Eating Disorders

Aug 3, 2011

Krissy Schwerin, MD
Assistant Professor of Psychiatry
Child and Adolescent Psychiatry
kristinaschwerin@ucdmc.ucdavis.
edu
Overview
 Anorexia Nervosa  Diagnosis
 Bulemia Nervosa  Epidemiology
 Binge-eating disorder  Medical risks
 Eating Disorder NOS  Etiology
 Treatment
 prognosis
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…
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
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.
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
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
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
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
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%
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
 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

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!)

Etiology

From Silber et.al.

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

“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.
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.
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)
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
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
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
Bulemia: Etiology
 Multifactorial!!!
genetic
Family dynamics

Individual
Temperament
(ie. impulsive) Societal, cultural

Media factors biological

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***
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
Bulemia: Treatment (Therapy)
 Best evidence is for CBT or DBT (good outcomes, but
outcomes are short-term)
 Cognitive Behavioral Therapy (CBT)
thought

feeling behavior
 (ie. Help them challenge the thought that s(he) will gain weight if s(he) eat
normal amounts of food.)
 Dialectical Behavioral Therapy (DBT)
Called friend,
Fight with Felt angry She was too Felt lonely Ate pint of
mom ice cream
Busy to talk
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
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
Bulemia: Prognosis
 33% remit every year
 But another 33% relapse into full criteria
 Adolescent-onset better prognosis than
adult-onset
 Death-rate = 1%
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.
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
Binge Eating Disorder- Diagnosis
Also 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
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
Binge Eating Disorder:
Epidemiology
 Most common eating disorder
 Lifetime prevalence:
 3.5%women
 2% men
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
Binge Eating Disorder: Etiology
 Multifactorial!!!
genetic
Family dynamics

Individual
Temperament
(ie. impulsive) Societal, cultural

Media factors biological

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
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
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
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.
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
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
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
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”
Any questions?
 Krissy Schwerin, MD
kristina.schwerin@ucdmc.ucdavis.edu