Transcript Eating Disorders - American Academy of Child and Adolescent

Eating Disorders
Jess P. Shatkin, MD, MPH
Director of Education and Training
New York University School of Medicine
NYU Child Study Center
Learning Objectives
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1.
2.
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4.
Residents will be able to:
Distinguish between Anorexia and Bulimia
Nervosa
Describe the primary clinical findings in Anorexia
and Bulimia Nervosa
Identify rational diagnostic evaluation methods
for affected children and adolescents and their
families
Determine evidence-based treatments for patients
affected by Eating Disorders
Facts and Stats
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Among normal weight female teens, 40-60%
view themselves as too heavy
Up to 60% of female teens diet regularly
Over 50% of teens exercise in order to improve
their shape or lose weight
Approximately 45% of female teens smoke
cigarettes to control weight
Most female teens are preoccupied with their
food intake
70% of girls report that body shape is important to
their self-esteem (Strober and Schneider, 2005).
History
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In Western Europe of the 12th and 13th centuries, “miracle
maidens,” or women who starved themselves, were highly
regarded, and their behavior was imbued with religious
interpretations.
Catherine of Siena (1347 – 1380), whose complete control
over her food intake was seen as a sign of religious devotion,
was regarded as a saint (Heywood, 1996).
“Holy anorexia” was, however, short-lived
By the 16th century the Catholic Church began to disapprove
of asceticism.
Some anorexics were subsequently viewed as witches and
burned at the stake (Brumberg, 2000).
History cont’d
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First cases reported in 1689 by Richard
Morton – “wasting” disease of nervous
etiology in one male and one female (Gordon,
2000).
The first formal description of AN, however, is
credited to Sir William Gull, physician to
Queen Victoria, who in 1868 named the
disorder anorexia hysterica, emphasizing
what he believed to be its psychogenic
origins.
History: Anorexia Nervosa
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Gull later changed the name to “nervosa” to
avoid confusion with hysteria
Although quite descriptive, the word anorexia
is a misnomer, as the term literally means
“lack of appetite,” which is, in fact, rare.
Not simply a product of the modern society
Both Anorexia Nervosa and Bulimia Nervosa
patients share an intense preoccupation with
body weight and shape
History: Bulimia Nervosa
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Bulimia Nervosa (BN), by contrast, was first clinically
described in 1979
Historical accounts date to 1398, when “true
boulimus” was described in an individual having an
intense preoccupation with food and over eating at
very short intervals, terminated by vomiting (Stein &
Laakso, 1988).
The word bulimia is derived from Greek and means
“ravenous hunger,” quite the opposite of anorexia.
Much less has been historically made of bulimic
behavior, and consequently, we have significantly
less knowledge of this disorder.
Eating Disorders
Anorexia Nervosa
 Restricting Type
 Binge Eating/Purging (Bulimic) Type
 Bulimia Nervosa
 Purging Type
 Nonpurging Type
 Eating Disorder NOS
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Anorexia Nervosa
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Diagnosis requires:
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Refusal to maintain body weight at or above a minimally normal
weight for age and height (e.g., weight loss leading to maintenance
of body weight less than 85% of that expected; or failure to make
expected weight gain during period of growth, leading to body
weight less than 85% of that expected)
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Intense fear of gaining weight or becoming fat, even though
underweight
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Disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body
weight
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In post-menarcheal females, amenorrhea, i.e., the absence of at
least 3 consecutive menstrual cycles. (A woman is considered to
have amenorrhea if her periods occur only following hormone,
e.g., estrogen, administration)
AN: Characteristics
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The discrepancy between weight and perceived body image is
key to the diagnosis of anorexia; anorexic patients delight in
their weight loss and express a fear of gaining weight
Have changes in hormone levels which, in females, result in
amenorrhea (if the weight loss occurs before puberty begins,
sexual development will be delayed and growth might cease)
