eating disorders

1: Eating disorders

Slide 2:*Strober and Humphrey (1987; see PIP p.842) found that relatives of those with eating disorders had a rate of these disorders four to five times higher in the rest of the population. *Holland et al. (1988; see PIP p.842) found concordance rates for anorexia of 56% in MZ twins compared with 7% in DZ twins. *Kendler et al. (1991; see PIP p.842) found a concordance rate for bulimia of 23% in MZ twins and 9% in DZ twins. *Strober and Humphrey (1987; see PIP p.842) found that relatives of those with eating disorders had a rate of these disorders four to five times higher in the rest of the population. *Holland et al. (1988; see PIP p.842) found concordance rates for anorexia of 56% in MZ twins compared with 7% in DZ twins. *Kendler et al. (1991; see PIP p.842) found a concordance rate for bulimia of 23% in MZ twins and 9% in DZ twins.

3: Anorexia Nervosa ARID A Amenorrhoea for 3 cycles R Refusal to maintain / gain weight > 85% expected I Intense fear gaining weight despite underweight D Disturbed self-image Diagnostic criteria for 307.1 Anorexia NervosaA. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% ofthat expected; or failure to make expected weight gain during period of growth,leading to body weight less than 85% of that expected).B. Intense fear of gaining weight or becoming fat, even though underweight.C. Disturbance in the way in which one's body weight or shape is experienced,undue influence of body weight or shape on self-evaluation, or denial of theseriousness of the current low body weight.D. In postmenarcheal females, amenorrhea, i.e., the absence of at least threeconsecutive menstrual cycles. (A woman is considered to have amenorrhea if herperiods occur only following hormone, e.g., estrogen, administration.) Restricting // Binge-Eating/Purging Type Amenorrhoea is due to abnormally low levels of estrogensecretion that are due in turn to diminished pituitary secretion of follicle-stimulatinghormone [FSH] and luteinizing hormone [LH] Associated features are: depressed mood, social withdrawal, irritability, insomnia, anddiminished interest in sex Other features sometimes associated with Anorexia Nervosa include concernsabout eating in public, feelings of ineffectiveness, a strong need to control one'senvironment, inflexible thinking, limited social spontaneity, and overly restrainedinitiative and emotional expression.Compared with individuals with Anorexia Nervosa, Restricting Type, those withthe Binge-Eating/Purging Type are more likely to have other impulse-controlproblems, to abuse alcohol or other drugs, to exhibit more mood lability, and to besexually active. Amenorrhoea is due to abnormally low levels of estrogensecretion that are due in turn to diminished pituitary secretion of follicle-stimulatinghormone [FSH] and luteinizing hormone [LH] Associated features are: depressed mood, social withdrawal, irritability, insomnia, anddiminished interest in sex Other features sometimes associated with Anorexia Nervosa include concernsabout eating in public, feelings of ineffectiveness, a strong need to control one'senvironment, inflexible thinking, limited social spontaneity, and overly restrainedinitiative and emotional expression.Compared with individuals with Anorexia Nervosa, Restricting Type, those withthe Binge-Eating/Purging Type are more likely to have other impulse-controlproblems, to abuse alcohol or other drugs, to exhibit more mood lability, and to besexually active.

4: Anorexia nervosa *Mean age of onset in DSM is 17 �suicide, starvation, electrolyte abnormalities*Mean age of onset in DSM is 17 �suicide, starvation, electrolyte abnormalities

5: Anorexia nervosa: predictors of outcome following 1st present.

6: Anorexia nervosa management From college CPGsFrom college CPGs

7: AN: criteria for inpatient mgt College CPGs Note for kids: HR<50 BP<80/60 Only rapid weight loss (no specific BMI) is specified.College CPGs Note for kids: HR<50 BP<80/60 Only rapid weight loss (no specific BMI) is specified.

