Working with Eating Disorder Patients

Working with Eating Working with Eating Disorder Patients Disorder Patients

Elise Curry Psy.D.Elise Curry Psy.D.Program ManagerProgram Manager

UCSD IOPUCSD IOP

Terry Schwartz MDTerry Schwartz MDMedical Director UCSD Eating Disorders Medical Director UCSD Eating Disorders

ProgramProgramAsst Clinical Professor UCSDAsst Clinical Professor UCSD

Structure of 3 day trainingStructure of 3 day training

Day 1: Intro to ED assessment and Day 1: Intro to ED assessment and treatmenttreatment

Day 2 and 3: More specifics “how to”, Day 2 and 3: More specifics “how to”, therapy modalities, special therapy modalities, special populationspopulations

Anorexia NervosaAnorexia Nervosa

Most homogenous psychiatric Most homogenous psychiatric disorderdisorder

90-95% female90-95% female Onset teenage years – puberty Onset teenage years – puberty Monotonous puzzling Monotonous puzzling

symptoms symptoms Poor response to treatmentPoor response to treatment Highest mortality rate Highest mortality rate 50% to 80% contribution of 50% to 80% contribution of

genes genes

DSM IV Criteria for Anorexia DSM IV Criteria for Anorexia NervosaNervosa

Preoccupation with body shape, Preoccupation with body shape, weight/sizeweight/size

<85% ideal BW<85% ideal BW Fear of becoming fat despite low Fear of becoming fat despite low

weightweight Loss of 3 consecutive periods in Loss of 3 consecutive periods in

womenwomen Types: restricting,binge/purge,purgeTypes: restricting,binge/purge,purge

DSM IV criteria for Bulimia DSM IV criteria for Bulimia NervosaNervosa

Recurrent episodes of binge eating, characterized by Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete eating an excessive amount of food within a discrete period of time and by a sense of lack of control over period of time and by a sense of lack of control over eating during the episode eating during the episode

Recurrent inappropriate compensatory behavior in order Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diurética, enemas, or other misuse of laxatives, diurética, enemas, or other medications (purging); fasting; or excessive exercise medications (purging); fasting; or excessive exercise

The binge eating and inappropriate compensatory The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week behaviors both occur, on average, at least twice a week for 3 months for 3 months

Self-evaluation is unduly influenced by body shape and Self-evaluation is unduly influenced by body shape and weight weight

Diagnostic challenges in EDs Diagnostic challenges in EDs (ED NOS)(ED NOS)

BN vs. AN: binge/purge typeBN vs. AN: binge/purge type Sandy is 5 ft tall and weighs is 80 lbs. She Sandy is 5 ft tall and weighs is 80 lbs. She

has regular periods and no body distortion. has regular periods and no body distortion. She is 16 yrs old.She is 16 yrs old.

Sally purges normal meals, but does not Sally purges normal meals, but does not binge.binge.

Tom thinks he needs to gain weight. He Tom thinks he needs to gain weight. He uses exercise to purge. He binges 2 times uses exercise to purge. He binges 2 times per week and then goes running.per week and then goes running.

Shelly chews and spits her food several Shelly chews and spits her food several times a daytimes a day

Possible Signs of an Eating Possible Signs of an Eating Disorder Disorder

Preoccupation with Preoccupation with food/weightfood/weight

Dramatic weight loss Dramatic weight loss or gainor gain

Chronic dietingChronic dieting Feels cold all the timeFeels cold all the time Dental problemsDental problems History of ballet, History of ballet,

wrestling, or modelingwrestling, or modeling Disgusted by red meat Disgusted by red meat

or dessertsor desserts

Has difficulty eating Has difficulty eating with peoplewith people

Cuts out food groups Cuts out food groups Becomes Becomes

vegetarian/vegan as a vegetarian/vegan as a teenteen

Uses bathroom after Uses bathroom after mealsmeals

Wears baggy clothes Wears baggy clothes or layersor layers

Cooks for other Cooks for other excessivelyexcessively

Excessive exerciseExcessive exercise

Scope of The ProblemScope of The Problem

Prevalence increasingPrevalence increasing AN: .5-2%AN: .5-2% BN: 3-4%BN: 3-4% AN BN More common westernized culturesAN BN More common westernized cultures 10% of eating disordered individuals in 10% of eating disordered individuals in

treatment are maletreatment are male 5%-20% of AN patients die (disorder or 5%-20% of AN patients die (disorder or

suicide)suicide)