Feel driven to lose weight because they experience themselves
as fat, even when at a subnormal weight
Intensely afraid of becoming fat and preoccupied with worries
about their body size and shape
Direct all their efforts towards controlling their weight by
restricting their food intake, but may also binge eat, self induce
vomiting, misuse laxatives or diuretics (purging behaviors),
exercises excessively or misuse appetite suppressants
Bulimia Nervosa
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Diagnosis requires:
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Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
 eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than most people would
eat during a similar period of time and under similar circumstances
 a lack of control over eating during the episode (e.g., a feeling that
one cannot stop eating or control what or how much one is eating)
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Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives,
diuretics, enemas, or other medications; fasting; or excessive exercise
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The binge eating and inappropriate compensatory behaviors both
occur, on average, at least twice a week for 3 months
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Self-evaluation is unduly influenced by body shape and weight
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The disturbance does not occur exclusively during episodes of
Anorexia Nervosa
BN: Characteristics
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Frequent episodes of binge eating, during which they
consume a large amount of food within a short period of
time
Feels overwhelmed by the urge to binge and can only
stop eating once it becomes too uncomfortable to eat
any more
Feels guilty, anxious and depressed, because they have
been unable to control their appetite any they fear
weight gain
Tries to regain control by getting rid of the calories
consumed ( the most common method is vomiting, but
they might misuse laxatives, diuretics or appetite
suppressants, fast or excessively exercise
Subclassification
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2 major subtypes of anorexia:
(1) Restricting Type: fasting, introverted, decreased
risk of substance abuse, family conflict is covert
 (2) Bulimic Type: binge eating or purging, more
volatile, family frequently disengaged, prone to
substance abuse
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2 major subtypes of bulimia:
(1) Purging Type: self-induced vomiting or use of
laxatives, diuretics, or enemas
 (2) Nonpurging Type: use of other compensatory
mechanisms, such as fasting or excessive exercise
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Anorexia vs. Bulimia
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Denies abnormal
eating behavior
Introverted
Turns away food in
order to cope
Preoccupation with
losing more and more
weight
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Recognizes abnormal
eating behavior
Extroverted
Turns to food in order
to cope
Preoccupation with
attaining an “ideal”
but often unrealistic
weight
Eating Disorders NOS
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Likely to be similar to people with AN or BN but
not quite meet the diagnostic criteria
Might vomit after eating small amounts of food
Might chew food and then spit it out
Might binge eat, but not attempt to get rid of the
calories consumed (this behavior is now called
Binge Eating Disorder [BED], the phrase
compulsive eating is sometimes used, but has
never been adequately defined)
Obesity
Defined as 20% over ideal body weight
or BMI > 30
 Not an eating disorder per se and unlike
an eating disorder is not an mental illness.
However, many people who binge eat
become obese and can have mental health
problems
 1/3 of NYC public high school students
are overweight or obese
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What is a healthy weight?
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Body Mass Index (BMI) is the best currently
accepted measure
BMI (kg/m²) = (pounds x 703) ÷ height in
inches² or = kilograms ÷ height in meters²
BMI Parameters
Underweight = < 18.5
 Normal weight = 18.5 – 24.9
 Overweight = 25 – 29.9
 Obese = > 30
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These next slides show 20 years of obesity in the
United States
Why are we so overweight?
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Genes
Diet
Exercise
Nutrition Education
Social (single parent, no time to prepare meals,
etc.)
What does our weight cost?
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Direct Costs
Indirect Costs
1995 = $99 billion
2000 = $117 billion
Most of the cost associated with obesity is due
to type 2 diabetes, coronary heart disease, and
hypertension.
