EATING DISORDERS Review Course in Psychiatry University of Ottawa 2012

1. EATINGDISORDERSReview Course in PsychiatryUniversity of Ottawa2012 Dr. Wendy Spettigue, Associate Professor and Dr. Clare Roscoe, Assistant Professor University of Ottawa wspettigue@cheo.on.ca

2. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

3. Epidemiology: • Prevalence A.N. 0.5-1% (for strictly defined) B.N. 1-3% EDNOS 3-10% • ♀ : ♂ 10 : 1 • Onset • A.N. : 13-20 yrs (peaks at 14 and 18 yrs) : 5% present after 20 years of age • B.N. : 16.5-19 yrs old

4. Types of Eating Disorders • Anorexia Nervosa • Restricting Type • Binge-Eating/Purging Type • Bulimia Nervosa • Purging Type • Nonpurging Type • Eating Disorder NOS

5. Definitions: Anorexia Nervosa A. Refusal to maintain body weight Body weight <85% of expected B. Intense fear of gaining weight C. Distorted body image - or Undue influence of weight on self-worth, - or Denial of seriousness of the low weight D. Amenorrhea: the absence of at least 3 consecutive menstrual cycles

6. Common Symptoms of A.N.: • Restricting intake • Exercising • Standing, moving, restlessness • Self-induced vomiting • Diet pills, laxatives

7. Anorexia Nervosa cont’d • Specify: • Restricting Type • Binge-Eating / Purging Type Purging - Vomiting - Laxatives - Diuretics - Enemas

8. Bulimia Nervosa A. Recurrent Binge Eating: • Eating a very large amount of food in a discrete period of time 2. Lack of control during the episode B. Recurrent Compensatorybehavior to prevent weight gain (vomiting, laxatives, fasting, over-exercising…)

9. Bulimia Nervosa • A. and B. occur at least: • 2x / week for 3 months • Self-worth unduly influenced by shape and weight • Not A.N.

10. Bulimia Nervosa Cont.. • Specify: • Purging Type • Nonpurging Type

11. A binge is almost always the result of dieting and food restriction. Purging is the result of: Fear of weight gain The perception of stomach discomfort Shame caused by the loss of control over eating Restrict Binge Purge The Bulimic Cycle

12. Eating Disorder NOS (EDNOS) Patient does not meet all the criteria for an eating disorder. For example: • A.N. with normal periods • A.N. with the psychological criteria but is above 85%ile for weight • Frequent purging but no binge-eating and above 85%ile for weight • Binge Eating Disorder will be a new diagnostic category in the next DSM

13. Understanding Eating Disorders • Rates of body dissatisfaction are > 85% in females, and up to 90% of teenage girls will go on a diet. What happens to the 5%, (and the boys), that go on to develop Eating Disorders?

14. Eating Disorders: • Eating disorders are not a fad or phase, and not the same as dieting • Eating disorders are severe mental illnesses with significant medical risks • Eating disorders are not the fault of the parents or the child

15. The Development of an ED Need to Gain Control / Feel Better Dieting Stressors Sense of Achievement Increased Dieting • Vulnerable Youth • Risk factors • Comorbidities • Low self-esteem Snowballing of behaviours Eating Disorder

16. Risk Factors for AN

17. Risk Factors for BN

18. Co-Morbidity of A.N.: • 50-65% Depression (i.e. #1 comorbidity) • >50% Anxiety Disorders (esp. GAD, Social Phobia and OCD) • Perfectionism • “Cluster ‘C’ P.D. traits, e.g.. OCPD (rigidity, restraint, obsessiveness)

19. Comorbidity of B.N.: • Depression 50-65%%, #1 comorbidity • Anxiety in >50% (esp. GAD and Social Phobia) • Substance Abuse • Impulsivity/risk-taking behaviors • Borderline Personality Disorder traits • PTSD • Bipolar Spectrum disorders

20. E.D. Spectrum • A.N.-------------A.N./B-P--------------B.N. • Perfectionistic Chaotic • Compliant Unstable moods • Anxious Substance abuse • Sensitive Impulsive • Possible OCPD Possible BPD

21. Understanding Eating Disorders:

22. Eating Disorders come from: • Feeling “not good enough” • Feeling worried or stressed • Feeling “out of control” • Feeling you don’t deserve good things • Feeling like you should keep your problems to yourself / not burden others • Wanting to be accepted and liked • Not wanting to give others something to criticize or tease you about

23. The Development of an ED Need to Gain Control / Feel Better Dieting Stressors Sense of Achievement Increased Dieting Snowballing of behaviours • Vulnerable Youth • Risk factors • Comorbidities • Low self-esteem Powerful Eating Disorder

24. i.e. What makes an Eating Disorder so Strong?

