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