Eating Disorders

Joan R. Griffith, MD, MHA, MPHAssociate ProfessorDepartment of PediatricsUniversity of Toledo

Objectives

Review eating disorders categories Discuss salient research studies

Case Presentation

15 yo female with history restricted food intake and poor weight gain over past 6-9 months

Active in school, friends have noticed her decreased food intake

Significant family dynamics BMI 16

Introduction 1

“Understanding the complexities of eating disorders, such as influencing factors, comorbid illness, medical and psychological complications, and boundary issues, is critical in the effective treatment of eating disorders”

-- American Dietetic Association Position Statement, J Am Diet Assoc.2006 Dec;106(12):2073-2082

Introduction 2

News media’s role in shaping public perception of eating disorders-- Simplifies and sensationalizes versus view as complex medical phenomena-- Impact on insurance coverage: “serious or biologically based”-- Stigma: “fear, hostility, disapproval versus compassion, support, understanding”

-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51

Introduction 3

British polls: -- 35% feel patients should “pull themselves together” -- 33% blame the individual

--- View AN as “extreme form of dieting, often for narcissistic motives”

2005 National Eating Disorders Association sponsored poll of American adults for primary causes of eating disorders:-- Dieting (66%)-- Media (64%)-- Families (52%)-- Genetics (33%)

-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51

Dieting Data

Prevalence of eating disorders in teens increased during past 50 years

40% to 60% of high school girls in US diet to lose weight

13% induce vomiting or use diet pills, laxatives or diuretics

30% - 40% of junior high girls admit concern about weight

Eating Disorder Categories

Anorexia nervosa (AN) Bulimia nervosa (BN) Eat disorder not otherwise specified

(EDNOS) Binge-eating disorder (rarely seen in

adolescents)

Anorexia Nervosa:Diagnostic and Statistical Manual of Mental Disorders (DSM) IV Criteria

Refusal to maintain body weight at or above minimally normal for age & height

Intense fear of gaining weight or becoming fat, even though underweight

Disturbance in the way in which one’s body weight or shape is experienced, or shape on self evaluation, or denial of the seriousness of the current low weight

DSM IV Criteria--continued

In post-menarcheal females, amenorrhea, i.e., absence of at least 3 consecutive menstrual cycles

Type:

a. Restricting type

b. Binge-eating/purging type

Anorexia Nervosa

90% to 95% are females 90% diagnosed before age 25 years Two peaks for symptoms begin:

- 13 to 14 years

- 17 to 18 years Diagnosis may be delayed 1 to 2 years

Anorexia Nervosa

Prevalence in US and Great Britain: 0.5% of adolescent females

Middle & upper socioeconomic classes- 1 in 300 of 15-19 yr girls in elite private schools

Increasing in other ethnic/racial groups and SES

Etiology/Pathogenesis

Biologic/genetic evidence

-- Biomedical framework: genetic and environmental*

-- Genetic factors explain more than 50% of risk for developing eating disorder*

Increased in monozygotic twins Increased incidence in sisters Increased prevalence of affective disorders in

families

Psychological

Personality traits: negative emotionality, perfectionism, drive for thinness, poor interoceptive awareness, ineffectiveness, obsessive-compulsive*

Family characteristics: enmeshment, over-protectiveness, rigidity, lack of conflict resolution and history of early separation stress and sexual abuse

-- Lilenfeld et al. Clinical Psychology Review.2006;26:299-230.

