PSYCHIATRY AND BEHAVIOR COURSE: Eating Disorders

1. PSYCHIATRY AND BEHAVIOR COURSE: Eating Disorders Dr. Satu Michele Repo-Hendsbee Psychiatrist Regional Mental Health Care London 455-5110 extension 47417

2. OBJECTIVES • 1. Know the general criteria for anorexia nervosa, bulimia nervosa and binge eating disorder • 2. List predisposing factors for each of these disorders • 3. Know the usual course and prognosis of each disorder • 4. Know the complications of each disorder. • 5. Describe the management (assessment/treatment/follow-up) for each disorder.

3. WHY STUDY EATING (DIETING ) DISORDERS? • The most lethal of all psychiatric disorders • Significant source of mortality and morbidity (interferes with normal growth and development) • Significant number of patients struggle chronically

4. EPIDEMIOLOGY • Lifetime prevalence of AN is 0.5% for females & 0.05% for males • Lifetime prevalence of BN is 1-3% for females & 1/10th of that for males • Incidence of AN appears to have increased in last few decades • Up to 1/3 of those seeking obesity treatment in hospital settings have binge eating disorder

5. ETIOLOGIC THEORIES • In general: multiple biopsychosocial determinants • BIOLOGICAL: genetics, dieting/restriction • PSYCHOLOGICAL: affect regulation; avoidance; control • SOCIAL: family pressure; cultural norms

6. ANOREXIA NERVOSA CRITERIA (the short version) • A. refusal to maintain weight at a normal level • B. intense fear of being fat • C. Preoccupation/misperception/lack of insight as related to weight and shape • D. Amenorrrhea • May be restricting or binge/purge type

7. ANOREXIA NERVOSA – associated psychiatric features • 1. Ego syntonic symptoms • 2. Lack of motivation • 3. Lack of insight (denial) • 4. Ambivalence

8. ANOREXIA NERVOSA- associated bps factors • BIOLOGICAL: first degree relatives with AN, history of obesity, dieting • PSYCHOLOGICAL: negatives feelings about the body, perfectionism, eager to please, difficulty expressing feelings verbally, difficulty resolving conflicts, maturation fears • SOCIAL: female, Caucasian, middle to upper-class, industrialized societies, certain sports, maternal preoccupation with diets, compliments for losing weight

9. ANOREXIA NERVOSA – Course and Prognosis • ONSET - usually between 14 & 18 • GENERAL OUTCOME – up to 50% develop BN, 66% still preoccupied with food and weight; 44% weight restored within normal limits; after 10-15 years 12% remain anorexic • MORTALITY – 5% mortality over 10 years (metabolic complications/suicide) and 10% of those admitted to university hospitals

10. ANOREXIA NERVOSA – Complications/Associations • Vitals: bradycardia, hypothermia, hypotension • Psychiatric: depression, anxiety, irritability, depression/dysthymia (20%), 25% of those with OCD, cluster C personality disorders, social isolation • ENT: dental erosion (p), parotid hypertrophy

11. ANOREXIA NERVOSA – Complications/Associations (2) • CVS: bradycardia, QT proongation, arrhythmias • GI: delayed gastric emptying, constipation, abdominal pain, malabsorptio9n • GU: peripheral edema • OB/GYN: premature births • MSK: osteopenia, stunting of growth osteoporosis, pathological fractures

12. ANOREXIA NERVOSA – Compliations/Associations (3) • Derm: lanugo, dry hair, dry skin, carotenemia, Russell’s sign, acrocyanosis • Metabolic: hypochloremia and hypokalemia (p), low phosphate, low magnesium • Heme: anemia, leukopenia • Endocrine: low FSH, low LH, low libido, infertility, increased cholesterol, increased cortisol

13. ANOREXIA NERVOSA – Management (1) • Scare tactics are futile • Emotional Impact on physicians can be significant • Studies are generally based on treatments of 6-12 weeks duration; results have to extrapolated in the treatment of this often chronic condition

