Eating Disorders

1. Eating Disorders Dr Jackie Hoare Liaison Psychiatry GSH

2. Anorexia nervosa (AN) • is an illness characterised by extreme concern about body weight • with serious disturbances in eating behavior • leading to a self-imposed starvation state • Severe weight loss. • Body image becomes the predominant measure of self-worth • denial of the seriousness of the illness.

3. International Classification of Diseases, revision 10(ICD-10) (WHO 1992), • (a) refusal to maintain weight within the normal range for height and age • (b) fear of weight gain; • (c) body image disturbance • (d) absence of menstrual cycles or • amenorrhea in women (and loss of sexual interest in men).

4. Important Changes in Eating Disorder Diagnoses in DSM-V • Criterion A focuses on behaviors, like restricting calorie intake • But no longer includes the word ‘refusal’ • in terms of weight maintenance since that implies intention on the part of the patient • The DSM-IV Criterion requiring amenorrhea, is deleted. • This criterion cannot be applied to males, children, OC, and post-menopausal females. • exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity

5. DSM V • All 3 of the following: • Energy restriction leading to significantly low body weight • Fear of weight gain or behavior interfering with weight gain • Disturbance in self perceived weight or shape

6. Subtypes and severity • Restricting type • Binge eating /purging type; recurrent episodes of bingeing or purging in the last 3 months • Mild BMI>17 kg/m2 • Moderate 16-16.9 • Severe 15-15.9 • Extreme <15

7. General guidance • Few controlled trials to guide treatment • Weight restoration, family therapy and structured psychotherapy • Improve nutritional health – refeeding • Drugs can be used to treat co-morbid conditions • Limited role in weight restoration • Phosphate, K+, thiamine, Mg, Ca2+ supplementation in oral form

8. Refeeding syndrome • Can occur in any individual who has had negligible nutrient intake for >5 consecutive days • occurs within four days of starting to feed • develop fluid and electrolyte disturbances • results in a decrease in the serum levels of phosphate, potassium, and magnesium, all of which are already depleted. • Causing cardiac arrhythmia, respiratory failure, neuromuscular junction conduction failure

9. Starvation • hormonal and metabolic changes are aimed at preventing protein and muscle breakdown. • use fatty acids as the main energy source. • increase in blood levels of ketone bodies • brain to switch from glucose to ketone bodies as its main energy source. • The liver decreases its rate of gluconeogenesis, thus preserving muscle protein. • several intracellular minerals become severely depleted • serum concentrations of these minerals (including phosphate) may remain normal. • reduction in renal excretion.

10. Refeeding • During refeeding, glycaemia leads to increased insulin and decreased secretion of glucagon. • Insulin stimulates glycogen, fat, and protein synthesis. • Insulin stimulates the absorption of potassium into the cells through the sodium-potassium ATPase symporter, which also transports glucose into the cells. • Magnesium and phosphate are also taken up into the cells. • Water follows by osmosis. • These processes result in a decrease in the serum levels of phosphate, potassium, and magnesium • The clinical features of the refeeding syndrome occur as a result of the functional deficits of these electrolytes and the rapid change in basal metabolic rate.

11. Treatment • Refeeding syndrome can be fatal if not recognized and treated properly. • An awareness of the condition and a high index of suspicion are required in order to make the diagnosis. • The electrolyte disturbances can occur within the first few days • Close monitoring of blood biochemistry is therefore necessary in the early refeeding period. • rate of feeding should be slowed down and essential electrolytes should be replenished. • Fluid repletion should be carefully controlled to avoid fluid overload

12. Osteoporosis • Bone loss complication serious consequences • Hormonal treatment with oestrogen or dehydroepiandrosterone(DHEA) no positive effect on bone density • Oestrogen not recommended in children and adolescents – risk premature fusion of bones

