Transcript Eating Disorders February 9, 2010 Medical Student didactics

Eating Disorders
Aug 3, 2011
Krissy Schwerin, MD
Assistant Professor of Psychiatry
Child and Adolescent Psychiatry
[email protected].
edu
Overview
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Anorexia Nervosa
Bulemia Nervosa
Binge-eating disorder
Eating Disorder NOS
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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, young children, older adults, and other
ethnic groups.
Our field needs to do a better job screening and
treating…
Risk Factors for EDs
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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
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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
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Anorexia: chief complaint…
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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…
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“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%
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Medical Risks
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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
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vitals (w/ temperature)
EKG
Lytes, LFTs, ESR, prealbumin, amylase, TFTs,
UA, Upreg
β-HCG, LH, FSH, prolactin, estradiol if indicated
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Bone density
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(don’t be fooled by normal labs!)
Etiology
From Silber et.al.
Anorexia Nervosa: Treatment
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Determine inpatient vs. day treatment vs. outpatient
Multidisciplinary teams are ESSENTIAL!
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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
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<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!
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Anorexia Nervosa: Therapy
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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
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No approved medication treatments for Anorexia
Nervosa
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Prozac (or other SSRI) for co-morbid depression or
anxiety
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Low-dose Atypical Antipsychotics off-label for nearpsychotic 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
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 Risk
of death
Suicide
 Cardiac arrest
 Malnutrition
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> 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: nonfat 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)
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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
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Bulemia: How patients may
present…
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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
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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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High prevalence of sexual abuse history in
bulemics, especially boys
Extremely rare in young 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
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
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Again, multidisciplinary team!!!
 Primary care provider
 Consultation with eating
 Psychiatrist
 Individual therapist
disorders specialty clinic
 Family therapist
 Nutritionist
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Best evidence: CBT + Antidepressant (SSRI)
Evidence for adolescents is sparse; we
extrapolate from the evidence for adult treatment
Bulemia: Treatment (Therapy)
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Best evidence is for CBT or DBT (good outcomes, but
outcomes are short-term)
Cognitive Behavioral Therapy (CBT)
thought
feeling
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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)
Fight with
mom
Called friend,
Felt angry She was too Felt lonely
Busy to talk
Ate pint of
ice cream
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
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Bulemia: Medicaions
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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%
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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
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Binge Eating Disorder- Diagnosis
Also needs 3 of the following:
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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
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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:
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
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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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Topomax, 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
Family need help with co-dependency
 Weight loss programs
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 Weight
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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
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Does not meet full criteria for any of the specific eating
disorders
Doesn’t mean less clinically significant!
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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
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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
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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! (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
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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
[email protected]
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