8: AN: inpatient re-feeding

9: Re-feeding syndrome *Glucose intolerance can occur *Glucose intolerance can occur

10: Anorexia nervosa management

11: AN pharmacotherapy Cisapride is only approved for use in gastroparalysis under the supervision of a physicianCisapride is only approved for use in gastroparalysis under the supervision of a physician

12: AN pharmacotherapy The black at the bottom is the College�s overall guidelineThe black at the bottom is the College�s overall guideline

13: AN psychotherapies

14: Family therapy in AN

15: Bulimia Ox-hunger Nervosa BIAS B Binge: recurrent, uncontrollable, 2 per week for 3/12 I Inappropriate compensatory behaviour A Anorexia excluded S Self-evaluation influenced by body shape / weight Diagnostic criteria for 307.51 Bulimia NervosaA. Recurrent episodes of binge eating. An episode of binge eating ischaracterized by both of the following:(1) eating, in a discrete period of time (e.g., within any 2-hour period), an amountof food that is definitely larger than most people would eat during a similar period oftime and under similar circumstances(2) a sense of lack of control over eating during the episode (e.g., a feeling thatone cannot stop eating or control what or how much one is eating)B. Recurrent inappropriate compensatory behavior in order to prevent weightgain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or othermedications; fasting; or excessive exercise.C. The binge eating and inappropriate compensatory behaviors both occur, onaverage, at least twice a week for 3 months.D. Self-evaluation is unduly influenced by body shape and weight.E. The disturbance does not occur exclusively during episodes of AnorexiaNervosa. Purging // non-purging type Binge eatingis typically triggered by dysphoric mood states, interpersonal stressors, intensehunger following dietary restraint, or feelings related to body weight, body shape,and food Althoughindividuals with Bulimia Nervosa consume more calories during an episode ofbinge eating than persons without Bulimia Nervosa consume during a meal, thefractions of calories derived from protein, fat, and carbohydrate are similar. 80%-90% compensate by purging one-third of those with Bulimia Nervosa misuse laxatives Exercise may beconsidered to be excessive when it significantly interferes with important activities,when it occurs at inappropriate times or in inappropriate settings, or when theindividual continues to exercise despite injury or other medical complications. Substance Abuse or Dependence, particularly involving alcohol andstimulants, occurs in about one-third of individuals with Bulimia Nervosa. betweenone-third and one-half of individuals with Bulimia Nervosa also have personalityfeatures that meet criteria for one or more Personality Disorders (most frequentlyBorderline Personality Disorder). hypokalemia,hyponatremia, and hypochloremia. The loss of stomach acid through vomiting mayproduce a metabolic alkalosis (elevated serum bicarbonate), and the frequentinduction of diarrhea through laxative abuse can cause metabolic acidosis. Someindividuals with Bulimia Nervosa exhibit mildly elevated levels of serum amylase,probably reflecting an increase in the salivary isoenzyme. Serious cardiac andskeletal myopathies have been reported among individuals who regularly use syrupof ipecac to induce vomiting. Menstrual irregularity or amenorrhea sometimes occurs among females withBulimia Nervosa; whether such disturbances are related to weight fluctuations, tonutritional deficiencies, or to emotional stress is uncertain Rare butpotentially fatal complications include esophageal tears, gastric rupture, and cardiacarrhythmias. Female prevalence: 1%-3%, males 1/10 Kleine-Levinsyndrome, there is disturbed eating behavior, but the characteristic psychologicalfeatures of Bulimia Nervosa, such as overconcern with body shape and weight, arenot present. [Kleine-Levin syndrome is a rare disorder characterized by the need for excessive amounts of sleep (hypersomnolence), (i.e., up to 20 hours a day); excessive food intake (compulsive hyperphagia); and an abnormally uninhibited sexual drive. The disorder primarily affects adolescent males. When awake, affected individuals may exhibit irritability, lack of energy (lethargy), and/or lack of emotions (apathy). They may also appear confused (disoriented) and