Post on 08-May-2015
description
Heba Essawy , MDProfessor of PsychiatryAin Shams University
RoadmapAnorexia NervosaBulemia NervosaBinge-eating
disorderObesity
DiagnosisEpidemiologyMedical risksEtiologyTreatment prognosis
Risk Factors for EDs Perfectionism for AN Early Puberty Failed attempts to lose weight Athletics Beginning a diet Family history of eating disorder, substance
abuse or mood disorder
Diagnosis of Anorexia Nervosa DSM IVRefusal to maintain 85% of ideal body
weightIntense fear of becoming fatBody image distortion; undue influence of
weight on self evaluation; denial of risks of low weight
Amenorrhea (in post-menarchal females)
Purging-typeRestricting-type
Proposed DSM V changes“less than minimally expected” instead of 85%
ideal body weightRemove “refusal” (pejorative)Add “behavior” to avoid weight gain, since
many patients deny fear of gaining weightRemove amenorrheaSubtyping be for current episode
Diagnosis AN (DSM-5):Diagnosis AN (DSM-5):
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex.
Intense fear of gaining weight or becoming fat, or persistent behavior that interferes
with weight gain.Disturbance in one's body weight or shape ,
persistent lack of recognition of the seriousness of low body weight
Specify: Restricting typePurging type/Binge Eating.
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex.
Intense fear of gaining weight or becoming fat, or persistent behavior that interferes
with weight gain.Disturbance in one's body weight or shape ,
persistent lack of recognition of the seriousness of low body weight
Specify: Restricting typePurging type/Binge Eating.
Subtypes AN (DSM-5):
Restricting Type: during last 3months, the person has not engaged in recurrent episodes of binge eating or purging behavior Binge-Eating/Purging Type: during last 3 months, the person engaged inrecurrent episodes of binge eating or purging behavior
Epidemiology:Life time prevalence 0.5- 3.7% Girls from 14- 18ys 0.5- 1%AN and BN 30 - 50%Death 3-8% Age: 10-30years. Risk : Sp. After
stressM:F ratio 1: 20In professions modeling – ballet
dancers.
Epidemiology:Life time prevalence 0.5- 3.7% Girls from 14- 18ys 0.5- 1%AN and BN 30 - 50%Death 3-8% Age: 10-30years. Risk : Sp. After
stressM:F ratio 1: 20In professions modeling – ballet
dancers.
Medical Complication Death (hypokalemia , starvation, sudden cardiac death) Hypometabolic state (bradycardia, hypotension, hypothermia) Dehydration Arrhythmia, heart failure. Bone loss Peripheral edema Delayed sexual maturity Hair loss, brittle hair, Lanugo. On recovery: Re-feeding syndrome
Etiology
(kristinaschwerin et.al.2010)
Eating Disorder Inventory (EDI) The EDI is a 64 item, self-report for the
assessment of psychological and behavioral traits common in anorexia nervosa (AN) and bulimia.
EDI consists of eight sub-scales measuring: 1) Drive for Thinness, 2) Bulimia, 3) Body Dissatisfaction, 4) Ineffectiveness, 5) Perfectionism, 6) Interpersonal Distrust, 7) Interoceptive Awareness ,8) Maturity Fears
Anorexia Nervosa: Treatment Determine inpatient vs. day treatment vs.
outpatient Multidisciplinary teams are ESSENTIAL!
Primary care provider 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: TherapyBest evidence is for family-based treatment
(Maudsley approach)Who: younger patients who live at home, intact
familyPhilosophy: no-blame, family did not cause anorexia;
family is the best resource to help her get betterElevate 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 NERVOSAANOREXIA NERVOSAPrognosis: 40% → recover.
30% → continue with milder course.
