Olivia L. Shuttleworth, LICSW, BCDAssistant Professor

West Virginia University oshuttleworth@hsc.wvu.edu

WHERE’S THE BEEF?

Eating Disorders: an Overview

Objectives of the Presentation

History of Eating Disorders

Participants will be able to identify the different types of eating disorders.

The DSM IV criteria for each of the eating disorders.

Is the elderly population at risk for eating disorders?

Current treatment for eating disorders.

History of Eating Disorders

• Saints fasted and Romans purged.

• Kaplan and Garfield (1984) reported on references to Bulimia like symptoms in the Talmud, this dating the existence of the disorder back over 5,000 years.

• The earliest English-language report of Anorexia nervosa is that of Richard Morton’s (1694) reporting on cases of Anorexia nervosa in a young man and young woman.

Prevalence• Bulimia Nervosa 3 to 8% Women to Men 10 to 1 ratio

• Women Age Range 15 to 40 (excluding elderly population)

• Anorexia Nervosa 1 to 2% Adolescents

• Binge Eating Disorders 3 to 8% Male Athletes

• ED in the Elderly 3 to 1 Women to Men

Diagnostic Statistic Manual Eating Disorders

Anorexia Nervosa• Greek word meaning “loss of appetite” misnomer.

• 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 a period of growth, leading to body weight less than 85% of that expected.

• 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, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current body weight.

• (How this relates to the elderly population)

• In postmenarchal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

Bulimia Nervosa• A. 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 two 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 sense of 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).

• B. 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.

• C. The binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for three months.

• D. Self-evaluation is unduly influenced by body shape and weight.

• E. The disturbance does not occur exclusively during episodes of Anorexia nervosa.

• Type: Purging Type vs. Non-purging Type (exercise and fasting to compensate).

Risk FactorsBiological

Parent/FamilyAnorexia Nervosa Overprotective FamilyBulimia Nervosa Chaotic FamilyMother’s AttitudesFather’s CommentsMother’s Behavior in Relation to FeedingMother’s Eating Disorder

Society/CultureMediaFashion IndustryView of WomenToys and ImagesThin…..Success and PowerPeer Pressure, Eating and Weight

Psychological/DevelopmentBody DissatisfactionSelf-EsteemDevelopment TasksCo-morbid ConditionsPre-morbid Conditions

Assessment of Eating Disorders

• Detecting Eating Disorders in Patients• Patients present for unrelated illness• History includes a psychological assessment, weight history, change in weight (highest to

lowest) and patient’s satisfaction with his/her weight• Note: Bulimic women can have a 10 lb. weight gain in a 2-3 week period

• Assessment May Be the Key in Detecting Eating Disorders in One’s Patients. Primary care physicians need to ask the right questions in identifying a patient with an eating disorder.

• The anorexia patient is consistently below ideal weight for height.• Do a 24 hour diet recall.• Include in your questions, “Is this person always dieting?”• Anorexics may not give accurate information.• Look for Rigid Rules (never eating sweets) and eating rituals (how food is consumed and

types)• Explore what constitutes a binge and if there is a feeling of loss of control.• Ask questions about body image; 80% of women think they are too fat and need to lose

weight.• Exercise Patterns: to stay healthy or a part of the bingeing behavior• Relationships and developmental task (Do they date?)

Physiological Symptoms and Medical Complications

• From Starvation and Weight Loss• Abdominal Pain• Acrocyanosis amenorrhea or irregular periods• Anemia, leucompenia, thrombocytopenis• Arrhythmias• Brittle nails• Bradycarydia• Cold intolerance• Constipation• Decreased LH, FSH, estrogen• Edema• Elevated liver enzymes• Emaciation• Fatigue• Hair thinning or loss• Hypotension• Hypothemia• Insomnia• Osteoporosis

From Purging

• Arrhythmias• Chest pain or burning• Dental enamel erosion• Electrolyte imbalance (particularly hypokalemia)• Elevated liver enzymes• Esophageal tears• Esophagitis• Hermatemisis• Ipecac cardiomyopathy