experience hallucinations. Symptoms of Kleine-Levin syndrome are cyclical. An affected individual may go for weeks or months without experiencing symptoms. When present, symptoms may persist for days to weeks. In some cases, the symptoms associated with Kleine-Levin syndrome eventually disappear with advancing age. However, episodes may recur later during life.????he exact cause of Kleine-Levin syndrome is not known. However, researchers believe that in some cases, hereditary factors may cause some individuals to have a genetic predisposition to developing the disorder. It is thought that symptoms of Kleine-Levin syndrome may be related to malfunction of the portion of the brain that helps to regulate functions such as sleep, appetite, and body temperature (hypothalamus). Some researchers speculate that Kleine-Levin syndrome may be an autoimmune disorder.]Binge eatingis typically triggered by dysphoric mood states, interpersonal stressors, intensehunger following dietary restraint, or feelings related to body weight, body shape,and food Althoughindividuals with Bulimia Nervosa consume more calories during an episode ofbinge eating than persons without Bulimia Nervosa consume during a meal, thefractions of calories derived from protein, fat, and carbohydrate are similar. 80%-90% compensate by purging one-third of those with Bulimia Nervosa misuse laxatives Exercise may beconsidered to be excessive when it significantly interferes with important activities,when it occurs at inappropriate times or in inappropriate settings, or when theindividual continues to exercise despite injury or other medical complications. Substance Abuse or Dependence, particularly involving alcohol andstimulants, occurs in about one-third of individuals with Bulimia Nervosa. betweenone-third and one-half of individuals with Bulimia Nervosa also have personalityfeatures that meet criteria for one or more Personality Disorders (most frequentlyBorderline Personality Disorder). hypokalemia,hyponatremia, and hypochloremia. The loss of stomach acid through vomiting mayproduce a metabolic alkalosis (elevated serum bicarbonate), and the frequentinduction of diarrhea through laxative abuse can cause metabolic acidosis. Someindividuals with Bulimia Nervosa exhibit mildly elevated levels of serum amylase,probably reflecting an increase in the salivary isoenzyme. Serious cardiac andskeletal myopathies have been reported among individuals who regularly use syrupof ipecac to induce vomiting. Menstrual irregularity or amenorrhea sometimes occurs among females withBulimia Nervosa; whether such disturbances are related to weight fluctuations, tonutritional deficiencies, or to emotional stress is uncertain Rare butpotentially fatal complications include esophageal tears, gastric rupture, and cardiacarrhythmias. Female prevalence: 1%-3%, males 1/10 Kleine-Levinsyndrome, there is disturbed eating behavior, but the characteristic psychologicalfeatures of Bulimia Nervosa, such as overconcern with body shape and weight, arenot present. [Kleine-Levin syndrome is a rare disorder characterized by the need for excessive amounts of sleep (hypersomnolence), (i.e., up to 20 hours a day); excessive food intake (compulsive hyperphagia); and an abnormally uninhibited sexual drive. The disorder primarily affects adolescent males. When awake, affected individuals may exhibit irritability, lack of energy (lethargy), and/or lack of emotions (apathy). They may also appear confused (disoriented) and experience hallucinations. Symptoms of Kleine-Levin syndrome are cyclical. An affected individual may go for weeks or months without experiencing symptoms. When present, symptoms may persist for days to weeks. In some cases, the symptoms associated with Kleine-Levin syndrome eventually disappear with advancing age. However, episodes may recur later during life.????he exact cause of Kleine-Levin syndrome is not known. However, researchers believe that in some cases, hereditary factors may cause some individuals to have a genetic predisposition to developing the disorder. It is thought that symptoms of Kleine-Levin syndrome may be related to malfunction of the portion of the brain that helps to regulate functions such as sleep, appetite, and body temperature (hypothalamus). Some researchers speculate that Kleine-Levin syndrome may be an autoimmune disorder.]

