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Eating Disorders. Babatunde Idowu Ogundipe M.D. M.P.H. Comprehensive Clinical Services P.C. August 19 2011. Eating Disorders. I llnesses in which the victims suffer severe disturbances in their eating behaviors and related thoughts and emotions.
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Eating Disorders BabatundeIdowuOgundipe M.D. M.P.H. Comprehensive Clinical Services P.C. August 19 2011
Eating Disorders • Illnesses in which the victims suffer severe disturbances in their eating behaviors and related thoughts and emotions. • Typically become obsessed with food & their body weight. • Affects several million people at any given time, most often women between the ages of 12 &35. • There are two main types of eating disorders, anorexia nervosa and bulimia nervosa; a third disorder, binge eating disorder, is still being examined. • People with anorexia nervosa and bulimia nervosa tend to be perfectionists, suffer from low self-esteem & are extremely critical of themselves and their bodies. They usually “feel fat” and see themselves as overweight, sometimes even despite life-threatening semi-starvation (or malnutrition). • An intense fear of gaining weight and of being fat may become all pervasive. • In early stages often deny that they have a problem.
Anorexia Nervosa • Eating disorder characterized by disturbed body image & severe self-imposed dietary restrictions. • Clinical Features: • Body weight 15% below normal for patients age & height. • Intense fear of being fat in spite of being underweight. • A distorted body perception in which patient experiences him/herself as fat although emaciated. • Loss of > 3 consecutive menstrual periods because of starvation. trendsla.wordpress.com
Anorexia Nervosa Epidemiology • Potentially fatal disorder. Mortality from suicide/medical complications is 10%. • Major depression is common comorbid condition. • Begins between ages 13-20(peaks 14-19). Peak incidences at age 14 & 18. Average age onset =19. • 9-10 x more common in females(90% cases) vs males. • Affects > 1 % adolescent girls. • More common in middle & upper socioeconomic groups than in low socioeconomic groups. • Women pursuing careers that emphasize appearance are most vulnerable. • Often anxious, obsessive, & rigid. • Disorder often begins in context of conflict about independence or sexuality. • May coexist with Bulimia nervosa in cycles of rigid starvation followed by loss of control, with eating binges causing guilt induced vomiting.
DSM IV Anorexia Nervosa Diagnostic Criteria • A.Refusal to maintain body weight at or above a minimally normal weight for age & height( i.e.weight loss maintenance body weight < 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight < 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 the seriousness of the current low body weight. • D.Inpostmenarcheal females, amenorrhea, i.e., the absence of > 3 consecutive menstrual cycles. ( A woman is considered to have amenorrhea if her periods occur only after hormone, i.e. estrogen administration.) • Specify type: • Restricting type: during current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) • Binge-eating/purging type: during current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e.self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
Management Anorexia Nervosa: Indications For Hospitalization of patients with eating disorders • Emergency: • Weight loss > 30% over 3 months. Society Adolescent Medicine states severe malnutrition with weight < 75% average for age, height, sex. Including acute food refusal • Severe Metabolic disturbance including: • (1)Bradycardia, pulse< 50bpm • (2)Hypothermia, temperature < 96 F • (3)Hypotension, BP < 80/50 + orthostatic hypotension • (4)Dehydration • (5) Electrolyte abnormalities (hypokalemia-serum potassium <2.5nmol/L, hyponatremia) • Acute medical/psychiatric emergencies including: • (1)Pancreatitis • (2)Seizures • (3)Syncope • (4)Severe depression/suicide risk • (5)Psychosis • (6)Cardiac arrythmia • Diabetes mellitus in poor control • Failure of elective outpatient treatment • Elective: • Family crisis, Complex differential diagnosis, Need to confront patient or family denial.
Management Anorexia Nervosa • Hospitalize when need as per guidelines. i.e. family crisis/risk of suicide, medical stabilization electrolyte imbalance, dehydration, cardiac arrhythmias, or gastrointestinal complications, etc. • Medical complications may necessitate forcible treatments. i.e. IV fluids or nasogastric feedings. Monitor caloric intake & focus on slow weight gain. • Once medical stabilization & restoration nutritional status achieved: • Individual, family, & group psychotherapy crucial. Cognitive behavioral approaches been found effective in changing patient’s perceptions about body image & food. • Antidepressants i.e. SSRI’s (fluoxetine/Prozac, sertraline/zoloft, & paroxetine/paxil) been used successfully. Avoid Bupropion/wellbutrin (seizure risk).