Treatment for Anorexia Nervosa

Family involvement is very important.Medication may be warranted if co-morbid symptoms are present:

– Depression and/or Obsessive Compulsive Disorder

Inpatient may be necessary for the individual with severe emaciation.Ideal would be an eating disorder unit/program.Behavior Modifications to establish normal eating patterns.Patient may need a caloric intake: 3,000 – 4,000 calories daily.Exercise may be reduced or restricted.Patient may be monitored for input/output and may require a lock door

order to monitor purging behavior.Goal: To increase patient weight to 5-10% recommended weight.Outpatient, Individual, and Family Therapy

Treatment for Bulimia Nervosa

• May require inpatient treatment depending on medical problems or psychiatric disturbance, i.e., suicide.

• Outpatient, Individual, Group, and Family Therapy. Food diaries kept by the individual and Cognitive Behavior Therapy.

More In-Depth Look at Treatment

Gender Based Diagnoses and Treatment of MalesThe males may present with a different presentation than females. Males may not present with a drive

for thinness but a better body image and improving strength. Screening instruments may be used to look at male body image attitudes and the drive to exercise.

Mental Health/Primary care professionals should include questions about diet, eating, and exercise behaviors as a standard part of their intake protocol, rather than limiting them for times when they suspect a client suffers from an eating disorder.

Questions that should be assessed for men include: the use of steroids (men use steroids to improve appearance, muscularity, and body image disturbance); daily smoking, alcohol use, and pain medication are correlates for binge eating among men.

The Eating Disorder Inventory and the Eating Disorder Attitudes Test, which measure disordered eating attitudes and behaviors are typically used for females but do not assess muscularity body image concerns . (“The Psychology of Men and Muscularity” McCreary 2007)

The Eating Disorder Inventory is still valid for men but some have added items to existing subscales (Oates-Johnson and DeCourville, 1999) EDI to assess not only desire to lose weight, which is what the original measure assessed, but also men’s desire to gain weight and muscle mass.

Other Key Points in Male Gender Based Therapy

“Males and Eating Disorders: Gender-Based Therapy for Eating Disorder Recovery” (Teri Greenberg Stefanie and Eva Schoen 2008)

1. Begin therapy by assessing men’s ideas about therapy and preconceived notions about what therapy can and cannot accomplish.

2. Explore the client’s masculine identity and validate his socialization experiences, including per influences or significant events related to disordered eating.

3. The mental health professional can inform the client about realistic body images, proper nutrition and the dangers of steroids; and can challenge disturbed body image while examining media images.

4. Explore what purpose the eating disorder serves; cope with stress, identifying and expressing feelings, including sexual feelings associated with disordered eating.

5. Assess family interactions, communication styles and family roles, males may adopt a patient role within the family.

Cognitive Behavior Therapy for Eating Disorders (CBT-E)

CBT-E:Is a transdiagnostic approach to be used with a full range of eating disorders.For including Bulimia and eating disorders NOS which comprises the majority of eating disorders in out patient settings. Is recommended for patients/clients with a BMI between 15 and 40Differs from regular CBT by not referring to CBT concepts such as automatic thoughts, core beliefs, and schemas, but instead emphases is placed on helping patients change the ways they behave and then analyzing the results. Essential to the treatment is that patients learn to de-center from their eating problem.The origin of the problem is not addressed, nor is every clinical feature of the eating disorder.The amount of change which occurs in the first few weeks of treatment is said to be a strong predictor of eventual outcome.

The Core of CBT-EThe core of CBT-E is to address the six main mechanisms

which serve to maintain most eating disorders:1. The over evaluation of shape and weight2. The over evaluation of control over eating3. Dietary restraint4. Dietary restrictions5. Being underweight6. Event or mood triggered change in eating– If a patient is underweight this is the top priority of treatment

“Cognitive Behavior Therapy and Eating Disorders” (Christopher G. Fairburn 2008)

Eating Disorders in the Elderly

Older Americans are being diagnosed with the eating disorder Anorexia nervosa. Although statistics are not available, therapists and rehabilitation centers that specialize in eating disorders report that every year they are ministering to more middle aged and older patients.