14. ANOREXIA NERVOSA – Management Goals • Biological: weight restoration, restore ovulatory function/hormone levels and sex drive, treat co-morbid conditions • Psychological: enhance motivation, provide education, correct maladaptive thoughts and behaviors, relapse prevention • Social – improve family functioning, improve peer relationships, expand activities

15. ANOREXIA NERVOSA – Management Setting • Setting: based on nature and severity of symptoms, medical status, motivational status, treatment history, logistic considerations • Inpatient criteria: medically and/or psychiatrically unstable, less than 75% of IBW, outpatient failure, inappropriate home environment

16. ANOREXIA NERVOSA – Setting continued • Day treatment: transition from inpatient to outpatient, supportive home environment • Outpatient: weight close to 85% of ideal, motivated and reliable

17. ANOREXIA NERVOSA – Management (Assessment) • Biological: history, physical, growth charts, dieting history, blood work, ECG, bone studies, rule out diff. Diagnosis • Psychological: mental status exam, dietary and exercise history, assess motivation, patient goals and expectations, self-portrait • Social: family and couple’s assessment, collateral history from school/work/sports

18. ANOREXIA NERVOSA – Management (Assessment) • Sample questions: • How would your life be different if you were at your ideal weight? If you were “overweight”? • How does gaining weight influence your thoughts/feelings? How does losing weight influence those areas? • What would it mean if you were overweight? If you were skinny?

19. ANOREXIA NERVOSA - Treatment • Biological: nutritional rehabilitation, medical stabilization, SSRIs, atypical antipsychotics, activity limitations • Psychological: therapeutic alliance, motivational interviewing, supportive psychotherapy, cognitive behavioral therapy, dialectical behavior therapy, • Social: skill based group therapy, family therapy

20. ANOREXIA NERVOSA – follow-up • Therapy often needs to continue beyond the restoration of weight • Regular medical check-ups • Relapse prevention through ongoing group/individual support

21. BULIMIA CRITERIA – (the short version) • A. Binge eating • B. Unhealthy attempts to get rid of “extra” food/weight • C. at least 2x/week for 3 months • D. Self-esteem based on weight and shape • E. It’s not anorexia nervosa • Types: Purging or non-purging

22. BULIMIA NERVOSA – associated psychiatric features • Ego dystonic • Increased insight and shame • Impulsivity • Sexual promiscuity • Substance abuse • Self-harm behavior

23. BULIMIA NERVOSA – Associated bps factors • Biological: first degree relatives with BN, dieting, anorexia nervosa • Psychological: low self-esteem, interpersonal sensitivity, impulsivity, history of sexual abuse • Social: negative comments from family, encouragement to diet, cultural emphasis on slimness, bullying by peers

24. BULIMIA NERVOSA – Course and prognosis • Disturbed eating generally persists for years • @ 6 years: 60% had a “good” outcome, 29% intermediate, 10% poor and 1% deceased • Meta-analysis over 5-10 years showed that 50% fully recovered but 20% fully bulimic • Approximately 30% relapse 1-4 years after full recovery • Worse if inpatient care, multiple purges, low functioning,

25. BULIMIA NERVOSA – complications and associations • Vitals: hypotensive • Psychiatric: 30% have substance abuse, 50-75% have depression/dysthymia, increased incidence of borderline personality diosrder • ENT: parotid hypertrophy, dental decay • CVS: ipecac cardiomyopathy, arrhythmia

26. BULIMIA NERVOSA – complications and associations • GI: hematemesis, Mallory-Weiss tear, GERD, uncontrolled vomiting, gastritis, esophagitis, colonic dysmotility • GYNE: infertility, irregular periods • Metabolic: hypokalemia, hypochloremia • Derm: Russell’s sign

27. Bulimia Nervosa – Management Goals • Biological: reduce binge eating and purging (usually requires reduction in restriction and dieting), treatment of co-morbid medical conditions • Psychological: reduce cognitive distortions, “peace of mind” treatment of co-morbid conditions • Social: improved family functioning and understanding, improved occupational/ social/education functioning