16: Bulimia Nervosa

17: Bulimia Nervosa - Treatment CBT: the only evidence based treatment Self-help CBT Psychoeducation Psychotherapy e.g. IPT Groups/ group therapy ?SSRI No evidence in youngsters Important if comorbid depression

18: Prognosis About half fully recover One quarter improve One quarter chronic PD, suicide attempts, alcohol abuse, low self-esteem negative prognostic factors No/contradictory evidence for other prognostic factors, including severity

19: Anorexia Nervosa: Physical Exam findings V= problems particularly associated with vomiting In addition to amenorrhea, there may be complaints of constipation,abdominal pain, cold intolerance, lethargy, and excess energy. The most obviousfinding on physical examination is emaciation. There may also be significanthypotension, hypothermia, and dryness of skin. Some individuals develop lanugo, afine downy body hair, on their trunks. Most individuals with Anorexia Nervosa exhibitbradycardia. Some develop peripheral edema, especially during weight restorationor on cessation of laxative and diuretic abuse. Rarely, petechiae, usually on theextremities, may indicate a bleeding diathesis. Some individuals evidence ayellowing of the skin associated with hypercarotenemia. Hypertrophy of the salivaryglands, particularly the parotid glands, may be present. Individuals who inducevomiting may have dental enamel erosion and some may have scars or calluses onthe dorsum of the hand from contact with the teeth when using the hand to inducevomiting.V= problems particularly associated with vomiting In addition to amenorrhea, there may be complaints of constipation,abdominal pain, cold intolerance, lethargy, and excess energy. The most obviousfinding on physical examination is emaciation. There may also be significanthypotension, hypothermia, and dryness of skin. Some individuals develop lanugo, afine downy body hair, on their trunks. Most individuals with Anorexia Nervosa exhibitbradycardia. Some develop peripheral edema, especially during weight restorationor on cessation of laxative and diuretic abuse. Rarely, petechiae, usually on theextremities, may indicate a bleeding diathesis. Some individuals evidence ayellowing of the skin associated with hypercarotenemia. Hypertrophy of the salivaryglands, particularly the parotid glands, may be present. Individuals who inducevomiting may have dental enamel erosion and some may have scars or calluses onthe dorsum of the hand from contact with the teeth when using the hand to inducevomiting.

20: Anorexia Nervosa: Investigation findings Hematology: Leukopenia and mild anemia (normochromic normocytic) are common; thrombocytopeniaoccurs rarely.osteoporosis (resulting from low calcium intake and absorption, reduced estrogensecretion, and increased cortisol secretion).Chemistry: Dehydration may be reflected by an elevated blood urea nitrogen(BUN). Hypercholesterolemia is common. Liver function tests may be elevated.Hypomagnesemia, hypozincemia, hypophosphatemia, and hyperamylasemia areoccasionally found. Induced vomiting may lead to metabolic alkalosis (elevatedserum bicarbonate), hypochloremia, and hypokalemia, and laxative abuse maycause a metabolic acidosis. Serum thyroxine (T) levels are usually in the low-normalrange; triiodothyronine (T) levels are decreased. Hyperadrenocorticism andabnormal responsiveness to a variety of neuroendocrine challenges are common.In females, low serum estrogen levels are present, whereas males have low levelsof serum testosterone. There is a regression of the hypothalamic-pituitary-gonadalaxis in both sexes in that the 24-hour pattern of secretion of luteinizing hormone (LH)resembles that normally seen in prepubertal or pubertal individuals.Electrocardiography: Sinus bradycardia and, rarely, arrhythmias are observed.Electroencephalography: Diffuse abnormalities, reflecting a metabolicencephalopathy, may result from significant fluid and electrolyte disturbances.Brain imaging: An increase in the ventricular-brain ratio secondary to starvation isoften seen.Resting energy expenditure: This is often significantly reduced.Hematology: Leukopenia and mild anemia (normochromic normocytic) are common; thrombocytopeniaoccurs rarely.osteoporosis (resulting from low calcium intake and absorption, reduced estrogensecretion, and increased cortisol secretion).Chemistry: Dehydration may be reflected by an elevated blood urea nitrogen(BUN). Hypercholesterolemia is common. Liver function tests may be elevated.Hypomagnesemia, hypozincemia, hypophosphatemia, and hyperamylasemia areoccasionally found. Induced vomiting may lead to metabolic alkalosis (elevatedserum bicarbonate), hypochloremia, and hypokalemia, and laxative abuse maycause a metabolic acidosis. Serum thyroxine (T) levels are usually in the low-normalrange; triiodothyronine (T) levels are decreased. Hyperadrenocorticism andabnormal responsiveness to a variety of neuroendocrine challenges are common.In females, low serum estrogen levels are present, whereas males have low levelsof serum testosterone. There is a regression of the hypothalamic-pituitary-gonadalaxis in both sexes in that the 24-hour pattern of secretion of luteinizing hormone (LH)resembles that normally seen in prepubertal or pubertal individuals.Electrocardiography: Sinus bradycardia and, rarely, arrhythmias are observed.Electroencephalography: Diffuse abnormalities, reflecting a metabolicencephalopathy, may result from significant fluid and electrolyte disturbances.Brain imaging: An increase in the ventricular-brain ratio secondary to starvation isoften seen.Resting energy expenditure: This is often significantly reduced.