Epidemiology
More likely than a true increase in these
disorders in recent years is that the public is
more aware of them
 The prevalence rate of anorexia is 0.5-1%;
incidence <0.1%
 The prevalence rate of bulimia is 3-8% in
females 12 – 40 y/o; incidence <0.1%
 The prevalence of both disorders for men is
about one-tenth that for women
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Epidemiology (2)
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Individual symptoms characteristics of each
disorder (such as binge eating, purging, or
fasting) are far more common than the disorders
themselves
The typical age of onset is adolescence or young
adulthood (peaks at 14 – 15 y/o and again at 18
y/o)
These disorders are thought to be more prevalent
among higher SES; anorexia in particular is
uncommon in poorly developed countries and had
been rare among blacks in the US for years;
although now there is minimal difference among
ethnic groups in America
Comorbidity
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Anorectics face an increased risk of depression,
anxiety d/o (especially OCD & Social Phobia), and
personality d/o (cluster C in anorectic restrictors;
cluster B and C in anorectic bulimics)
Bulimics face an increased risk of depression; anxiety
d/o may also be increased
The lifetime prevalence of substance
abuse/dependence among bulimics (particularly
alcohol and stimulants) is at least 30% (25% among
all patients with an eating disorder)
The diagnosis of a personality d/o among bulimics is
not uncommon (especially Borderline PD)
Etiology
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There are numerous, as yet unproven theories, as to
why people develop anorexia
Early psychological theories proposed that anorexia
represents a phobic avoidance to food and an
association with the sexual tensions generated during
puberty
Psychodynamic formulations have suggested that
anorexic patients have fantasies of oral impregnation
Social theories stress the importance of conforming to
the American ideal of youth, beauty, and slimness
Etiology (2)
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Modern psychological theories stress that these
patients are avoidant of maturational
challenges which are perceived as
insurmountable; concretization and avoidance
of psychological discord follow thereafter
They aim for the antithesis of puberty – these
kids are unprepared and exert control by not
eating, thereby staying young and immature;
they experience profound self-loathing, along
with the illusion of competence because of the
ability to follow rules
Etiology (3)
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Family theory suggests that AN results from a cry for help
from a child enmeshed in a conflicted and disfunctional family
(Minuchin et al, 1978)
Unconscious collusion among family members perpetuates
the child’s symptoms because focus on the child defuses the
parental conflicts.
Cognitive-behavior theory, meanwhile, proposes that
individuals are rewarded by peers and society for being
slender, which for some can be sufficiently powerful to
maintain the illness despite the health risks.
Finally, the social and cultural emphasis upon being thin and
the associated pressures that are overtly and covertly placed
upon children are believed to contribute in some way to the
genesis of Eating Disorders (Brumberg, 1988).
Etiology: Biological Theory
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Biological theories focus on the role of the hypothalamus
(the region concerned with the regulation of body
functions, such as temperature, weight, appetite, & general
homeostasis); support for this theory comes from
neurotransmitter studies showing an increase in
Corticotropin Releasing Factor (CRF) in the CSF of
anorexic patients
When administered to rats, CRF leads to a reduction in
food intake, feeding time, & feeding episodes; it also leads
to an increase in grooming time & grooming episodes
The occurrence of amenorrhea before weight loss also
suggests a hypothalamic disturbance (occurs in 20% of
patients)
Etiology: Biological Theory (2)
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There is also evidence of a central
neurotransmitter system dysregulation affecting
5HT, DA, and NOREPI; the strongest evidence
supports reduced NOREPI activity and turnover
Vomiting leads to an increase in DA levels which
reinforces/rewards the vomiting behavior
Theories of serotonergic hyperfunctioning in
anorexia and serotonergic hypofunctioning in
bulimia are attractive but don’t explain why
SSRIs are sometimes helpful for both
Etiology: Genetics
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Eating Disorders are familial.
The risk of AN among mothers and sisters of probands is
estimated at 4% or about eight times the rate among the
general population (Strober et al, 2000).
A large twin registry study appears to confirm that BN and AN
are related. This study found that the co-twin of a child with
AN was 2.6 times more likely to have a diagnosis of BN than
were co-twins of children without an Eating Disorder (Walters
and Kendler, 1995).
