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Rogers treats children, adolescents and adults with:• Anxiety disorders• Eating disorders• Mood disorders• Substance use disorders

Eating Disorders:An Overview

Brad E.R. Smith, M.D.Medical DirectorEating Disorder ServicesRogers Memorial Hospital

Eating Disorders

• Anorexia Nervosa

• Bulimia Nervosa

• Binge Eating Disorder

• Other Specified Feeding or Eating Disorder– Atypical anorexia nervosa, bulimia with low frequency, binge

eating with low frequency, purging disorder, night eating disorder

• Unspecified Feeding or Eating Disorder

Illness, Not Choice

• Combination of longstanding behavioral, emotional, psychological, interpersonal, biological and social factors.

• Natural size and shape largely determined by genetics, so fighting that can lead to unhealthy practices.

• 20 million women and 10 million men suffer from clinically significant eating disorder at some time in their life.

• Highest mortality rate of any psychiatric disorder

Anorexia Nervosa: Criteria (DSM-5)

• Restriction of energy intake relative to requirements, leading to significantly low body weight

• Intense fear of gaining weight or becoming fat, even though underweight

• Disturbed way in which body weight or shape is experienced, undue influence of weight on self-evaluation, or denial of seriousness of low weight

Anorexia: Subtypes

• Restricting type: no binge eating or purging behavior (purge is vomiting or misuse of laxatives, diuretics, enemas) in past 3 months

• Binge-eating/purging type: regularly engaged in binge-eating or purging behavior in past 3 months

Anorexia Severity Specifiers

• Mild: BMI less than or equal to 17

• Moderate: BMI between 16 and 16.99

• Severe: BMI between 15 and 15.99

• Extreme: BMI less than 15

Anorexia: Demographics

• Prevalence: 0.4% of late adolescent to early adult females meet full criteria. Subthreshold rates higher. Limited data in male populations.

• Age of Onset: mean is 17 y.o., possibly bimodal at 14 and 18 y.o.

• Mortality: 5% per decade

Anorexia: Etiology/Course

• Often begins after stressful life event (transition to college)

• Recovery after single episode, fluctuating course of recovery and relapse, chronic deterioration over years

• Increased risk among first degree biological relatives with Anorexia Nervosa and mood disorders

• Increased risk in occupations/avocations that encourage thinness: modeling, elite athletes, dancing

Anorexia: Medical Complications

• Whole Body: low weight, dehydration, hypothermia, cachexia, weakness, fatigue

• Cardiovascular: palpitations, lightheadedness, dizziness, weakness, SOB, chest pain, cold extremities, bradycardia, orthostatic, weak pulse

• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, neuropathy

• Endocrine: fatigue, cold intolerance, diuresis, hypothermia

Anorexia: Medical Complications, cont.

• GI: vomit, pain, bloating, constipation, distension with meals, parotid swelling, dental caries, diarrhea

• GU: changes in urinary volume

• Hematology: fatigue, cold intolerance, bruising

• Immune: low white blood cells, reduced febrile response to infections

• Integument: changes in hair, hair loss, dry/brittle hair, yellow skin, lanugo, acne

• Muscular: weakness, aches, cramps, muscle wasting

• Pulmonary: reduced aerobic capacity, wasting of respiratory muscles

• Reproductive: arrested development of sex characteristics and psychosexual maturation, loss of libido, loss of menses, regression of sex characteristics, fertility problems, pregnancy complications

• Skeletal: bone pain, short stature and arrested skeletal growth, osteopenia, osteoporosis

Anorexia: Medical Complications, cont.

Bulimia Nervosa: Criteria (DSM-5)

• Recurrent binge eating episodes– Eating large amount in period of time compared to normal

– Sense of lack of control during episode

• Recurrent compensatory behavior to prevent weight gain (vomiting, laxatives, diuretics, enemas, meds, fasting, overexercise)

• Once per week for three months

• Self-evaluation unduly influenced shape, weight

• Not exclusively during anorexia

Bulimia: Severity Specifiers

• Mild: 1-3 episodes of compensatory behaviors per week

• Moderate: 4-7 episodes of compensatory behaviors per week

• Severe: 8-13 episodes of compensatory behaviors per week

• Extreme: 14 or more episodes of compensatory behaviors per week

Bulimia: Demographics

• Prevalence: 1-1.5% in adolescent and young adult females, 0.1-0.3% in males. Subthreshold symptoms higher.

• Age of Onset: late adolescence or early adulthood

• Mortality: 2% per decade

Bulimia: Etiology/Course

• Often begins during or after dieting

• Chronic or intermittent

• Increased risk if Bulimia Nervosa, a mood disorder, or substance abuse in relatives

• Cross-over to Anorexia Nervosa: 10-15%

Bulimia: Medical Complications

• Cardiovascular: weakness, palpitations, arrhythmias

• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, peripheral neuropathy

• GI: heartburn, reflux, blood in vomit, pain, constipation, bloating, gastric or esophageal rupture, perforation, enlarged salivary glands, esophageal erosions, pancreatitis, colonic dysmotility

• Integument: scarring on dorsum of hand (Russell’s sign), petechia, conjunctival hemorrhages after vomit

Bulimia: Medical Complications, cont.