28. BULIMIA NERVOSA – Management (Setting) • Inpatient: failure of outpatient treatment, symptom interruption beds, medical/ psychiatric instabilty, substance abuse • Day Hospital: ability to work in a group program, structured and supportive environment outside of hospital • Outpatient: medical stability, supportive environment, work/school obligations

29. BULIMIA NERVOSA – Management (Assessment) • Biological: history and physical exam, blood work, ECG • Psychological; mental status exam, diet/exercise history, goals and expectations, motivational assessment, identify cognitive distortions • Social: family and couples assessment, collateral from school/work

30. BULIMIA NERVOSA – Management (Treatment) • Biological: nutritional counseling, SSRIs • Psychological: motivational interviewing, psychoeducation, individual therapy (CBT, DBT, interpersonal therapy), bibliotherapy, self-help manuals (www. Gurze.com) • Social: family therapy, couples therapy, group therapy

31. BULIMIA NERVOSA – Management (Follow-up) • Monitor for high risk situation and prepare proactively (pregnancy, marriage, moves, schooling, jobs changes) • Relapse prevention through group and individual therapy

32. EATING DISORDERS - NOS • Binge eating disorder • Orthorexia Nervosa • Compulsive Exercise • Disordered Eating • Obesity:

33. OBESITY • “Simple obesity does not appear in the DSM-IV because it has not been established that it is consistently associated with a psychological or behavioral syndrome.” (DSM-IV) • “One can say with confidence that there is little relationship between obesity and gross psychologic abnormalities.” (Medical Clinics of North American, 2000)

34. BINGE EATING DISORDER CRITERIA (the short version) • Binge eating • Absence of significant attempts to get rid of weight/food by vomiting/exercise/diuretics etc.

35. BINGE EATING DISORDER – associated bps factors • Biological: dieting, past history of bulimia • Psychological: judgmental stance towards self, low self-efficacy, childhood abuse • Social: negative judgments or comments from friends/family, cultural endorsements of dieting, bullying by peers

36. BINGE EATING DISORDER – course and prognosis • 30% of those in weight control programs • Females 1.5 times the rate of males • Approximately 2% of community samples • Chronic, relapsing condition

37. BINGE EATING DISORDER – associations and complications • Vitals: hypertension • Psychiatric: depression • RESP: sleep apnea, SOB • CVS: cardiac risk factor • GI: hiatus hernia, gallbladder disease, colon cancer • GU: stress incontinence

38. BINGE EATING DISORDER – associations and complications • Gyne: endometrial cancer, breast cancer, PCOD • MSK: osteoarthritis • Endocrine: type II diabetes, hyperandrogeneic states infertility • Metabolic: dyslipedemias • Derm: hirsutism, venous stasis

39. BINGE EATING DISORDER – Management (Goals) • Biological: normalization of eating, decreased binge eating, improved physical health. • Psychological: improved emotional health: improved self-esteem and self-confidence • Social: Improved family understanding of disorder, improved social, occupational and educational functioning

40. BINGE EATING DISORDER – Management (Setting) • Inpatient: symptoms interruption bed • Day Treatment: Frequent relapses • Outpatient: almost 100% of the time

41. BINGE EATING DISORDER – Management (Assessment) • Biological: history and physical exam, blood work, ECG • Psychological: mental status exam, dieting and exercise history, motivational assessment, goals and expectations determined, cognitive distortions identified, assess coping mechanisms • Social: family & marital assessment, collateral history

42. BINGE EATING DISORDER – Management (Treatment) • Biological: SSRIS, naltrexone, topiramate • Psychological: CBT, BT, non-dieting philosophy, self-help (TOPS) • Social: group therapy, family and couples therapy

43. BINGE EATING DISORDER – Management (Follow-up) • Ongoing support and treatment needed by many patients • Reduce follow-up visits as remission extends in length

44. EATING DISORDERS - Summary • 1. Disordered eating comes in many forms, each of which can be extremely destructive to physical, emotional and social functioning • 2. Chronicity of disorder often mandates long-term treatment • 3. Team management is often crucial to avoid clinician burn-out • 4. Can be very satisfying when results are achieved.