PNM Cell Group CME:Overview of Eating

Disorders, in particular Bulimia Nervosa

Overview of Epidemiology, Aetiology, DiagnosisOverview of Evidence-Base re TreatmentQ+A and Cases from Group

Epidemiology of Eating Disorders

Anorexia Nervosa – relatively rare BUT more severe, relapsing-remitting and/or chronic NZ Community Sample – lifetime risk - 0.3-0.5% Female risk 10x male risk Age of onset usually adolescence Mortality rate highest of any psychiatric condition Suicide rate higher than Major Depression Co-morbidity very common – Major Depression, OCD,

Personality Disorder

Epidemiology of Eating Disorders

Bulimia Nervosa – more common BUT less severe NZ Community Sample – lifetime risk using formal

diagnostic criteria - 1.5-3.0% Secondary school girls – rates of binge

eating/vomiting high – up to 20% - mostly self-limiting/does not progress to full disorder

Female risk 10x male risk Co-morbidity very common – Major Depression, A+D

conditions, Personality Disorder

Aetiology of Eating Disorders

Multifactorial Stress-vulnerability model useful framework

for conceptualising “why this person, why now?” – commonly precipitated by stressful event in a vulnerable individual

Cultural component – attitudes to women’s ideal body size/image, media/advertising images and messages, societal pressure etc.

Ballerina’s, Gymnasts, Models at higher risk Very rare in PI women in Islands, NZ PI women

same rate as pakeha by 3rd generation in NZ Onset often after a period of “normal” dieting

Aetiology of Eating Disorders

Contd… Genetic Component – increased risk among 1st-

degree relatives of individuals with an eating disorder, twin studies show high concordance rates identical twins

Genetic Component – also increased risk of mood disorders and A+D conditions among first degree relatives of individuals with an eating disorder

?Family factors – contentious, some evidence Early life disruption/trauma – increased risk of

Eating Disorder, most often co-morbid with Personality Disorder, A+D issues etc.

Diagnosis – Anorexia Nervosa

Weight loss/refusal to maintain body weight above 85% of expected weight for age/height

Intense fear of gaining weight/becoming fat even though under weight

Body image disturbance Amenorrhoea Restricting type vs Binge-Eating/Purging

type

Diagnosis – Bulimia Nervosa

Recurrent episodes of binge eating, associated lack of control over eating – at least 2x wkly for at least 3 mths

Associated compensatory behaviour to avoid weight gain – dieting, purging, excessive exercise, misuse of laxatives/diuretics

Self-evaluation unduly influenced by body shape/weight, some degree of body image distortion

Purging type vs Non-Purging type

Eating Disorders – Medical Complications

Purging – dental decay, parotid enlargement, fluid/electrolyte disturbance esp. hypokalemia (subsequent risk of arrythmias)

Starvation – anaemia, hypotension, hypothermia, elevated LFT, impaired renal function, sinus bradycardia and arrythmias, EEG abnormalities, enlarged brain ventricles/cerebral atrophy, osteoporosis

Eating Disorders – Evidence-Based Treatments

Best treatment approach multidisciplinary/multidimensional – Medical – assess for and treat medical

complicationsDietician – dietary advice/prescriptionPsychology – CBT/Family TherapyPsychiatry – symptomatic treatment,

treatment of co-morbid conditions

Eating Disorders – Evidence-Based Treatments

Behavioural Interventions –Eating diaryPsychoeducation, advice re healthy eating

and body weightMotivational interviewing

Eating Disorders – Evidence-Based Treatments

Medications –Some evidence for benefit of high-dose SSRI

in BulimiaOtherwise no effective drug treatmentBenefits from treating co-morbid conditions

e.g., depressionMedication can be helpful targeting specific

symptoms – e.g., sleep disturbance, anxiety

Eating Disorders – Evidence-Based Treatments

Psychotherpeutic interventions -Family Systems Therapy and CBT both

effectiveSome evidence for Family Therapy better in

teens/unemancipated individuals, CBT better in adult/emancipated

Group CBT programme very cost-effective in treating Bulimia Nervosa

Cognitive Behaviour Therapy (CBT)

Structured, time-limited, ‘here and now’ Specific skills for now and future Five components to problem (“Five-Part

Model”) Cognitive model Evidence Balanced thinking

CBT - 5-Part Model

Thoughts orCognitions

Physiology,Sensations

Behaviours,Actions

Feelings,Emotions

Environment (Past & Present), Situation

CBT - 5-Part Model (contd)

SITUATIONAUTOMATIC

THTS ANDIMAGES

REACTION

EMOTIONAL

BEHAVIOUR

PHYSIOLOGYLENS OR FILTER THROUGH WHICH WE PRECEIVE ORINTERPRET SITUATIONS

COGNITIVE COMPONENT

?Questions

?Cases to Discuss