“Thin Gray Line” (Michelle Time Lodge, 2006)

Age Related Anorexia and the Epidimiology of Eating Problems in Older Adults, with a Focus on Italy “International Psychogeriatrics” (March 2003)

An unintentional reduced energy intake causing weight loss may be caused by social or physiological factors. Poverty, loneliness, and social isolation are the predominant social factors that contribute to decreased food intake in older adults. Depression is a common problem in this population that can cause loss of appetite. The reduction of food intake may be due to the reduced drive to eat (hunger) resulting from a lower need state, or it arises because of more rapidly acting or more potent inhibitory (satiety) signals. Physical factors such as poor dentition and ill-fitting dentures or age-associated changes in taste and smell may influence food choice and limit the type and quantity of food eaten by older adults. Older adults are also major users of prescription drugs, a number of which can cause malabsorption of nutrients, gastrointestinal symptoms, and loss of appetite. Although age-related reduction in energy intake is largely a physiologic effect of healthy aging, it may predispose older adults to the harmful anorectic effects of psychological, social, and physical problems.

Age Related Anorexia and the Epidimiology of

Eating Problems in Older Adults

Death from Anorexia Nervosa: Age Span and Sex Differences (P.L. Hewitt, S. Coren and G.D. Steel 2000)

Although there is little written on differences in clinical presentation for elderly vs. young individuals with Anorexia nervosa, there are suggestions that the clinical picture is very similar, with the exception, of course, that amenorrhea may be due to menopause in women. For example, Cosford and Arnold (1992) reviewed several cases of Anorexia nervosa in elderly patients and found that the elderly patients showed similar psychopathology to that of typical younger individuals with Anorexia nervosa, which is consistent with other work on subclinical anorexia nervosa in elderly men (Miller, et al., 1991).

Death from Anorexia Nervosa (cont’d)

Moreover, they also found that about half had initial onset of the disorder early on whereas the other half had a late onset after age 50. Numerous reports indicate that elderly individuals with Anorexia nervosa come to the attention of clinicians following significant stressful events. The elderly can experience significant stressors, such as loss of a loved one, retirement, changes in living situations; thus these environmental events may play a role in exacerbating or initiating an episode of Anorexia nervosa in elderly individuals.

The hypothesis by Hewitt, Coren and Steel suggests that there are two forms of Anorexia nervosa.

The first they call, “Classic Anorexia,” characterized by early onset prior to age 45 and the latter form of the disorder which should be called “Presbyanorexia.”

Overall their study provides descriptive and demographic data based on death certificates that more women die from Anorexia nervosa than do men, although the ratio of women to men changes among older individuals. This study suggests there are two fatal forms of the disorder; one that impacts mainly younger women, and a second form that comes later in life.

Body Image, Body Dissatisfaction, and Eating Attitudes in Midlife and Elderly Women

(Diane M. Lewis and Fary M. Cachelin; CSU, LA, CA USA 2001)

Cohort differences in body image, drive for thinness, and eating attitudes in middle-aged and elderly women were examined. Participants were 125 women between the ages of 50 and 65 (middle-aged group), and 125 women 66 years and older (elderly group). Instruments used were figure ratings (Stunkard, Sorensen, & Schulsinger, 1983), and scales of the Eating Disorder Inventory (EDI; Garner, Olmstead, & Polivy, 1983). Items were developed to assess fear of aging. The middle aged group, as compared to the elderly group, had more drive for thinness, disinhibited eating, and interoceptive confusion. The elderly group reported body size preferences and levels of body dissatisfaction that were similar to the younger women. There was a positive relationship between fear of aging and disordered eating. Sociocultural standards of body image and pressures toward thinness affect different generations of older women in similar ways.