13. Acute illness: antidepressants • 2009 Cochrane review: no evidence from 4 placebo controlled trials • On weight gain, eating disorder or associated psychopathology • Suggested neurochemical abnormalities in starvation may explain non-response • Co-prescribing supplementation incl. tryptophan with fluoxetine does not increase efficacy

14. Other psychotropic drugs • Olanzapine, benzodiazepines or promethazine to reduce anxiety with refeeding • 1 RCT showed 88% of patients given olanzapine achieved weight restoration (55% placebo) • Quetiapine may improve psychological symptoms but few data

15. Relapse prevention and co-morbid disorders • Small trial suggested that fluoxetine useful in improving outcome and preventing relapse after weight restoration • Other studies found no benefit • Antidepressants often used to treat co-morbid depression and OCD • However these conditions may resolve with weight gain alone

16. Avoidant/restrictive food intake disorder • Significant disturbance in eating manifested by persistent failure to meet nutritional/energy requirement associated with 1 of: • Significant weight loss • Significant nutritional deficiency • Dependence on enteral feeding or supplements • Interference with psychosocial functioning • NOT due to lack of food or body image disturbance

17. Clinically Significant Restrictive Eating Problems Are Key • Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood and EDNOS which was described in the DSM-IV. • While few data on ARFID have been published, it appears that it usually presents in infancy or childhood, but it can also present or persist into adulthood. • The course of illness for individuals relatively unknown. • Avoidance due to sensory characteristics of food, emotional difficulties, food beliefs etc. • ARFIDmay be associated with impaired social functioning and affect family functioning, especially if there is great stress surrounding mealtimes.

18. Distinguishing ARFID from Other Disorders • The presence of other psychological disorders may be risk factors for ARFID, such as anxiety disorders, obsessive-compulsive disorders, attention deficit disorders, and autism spectrum disorders • If an individual presents with one of these illnesses and an eating problem, a diagnosis of ARFID should be given only when the feeding disturbance itself is causing significant clinical impairment • individuals with a history of gastrointestinal conditions such as gastroesophageal reflux may develop feeding disturbances, but a diagnosis of ARFID should be assigned only when the feeding disturbances require significant treatment beyond that needed for the gastrointestinal problems.

19. Treating ARFID • Little is currently known about effective treatment interventions for individuals presenting with ARFID • given the prominent avoidance behaviors, it seems likely that behavioral interventions, such as forms of exposure therapy • depression or anxiety that affects feeding, cognitive behavioral therapy and other treatments for the underlying condition

20. Bulimia nervosa • Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food • feeling a lack of control over the eating. • purging (e.g., vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise • DSM-5 criteria reduce the frequency of binge eating and compensatory behaviors to once a week from twice weekly as specified in DSM-IV.

21. BN treatment • Psychological treatments first choice • Adults mat be offered antidepressants • SSRI’s esp fluoxetine • 60mg effective dose • Can reduce frequency of binge eating and purging • Long term effects unknown • Early response at 3 weeks strong indicator of response overall • Used off licensed in adolescents • Some evidence for topiramate, duloxetine, lamotrigineand sertraline reduce binges

22. Binge eating disorder • Binge eating disorder will now have its own category as an eating disorder. • In the DSM-IV, under the category Eating Disorder Not Otherwise Specified • “recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes accompanied by feelings of lack of control.”  • eat quickly and uncontrollably, despite hunger signals or feelings of fullness. • feelings of guilt, shame, or disgust • behavior will have typically taken place at least once a week over a period of three months.

23. BED treatment • NICE recommends • Evidenced based self help programme of CBT as first line • Trial of SSRI as an alternative or additional first step

24. Although AN is not a common condition • its morbidity and mortality are amongst the highest psychiatric disorders • due to malnutrition, purging • behavior and suicide. • 18-fold increase in mortality in patients with AN

25. Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa: Implications for DSM-VKamryn T. Eddy, • Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa

26. Conclusion • Key is MDT • Dietician, psychology, medicine, psychiatry, OT and social worker • Clearly defined case manager , roles of team members in case defined