Primary Causes of Death in Patients Primary Causes of Death in Patients with Eating Disorderswith Eating Disorders

AN, AN, Restricting Restricting SubgroupSubgroup

AN, Bulimia AN, Bulimia SubgroupSubgroup

Bulimia Bulimia NervosaNervosa

1. Starvation1. Starvation+ ++ + ++

2. Cardiac 2. Cardiac arrhythmia/failure arrhythmia/failure from hypokalemia from hypokalemia of ipecac abuseof ipecac abuse

++ + ++ + + ++ +

3. Suicide3. Suicide++ + ++ + + ++ +

4. Gastric Dilation4. Gastric Dilation++ ++

Scope of the problem: Scope of the problem: continuedcontinued

One of the highest death rates from any One of the highest death rates from any mental health condition (AN)mental health condition (AN)

Increasing incidence in elementary age Increasing incidence in elementary age children (8-11 year old)children (8-11 year old)

The incidence of bulimia in 10-39 year old The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993. women TRIPLED between 1988 and 1993.

There has been a rise in incidence of There has been a rise in incidence of anorexia in young women 15-19 in each anorexia in young women 15-19 in each decade since 1930. decade since 1930.

Ethnic Diversity in EDsEthnic Diversity in EDs

Minnesota Adolescent Health Study found Minnesota Adolescent Health Study found that dieting was associated with weight that dieting was associated with weight dissatisfaction, perceived overweight, and dissatisfaction, perceived overweight, and low body pride in all ethnic groups (Story low body pride in all ethnic groups (Story et al, 1997). et al, 1997).

Among the leanest 25% of 6th and 7th Among the leanest 25% of 6th and 7th grade girls, Hispanics and Asians reported grade girls, Hispanics and Asians reported significantly more body dissatisfaction significantly more body dissatisfaction than did white girls. Robinson et al (1996)than did white girls. Robinson et al (1996)

Cultural IssuesCultural Issues More common in Westernized SocietiesMore common in Westernized Societies Historically self starvation reported prior to 19Historically self starvation reported prior to 19thth

century (religious/spiritual “reasons”)century (religious/spiritual “reasons”) Cultural importance placed on “thinness”Cultural importance placed on “thinness” Less common in cultures where roundness is sign Less common in cultures where roundness is sign

of fertility, health, prosperityof fertility, health, prosperity Hong kong, India : AN w/o fear of fat.Hong kong, India : AN w/o fear of fat. ““Many individuals in our culture, for a number of reasons, Many individuals in our culture, for a number of reasons,

are concerned with their weight and diet. Yet less than half are concerned with their weight and diet. Yet less than half of one percent of all women develop anorexia nervosa, of one percent of all women develop anorexia nervosa, which indicates to us that societal pressure alone isn’t which indicates to us that societal pressure alone isn’t enough to cause someone to develop this disease,” said enough to cause someone to develop this disease,” said Kaye.Kaye.

Media StatsMedia Stats The average young adolescent watches 3 to 4 The average young adolescent watches 3 to 4

hours of TV per day (Levine, 1997).hours of TV per day (Levine, 1997). A study of 4,294 network television commercials A study of 4,294 network television commercials

revealed that 1 our of every 3.8 commercials send revealed that 1 our of every 3.8 commercials send some sort of “attractiveness message,” telling some sort of “attractiveness message,” telling viewers what is or is not attractive (as cited in viewers what is or is not attractive (as cited in Myers et al, 1992). These researchers estimate that Myers et al, 1992). These researchers estimate that the average adolescent sees over 5,260 the average adolescent sees over 5,260 “attractiveness messages” per year.“attractiveness messages” per year.

