Transcript Eating Disorders - American Academy of Child and Adolescent

Eating Disorders
21 November 2013
Krissy Schwerin, MD
Child and Adolescent Psychiatrist
Canterbury District Health Board
South Island Eating Disorders Service
Child Adolescent & Family Rural Service
Overview
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Anorexia Nervosa (AN)
Bulemia Nervosa (BN)
Binge Eating disorder
(BED)
Unspecified Feeding or
Eating Disorder (UFED)
Other Eating/Feeding
problems
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Diagnosis
Epidemiology
Medical risks
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, younger children, older adults, and other
ethnic groups.
Our field needs to do a better job screening and
treating…
Case Vignette #1 - Carla
Carla is a 13 year-old 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. Carla had always
been a happy child and great student, but had
recently become obsessed with her schoolwork
and isolated from her friends and close-knit
family.
Carla began losing weight after her PMD told her
she was overweight. This coincided with a
family trip to parents’ country of origin where
Carla didn’t like the food. She lost >40 pounds
and stopped getting her period
Anorexia Nervosa (AN) - DSM V
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Persistent restriction of energy intake leading low
weight (lower than minimally expected for age/sex)
Intense fear of gaining weight or becoming fat, or
behaviour that interferes with weight gain
Disturbance in body image, undue influence of
shape/weight on self-evaluation, lack of recognition of
seriousness of low body weight
Restricting sub-type
Binge-eating/purging sub-type
**DSM-IV: 1. “refusal” to maintain weight 2. <85 percentile weight
3. amnorrhea was required
Anorexia Nervosa:
chief complaint…
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Family or school is concerned about eating
habits or personality change
Physical symptoms
Other psychological concerns – depression,
anxiety, obsessive
“unintentional” weight loss
Amenorrhea
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Patient: “I’m fine!”
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Anorexia Nervosa:
Risk Factors, Precipitating Factors, & Traits
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Perfectionism
Early Puberty
Failed attempts to lose weight
Antecedent illness with weight loss
Athletics
Beginning a diet
Family history of eating disorder
Life/family stressors
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%
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Physical Risks
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Death (suicide, starvation, sudden cardiac death)
Hypometabolic state (bradycardia, hypotension, hypothermia)
Orthostasis
Dehydration
Arrhythmia, heart failure, liver failure
Bone marrow suppression
Malnourishment
Bone loss
Lanugo
Peripheral edema
Stunted growth
Delayed sexual maturity
Hair loss, brittle hair
Cognitive impairment
Water intoxication
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
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Vitals (w/ temperature)
ECG (look for long QTc)
Lytes, CBC, LFTs, ESR, TFTs, CK
β-HCG, LH, FSH, prolactin, estradiol if indicated
Bone density
(don’t be fooled by normal bloods!!!)
Etiology
From Silber et.al.
Anorexia Nervosa: Treatment
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Determine level of care
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Inpatient medical stabilization
Inpatient eating disorders service
Outpatient treatment
1st: weight restoration
2nd: psychological
3rd: maintenance (long-term)
Multidisciplinary Team Approach! (psychiatrist, PCP,
nurse, psychologist, family therapist, social worker,
occupational therapist, dietician)
Considering Medical Admission
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<75% ideal body weight
Hypothermia T<35.5 C
Bradycardia HR<50 (peds) or HR <40 (adults)
Orthostasis-drop in sbp >10, increase in HR>35
Dehydration
Potassium < 2.5 or other electrolyte abnormality
Acute medical complication
Delirium
Re-feeding syndrome
Severe depression/suicidality– psychiatric admit
Anorexia Nervosa: Treatment
No evidence-based psychotherapy for
Anorexia Nervosa in adults!
 No evidence-based pharmacologic
treatments in any age!
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Psychological Treatments:
Adolescents with AN
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Family Based Treatment (FBT) (aka
“Maudsley Approach”)
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no-blame approach, family did not cause anorexia
family is the best resource to help her/him get better
Empower parents to get the young person to eat in order to save
his/her life: “intense scene”
Align siblings with the patient for support
“Externalize” the anorexia
Family Meal (Session #2)
Focus on weight restoration first
then explore the family dynamics and psychological issues that
may get in the way of maintaining weight
Psychological Treatments:
Adults with AN
None are “evidence-based”
We use…
Motivational
Interviewing
Cognitive Behavioural Therapy (CBT)
Supportive Psychotherapy
Metacognitive Therapy
Couples or Family Therapy, or family involvement
Psychodynamic Therapy
Interpersonal Therapy (IPT)
Group Therapy
Anorexia Nervosa: Medications
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No approved medication treatments for Anorexia
Nervosa
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Fluoxetine (or other SSRI) for co-morbid depression or
anxiety
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Growing evidence for low-dose atypical antipsychotics
(Olanzapine) for obsessive ruminations and possibly
weight gain (still off-label)
Re-feeding Syndrome
 Metabolic
abnormalities as a result of reinstating
nutrition to patients who are malnourished
 Potentially fatal
 Low phosphate
 Edema
 Tachycardia
 Hypoglycemia (hyperinsulinemic response)
 Treatment
 admit
 replace phosphate
 higher protein: carbohydrate ratio
Anorexia Nervosa: Prognosis
1/3 recover
 1/3 continue with milder course
 1/3 chronic severe
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Young age of onset, short time since onset
of illness: very good prognosis
 >7 years of illness, very unlikely recovery
(but not zero!!!)