Twin studies confirm a genetic link. Studies of identical or
monozygotic twins show concordance of up to 90% for AN
and 83% for BN (Kaye et al, 2000).
Nearly all women in Western society diet at some point in
adolescence or young adulthood, yet fewer than 1% develop
AN.
The Highly Familial Nature of
Anorexia Nervosa
(Strober, 2000)
Lifetime Rate of AN in Female Relatives of AN
Probands and Controls
Rate per 100
4
3
2
1
0
Anorexia
Nervosa
Control
Proband Group
Support for A Primary Role of Fear
and Anxiety Related Traits in AN
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Comorbidity with anxiety disorders
 major
anxiety syndromes occur in upwards of
80% of AN patients, roughly 4 times the rate in
the general female population
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Association with ‘anxious’ personality
phenotype – tendency toward greater restraint,
caution, regimentation, and perfectionism
compared to persons without AN
Anxiety in Families
Stavro et al (submitted)
Rate per 100
Lifetime Rate of Anxiety Illness in Parents of
AN Subjects vs Controls
50
40
30
20
10
0
Parents
of AN
Parents
of
Controls
AN: Risk Factors & Prognosis
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Risk factors for AN: puberty; perfectionistic
personality; family h/o affective, OCD, and Anxiety
D/O; impaired family interactions, stressful life
events (e.g., sexual abuse, beginning college, leaving
home, etc.)
Prognostic indicators for AN: age of onset (12 - 18 is
better b/c prior to 18 y/o families can mandate
treatment; prior to 12 y/o is bad prognosis);
bulimic/purging symptoms lead to a worse prognosis
(restrictors do better); chronicity of illness (>6 years
of illness with little treatment benefit); weight at
treatment; repeated hospitalizations; poor social
functioning
BN: Risk Factors & Prognosis
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Risk Factors for BN: dieting, puberty,
transitions (e.g., college, new job, relationship
break-up), various jobs (athletes, actors,
models), anorexia, impulsivity, anxiety,
Favorable Prognostic Indicators for BN:
younger age at onset; higher social class, and
family history of alcohol abuse
Clinical findings (1)
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A repertoire of behaviors in the pursuit of weight loss
(e.g., extreme dieting, adopting unusual diets or
vegetarianism, refusal to eat with family or in
restaurants, etc.)
Patients show an unusual interest in food that belies their
fear of gaining weight (e.g., collecting recipes, preparing
elaborate meals for others, developing an interest in
nutrition)
Many patients begin to abuse laxatives, diuretics, or
stimulants in an effort to lose more weight
Anorexic patients commonly develop an intense, almost
obsessive interest in physical exercise and have strict
work-out routines
Clinical findings (2)
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Bulemics tend to carry on their behavior in private, often
with foods high in calories or carbohydrates
The binge may at first bring feelings of relief from tension,
which is followed by guilt and feelings of disgust
Some patients abuse emetics (e.g., ipecac)
About 10% of bulimics steal food by shoplifting or other
means
Clinical lore states that patients with anorexia tend to have
above-average scholastic achievement, are highly
perfectionist, and come from achievement oriented families;
they often have poor sexual adjustment, which has suggested
to some that anorexia represents an attempt to prolong
childhood and escape the responsibilities of adulthood
Anorectic families are characterized as non-conflictive,
intrusive (e.g., parents answer for patient), overly protective,
rigid, and inflexible
Clinical findings (3)
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Bulimic families are characterized as notable for a lack of
parental affection, negative/hostile and disengaged interactions,
parental impulsivity, alcoholism, obesity, and chaos
The anorexic temperament is classically risk avoidant,
emotionally restrained, compliant/conventional, perseverative,
perfectionistic, with decreased resiliency, and preferring order
and routine
With severe weight loss, other physical changes may develop
(hypothermia, dependent edema, bradycardia, HOTN, lanugo,
osteoporosis, brain atrophy)
Hormonal abnormalities in anorexia may include elevated
growth hormone and plasma cortisol levels and reduced
gonadotropin levels (along with low FSH, LH, and estrogen);
T3 may be reduced, but T4 and TSH are often normal.
