Eating Disorders Aug 3, 2011

1. Eating DisordersAug 3, 2011 Krissy Schwerin, MD Assistant Professor of Psychiatry Child and Adolescent Psychiatry kristinaschwerin@ucdmc.ucdavis.edu

2. Anorexia Nervosa Bulemia Nervosa Binge-eating disorder Eating Disorder NOS Diagnosis Epidemiology Medical risks Etiology Treatment prognosis Overview

3. Misconceptions Myth: White, upper-middle class females in metropolitan areas of the western world Eating disorders are increasing in prevalence in males, young children, older adults, and other ethnic groups. Our field needs to do a better job screening and treating…

4. Risk Factors for EDs • Perfectionism for AN • Early Puberty • Failed attempts to lose weight • Antecedent illness with weight loss • Discovery that purging, fasting or exercising can compensate for binging • Athletics • Beginning a diet • Family history of eating disorder, substance abuse or mood disorder

5. Case Vignette #1 “Carla” Carla is a 13 year-old Latina female who presented to the ER with a grand-mal seizure from hyponatremia. She had been binging on water in order to fend off hunger. She was 5 ft 4 inches and 90 pounds at presentation (her previous weight had been 160 lbs). She had stopped getting her period. Carla had always been a happy child and near-straight-A student, but had recently become obsessed with her schoolwork and isolated from her friends and close-knit family. She was also angry that her mother pregnant.

6. Anorexia Nervosa- DSM IV • Refusal to maintain 85% of ideal body weight • Intense fear of becoming fat • Body image distortion; undue influence of weight on self evaluation; denial of risks of low weight • Amenorrhea (in post-menarchal females) • Purging-type • Restricting-type

7. Proposed DSM V changes • “less than minimally expected” instead of 85% ideal body weight • Remove “refusal” (pejorative) • Add “behavior” to avoid weight gain, since many patients deny fear of gaining weight • Remove amenorrhea • Subtyping be for current episode

8. Anorexia: chief complaint… • Family or school is concerned about eating habits or personality change • Physical symptoms • Other psychiatric concerns – depression, anxiety, obsessive • “unintentional” weight loss • amenorrhea

9. Anorexia: How patients may present… • “She is not the same ‘Carla’” • Perfectionistic, obsessive • Ritualistic or peculiar eating habits • More restrictive eating patterns • “I’m just trying to be healthy” • Extreme self-discipline in other areas of life • Isolative, no interests except food • Lack of identity of self • Overexercising • Anorexic “voice” • Stubborn – food as expression of autonomy

10. Anorexia Nervosa: Epidemiology • Lifetime prevalence 0.5-1% • Females:Males 10:1 • Usually arises during adolescence or young adulthood • Increased risk in 1st degree biological relatives with AN • 1/3 will develop bulimia nervosa • Long-term mortality 10-20%

11. Medical Risks • Death (suicide, starvation, sudden cardiac death) • Hypometabolic state (bradycardia, hypotension, hypothermia) • Orthostasis • Dehydration • Arrhythmia, heart failure, liver failure • Malnourishment • Bone loss • Lanugo • Peripheral edema • Stunted growth • Delayed sexual maturity • Hair loss, brittle hair • Cognitive impairment • Water intoxication • On recovery: Re-feeding syndrome

12. Neurological Effects • Cerebral Atrophy • Associated with weight loss but not necessarily with lowest BMI • May improve but do not necessarily return to normal Katzman D et al, Journal of Pediatrics 1996

13. Anorexia Nervosa: Medical Workup • vitals (w/ temperature) • EKG • Lytes, LFTs, ESR, prealbumin, amylase, TFTs, UA, Upreg • β-HCG, LH, FSH, prolactin, estradiol if indicated • Bone density (don’t be fooled by normal labs!)