Bulimia Nervosa • Eating Disorder characterized by episodic uncontrolled binge eating followed by self-induced vomiting or other purgative maneuvers designed to prevent weight gain. • Patients with distorted body image and are responding to societal pressures to be thin. cbsnews.com nativeremedies.com
Bulimia Nervosa Clinical Features • Patient may engage in compulsive exercise & laxative abuse. • Vomiting common usually induced by sticking a finger down throat. Vomiting relieves postbinge bloating and allows patient to binge without fear of gaining weight. • Patient generally binges on sweet, soft, high-calorie foods, such as pastry & cakes. • Patient may plan binging, although it may be done impulsively when person is angry. • Most bulimics concerned about their sexual attractiveness, body image & appearance to others. • Unlike patients with anorexia nervosa, most bulimic patients are of normal weight. • Unlike patients with anorexia nervosa, most bulimic patients are sexually active & rarely amenorrheic or incapacitated. • More disturbed by their eating disorder than are anorexics and thus more likely to seek help. http://flipper.diff.org/app/items/info/2813
Bulimia Nervosa Epidemiology • Much more common in women than men. 9:1, women to men. • Affects 1-3 % young adult females. Lifetime prevalence 0.6 % U.S adult population. • Usually begins in adolescence or early adulthood. • Substance abuse, suicide attempts, shoplifting, depression, & emotional lability/ borderline personality disorder may co-occur. • Prognosis better than that for anorexia nervosa. geronguide.com
DSM IV Bulimia Nervosa Diagnostic Criteria • A.Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • (1)Eating, in a discrete period of time (i.e., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances. • (2) A sense of lack of control over eating during the episode (i.e. a feeling that one cannot stop eating or control what or how much one is eating). • B.Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. • C.The binge eating & innapropriate compensatory behaviors both occur, on average, > 2 times a week for 3 months. • D.Self-evaluation is unduly influenced by body shape & weight. • E. The disturbance does not occur exclusively during periods of anorexia nervosa. • Specify type: • Purging type: during current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. • Nonpurging type: during the current episode of bulimia nervosa, the person has used other innappropriatecompensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
http://www.womenshealthzone.net/eating-disorders/bulimia-nervosa/effects/http://www.womenshealthzone.net/eating-disorders/bulimia-nervosa/effects/
Management BulimiaNervosa • Consider hospitalization patients with poor impulse control, suicidality, or medical complications(electrolyte imbalance, dehydration, cardiac arrhythmias, or gastrointestinal complications) due to their eating disorder. • After medical stabilization: • Psychotherapy: • (1)Cognitive-Behavioral therapy-most effective treatment. • (2)Insight-oriented psychotherapy • Pharmacotherapy: • Antidepressants (Fluoxetine)-useful even if patient not depressed. • Avoid Bupropion(seizure risk).
Binge-eating disorder. • Characterized by recurrent binge-eating episodes during which person feels a loss of control over his or her eating. • Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are overweight or obese. • They also experience guilt, shame and/or distress about the binge-eating, which can lead to more binge-eating. • The binge eating is chronic and can lead to serious health complications, particularly severe obesity, diabetes, hypertension and cardiovascular diseases. drkpadmanaban.blogspot.com
Diagnostic Criteria DSM IV Criteria for Binge Eating Disorder (307.50) A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances (2) The sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Binge-eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating along because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present D. The binge eating occurs, on average, at least 2 days a week for 6 months Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating E. The binge eating is not associated with the regular use of inappropriate compensatory behavior (e.g., purging, fasting, excessive exercise, etc.) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa DSM, Diagnostic and Statistical Manual. http://www.ahrq.gov/downloads/pub/evidence/pdf/eatingdisorders/eatdis.pdf
References • http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml • http://www.healthyminds.org/Document-Library/Brochure-Library/Eating-Disorders.aspx • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1414759/pdf/wpa040142.pdf • Agency for Healthcare Research and Quality (AHRQ), Management of Eating Disorders, Evidence Report/Technology Assessment, Number 135, 2006. AHRQ publication number 06-E010, www.ahrq.gov. • FIRST AID for the USMLE 3, Tao Le, VikasBhushan, Robert W. Grow, Veronique Tache. • Psychiatry History Taking. Third Edition. A Current Clinical Strategies medical book. Alex Kolevzon, Craig L.Katz. • Pocket Handbook of Primary Care Psychiatry. Harold I kaplan, M.D. Benjamin J. Sadock, M.D.