Increased corticotropin CSF levels may act as a potent
anorectic which ironically perpetuate anorexia by further
decreasing appetite
Clinical findings (4)
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Bulimic patients often develop calluses on the dorsal
surface of their hands (self-induced vomiting), dental
erosion and carries, esophageal erosion, lanugo hair,
enlarged parotid glands (chipmunk face secondary to
increased amylase), bradycardia, hypotension, and
arrhythmias (secondary to hypokalemia)
Medical complications in bulimics may include
hypocalcemia, hypochloremia, or hypokalemia
(secondary to vomiting and/or laxative/diuretic abuse);
metabolic alkalosis; electrolyte disturbances
(arrhythmias, lethargy, weakness, seizures); serum
transaminase levels may increase reflecting fatty
degeneration of the liver; parotid gland enlargement and
elevated amylase; elevated serum amylase may develop;
elophageal tears (uncommon) can be life threatening
Course and Outcome
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Long-term follow-up studies of anorexics show death
rates of over 10% after 10 years (7% at 10 yr f/u and
18-30% at 30 yr f/u – highest mortality rate in
psychiatry)
Those who improve may continue to display
characteristic symptoms of the illness, such as a
distorted body image
Fewer than 25% have a good psychological outcome
(e.g., no abnormal eating behaviors in a well-adjusted
person)
Poor out-come is generally associated with a longer
duration of illness, older age at onset, prior psych
hospitalizations, poor premorbid adjustment, and
comorbid personality d/o
Course and Outcome (2)
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20-30% of restricting anorexics eventually develop
binge eating within the first 5 years of onset
These illnesses have a chronicity of 5-10%
Generally favorable outcome is achieved in 60-70% of
patients at 5-7 year outcome
Prognosis of Bulimia is better than Anorexia: rule of
thirds applies for Bulimia – 1/3 doing well, 1/3 still
affected with sx, 1/3 doing poorly at 5 year f/u (at 5 –
10 yr f/u, 50% recovered, 20% with Bulimia Nervosa,
30% with bulimic symptoms)
Differential Diagnosis
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Schizophrenia, MDD, OCD (ritualistic eating behaviors)
The majority of patients with an eating disorder will also
meet criteria for another psychiatric disorder, most
commonly MDD or a PD such as Borderline
Rates of OCD in anorexia is about 5x the general
population; OCPD found in 30% of parents of anorexics
Important general medical conditions are: (1) Kleine-Levin
Syndrome (hyperphagia, hypersomnia, and irritability seen
in adolescents with a self limiting course); and (2) KluverBucy Syndrome (limbic system dysfunction with visual and
auditory agnosia, placidity, hyperorality, hypersexuality,
hyperphagia, seen in Pick’s Disease, HIV Encephalopathy,
Herpes Encephalitis, Brain Tumors, etc.)
The Impact of Media
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90% of all girls ages 3-11 yrs have a Barbie Doll
If Barbie were a real woman, her measurements
would be 38-18-33
The body type portrayed in advertising as the ideal is
possessed naturally by only 5% of females
The desirable female figure had curves and ample fat
until Twiggy and the diet industry came on the scene
in the 1960’s
Clinical Management (1): AN
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The treatment of AN must focus on three primary
issues: (1) Restoring weight; (2) modifying distorted
eating behavior; and (3) addressing the
psychological and family issues.
Treatment methods typically include nutritional
rehabilitation, psychotherapy, and medication.
Treatment is often outpatient, often with intensive
day treatment
In the U.S., about half of all paitents with AN who
seek treatment are hospitalized
Clinical Management (2): AN
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Hospitalization is typically encouraged when the
patient is severely malnourished, dehydrated,
suffering from an electrolyte imbalance, or facing
other physically threatening complications.