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Case Vignette #2: Katie
Katie is a 20 year-old University student who had been in
therapy for anxiety, self-harm, and a prior trauma that
occurred in early adolescence. One session Katie
revealed to her therapist that she had an embarrassing
secret that she wanted to disclose. She had been
bingeing and purging multiple time per week throughout
the course of treatment. For years she had gone to
great lengths to hide this from roomates/family, going to
extents of hiding bags of vomit in the outside rubbish.
She finally decided to tell her therapist and ask for help,
because after years of being under 130 pounds, her
weight has now increased to 134 pounds and she thinks
her body is “disgusting”. Current BMI is 22.
Bulemia Nervosa (BN)– DSM V
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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 episodes of compensatory behavior (vomiting,
laxatives, diuretics, excessive exercise)
Both occur at least 1x/week for 3 months
Self-evaluation is unduly influenced by body shape or
weight
Does not occur exclusively during episodes of Anorexia
Nervosa
**DSM-IV: compensatory episodes had to be 2x/week
Bulemia Nervosa:
Risk Factors, Precipitating Factors, & Traits
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Often normal weight or overweight (easy to forget to
screen for eating disorders!)
Shame and guilt
History of sexual abuse not uncommon
Impulsivity, risk-taking behaviours
Depression/anxiety, emotional dysregulation, self-harm
Less denial compared to AN, but may go to great lengths
to keep symptoms secret
Bulemia Nervosa: Epidemiology
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Lifetime Prevalence
 1.5%
women
 0.5% men
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Prevalence of binge-purge behaviors:
 13%
girls
 7% boys
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Slightly older average age of onset compared to
Anorexia Nervosa
Purging extremely rare in children
Bulemia: Etiology
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Multifactorial!!!
genetic
Family dynamics
Individual
Temperament
(ie. impulsive)
Media factors
Societal, cultural
biological
Medical Risks
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Electrolyte abnormalities (hypokalemia, ketosis)
Dental – loss of enamel, chipped teeth, cavities
Parotid hypertrophy
Conjunctival hemorrhages
Calluses on dorsal side of hand (Russell’s sign)
Esophagitis, Mallory-weiss tears, Barrett esophagus
hematemesis
Latxative-dependent: cathartic colon, melena, rectal
prolapse
Elevated CK or other injuries (over-exercising)
Poor nutrition (if severe purging)
Edema upon cessation of purging
Bulemia Nervosa: Treatment
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Again, multidisciplinary team!!!
Adults:
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Best evidence: Cognitive Behavioural Therapy (CBT)
+ Antidepressant (SSRI)
Adolescents
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Evidence for adolescents is sparse; we extrapolate
from the evidence for adult treatment
 CBT + SSRI
 or Family-Based Treatment (FBT) modified for BN
(good evidence, but not as good as for AN)
Bulemia Nervosa: CBT or DBT
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Best evidence is for CBT or DBT (good outcomes, but
outcomes are short-term)
Cognitive Behavioral Therapy (CBT)
thought
feeling
behavior
Thought Challenging: “I will gain weight if I eat normal amounts of food.”
 Break the cycle of: “dieting” -> feel hungry/deprived -> binge -> guilt -> purge
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Dialectical Behavioral Therapy (DBT)
Chain analysis, mindfulness, emotion-regulation skills
Fight with
mom
Called friend,
Felt angry She was too Felt lonely
Busy to talk
Binge
Bulemia: Other Therapies
Family Therapy and/or family involvement
 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)
 Psychotherapy for comorbidities
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Bulemia Nervosa: Medications
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High-dose Fluoxetine (SSRI) – very good
evidence!
Sertraline (SSRI) – some good evidence
Topiramate (mood stabalizer, promotes weight
loss) – some good evidence, but use with
caution especially if low-weight
Remember: Buproprion (other antidepressant)
is contraindicated! (risk of seizures if history of
purging)
Bulemia: Prognosis
33% remit every year
 But another 33% relapse into full criteria
 Adolescent-onset better prognosis than
adult-onset
 Death-rate = 1%
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Case Vignette #3 - Laura
Laura is a 47 year-old divorced female in treatment 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 visits multiple different fastfood restaurants in succession and in neighborhoods far
from home, so that this behavior will not get noticed by
others. Laura one of 7 siblings. She is always identified
as the “strong” one in the family who will take care of
others who are ailing.