30% → chronic cases. Risk of death
Suicide Cardiac arrest Malnutrition
> 3 years of illness: prognosis is poor
Bulemia Nervosa – DSM IVRecurrent 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 monthsSelf-evaluation is unduly influenced by body
shape or weight(purging type, non-purging type)
Proposed DSM V changesChange frequency of compensatory behaviors
from 2x/week to 1x/weekDeletion of non-purging subtype, because it
more closely resembles binge-eating disorder
Diagnostic Criteria for Bulemia Nervosa DSM-5A. Recurrent episodes of binge eating: (1) Eating large amount in a discrete period
of time (2) lack of control over eating B. Recurrent compensatory behavior in order
to prevent weight gain.C. Binge eating and inappropriate
compensatory behaviors is at least once a week for 3 months.
Bulemia: EpidemiologyLifetime Prevalence
1.5% women 0.5% men
Prevalence of binge-purge behaviors: 13% girls7% boys
Bulemia: Etiology
Media factors
Individual Temperament(ie. impulsive)
biological
Family dynamics
Societal, cultural
Medical ComplicationElectrolyte abnormalitiesDental – loss of enamel, chipped teeth, cavitiesParotid enlargement Conjunctival hemorrhagesCalluses on dorsal side of hand (Russel’s sign)EsophagitishematemesisLatxative-dependent: cathartic colon, melena,
rectal prolapse
Bulemia: Treatment Multidisciplinary team
Primary care providerPsychiatristFamily therapistNutritionist
Evidence based : CBT + Antidepressant (SSRI)
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: MedicaionsHigh-dose Fluoxetine/Prozac (SSRI) – very
good evidence! Sertraline/Zoloft (SSRI) – some good
evidenceBuproprion/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: Prognosis33% remit every yearBut another 33% relapse into full criteriaAdolescent-onset better prognosis than adult-
onsetDeath-rate = 1%
Binge Eating Disorder – DSM IV (only in appendix)Episodic intakes of larger than typical
amounts of foodEpisodes occur in brief (<2 hrs) periods of
timeSubjectively, sense of loss of control while
eatingAt least 2 days/week for 6 months
Binge Eating Disorder- DiagnosisAlso needs 3 of the following: Eating much more rapidly than normalGetting uncomfortably fullLarge amounts of food when not physically
hungryEating alone because embarrassed about
how much one is eatingFeeling disgusted with oneself, depressed,
or guilty when over-eating
Proposed DSM-V changesThat binge eating disorder should become a
free-standing diagnosis, rather than only in the appendix
Less Frequency: once a week for 3 months
DSM-5 Diagnostic Criteria for Binge Eating Disorder Eating, in a discrete period of time , large
amount Lack of control over eating during the
episode Binge eating occurs, on average, at least
once a week for three month
DSM-5 Diagnostic Criteria for Binge Eating DisorderBE are associated WITH :1. Eating much more rapidly than normal2. Eating until feeling uncomfortably full3. Eating large amounts of food when not
feeling hungry4. feeling disgusted with oneself, depressed, or
very guilty afterwards
Binge Eating Disorder:EpidemiologyMost common eating disorderLifetime prevalence:
3.5% women2% men
Binge Eating Disorder: Medical RisksLess acute risk than with restrictive eating
patternsLong-term risks significant: the many organ
systems affected by obesity, shortened life-span, etc
Binge Eating Disorder: Etiology
Media factors
genetic
Individual Temperament(ie. impulsive)
biological
Family dynamics
Societal, cultural
Binge Eating Disorder:Treatment (Medication)SSRI
high dose reduces binge behavior short-termbut doesn’t help weight loss
Topomax, Zonisamide (anticonvulsants, mild mood stabalizer)Helps binge reductionHelps weight lossCaution for adverse effects, high
discontinuation rates
Binge Eating Disorder:Treatment (Therapy)Therapies either prioritize…
Weight lossBinge-reduction Neither (ie. relationships, depression etc)
Group psychotherapyThere 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-dependencyWeight loss programs
Weight watchers, Jenny Craig, etc.12-step Self help groups
Food Addicts in Recovery AnonymousOvereaters Anonymous
Any questions? Heba EssawyWebsite www. Hebaessawy.comFacebook Dr.heba essawyEmail essawi_h@yahoo.com