One Size Does Not Fit All: An Overview of Eating Disorders

1. One Size Does Not Fit All: An Overview of Eating Disorders Kristin Grasso, Psy.D. Clinical Psychologist and College Liaison

2. Spectrum of Eating Disorders

3. Risk Factors • Female gender • Ethnicity • Weight and Shape factors • Psychiatric history • Genetic predispositions • Participation in activities that promote thinness • Certain personality traits

4. What’s the risk of dieting? • The more severely girls diet, the more likely they are to drink frequently and heavily, as well as to use marijuana and other illicit drugs • Adolescent girls who engage in dieting have a 324% greater risk for obesity than those who do not diet (Stice et al., 1999). • 95% of all dieters will regain their lost weight in 1-5 years (Grodstein, 1996). • 35% of "normal dieters" progress to pathological dieting. Of those, 20-25%progress to partial or full-syndrome eating disorders. (Shisslak & Crago, 1995).

5. Anorexia Nervosa • Refusal to maintain minimum body weight • Intense fear of gaining weight or becoming fat, even though underweight • Disturbance in experience of weight or shape, undue importance of weight or shape, or denial of seriousness of problem • Amenorrhea

6. Subtypes of AN • Restricting Type: • person does not engage in binge eating or purge behavior • Binge Eating/Purging Type: • person regularly engages in binge eating or purging (self-induced vomiting or misuse of laxatives, diuretics, or enemas)

7. Bulimia Nervosa • Recurrent episodes of binge eating • Eating a large amount of food given the context • An associated sense of loss of control • Recurrent inappropriate compensatory behavior • E.g., purging, fasting, excessive exercise • Diuretics and laxatives

8. BN cont’d • Binge eating and compensatory behavior occur at least twice per week for 3 months • Self-evaluation is unduly influenced by body shape and weight • Disturbance does not occur exclusively during episodes of anorexia nervosa

9. Subtypes of BN • Purging Type: • Regularly engages in self-induced vomiting, or the misuse of laxatives, diuretics, or enemas • Non-Purging Type: • Regularly engages in other inappropriate compensatory behaviors, i.e. fasting or excessive exercise, but has not regularly engaged in the above stated purging behavior

10. ED-NOS • Most common • Patient has clinically significant disorder, BUT does not meet AN or BN criteria • Comparably severe in relation to AN and BN

11. Binge Eating Disorder • Recurrent episodes of binge eating • Episodes are associated with 3 or more of the following: • Eating more rapidly than normal • Eating until uncomfortably full • Eating large amounts when not hungry • Eating alone because of embarrassment about how much one is eating • Feeling disgusted with self, depressed, or guilty after overeating

12. BED cont’d • Marked distress regarding binge eating • Binge eating occurs at least two days a week for 6 months • Binge eating is not associated with regular inappropriate compensatory behavior, and does not occur exclusively in course of AN or BN

13. What’s the difference? • AN trumps BN • Presentation of AN vs. BN • The dieting factor • Binge Eating Disorder and obesity

14. “Drunkorexia” and other terms to be aware of…

15. Prevalence • Anorexia: .5-1% • Bulimia: 1-3% • Binge Eating Disorder: .7-4%

16. Etiology • The etiology of eating disorders is multi-factorial, with importance of specific factors varying with each individual

17. Men and Eating Disorders • 10% of eating disordered individuals are male • There is a greater stigma for males than females • Eating disorder behavior can present differently in males

18. Beyond Food… • Eating disorders appear to be all about food…they are not. • Simply eating more/less will not make things better and often, when someone begins to eat, things get harder • Issues related to control, coping with emotions, self-esteem, guilt and shame, etc will become MORE intense as someone stabilizes

19. Common Comorbid Disorders • Major Depressive Disorder or Dysthymia • 50-75% • Anxiety Disorders • 64% • Sexual Abuse • 20-50% • Obsessive-Compulsive Disorder • 25% (AN); 41% overall • Substance Abuse • 12-18% (AN); 30-37% (BN) • Bipolar Disorder • 4-13%

20. Health Consequences Anorexia Abnormally slow heart rate & blood pressure Reduction of bone density Muscle loss, weakness Severe dehydration Anemia, Leukopenia Reproductive consequences 5-20% mortality rate PHYSICAL SIGNS: lanugo, headaches, feeling cold, tingling in extremities, feeling faint, dry skin, hair loss 20

21. Health Consequences Bulimia Electrolyte Imbalances Esophageal tears Ulcers Salivary gland enlargement Dental Disease PHYSICAL SIGNS: headaches, fatigue, tingling in extremities, feeling faint, sore throat and swollen glands, Russell’s sign, dental problems 21

22. Health Consequences • BED • High blood pressure • High cholesterol levels • Heart disease as a result of elevated triglyceride levels • Secondary diabetes • Gallbladder disease PHYSICAL SIGNS: temperature irregularities, joint pain, decreased endurance and fatigue

23. Treatment: Anorexia • Psychopharmacoloy: • interventions typically recommended after weight restoration • Medication can begin earlier with focus on maintaining weight and normalizing eating • Psychological • Insufficient evidence regarding psychological interventions • CBT, IPT, Family Therapy 23

24. Treatment: Bulimia • Psychopharmacology • reduce frequency of disturbed eating behaviors. • FDA approved medication for BN: fluoxetine (Prozac) • Bupropion (Wellbutrin) has been associated with seizures in purging bulimic patients and its use is not recommended. • Psychological • First line is CBT • IPT and DBT 24

25. General Treatment Issues • Require multidisciplinary approach • Nutritional counseling and medication must not be sole treatment • Psychotherapy will generally require at least 1 year and most likely longer • Specialist in Eating Disorders preferred over general practitioner 25

26. Levels of Care • Inpatient • Partial Hospitalization • Intensive Outpatient • Outpatient

27. Indicators for Hospitalization • In general: • individual is below estimated healthy weight • Rapid, persistent decline in oral intake or weight and/or or uncontrollable purging • weight at which physical instability is likely to occur • Serious medical abnormalities • Comorbid psychiatric issues that warrant increased support 27

28. Prognosis • Anorexia • 50% recover • 33% improve somewhat • 20% remain chronically ill **mortality is 6x peers without anorexia and is the highest of any psychiatric illness!! • Bulimia • 50% recover • 18-30% improve somewhat • 20% continue to meet full criteria

29. References • Deshmukh, R. & Franco, K. (2003). Eating Disorders. Retrieved December 9, 2006, http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating.htm • Grodstein, F., Levine, R., Spencer, T., Colditz, G.A., Stampfer, M. J. (1996). Three-year follow-up of participants in a commercial weight loss program: can you keep it off? Archives of Internal Medicine. 156 (12), 1302. • National Eating Disorders Association's Information website: www.NationalEatingDisorders.org • Practice Guideline for the Treatment of Patients with Eating Disorders (3rd Edition) http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisorders3ePG_04-28-06 • Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209-219. • Stice, E., Cameron, R., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight reduction efforts prospectively predict growth in relative weight and onset of obesity among female adolescents. Journal of Consulting and Clinical Psychology, 67, 967-974.

30. For More Information: • http://www.nationaleatingdisorders.org • NEDA Educator Toolkit • http://www.eatingdisorders.org • The Center for Eating Disorders at Sheppard Pratt • http://www.something-fishy.org • Handbook of Treatment for Eating Disorders: 2nd Edition by David Garner Ph.D. and Paul E. Garfinkel, M.D.