Body Image, Body Dissatisfaction, and Eating Attitudes in Midlife and Elderly Women (cont’d)

The elderly population in the US has been increasing steadily, and it is expected that in the next millenium, the growth of this segment of the population will exceed that of all other age groups. The majority of the elderly population are, and will continue to be, women (U.S. Bureau of the Census, 1966). The changes associated with the aging of the body most likely have an effect upon body image (Krueger, 1989). Yet, until recently, research on body image and eating disorders has focused almost exclusively on younger, adolescent and college-aged populations.The clinical picture of eating disorders in the elderly is similar to that seen in adolescents (Hsu and Aimmer, 1988), and there appears to be considerable continuity between midlife-and adolescent-onset Anorexia nervosa (Dally, 1984). It has been suggested that the psychological and physical changes associated with aging and menopause may parallel the changes associated with puberty and menarche, producing eating and weight related concerns that are similar in the different age groups of women (Gupta, 1990); (Kellett, Trimble, and Thorley, 1976).

Never Too Old For Eating Disorders or Body Dissatisfaction: A Community Study of Elderly Retired Women in Innsbruck, Austria

(Barbara Mangweth-Matzek, PhD, Claudia Ines Rupp, PhD, Armand Hausmann, MD, Karin Assmayr, MA, Edith Mariacher, MA, Georg Kemmler, PhD, Alexandra Whitworth, MD, and

Wilfried Biebl, MD 2006)

A randomly selected nonclinical sample of 1,000 women, aged 60-70 years, was contacted for our questionnaire survey covering current eating behavior, weight history, weight control, body attitude, and disordered eating (DSM-IV).

The 475 (48%) women included in our analyses had a mean BMI of 25.1 but desired a mean BMI of 23.3. More than 80% controlled their weight and over 60% stated body dissatisfaction.

Although EDs and body dissatisfaction are typical for young women, they do occur in female elderly and therefore should be included in the differential diagnosis of elderly presenting with weight loss, weight phobia, and/or vomiting.

It has been established that eating disorders may be present in those of older age, despite the fact that diagnostic criteria of DSM-IV and ICD-10 are ambiguous on this aspect. (1.2). What is less established is whether these presentations represent a continuation of a lifelong illness or whether eating disorders can present for the first time in older age. (Samantha Scholtz, MRCPsych, Laura S. Hill, MSc, MRCPsych, Hugbert Lacy, MD, Mphil, FRCPsych 2009)

This study was to determine whether eating disorders can present for the first time in older people.

This is a descriptive study of patients above the age of 50 years who have presented to a national eating disorder center within the last 10 years.Thirty-two patients were identified; data were available for 26 of these patients and 11 agreed for further interview and questionnaire completion. There were no cases where the eating disorder had its onset late in life. Of the 11 interviewed, six participants retained a diagnosis of Anorexia nervosa, four had EDNOS and only one was recovered. Co-morbid depression was universal in those still suffering with an eating disorder diagnosis, and their level of social functioning was impaired.

“Anorexia nervosa is a chronic and enduring mental illness that, although rare, can be found in older people. In our sample, we found no evidence of late-onset disorders; all describe cases that were lifelong.”

Two Case Studies on Eating Disorders and the ElderlySevere Eating Disorder Initially Diagnosed in a 72-Year Old Man

(Susan G. Maneijias Parke, MD, Joel Yager, MD, and William Apfeldorf, MD, PhD 2008)

Mr. T., a 72-year old Caucasian, divorced, retired, male engineer was brought to our psychiatric emergency services by police due to concern of grave passive neglect when he failed to follow-up from post-surgical treatment of a significant basal cell carcinoma. Mr. T’s daughter had involved Adult Protective Services when her father began to show progressive difficulty managing finances, shopping and keeping appointments. His apartment was found to be filthy and without electricity, phone service, or food. Upon presentation, Mr. T. was cachectic, disheveled, and maladorous, with a nonhealing, unattended facial lesion. He denied current alcohol or substance abuse. He denied depressed, irritable, or elevated mood, overt psychotic symptoms or suicidal or homicidal ideation, and asked to be left alone. He was admitted to the geriatric-psychiatry ward for further assessment, safety, and stabilization.