14. Etiology From Silber et.al.

15. Anorexia Nervosa: Treatment • Determine inpatient vs. day treatment vs. outpatient • Multidisciplinary teams are ESSENTIAL! • Primary care provider • Consultation with eating disorders specialty clinic • Psychiatrist • Individual therapist • Family therapist • Nutritionist • 1st: weight restoration • 2nd: psychological • 3rd: maintinance (long-term)

16. Medical Admission Criteria • <75% ideal body weight • Hypothermia T<36 • Bradycardia HR<50 while awake, <45 asleep • Orthostasis-drop in sbp >10, increase in HR>35 • Dehydration • Severe hypokalemia (<2-3 mmol/L) or other electrolyte abnormality • Acute medical complication • Severe depression/suicidality– Psychiatric admit • Refractory to outpatient treatment

17. Anorexia Nervosa: Treatment • No evidence-based psychotherapy for Anorexia Nervosa in adults! • No evidence-based pharmacologic treatments!

18. Anorexia Nervosa: Therapy • Best evidence is for family-based treatment (Maudsley approach) • Who: younger patients who live at home, intact family • Philosophy: no-blame, family did not cause anorexia; family is the best resource to help her get better • Elevate family’s anxiety about the gravity of the illness. Empower parents to do whatever they need to do to get the anorexic to eat. Align siblings with the patient for support. Externalize the anorexia. • “Family Meal” • Once weight-restored: explore the family dynamics and psychological issues.

19. Anorexia Nervosa: Medications • No approved medication treatments for Anorexia Nervosa • Prozac (or other SSRI) for co-morbid depression or anxiety • Low-dose Atypical Antipsychotics off-label for near-psychotic thinking that is characteristic of anorexia, Zyprexa may help with weight gain - problem: informed consent for risks of weight gain

20. Anorexia Nervosa: Prognosis • 1/3 recover • 1/3 continue with milder course • 1/3 chronic severe • Risk of death • Suicide • Cardiac arrest • Malnutrition • > 3 years of illness: prognosis is poor

21. “Case Vignette #1: Carla” After acute medical stabilization, Carla reluctantly agreed to eat enough food to get to 105 lbs (BMI of 50%). She maintained this weight, as well as normal vital signs, for 6 months by eating the exact same thing every day: non-fat yogurt and non-fat cheese sandwiches. She remained depressed, suicidal, obsessive, isolative, cognitively slowed, and amenorrheic. She refused to believe that anorexia could kill her. Finally, Carla’s care was transferred to a multidisciplinary team. She started weekly Maudsley family therapy, and Prozac for depression. She gained 25 pounds in 2 months. She began menstuating only after she reached a BMI in the 75th percentile for her age/height. She now eats enchiladas, hamburgers, and pizza and hangs out with friends regularly. She still thinks she is fat, but is continuing family therapy to develop a sense of her own identity beyond food and body image.

22. Case Vignette #2: Selena Selena is a smart, talented 18 year-old Filipina college freshman with a history of molestation by a neighbor when she was a child. She gained “the freshman 15” in her first semester of college, and when she went home for winter break, her mother pointed out that she was “putting on a few pounds”. In the Spring, Selena’s roommates became concerned because they would hear her throwing up in the bathroom after dinnertime. They had to escort her to student health several times from parties after drinking to the point of blacking out, having “hooked-up” with boys in a semi-conscious state.

23. Bulemia Nervosa – DSM IV • Recurrent episodes of binge-eating (eating larger amounts of food than others would eat in a discrete- 2 hour- period of time, with a sense of lack of control) • recurrent inappropriate compensatory behavior (vomitting, laxatives, excessive exercise, etc) • Both occur at least 2x/wk for 3 months • Self-evaluation is unduly influenced by body shape or weight (purging type, non-purging type)

24. Proposed DSM V changes • Change frequency of compensatory behaviors from 2x/week to 1x/week • Deletion of non-purging subtype, because it more closely resembles binge-eating disorder