25. What an Eating Disorder does…. • Complete preoccupation with food and weight • Isolation • Give up or dramatically alter relationships with family and friends • Effects on school / work • Effects on sports / hobbies

26. Why so powerful? Understanding the Eating Disorder • Effects of starvation • The Meaning of the Eating Disorder • An illness by nature that creates denial / poor insight

27. Effects of Starvation • Ancel Keys, University of Minnesota, during WWII • Psychologically “Normal” men, with superior “psychobiological stamina”  Semi-starvation (lost 25% body weight)

28. Effects of Starvation • Change of Eating Habits • Started to eat in silence, prolonged time, unusual mixing of food • Social Changes • Men became withdrawn, decrease wish to socialize, lack of interest in sex or intimacy • Less humour • Cognitive Changes • Impaired concentration • Impaired comprehension and judgment

29. Effects of Starvation • Emotional Changes • Depression • Irritability • Frequent outbursts of anger • Extreme mood swings • Social withdrawal • High levels of anxiety (including nail biting) • Almost 20% experienced extreme emotional deterioration, even psychosis (some hospitalized) • Most changes persisted through refeeding, became worse for some

30. The Power of an Eating Disorder: Sadness Shame Guilt Fear Emptiness FAT Weight control Powerless Powerful

31. The Meaning of the Eating Disorder • The Eating Disorder is one thing I am good at • Not eating pushes my other worries away • The Eating Disorder makes me feel powerful, special and in control • The Eating Disorder means I don’t have to grow up • Eating means I am weak and a failure • The Eating disorder is who I am

32. Medical Complications of Eating Disorders

33. Eating Disorders affect the whole body • Brain, thinking, cognitions • Hair • Dental Disease • Heart • Fluids/ electrolytes • Muscles, bones • Kidneys • GI system • Hormones • Skin

34. Eating Disorders can..… • Result in heart arrhythmias which, in severe cases can be fatal. • Result in structural brain changes • Cause osteoporosis (poor bone health) • Delay puberty • Stop/ Stunt Growth • Interfere with pregnancy

35. Medical Complications of Eating Disorders

36. Electrocardiograms (EKGs) • Normal Malnourishment QTc

37. Medical Complications

38. Medical Complications

39. Osteoporosis • Resorption (losing) > Deposition (gaining) • Absolute Bone Mineral Density Low

40. Structural brain changes MRI Findings - Katzman et al, 1996 Adolescent Females With AN Adolescent Females Controls 15 years 16 years 14 years

41. Labs in Eating Disorders: •  • BUN (dehydration) • Amylase (vomiting) • Cholesterol • (starvation) •  • Na, K, CL (vomiting/laxatives) • LH, FSH, estrogen (starvation) • RBCs (starvation) • WBCs (starvation) • T3

42. Refeeding Syndrome • May occur within 4 days, in severely malnourished pts (<70% IBW) • During starvation: There is a an intracellular loss of electrolytes, in particular phosphate. • With feeding, insulin is secreted • This stimulates cellular uptake of phosphate (and other electrolytes), which can lead to profound hypophosphataemia.

43. Refeeding Syndrome •  Phosphate < 0.50 mmol/l (normal range 0.85-1.40 mmol/l) • rhabdomyolysis, leukocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death • Therefore initial feeding must be slow and gradual, with careful medical monitoring, and possible phosphate supplementation

44. Clinical features of a Patient at Higher Risk of Death • Very low weight at admission • Bradycardia • No medical follow-up • Longer duration of illness • Multiple purging methods • Chronic self-harm or suicide attempts • Amphetamine or cocaine use • Severe alcohol abuse

45. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

46. Principles of Treatment for Eating Disorders

47. Key Treatment Principles: • Specialized, multi-disciplinary team • Meet the medical, nutritional and psychological needs of the patient • Medical stabilization and renourishment is necessary but not sufficient • Match severity of illness to intensity of treatment • Structured meals, with goal of normalized eating • Combine psychoeducation with therapy • For adults or adolescent BN: group therapy or individual therapy • For adolescent AN: Family-based Therapy

48. AN – Initial Assessment Start with a thorough assessment [I] • Therapeutic alliance & positive regard • Biopsychosocial formulation using a non-blaming model • May take several hours • Essential involvement of family for children and adolescents • Involvement of multidisciplinary team (dietician, other physicians, social work etc)

49. AN- Initial assessment Choosing a treatment setting • Inpatients • Day Program (5 days / week, 8 hours day) • Outpatients

50. Treatment of Anorexia Nervosa: • Medical and Nutritional: • reversal of the effects of starvation; re-feeding • “food is the medicine” • meal plan, “mechanical eating” • medical management and weighing • No medication found to be effective; (recent use of atypical antipsychotics); SSRI’s not effective at low weight