Socio-cultural stressors

Affluence in industrial countries Social standard: thinness = beauty Media bombardment: thinness = success Media: women as sex objects Some sport requirements for thinness:

gymnastics, distance running & ballet

Presenting Symptoms

Excessive weight loss

-- Female: 100 lbs at 5 feet plus 5 lbs for each additional inch

-- Male: 106 lbs at 5 feet plus 5 lbs for each additional inch

Primary or secondary amenorrhea GI symptoms: abdominal pain, vomiting, or bloating Growth failure or pubertal delay

Differential Diagnosis

Thyroid disease Diabetes mellitus Addison disease Inflammatory bowel disease Brain tumors Malignancy HIV

DDx--continued

Drug/alcohol abuse Depression Schizophrenia Personality disorders Obsessive/compulsive disorders

Diagnosis: Detailed History

Weight Diet Exercise Body image Self-induced binging; purging Self-medication with laxatives, diuretics, or

diet pills

Diagnosis— Detailed Hx continued

Menstrual/puberty Sexual/physical abuse history Family history of psychiatric illness,

alcoholism, and eating disorders Substance abuse, sexual behaviors,

compulsive/impulsive behaviors

Physical Exam

Significant weight loss or failure to make expected gain

Bradycardia, hypotension, orthostatic hypotension, hypothermia

Acrocyanosis, edema, cool mottled discoloration of extremities

Skin: lanugo, loss of scalp hair, jaundice, dry skin

Physical Exam--continued

Musculoskeletal weakness, loss of muscle mass

Cardiac arrhythmias

Lab Findings

Results of following are usually normal: CBC: rare to find anemia Lytes: unless associated with vomiting BUN: low to normal even with dehydration LFTs: increased with severe starvation due

to fatty liver

Labs--continued

Results of following sometimes abnormal UA: alkaline with ketones and protein Cholesterol: elevated Amylase: elevated ECG: bradycardia, low voltage & nonspecific

ST and T wave changes, prolonged QT Bone densitometry: may show osteopenia

Labs--continued

Results usually abnormal LH & FSH: low TFTs: low Cortisol: high

Treatment

Role of Primary Care Provider (PCP) Diagnosing the eating disorder Setting weight goals Planning with patient how to meet goal Negotiating consequences if goal not met Makes referrals and coordinates care:

psychotherapist, nutritionist

Treatment--continued

Manages complications of the eating disorder

Provides care for inter-current illnesses Establishes clear criteria for hospitalization if

treatment started as outpatient

Treatment--continued

Outline plans for changing unhealthy behaviors, e.g., binging, vomiting, dieting, excessive exercise

Psychotherapy

Close relationship with PCP Individual, family and/or group therapy Antidepressants as needed

Nutrition

Patient & family education Weight gain goal of 1 pound per week for outpatient

and 3 pounds per week for inpatient Normal active female adolescent requires about

1500 kcal/day to maintain weight;

-- AN may consume only 600 to 1000 kcal/day AN patients may require 2000 – 3000 calories/day

for sustained weight gain as 3 meals and 2-4 snacks per day

Indications for Hospitalization 1

Physiologic Weight 30% or more below ideal body weight Severe metabolic/cardiovascular problems Unusual presentation

Indications for Hospitalization 2

Psychiatric Severe depression or suicide risk Acute psychosis Uncontrollable binging & purging Acute food refusal Severe family dysfunction or family crisis

Outcome

50% of patients recover fully 30% recover partially, i.e., continue to have

dysfunctional eating, body image distortion, and impaired social relationships but do well in school/job

Approximately 20% remain chronically ill AN has the highest rate of mortality of any

psychiatric disorder*

-- O’Hara & Smith. Patient Education and Counseling.2007;68:43-51.*-- Franko & Keel. Clinical Psychology Review.2006;26:769-782.

Refeeding Syndrome

Severely malnourished patients (at least 30% below average body weight for height)

Risk of developing severe complications if refed too rapidly: -- Edema-- Fatty liver-- Hypophosphatemia

--- Cardiac failure, CNS depression, hemolytic anemia Can occur with oral, enteral or parental feeding Prevention: use prophylactic phosphorus and refeed slowly (800-1000

calories/day and increase by 100-200 calories/day)

-- C Holland-Hall & RT Brown. Adolescent Medicine Secrets.2002. Hanley & Belfus, Inc, Philadelphia.