25. Bulemia: How patients may present… • Often normal weight or overweight (hence, providers may overlook!) • Depression or anxiety • Feeling of disgust that is relieved by vomiting • Report that vomiting gives them a “high” • Shame and guilt • Go to great lengths to keep symptoms secret (ie. hiding bags of vomit) • Problems with emotion regulation • Other impulsive or self-destructive behaviors (substance abuse, cutting) • May have a history of sexual abuse

26. Bulemia: Epidemiology • Lifetime Prevalence • 1.5% women • 0.5% men • Prevalence of binge-purge behaviors: • 13% girls • 7% boys • High prevalence of sexual abuse history in bulemics, especially boys • Extremely rare in young children

27. Bulemia: Etiology genetic Family dynamics • Multifactorial!!! Individual Temperament (ie. impulsive) Societal,cultural Media factors biological

28. Medical Risks • Electrolyte abnormalities • Dental – loss of enamel, chipped teeth, cavities • Parotid hypertrophy • Conjunctival hemorrhages • Calluses on dorsal side of hand (Russel’s sign) • Esophagitis, Mallory-weiss tears, Barrett esophagus • hematemesis • Latxative-dependent: cathartic colon, melena, rectal prolapse • Poor nutrition (if severe purging) • ***Similar risks of AN if also restricting behaviors***

29. Bulemia: Treatment • Again, multidisciplinary team!!! • Primary care provider • Consultation with eating disorders specialty clinic • Psychiatrist • Individual therapist • Family therapist • Nutritionist • Best evidence: CBT + Antidepressant (SSRI) • Evidence for adolescents is sparse; we extrapolate from the evidence for adult treatment

30. Bulemia: Treatment (Therapy) • Best evidence is for CBT or DBT (good outcomes, but outcomes are short-term) • Cognitive Behavioral Therapy (CBT) • (ie. Help them challenge the thought that s(he) will gain weight if s(he) eat normal amounts of food.) • Dialectical Behavioral Therapy (DBT) thought feeling behavior Felt angry Called friend, She was too Busy to talk Felt lonely Ate pint of ice cream Fight with mom

31. Bulemia: Treatment (Therapy) • Family therapy is a good option if patient is young and still lives at home (But not as much evidence as for Anorexia) • Interpersonal therapy (IPT) (short-term treatment focused on life transitions) • Psychodynamic Psychotherapy (good for long-term results in people with chronic depressive and personality symptoms) • Nutrition plan, exercise, physical activity

32. Bulemia: Medicaions • High-dose Fluoxetine/Prozac (SSRI) – very good evidence! • Sertraline/Zoloft (SSRI) – some good evidence • Buproprion/Wellbutrin (other antidepressant) – contraindicated! (risk of seizures if history of purging) • Topiramate/Topomax (mood stabalizer, promotes weight loss) – some good evidence, but use with caution esp if low-weight

33. Bulemia: Prognosis • 33% remit every year • But another 33% relapse into full criteria • Adolescent-onset better prognosis than adult-onset • Death-rate = 1%

34. Case Vignette #3 Laura is a 47 year-old divorced African-American female in weekly psychotherapy for depression. She has suffered from morbid obesity ever since she stopped using cocaine 13 years ago. When Laura’s teenage son (who is involved in an inner city gang) does not come home on time, or when she feels empty and lonely about not having a romantic relationship, she eats excessive amounts of food, despite her mindset and efforts throughout the rest of the day to watch her diet. Laura one of 7 siblings. She is always identified by the family as the one who would take care of others’ in need, such as their ailing parents, but her own needs often fall by the wayside.