Binge Eating Disorder (BED) – DSM V
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Recurrent episodes of binge eating
 Eating definitely more than most people would eat in discrete 2hour period of time
 Sense of lack of control during the episode
Three or more of the following:
 Eating much more rapidly than normal
 Eating until uncomfortably full
 Eating large amounts when not physically hungry
 Eating alone because embarrassed by how much eating
 Feeling disgusted, depressed, or guilty afterwards
Marked distress regarding binge eating
On average at least once a week for 3 months
No compensatory behaviours such as in bulemia nervosa
**DSM IV: Binge-eating disorder was only in the appendix,
frequency of binge episodes was >2x/week
Binge Eating Disorder vs. Obesity
Binge Eating Disorder: may be overweight,
but not required for diagnosis
 Binge Eating Disorder: more subjective
distress about episodes of over-eating
compared to obese non-BED
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Binge Eating Disorder:
Epidemiology
Most common eating disorder
 Lifetime prevalence:
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 3.5%
women
 2% men
Binge Eating Disorder: Etiology
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Multifactorial!!!
genetic
Family dynamics
Individual
Temperament
(ie. impulsive)
Media factors
Societal, cultural
biological
Binge Eating Disorder:
Treatment (Medication)
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SSRI
 high
dose reduces binge behavior short-term
 but doesn’t help weight loss
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Topiramate, Zonisamide (anticonvulsants, mild
mood stabalizer)
 Helps
binge reduction
 Helps weight loss
 Caution for adverse effects, high discontinuation rates
Binge Eating Disorder:
Treatment (Therapy)
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Therapies either prioritize…
 Weight
loss
 Binge-reduction
 Neither (ie. relationships, depression etc)
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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
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Family may need help with co-dependency
 Attachment approach, particularly with youth
Weight loss programs
12-step self-help groups (addressing the
problem as an addiction)
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Food Addicts in Recovery Anonymous
Case Vignette #4: Alisa
Alisa is an 8 year-old 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.
Nasogastric feedings were initiated, and Alisa underwent
a complete GI workup which was negative for a medical
cause for her pain. Her parents had difficulty accepting
that there may be a psychological component to her
illness. Parents were divorced, with a high level of postdivorce conflict. Alisa’s older brother had low-functioning
Autistic Spectrum Disorder with behavior/aggression
problems, and the family were always impressed with
Alisa’s resilience. Alisa denied body image distortion or
desire for weight loss.
Other Eating/Feeding Disorders
DSM V
Pica- eating non-nutritive substances
 Rumination Disorder- chewing/spitting,
re-chewing, regurgitating
 Avoidant/Restrictive Food Intake
Disorder- failure to meet energy/nutritive
needs, dependence on enteral feeding or
supplements
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Unspecified Feeding or Eating Disorder
(UFED)
Formerly Eating Disorder NOS (EDNOS)
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Clinically significant distress/impairment but do not meet
criteria for other eating disorders
May be used when not enough clinical information (ie.
emergency room settings)
Atypical presentations
** Overall changes in eating disorders are meant to limit the use of this
“unspecified” category, which was too large in DSM-IV. (ED-NOS was
more common than AN or BN, and actually represented a very “sick”
group.)
Other Feeding Problems in
Infancy/Childhood (non-DSM)
Selective Eating
 Food Phobias
 Pervasive Food Refusal
 Food Avoidance Emotional Disorder
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Eating Disorders:
Take Home Points
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Great need for provider-awareness (both in mental
health and non-mental health)
Very medically risky!!! Need intense psychological AND
medical management!
Multifactorial etiology
Multidisciplinary treatment approach
Involve the family in treatment whenever you can
Young patient with new AN cannot afford to wait for FBT
Prevalent in teens, but much less research to guide us in
their treatment
Little evidence for medications in EDs: this is why
psychiatrists need to be more than med-managers!
References
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Hay et.al. “Psychological Treatments for Bulemia Nervosa and
Bingeing” The Cochrane Library 2010
Lock, J., “Evaluation of Family Treatment Models for Eating
Disorders” Current Opinion in Psychiatry 2011
Lock & LeGrange Treatment Manual for Anorexia Nervosa, Second
Edition 2013
Rosen et.al. “Identification and Management of Eating Disorders in
Children and Adolescents” Pediatrics 2010
Treasure et.al. “Eating Disorders” Lancet 2010
Vocks et.al. “Meta-Analysis of the Effectiveness of Psychological
and Pharmacological Treatments for Binge Eating Disorder”
International Journal for Eating Disorders 2010
www.dsm5.org Feeding and Eating Disorders Fact Sheet, American
Psychiatric Association 2013
Any questions?
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