Case Presentation

15 yo female with history of recurrent vomiting and diarrhea since Feb 2007

Weight in 90th percentile for age and height PE: Flat affect, marked erosion of dental enamel 10-26-08: admitted for full work-up including GI

evaluation; WNL 10-30-08: Psychology referral. Mother asks, “Does

she look like she has an eating disorder?”

Bulimia Nervosa

College age: 1% to 5% women; 1% men Secondary school: 1.1% girls; 0.2% boys Incidence is increasing Partial syndrome of vomiting and/or laxative

use without binge-eating may be more common, especially in college students

Do not have adequate knowledge of the etiology & maintenance of the syndrome

DSM-IV Diagnostic Criteria

Recurrent episodes of binge eating

-- Binge characterized by both:

1. Eating in a discrete period of time, an amount of food larger than most people would eat during a similar period of time & under similar circumstances

2. A sense of lack of control over eating

DSM-IV Continued

Recurrent inappropriate compensatory behavior to prevent weight gain, e.g., self-induced vomiting, laxatives, diuretics, enemas, fasting, excessive exercise

Binging and inappropriate compensatory behaviors both occur at least twice a week for 3 months

DSM-IV Continued

Self evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during episodes of anorexia nervosa

2 Types:

-- Purging

-- Non-purging

Etiology & Pathogenesis

Biologic factors:

1. Dysregulation of serotonin metabolism resulting in binge eating of high-carbohydrate foods

2. Family history of alcoholism and affective disorders, e.g. depression

Etiology Continued

Psychological factors:

1. History of incest, rape or sexual abuse

2. Dysfunctional family interactions

-- parental enmeshment to absence

-- chaotic, conflicted & critical Lead to feelings of being out of control, poor

self-esteem, and needing comfort

Etiology-- Psychological Continued

Personality differences in AN and BN

-- AN: anxious, inhibited, controlled

-- BN: affectively labile, under controlled, active

Etiology Continued

Socio-cultural factors:

1. Strong pressures for thinness lead to dissatisfaction with normal or overweight

-- physically attractive/socially acceptable

2. May begin after unsuccessful dieting

3. “Contagion” factors in college dorms for binging and purging “parties”

Differential Diagnosis

Thyroid disease Diabetes mellitus Addison disease Inflammatory bowel disease Brain tumors Malignancy HIV

DDX Continued

Drug/alcohol abuse Depression Schizophrenia Personality disorders Obsessive/compulsive disorders

Diagnosis--History

Weight history Detailed diet history Detailed exercise history Body image history History of self-induced binging; purging; self-

medication with laxatives, diuretics, or diet pills

Diagnosis--HX Continued

Detailed menstrual/puberty history Sexual/physical abuse history Family history of psychiatric illness,

alcoholism, and eating disorders History of substance abuse, sexual

behaviors, compulsive/impulsive behaviors

Physical Examination

Head & neck: bilateral parotid gland swelling, loss of tooth enamel (from acidic stomach contents), dental caries, subconjunctival hemorrhage (from forced vomiting)

Skin: scarring or hyperpigmentated calluses on knuckles (Russell’s sign); petechiae on face (from forced vomiting)

Physical Exam Continued

GI: abdominal distention, ileus, constipation, rectal bleeding, gastritis, esophagitis, esophageal tears

Pulmonary: aspiration pneumonia, pneumomediastinum

Cardiac: arrhythmias

Outcome

Variable course; majority chronic fluctuation of binge/purge behavior

Pts with history of sexual abuse, conflicting family environments, comorbid medical or psychiatric states, or inability to seek or accept Rx have more severe course

BN tend to be more responsive than AN

-- 60% BN vs. 50% AN recover in first 5 years

Outcome Continued

Potential lethal complications:

-- Esophageal tears from severe repetitive vomiting

-- Cardiac arrhythmias from hypokalemia due to vomiting and diuretic abuse

-- Cardiomyopathy and death from ipecac use

Outcome Continued

Antidepressants are somewhat effective in controlled short-term Rx of binge eating