35. Binge Eating Disorder – DSM IV (only in appendix) • Episodic intakes of larger than typical amounts of food • Episodes occur in brief (<2 hrs) periods of time • Subjectively, sense of loss of control while eating • At least 2 days/week for 6 months

36. Binge Eating Disorder- DiagnosisAlso needs 3 of the following: • Eating much more rapidly than normal • Getting uncomfortably full • Large amounts of food when not physically hungry • Eating alone because embarrassed about how much one is eating • Feeling disgusted with oneself, depressed, or guilty when over-eating

37. Proposed DSM-V changes • That binge eating disorder should become a free-standing diagnosis, rather than only in the appendix • Less Frequency: once a week for 3 months

38. Binge Eating Disorder:Epidemiology • Most common eating disorder • Lifetime prevalence: • 3.5% women • 2% men

39. Binge Eating Disorder: Medical Risks • Less acute risk than with restrictive eating patterns • Long-term risks significant: the many organ systems affected by obesity, shortened life-span, etc

40. Binge Eating Disorder: Etiology genetic Family dynamics • Multifactorial!!! Individual Temperament (ie. impulsive) Societal,cultural Media factors biological

41. Binge Eating Disorder:Treatment (Medication) • SSRI • high dose reduces binge behavior short-term • but doesn’t help weight loss • Topomax, Zonisamide (anticonvulsants, mild mood stabalizer) • Helps binge reduction • Helps weight loss • Caution for adverse effects, high discontinuation rates

42. Binge Eating Disorder:Treatment (Therapy) • Therapies either prioritize… • Weight loss • Binge-reduction • Neither (ie. relationships, depression etc) • Group psychotherapy • There is little evidence that obese individuals who binge should receive different therapy than obese individuals who do not binge

43. Binge Eating Disorder:Psychosocial Support • Family need help with co-dependency • Weight loss programs • Weight watchers, Jenny Craig, etc. • 12-step Self help groups • Food Addicts in Recovery Anonymous • Overeaters Anonymous

44. Case Vignette #4: Alisa Alisa is an 8 year-old caucasian girl who was admitted to the hospital for malnutrition. She had stopped eating due to a subjective sense of stomach pain every time she ate. Alisa underwent a complete GI workup which was negative for a medical cause for her pain. Her parents, who had a very tense relationship with one another and with hospital staff, had difficulty accepting that the explanation of her illness might be psychological. Alisa denied body image distortion or desire for weight loss, but one of the nursing staff saw her holding in her stomach. She was also fixated on when she would be able to exercise again.

45. Eating Disorder NOS • Does not meet full criteria for any of the specific eating disorders • Doesn’t mean less clinically significant! • 60 percent of EDNOS patients met medical criteria for hospitalization • On average “sicker” group than those with “full blown” bulimia • Most prevalent of the eating disorders • Can have significant morbidity and mortality • Children and males are amongst the groups who have “atyipical” presentations, hence do not fit DSM criteria for specific eating disorders

46. Proposed DSM-V changes • Many of the proposed DSM V changes to other eating disorder categories are meant to reduce the usage of Eating Disorder NOS • Anorexics who deny fear of weight gain but demonstrate the behaviors • Binge-eaters • Anorexics who meet all criteria except amenorrhea

47. Eating Disorders: Take Home Points • Great need for provider-awareness (both in mental health and non-mental health) • Very medically risky!!! Need intense psychological AND medical management! (especially with restricting eating patterns) • Multifactorial etiology • Multidisciplinary treatment approach • Involve the family in treatment whenever you can • Prevalent in teens, but much less research to guide us in their treatment • DSM criteria sometimes don’t capture cases which are clinically significant

48. References • Reinblatt, S.R. et.al. “Medication Management of Pediatric Eating Disorders”International Review of Psychiatry; April 2008 • Yager, J. et.al. “Practice Guideline for the Treatment of Patients with Eating Disorders – Third Edition” from the American Psychiatric Association (APA) 2005 • Silber, T. et.al. “Anorexia Nervosa Among Children and Adolescents”Advances in Pediatrics Vol 52, 2005 • Locke, J. “Treatment Manual for Anorexia Nervosa”

49. Any questions? • Krissy Schwerin, MD kristina.schwerin@ucdmc.ucdavis.edu