Hospitalization is also indicated when outpatient
treatment has not been effective, there is a risk of
suicide, psychosis is present, or there is a major
lack of motivation toward resolving the Eating
Disorder.
The benefits of inpatient versus outpatient treatment
remain unclear, however, and as yet we have no
evidence-based criteria for inpatient admission.
Additionally, adequate controlled studies comparing
day treatment to inpatient programs have not been
performed (Herpertz-Dahlmann and SalbackAndrae, 2009)
Clinical Management (3): AN
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The goals of nutritional rehabilitation are to restore
weight, normalize eating patterns, reestablish
normal perceptions of hunger and satiety, and
correct the biological and psychological sequelae of
malnutrition.
The treatment plan should establish clear goals for
target weight gain, which are generally accepted to
be 1 – 2 pounds per week for inpatients and 0.5 – 1
pound per week for outpatients.
Nutritionists and pediatricians are often involved
Physical activity must be monitored as well and
restricted if it interferes with weight gain.
Clinical Management (4): AN
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Many different types of individual psychotherapy
have been evaluated among adults with AN, but no
controlled studies have been performed in children
and adolescents.
CBT, IPT, cognitive analytic therapy, focal
psychoanalytic therapy, and specialist supportive
clinical management have all shown utility in adults,
and it is not clear that any one method is superior to
others.
Trusting relationship with therapist is key
Clinical Management (5): AN
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Regardless of the technique, therapists are
generally more effective with anorexics when they
actively engage the patient and directly address
body image and concept, growth and development,
and family and peer interactions.
Typical cognitive distortions affecting those with
anorexia that should also be addressed in therapy
include personalization, polarized thinking, mind
reading, catastrophizing, shoulds, over generalizing,
and global labeling.
Clinical Management (6): AN
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Group psychotherapy is also a mainstay of
treatment for AN in both inpatient and outpatient
settings. Still, only one randomized controlled trial
has examined the efficacy of group therapy for
anorexia, and no studies have compared individual
versus group psychotherapy.
Pilot studies of DBT in adolescents suggest utility in
the treatment of both AN and BN
Clinical Management (7): AN
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Family-Based Therapy (FBT) grew out of the work of
Minuchin and has been developed at the Maudsley
Institute in London
A problem-focused therapy that aims to change
behavior through unified parental action.
The family in FBT is not viewed as the cause of the
disorder but rather as a positive resource in the
adolescent’s weight restoration and return to normal
eating and health.
FBT takes no stance on disease etiology and tries
instead to separate the pathology of AN from the
adolescent herself.
Clinical Management (8): AN
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FBT focuses on family strengths
The first phase of treatment supports the parents in their efforts to
restore their child’s weight.
The second phase begins when the child has reached 90% of ideal
body weight and is eating without much resistance; at this point the
parents are supported in returning the responsibility for their
child’s eating back to the child.
The final phase generally begins when the adolescent has
achieved a healthy weight for age and height and focuses on the
general issues of adolescent development and how the Eating
Disorder affected this process. FBT, or the so-called “Maudsley
Method,” has been shown effective in 50 – 75% of adolescents,
who in randomized trials achieved weight restoration by the end of
treatment and maintained it for up to five years. In one trial of
adolescents with a short history of illness, the response rate
reached 90% (Eisler et al, 1997).
Medication Management (1): AN
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Medications have not generally proven themselves to be
remarkably effective for the treatment of AN.
However, TCAs, MAOIs, trazodone (Desyrel®), and the
SSRIs have demonstrated benefit in the treatment of
binge/purge behavior in BN. The greatest evidence lies with
fluoxetine (Prozac®), which has been approved by the FDA
for the treatment of adults with BN in both acute and
maintenance treatment at a dosage of 60 mg per day
Follow-up studies suggest that fluoxetine (Prozac®) should
be continued for at least one year among those who respond
positively to the medication within the first eight weeks, as it
extends the time to relapse.