Twelve-month follow-up studies show recovery rates up to 70% but frequent relapses occur

Lower recovery rates in patients requiring inpatient treatment or those with concurrent alcohol abuse

Outcome Continued

Cognitive-behavioral interventions reduce bingeing and vomiting as well as associated psychopathology

-- individual and group therapy effective

-- not uniquely effective as other non-behavioral psychotherapy seems effective

-- more effective than pharmacotherapy

Literature Review: Medication Use in Children and Adolescents with Eating Disorders 1

2 major classes of drugs: antidepressants (SSRIs) and atypical antipsychotics

Limited evidence-based: limited studies in children-- One retrospective study on the use of SSRIs -- Some case reports on atypical antipsychotics for children and adolescents with AN, -- One small open trail on SSRIs for adolescent BN

-- Couturier & Lock, J CAN Acad Child Adolesc Psychiatry. Nov 2007;16(4):173-176.

Literature Review: Medication Use in Children and Adolescents with Eating Disorders 2

Olanzapine (Zyrexa) and other atypical antipsychotics may prove useful for AN at low body weight-- Decrease eating-related anxiety-- Uncertain whether SSRIs prevent relapse in AN

Fluoxetine (Prozac): first line drug option in children and adolescents with BN-- Open trial: 10 adolescent, 12-18, 60 mg for 8 weeks-- Binging decreased from 4 to 0-- Purging decreased from 6 to 0

-- Couturier & Lock, J CAN Acad Child Adolesc Psychiatry. Nov 2007;16(4):173-176

Suicidality in Eating Disorders

High rates of completed suicide in patients with AN -- 50-fold increased risk-- Rate is 200 times greater than in general population-- Crude Mortality Rate = 0% to 5.3%

-- 2nd most common cause of death in meta-analysis of 42 studies Rates of completed suicide do not appear elevated in BN

-- Crude Mortality Rate = 0.1% Rates of suicide attempts:

-- 3 to 20% of patients with AN-- 25% to 35% of patients with BN

-- Franko DL, Keel PK. Clinicaly Psychology Review.2006;26:769-782

Role of Parenting Experiences in Development of Anxiety and agoraphobia in Eating Disorders

Social anxiety: fear of social situations in which the individual may be exposed to unfamiliar people or the scrutiny of others-- Associated with abandonment and emotional inhibition beliefs-- Associated with inhibiting parenting by fathers (parenting that reflects a lack of ability to share feelings with the child)

Agoraphobia: anxiety about being in places or situations from which escape might be difficult-- Associated with vulnerability to harm beliefs-- Associated with pessimistic/fearful parenting by mothers (parenting that reflects anxious, fearful traits in the mother and a pessimistic outlook on life)

-- Hinrichsen, Sheffield, Waller. Eating Behaviors.2007;8:285-290

Eating Disorders: Younger Girls vs. Older Teenagers

Girls presenting before menarche may have a long history of poor weight gain and growth retardation before the onset of weight loss

Older adolescents start weight loss at an above-average weight without prior poor weight gain

Psychopathology in young girls may be different and less evident compared to older teenagers

Important to be aware that poor weight gain and growth retardation may be associated with early-onset eating disorder

-- Swenne I, Thurfjell B. Acta Paediatr.2003 Oct;92(10):1133-1137.

Summary

Major roles of Primary Care Provider:-- Making the diagnosis-- Forming a bond of trust with patient -- Involving family -- Establishing therapeutic team- Managing patients health over the course

It will require trust and time. Exercise caution with vegetarians

-- May mask and eating disorder

References

Stoylen IJ, Laberg JC. Anorexia nervosa and bulimia nervosa. Perspectives on etiology and cognitive behavior therapy. Acta Psychiatr Scand Suppl 1990;361:52-58.

References Continued

Steiner H, Lock J. Anorexia nervosa and bulimia nervosa in children and adolescents: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1998;37(4):352-359.