• Metabolic: weight fluctuations, muscle cramping, pitting edema

• Muscular: weakness, myopathy (worst in ipecac users)

• Oropharyngeal: dental decay, pain in pharynx, swollen cheeks and neck, dental caries

• Reproductive: fertility problems, spotty menstrual periods

• Skeletal: bone pain, arrested skeletal growth, osteopenia or osteoporosis

Binge Eating Disorder: Criteria (DSM-5)

• Recurrent episodes of binge eating

• 3 or more: eat more rapidly, uncomfortably full, large amounts despite no hunger, eating alone due to embarrassment, disgusted with oneself/depressed

• Marked distress

• 1 day/week for 3 months

• No use of compensatory behaviors

Binge Eating Disorder: Severity Specifiers

• Mild: 1-3 episodes per week

• Moderate: 4-7 episodes per week

• Severe: 8-13 episodes per week

• Extreme: 14 episodes per week

Binge Eating Disorder: Demographics

• Prevalence: 1.6% females, 0.8% males

• Age of onset: late adolescence or early adulthood

Binge Eating Disorder: Etiology/Course

• Dieting often follows onset of illness

• Remission rates higher than Bulimia or Anorexia

• Cross-over to other eating disorders not as common

• Increased risk for obesity and associated complications

Co-morbid disorders in eating disorder patients

Depression 70% life time prevalence

Anxiety63% life time prevalence

40% OCDSocial phobia 20%

Alcohol abuse and/or dependence

Anorexia Nervosa 17%Bulimia Nervosa 46%

Posttraumatic stress disorder 13%

Substance Use Comorbidity

• Anorexia: estimates vary between restricting type vs binge/purge type, lower than BN and BED

• Bulimia Nervosa: 22.9% have alcohol abuse

• Binge Eating Disorder: 57% males and 28% females with lifetime substance abuse

• Associated with higher rates of impulsivity---shoplifting, self-injury, suicidal behaviors, laxative abuse

• Holderness et al, 1994 indicated 50% of ED patients had some form of substance abuse/dependence compared to 9% of general population

Suspected Eating Disorder?

• Any signs of the medical complications listed previously

• Significant weight changes

• Family reports

• Behaviors

What to Look for:

Behaviors

• Obsessively counting calories/nutritional content

• Cutting food into small pieces, hiding food, unusual combinations of condiments

• Gum, ice, candy

• Loose clothing

• Bathroom during or after meals

• Long time to eat

How to Approach

• Express concerns in non-judgmental way

• Offer information on illness/complications

• Avoid “triggering” terms – fat, healthy, better

• Ask open-ended questions

Choice

• Developing an eating disorder is not a choice….recovery is

Treatment: Levels of Care

• Comprehensive team: therapists, dietitian, primary care physician, psychiatrist

• Outpatient

• Intensive Outpatient

• Partial Hospital Program

• Residential Treatment Center

• Inpatient – ED Hospital– Medical/Surgical Hospital

Treatment: Types of Interventions

• Nutritional rehabilitation

• Psychotherapy– Individual, group– CBT, DBT, IPT, psychodynamic, family

• Medications– Antidepressants– Antipsychotics– Anxiolytics– Topiramate

Treatment: Efficacy

• Early intervention has best success– 70% of adolescents who received treatment had full

recovery at 5 yrs

• Adult hospitalized patients 4 yrs later – 44% good outcomes– 28% intermediate– 24% poor– 5% died

Drawing from other fields

• Community support

• Peer support (12 step programs)

• Transitional living

• Group homes

• Using legal system

• Earlier recognition

Resilience for Recovery

• Optimism

• Facing fear

• Moral compass, ethics, and altruism

• Spirituality and religion

• Social support

• Role models

• Training: physical health

• Brain fitness

• Cognitive and emotional flexibility

• Meaning, purpose, growth• Steven Southwick, M.D. and Dennis Charney, M.D.

Male Case Example

• 36 y.o. P.A. ---health care professional

• Started in HS, first admitted in past year---denial, covering up, deceit

• Going through divorce---high impact on family

• Lost job---high impact on work

• Wife wanted another child---testosterone level low

• Restricting primarily----a man restricts

• Started out trying to eat healthy for sports---slippery slope

• 5’11” admit weight 103 (BMI 14.5)---thinks he is overweight

Male Case Example (cont’d 1)

• Mood down---deficiency in protein leads to low neurotransmitter, meds cannot work

• Alcohol use at half pint of hard alcohol---numb self, calorie intake uncommon

• Started binge and purge---idea that starvation leads to binge

• Hypokalemia---supplement electolytes, high risk of arrhythmia

• Liver enzyme elevation---alcohol or ED

• One child age 5---nearly apathetic to being away from

• Edema with refeeding---fluid shifts, cardiac overload

• Pulse 42---cardiac dysfunction

Male Case Example (cont’d 2)

• Mother professor, father engineer---loving, professional parents can have child with ED

• Hiding food, deny even when caught---deceit and denial

• Grabbed excessive equal at AA meeting, presented completely innocent---deceit and denial

• NG tube for weeks, turning off---deceit

• Meals take long time, rituals---OCD high comorbidity

• Insurance MD thinks “must be something else”---severe ED is its own illness

• Compliance improved with insurance threatening to cut out---sometimes the insurance may help

Male Case Example (cont’d 3)

• 800 mg of quetiapine---distorted thinking unphased

• Able to improve compliance (i.e. when insurance threatening)---behavioral component of this leads to misperceptions

• Went on to RTC, improving---even very complex situations can improve

Resources

• Rogers Memorial Hospital:rogershospital.org

• National Eating Disorder Association (NEDA):nationaeatingdisorders.org

• National Association of Anorexia and Associated Diseases (ANAD): anad.org

800-767-4411rogershospital.org

Thank you

Rogers’ Eating Disorder Services are offered at these Wisconsin locations:• Oconomowoc

• Milwaukee (West Allis)

• Madison