Past history revealed long-standing food preoccupations and restrictive eating habits. We learned that decades earlier Mr. T. had published an “alternative health” book on nutrition and that the over-zealous rigidity with which he followed his unusual diet apparently contributed to his divorce years ago. According to his ex-wife, he ordinarily drank sufficient supply. Initially, he had felt that only grains, vegetables, and fruits were needed to survive, but over the years he further restricted his diet almost entirely to fruit.

Mr. T was presumptively diagnosed with EDNOS and Dementia secondary to nutritional deficiency (cyanocobalamin). During his hospital stay, he strongly denied feeling overweight or worrying about weight but would “power walk” every day and acknowledged, on the eating disorder questionnaire (EDQ), (20) that he did so to control weight. He revealed no overt signs of a distorted body image and, notably, ate well throughout his stay. Although he emphasized that he believed he required very little protein and no fat at all and requested a vegetarian diet, he was noted to hoard food and even order bacon, which he would hide, and later vehemently deny that he had ever asked for, or would ever eat bacon. Eventually Mr. T admitted to a history of “bulimia – years ago”, although on the EDQ he stated that the first/only time he had self-induced vomiting was at age 68. On repeated mental status examinations, Mr. T. was easily irritated and frustrated around issues of food and of not being able to return home.

Conclusion:True clinical “Anorexia” in elderly males usually results from the Anorexia of aging, i.e., with loss of appetite occurring with the “dwindles”. (21) Although Mr. T did suffer from some of the risk factors associated with Anorexia of aging (living alone, dire financial situation, decreased cognitive ability), he did not appear to have actually lost interest in eating or his appetite. He was preoccupied with food and, in fact, seemed to enjoy eating. However, he consistently and strictly maintained clearly erroneous beliefs about nutrition that led him to severely limit the variety and quantity of his food intake. Although he seemed not to harbor a strongly distorted body image, he steadfastly denied the serious medical risks imposed by his presenting low body weight and BMI, poor wound healing, and dangerously low cyanocobalamin status. Though he denied fearing weight gain, he initially exercised daily for long periods of time, and at least once admitted this was to control weight. According to criteria in the text revised 4th edition of the DSM, *(22) Mr. T’s symptoms were most consistent with AN (though he laced the distorted weight perception – a criterion that has been called into question with the emerging conceptualizations of “atypical” AN typologies (23,24), probably of the binge eating/purging type, notably with a past history of “Bulimia”, but currently with exercise as a form of compensatory behavior.

Anorexia Nervosa in the Elderly: a Multidisciplinary Diagnosis(Kodwo A. Pobee and Lawrence R. LaPalip 1996)

This case study describes an 82-year old female sheltered care resident with features of Anorexia nervosa and presents a literature review of Anorexia in the elderly. The woman was admitted to a sheltered care retirement home with complaints of lack of appetite and weight loss. On presentation she weighed 85 pounds (75% of her ideal body weight) and ate only one third to a quarter of her meals. Although she denied having a history of Anorexia nervosa, induced vomiting, or any concern about her figure or weight, nursing staff reported various gastrointestinal complaints like gagging, vomiting, and episodes of diarrhea, and found a collection of laxatives. Possible etiologies for the patient’s poor appetite and weight loss were discussed at several multidisciplinary care conferences attended by a dietitian, social worker, pharmacist, geropsychiatrist, nurses, and geriatricians. The final diagnosis of Anorexia nervosa evolved after considering the information contributed by all team members. The diagnostic features of three forms of Anorexia are described: classical or adolescent Anorexia nervosa, tardive Anorexia (Anorexia nervosa when it appears for the first time in the elderly and not a condition persisting from adolescence), and idiopathic Anorexia of the elderly (differing from tardive Anorexia mainly in that loss of appetite appears early, and there is no fear of obesity and no body image disturbance).

THE END