles: Specialized, multi-disciplinary team Meet the medical, nutritional and psychological needs of the patient Medical stabilization and renourishment is necessary but not sufficient Match severity of illness to intensity of treatment Structured meals, with goal of normalized eating Combine psychoeducation with therapy For adults or adolescent BN: group therapy or individual therapy For adolescent AN: Family-based Therapy

48. AN – Initial Assessment Start with a thorough assessment [I] a.Therapeutic alliance & positive regard b.Biopsychosocial formulation using a non- blaming model c.May take several hours d.Essential involvement of family for children and adolescents e.Involvement of multidisciplinary team (dietician, other physicians, social work etc)

49. AN- Initial assessment Choosing a treatment setting  Inpatients  Day Program (5 days / week, 8 hours day)  Outpatients

50. Treatment of Anorexia Nervosa: Medical and Nutritional: –reversal of the effects of starvation; re-feeding –“food is the medicine” –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

51. Treatment of A.N. cont’d: Psychological Therapeutic Alliance Supportive, compassionate, empathic Understanding the illness, education Externalize the illness, lift blame and shame, challenging ED Motivational techniques; exploring pros and cons, comparing to OCD Exploring and treating co-morbidities

52. Treatment of A.N. cont’d: –Family Therapy for Children and Adolescents (evidence based) –CBT; IPT; motivational therapy; groups

53. AN - Medication SSRI’s / antidepressants –do not seem to work in context of malnourishment [I] –With weight restoration – treating underlying comorbidities [I] Atypical antipsychotics –Limited evidence (help with obsessionality) [II] –Need to monitor for side effects Benzos –May help with anxiety prior to a meal [III]

54. Treatment of BN - Goals 1.Reduce and if possible eliminate binge eating and purging 2.Treat physical complications 3.Enhance motivation for Rx 4.Provide education (nutrition & normalized eating) 5.Help pts to reassess & change core dysfunctional thoughts, attitudes, motives, conflicts and feelings related to the ED

55. Treatment of BN - Goals 6.Treat co-morbid psychiatric conditions, including deficits in mood and impulse regulation, self-esteem and behaviour. 7.Enlist family support and provide counseling & therapy where appropriate. 8.Prevent relapse

56. Nutritional Structured meal plan [I] –Prevents binges and purges Assess nutritional intake for pts with all BMI’s (even “normal”), normal weight does not ensure appropriate intake or body composition [I] Nutritional education [I]

57. Psychological CBT: Strong support [I] IPT: Additional support [II] (Both individual and group) DBT: growing evidence Practically, in clinical practice, therapists combine CBT, IPT and other psychodynamic techniques. This combination may  better outcomes [II]

58. Psychological Self-help (& professionally guided self- help) programs [I] Family therapy for children and youth [II] Treatment of co-morbidities, eg. Substance abuse, PTSD…

59. BN - Medication SSRI: fluoxetine best evidence [I] –Reduces binge eating, purging and psychological features of ED –Higher doses than needed for MDE (e.g. 60) [I] –Recommend continuing for 9months – 1 year after symptom-free [II] Bupropion: Contraindicated because of seizure risk

60. Eating Disorders Overview Epidemiology Diagnosis Understanding Eating Disorders – Etiology, Risk Factors, and Power Medical Complications Principles of Treatment Outcome

61. Outcome for AN High morbidity and mortality (among highest of all psychiatric illnesses) Mortality: 5-20% –50% suicide –50% medical complications

62. Outcome for AN Prognosis in Adolescents: –50-70% full recovery in 5 years –10-20% develop chronic AN Prognosis in Adults: –50% “recover” –25% intermediate outcome –25% poor outcome

63. Outcome for B.N. Better treatment outcomes compared to A.N. Up to 70% recover with treatment 15-20% intermediate outcome 10-15% continue to do poorly

64. A.N.  B.N. A.N.  B.N. 50% of AN-R develop bulimic symptoms within 5 years of weight recovery (Crossover from B.N.  A.N. is rare)

65. 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.

66. 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

67. www. nedic.ca

68. References APA Guidelines, Practice Guideline for the Treatment of Patients with Eating Disorders, Third Edition, 2006 http://www.psychiatryonline.com/pracGuide/pracG uideTopic_12.aspx NICE Guidelines, Eating Disorders, Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders, January 2004 http://guidance.nice.org.uk/CG9

69. References Review of Outcome Research in Eating Disorders, International Journal of Eating Disorders, 40:4, May 2007. (Entire journal) Klump K et al, Academy for Eating Disorders Position Paper: Eating Disorders are Serious Mental Illnesses, International Journal of Eating Disorders, 42:2, p97-103, 2009. Le Grange D et al, Academy for Eating Disorders Position Paper: The Role of the Family in Eating Disorders, International Journal of Eating Disorders, 43:1, p1-5, 2010. Rosen, David, Identification and Management of Eating Disorders in Children and Adolescents, Pediatrics, Vol. 126 No. 6 December 2010, pp. 1240-1253

70. 1.What is the prevalence of Anorexia Nervosa in women? 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.True b.False

71. 3. First line treatment for Anorexia Nervosa in the weight restoration phase is: a. an SSRI b. an appetite stimulant c. none of the above 4. First line treatment for Bulimia Nervosa includes: a.an SSRI b.CBT c.all of the above