21: Somatoform disorders Most management information comes from New Oxford Textbook 2000Most management information comes from New Oxford Textbook 2000

22: The sick role & behaviour � Illness behaviour can interact with the sick role in two ways: May determine whether the person will enter the sick role/seek help 2. May cause conflict with society/doctor (esp. if abnormal) around whether patient should be in the sick role or not� Illness behaviour can interact with the sick role in two ways: May determine whether the person will enter the sick role/seek help 2. May cause conflict with society/doctor (esp. if abnormal) around whether patient should be in the sick role or not

23: Factitous disorder & malingering

24: Somatization disorder

25: Other somatoform diagnoses

26: Conversion

27: Conversion *Per the New Oxford Textbook of Psychiatry!*Per the New Oxford Textbook of Psychiatry!

28: Pain disorder

29: Treatment of pain disorder

Slide 30:*As well as identifying misrepresentations of signs and symptoms & modifying dysfunctional assumptions. Barsky et al. Did RCT of 102 patients with 85 patients responding well*As well as identifying misrepresentations of signs and symptoms & modifying dysfunctional assumptions. Barsky et al. Did RCT of 102 patients with 85 patients responding well

31: Body dysmorphic disorder Seek mirrors etc. BUT may not help (as it may reinforce their view) Sees YOU but repeated �reassurance� is unhelpfu, as it only provides temporaRy beliefs Reponse prevention may involve stopping the patient from checking mirrorsSeek mirrors etc. BUT may not help (as it may reinforce their view) Sees YOU but repeated �reassurance� is unhelpfu, as it only provides temporaRy beliefs Reponse prevention may involve stopping the patient from checking mirrors

32: Somatoform disorders: Assessment Referrers should validate concerns and don�t call them mad i.e. use a non-confrontational approach It is better for physicians to use UPS (unexplained physical symptoms) than place a medical diagnostic label on the patient e.g CFS or FMS Experiences of illness and/or medical treatment throughout life (and esp. in childhood) or in one�s family or the media significantly affects the interpretation of bodily sensations. Referrers should validate concerns and don�t call them mad i.e. use a non-confrontational approach It is better for physicians to use UPS (unexplained physical symptoms) than place a medical diagnostic label on the patient e.g CFS or FMS Experiences of illness and/or medical treatment throughout life (and esp. in childhood) or in one�s family or the media significantly affects the interpretation of bodily sensations.

33: Somatoform disorders: General Principles of Management

34: Somatoform disorders: Specific Psychological Treatments * Allen, L. A., Escobar, J. I., Lehrer, P. M., Gara, M. A., & Woolfolk, R. L. (2002). Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosomatic Medicine, 64, 939�950* Allen, L. A., Escobar, J. I., Lehrer, P. M., Gara, M. A., & Woolfolk, R. L. (2002). Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosomatic Medicine, 64, 939�950

35: Somatoform disorders: medications

36: Factitous disorder: management *In 33 patients 12 admitted, nil psychologically disturbed by process No published studies of treatment for malingering, it may be wise to tell referrer rather than the patient about the diagnosis as they may become very angry (per New Oxford Textbook)! *In 33 patients 12 admitted, nil psychologically disturbed by process No published studies of treatment for malingering, it may be wise to tell referrer rather than the patient about the diagnosis as they may become very angry (per New Oxford Textbook)!

37: Chronic Fatigue Syndrome* No identified organic aetiology ? A condition of physical unfitness Moderate period of inactivity leads to physical deconditioning There is reduced exercise tolerance so moderate activity leads to tiredness Further rest leads to further deconditioning Frustration at all this can lead to bursts of activity which are very exhausting �leading to further rest This can be depressing Time away from social activities can lead to an anxiety disorder *Afari, N., & Buchwald, D. (2003). Chronic fatigue syndrome: A review. Amer ican Jour nal of Psychiatr y, 160, 221�236. *Afari, N., & Buchwald, D. (2003). Chronic fatigue syndrome: A review. Amer ican Jour nal of Psychiatr y, 160, 221�236.

38: CFS: interventions

39: CFS: graded exercise/CBT

40: Pseudocyesis