Much less data supports the use of fluoxetine (Prozac®) and
other antidepressants for children and adolescents with BN.
Medication Management (2): BN
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The most impressive study is an open-label investigation,
which treated adolescents for eight weeks with 60 mg of
fluoxetine (Prozac®) per day, along with supportive
psychotherapy. The study found decreases in binge and
purge episodes, and 70% of subjects were rated as improved
or much-improved by study’s end (Kotler et al, 2003).
While fluoxetine (Prozac®) can also be used to treat
comorbidities, such as depression and OCD among patients
with Eating Disorders, the medication appears to treat binge
and purge behavior regardless of the presence of comorbid
depression (Goldstein et al, 1999).
Although other medications may be employed to treat the
comorbidities of BN, no other medications are indicated in the
treatment of BN itself. Certainly, bupropion (Wellbutrin®) is
contraindicated given seizure risk.
Clinical Management (1)
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Two goals: (1) Restore weight; (2) modify distorted
eating behavior
Behavior therapy (to restore normal eating behavior) is
often used along with individual psychotherapy
Patients are often observed after meals (to avoid
vomiting)
It is generally advisable to start at 500 calories more than
the amount required to maintain present body weight and
increase caloric intake slowly; it may be necessary to
space meals throughout the day to avoid discomfort in
somebody who is severely underweight
<10 DB/PC psychopharm trials; TCAs, MAOIs,
trazodone, and Prozac have been shown to decrease both
binge eating and purging behaviors, but they have no
specific role in anorexia
Clinical Management (2)
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TCAs have been shown to decrease binge eating by 5070% but almost no patients become totally abstinent of
binge/purging; additionally, relapse post treatment (and
often while on medication) at 50%
Some success has been reported with cyproheptadine
(Periactin) in helping patients to gain weight (particularly
anorexics with no h/o bulimia) at 24 – 28 mg/day but
follow platelets weekly
The possible role of endogenous opiates in maintaining a
state of starvation has prompted the use of opiate
antagonists
Chlorpromazine at 10 mg @ 30 min prior to meals
(follow BP and orthostasis); and olanzapine
Clinical Management (3)
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Sometimes SSRIs or BZDs are given to reduce associated
anxiety; all antidepressants are better than placebo in
decreasing binge/purge behavior (>30 studies); CBT
much more effective
All medications work only while being taken, whereas
therapy may have longer lasting effects
Family therapy may be helpful for bulimia, vital for
anorexia
CBT is superior to other types of therapy for bulimia
(approx a 70% decrease in binge eating/purging has been
shown) in >35 controlled trials
Most patients deny their illness and won’t seek help on
their own
Anorexia Nervosa (AN)
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The discrepancy between weight and perceived body image is key
to the diagnosis of anorexia; anorexic patients delight in their
weight loss and express a fear of gaining weight
Purposely loses weight to a point at least 15% below that expected
for their age, sex, and height.
Experiences changes in hormone levels which, in females, result in
amenorrhea (if the weight loss occurs before puberty begins,
sexual development will be delayed and growth might cease).
Feels driven to lose weight because they experience themselves as
fat, even when at a subnormal weight.
Is intensely afraid of becoming fat and preoccupied with worries
about their body size and shape.
Directs all their efforts towards controlling their weight by
restricting their food intake, but may also binge eat, self induce
vomiting, misuse laxatives or diuretics (purging behaviors),
exercises excessively or misuse appetite suppressants.
Bulimia Nervosa (BN)
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Experiences frequent episodes of binge eating, during
which they consume a large amount of food within a
short period of time.
Feels overwhelmed by the urge to binge and can only
stop eating once it becomes too uncomfortable to eat
any more.
Feels guilty, anxious and depressed, because they
have been unable to control their appetite any they
fear weight gain.
Tries to regain control by getting rid of the calories
consumed ( the most common method is vomiting,
but they might misuse laxatives, diuretics or appetite
suppressants, fast or excessively exercise.
