Eating Disorders Eating Disorders

Three Categories:

Anorexia Nervosa

Bulimia Nervosa

Bing Eating Disorder

Eating Disorders In General

Main Etiological Factors:

a) Family history of:

1) eating disorder

2) affective disorder

3) substance abuse

4) obesity

b) Personal History of:

1) affective disorder

2) obesity

3) sexual abuse

Etiology Continued:

c) History of disturbed family relations and /or parenting

d) Parental over-concerns about dieting, eating and body shape and weight

Etiology of Eating Disorders Ties in Strongly With a Persons Beliefs About:

- Self Esteem

- Attractiveness

- Beauty

- The “Relational Self”

Taking A Look at Diagnosing

• History Taking• MSE

“Ruling Out” May lead to delays in treatment and co-morbidity

Medical Assessment-good for understanding consequences and complications and decision making about treatment. Is NOT necessarily used for diagnosis.

DSM-IV Criteria

DSM-IV Handout

Anorexia Nervosa

Bulimia Nervosa

Risk Factors That Increase Probability of Eating Disorders

Gender: >females than males by 6-10:1

Age: Teens & 20’s mostly

Location: Western Societies that value thinness

Personality: Anorexia-sensitive, self-critical

persevering

Bulimia-unstable mood, impulsive

dramatic features

Family History: depressive illness, obesity, eating

disorders

Interest Groups: Ballet dancers, wrestlers, models,

jockeys, gymnasts

Risk Factors Continued:

Sexual Orientation: Gay males (not lesbians),

heterosexual females

Critical Sensitizing Events: Teasing, criticism for

overweight, especially comments

by mothers, coaches, peers,

occasional iatrogenic onset

Onset of Drive for Thinness: 40% by age 9 or 10 in

girls

Racial Group: Caucasians > African Americans but

depends on valuation of thinness

Eating Disorders Have Considerable:

* Morbidity and Mortality

* Relatively High Rates of Relapse

All Eating Disorders Share a Common Theme:

Body Shape & Body Image

Caveot

Symptoms of Starvation Resemble

Symptoms of Depression:• Dysphoria• Anhedonia• Poor sleep• Decreased energy• Decreased concentration• Decreased libido• Socially withdrawn

Anorexia Nervosa (AN)• Relatively Rare• High Mortality• Sensitive, self critical, persevering perfectionist• Obcessional, introverted, overly formalistic

(refer to hand-out)

Characteristics

Symptoms

Physical Findings

Bulimia Nervosa (BN)

Essential Features:

* overvaluation of weight and shape

* dietary restriction

* binging

* purging

* age of onset approximately 19

Two Sub-Categories:

Purging Type Non-Purging Type

laxatives exercise to compensate

Induced vomiting fasting

Bulimia Nervosa-continued

(refer to handout) Clinical and Physical Features

There exists similar incidences of co-morbidity inBulimia Nervosa as in Anorexia Nervosa: * depression * anxiety particularly OCD * alcohol and drug abuse * personality disorders

Persons with BN are more: impulsive, dramatic, unstable moods (Mehler & Andersen, 1999)

Binge Eating Disorder (BED)

Essential Features:

* Eating large amounts of food in short period

* Loss of control during the binge

* Associated with 3 or more of the following:

a) eating more rapidly than normal

b) eating until uncomfortably full

c) eating large amounts when not hungry

d) eating alone/hiding

e) feeling disgusted, depressed, guilty after

over-eating

Binge Eating continued: * The binge occurs minimum 2x/week for duration

of 6 months

* Not associated with purging, fasting, or

excessive exercise

BED also associated with co-morbidity (60%)

* Major Depression

*Obsessive Compulsive Disorder

* Panic Disorder

*Substance Abuse

* 35% have personality disorder

Assessment of Eating Disorders

Medical History

Screening Questions

Physical Exam

Signs and Symptoms

Assessment Continued

Common GI Symptoms with Weight Loss:

* bloating

* nausea

* constipation

* heartburn

* abdominal pain

* diarrhea

Assessment Continued

Common GI Symptoms with Bulimia:

* vomiting related

a) heartburn, hoarseness, sore throat,

dysphagia, (difficulty swallowing),

odynophagia (pain on swallowing)

* Purging related

a) diarrhea, abdominal cramping

Assessment Continued

(Handouts)

Recommended Laboratory Tests

Lab Results Indicating Possible Eating Disorder

Common Lab Abnormalities

Electrolytes (Serum and Urinary)

Differential Diagnosis for Eating Disorders

Anorexia Nervosa:

hyperthyroidism

diabetes mellitus

malignancies – lymphoma, stomach cancer

chronic infection – TB, AIDS, fungal diseases

cystic fibrosis

Inflammatory bowel disease – Crohn’s, colitis

chronic pancreatitis

malabsorption syndromes

psychiatric disorders associated with weight loss

Differential continued

Bulimia Nervosa

Inflammatory bowel disease

peptic ulcer disease

parasitic intestinal infections

chronic pancreatitis

hypothalmic lesions or tumors

diverticulum

scleroderma or other connective tissue disorder

with GI involvement

Differential Continued

Binge-Eating Disorder

temporal lobe or limbic seizures

lesions of the hypothalamus, frontal lobe,

or temporal lobe

degenerative neurologic conditions i.e.: Pick

disease, Alzheimer disease, Huntington

disease, Parkinson disease

Clinical Pearls

Anorexics are proud of their weight loss

Bulimic behavior is usually shameful or guilt-producing

Binge–Eating usually occurs in the obese and in older patients (ages 30s-50s)

Eating Disorders in older people are usually complicated by concurrent medical or psychiatric

Once EA is diagnosed, assess for psychiatric disorders as well as medical consequences as both these usually occur

Treatment for Eating Disorders

Goals: * nutritional rehabilitation and a “set point” weight maintenance

* Normal eating behavior

* Healthy thinking about weight

* Appropriate treatment plan with behavioral and pharmacological therapies

* Increased family awareness

* Relapse prevention with continued treatment

Treatment Continued

Mental Health treatments:

* Cognitive Behavioral Therapy (CBT)

* antidepressants

* self help plus brief therapy

* Interpersonal therapy (IP)

* Dialectic Behavioral Therapy (DBT)

Mental Health Treatment

Cognitive Behavioral Therapy-superior to others

* Phase I : focus on regular eating

(3 meals/day plus 2 snacks regardless if

hungry or not)

* Phase II : Modification of thoughts involving

diet and body shape

* Phase III : Relapse Prevention

Treatment Model: Cognitive Maintenance (specifically for BN)

When to Use Antidepressant?

Agras (2001) demonstrated that if patient does not have 70% reduction in symptoms by week 4 of CBT, he recommended initiating SSRI (Fluoxetine). Beginning dose 20 mg and titrate in 2-4 days to 60mg.

Use of antidepressants rational is linked to affective disorders. Possible role of serotonin in feeding behaviors ( serotonin =satiety)

Patients on 60mg Fluoxetine showed 80% response rate within two weeks of treatment

Physical Complications of BN

Metabolic: * weakness, poor skin turgor, dehydration

Gastrointestinal: * abd pain, blood in vomit

Reproductive: * fertility problems, scanty menses, possible hypoestrogenemic

Oropharyngeal: * dental decay, erosion of dental enamel painful throat, swollen cheeks & neck (painless), enlarged salivary glands

Cardiomuscular: * weakness, palpitations, cardiomyopathy, cardiac abnormalities

Physical Complications of AN

CNS: * apathy, poor concentration, depressed, irritable, cognitive impairment

Cardiovascular: * palpitations, dizziness, SOB, chest pain, cold extremities, irregular pulse, BP changes

Skeletal: * bone pain, point tenderness, arrested skeletal growth

Muscular: * weakness, muscle aches, muscle wasting,

Endocrine: * fatigue, cold intolerance, hypothermia

Hematologic: * rare bruising, clotting abnormalities

GI: vomiting, abd pain, bloating, constipation, pitting edema, abnormal bowel sounds