On the Brink of an Eating Disorder
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Body dissatisfaction
Skipping meals
Fasting for 24 hours
Weight loss to bottom to healthy range
Excessive exercise
Preferring to eat in private
A tendency toward perfectionism
Developing odd eating habits
Vomiting after occasional large meal
On the Brink Cont’d
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Picks only low-fat or low carb foods, or becomes a
vegetarian
Sudden episodes of bingeing
Not hungry in regular cycles - overeats then starves
Studies food labels for fat and carb content
Uncomfortable physically and emotionally after
eating due to anxiety over calories
Rigidly applies diet plans: Atkins, South Beach,
Weight Watchers, etc.
Strober and Schneider, 2005
Talking to Friends
About Eating Disorders
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No matter how strong the suspicion, do not make
a diagnosis without speaking with your friend
In a direct and non-punitive manner, relate all of
the specific observations that arouse your concern
Communicate concern, caring, and a desire to
listen and to talk
Avoid arguments or battle of wills
Do not become the therapist (or savior) for your
friends
Be knowledgeable about resources
Questions to Ask
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Are you constantly thinking about food?
Is it difficult to concentrate on the daily tasks of studying or work
because of food and weight thoughts?
Do you worry about what your last meal is doing to your body?
Do you experience guilt or shame around eating?
Is it difficult for you to eat in public?
Do you count calories every time you eat or drink?
When others tell you that you are too thin, do you still feel fat?
If you see yourself as thin, do you still obsess about your stomach,
hips, thighs, or buttocks being too big?
Do you weigh yourself several times daily?
Does the number on your scale determine your mood and outlook, for
the day?
More Questions to Ask
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When you are momentarily satisfied with your weight, do you
resolve to be even more vigilant?
Do you punish yourself with more exercise or restrictions if you
don’t like the number on the scale?
Do your exercise more than 45 minutes, 5 times each week with the
goal of burning calories?
Will you exercise to lose weight even if you are ill or injured?
Do you label foods as “good” and “bad”?
If you eat a “bad” or forbidden food do you berate yourself and
compensate by skipping your next meal, purging, or adding extra
exercise?
Do you vomit after eating and/or use laxatives or diuretics to keep
your weight down?
Do you severely limit your food intake?
Cognitive Distortions in
Eating Disorders
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Personalization
All-or-nothing
Mind-reading
Catastrophizing
Shoulds
Future-telling
Labeling
Body Image
Body image is how you think and feel
about your body
 Body image may have nothing to do with
actual appearance
 Poor body image can contribute to
disordered eating, depression, and low
self-esteem
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Body Image
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Help children to understand that the “ideals”
portrayed in fashion magazines are unrealistic
Talk openly with children about ads, articles,
websites or window displays that promote
either eating disorders or healthy body image
Watch for “fat talk” between yourself and
others
Warning Signs
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Anorexia Nervosa
Excessive weight loss
 Odd food rituals
 Lack of menstrual cycles
 Fine hair on face, arms and torso (lanugo)
 Wearing baggy clothing
 Vigorous exercise at odd hours
 Paleness, dizziness, fainting spells
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Warning Signs
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Bulimia Nervosa
 Fluctuating weight (10-15 lbs)
 Missing food/secretive eating
 Cuts/scrapes on back of hand from purging
 Tooth decay
 Uses bathroom after meals
 Diet pills/laxative abuse
 Self disparagement related to food intake
 Swollen glands, puffy cheeks, broken blood
vessels under the eyes
Resources
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Websites
www.AboutOurKids.org
 www.something-fishy.com
 www.mirror-mirror.org
 www.bodypositive.com
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Books
Strober and Schneider “Just A Little Too Thin”, 2005
 Pipher “Hunger Pains - The Modern Woman’s
Tragic Quest For Thinness”, 1995
 Natenshon “When Your Child Has An Eating
Disorder”, 1999
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