Another study of mass media magazines Another study of mass media magazines discovered that women’s magazines had 10.5 times discovered that women’s magazines had 10.5 times more advertisements and articles promoting weight more advertisements and articles promoting weight loss than men’s magazines did (as cited in Guillen loss than men’s magazines did (as cited in Guillen & Barr, 1994).& Barr, 1994).

Drive for thinness and dietingDrive for thinness and dieting

Girls who diet frequently are 12 times as likely to binge as girls Girls who diet frequently are 12 times as likely to binge as girls who don’t diet (Neumark-Sztainer,2005).who don’t diet (Neumark-Sztainer,2005).

Most fashion models are thinner than 98% of American women Most fashion models are thinner than 98% of American women (Smolak, 1996).(Smolak, 1996).

The average American woman is 5’4” tall and weighs 140 lbs. The The average American woman is 5’4” tall and weighs 140 lbs. The average model is 5’11” and weighs 117 lbs. average model is 5’11” and weighs 117 lbs.

35% of “normal dieters” progress to pathological dieting. Of 35% of “normal dieters” progress to pathological dieting. Of those, 20-25% progress to partial or full syndrome eating those, 20-25% progress to partial or full syndrome eating disorders (Shisslak & Crago, 1995).disorders (Shisslak & Crago, 1995).

95% of all dieters will regain their lost weight in 1 to 5 years 95% of all dieters will regain their lost weight in 1 to 5 years (Grodstein, et al., 1996).(Grodstein, et al., 1996).

Americans spend over $40 billion on dieting and diet related Americans spend over $40 billion on dieting and diet related products each year (Smolak, 1996). products each year (Smolak, 1996).

Body ImageBody Image

How you see yourself when you look in the How you see yourself when you look in the mirror or when you picture yourself in your mirror or when you picture yourself in your mind.mind.

What you believe about your own What you believe about your own appearance (including your memories, appearance (including your memories, assumptions, and generalizations).assumptions, and generalizations).

How you feel about your body, including How you feel about your body, including your height, shape, and weight.your height, shape, and weight.

How you sense and control your body as you How you sense and control your body as you more. How you feel more. How you feel in in your body, not just your body, not just about about your body.your body.

NEDA websiteNEDA website

Negative body imageNegative body image

A distorted perception A distorted perception of your shape – you of your shape – you perceive parts of your perceive parts of your body unlike how they body unlike how they really are.really are.

You are convinced You are convinced that only other people that only other people are attractive and that are attractive and that your body size or your body size or shape is a sign of shape is a sign of personal failure.personal failure.

You feel ashamed, You feel ashamed, self-conscious, and self-conscious, and anxious about your anxious about your body.body.

You feel You feel uncomfortable and uncomfortable and awkward in your awkward in your body.body.


Positive body imagePositive body image A clear, true perception A clear, true perception

of your shape – you of your shape – you see various parts of see various parts of your body as they your body as they really are.really are.

You celebrate and You celebrate and appreciate your natural appreciate your natural body shape and you body shape and you understand that a understand that a person’s physical person’s physical appearance says very appearance says very little about their little about their character and value as character and value as a person.a person.

You feel proud and You feel proud and accepting of your accepting of your unique body and refuse unique body and refuse to spend an to spend an unreasonable amount unreasonable amount of time worrying about of time worrying about food, weight, and food, weight, and calories.calories.

You feel comfortable You feel comfortable and confident in your and confident in your body.body.


Childhood Symptoms OC Personality Childhood Symptoms OC Personality Traits: Percentage of Individuals With Traits: Percentage of Individuals With

TraitsTraits

65

77

6272

61

80

50

25

50

0

20

40

60

80

100

Perfectionistic Inflexible Rule Bound

AN (n=26) AN-BN (n=18) BN (n=28)

% o

f Pat

ient

s

Anderluh MB, et al. Am J Psychiatry. 2003;160(2):242-247.

Psychological Correlates of Anorexia Psychological Correlates of Anorexia NervosaNervosa

Poor self conceptPoor self concept Obsessive compulsive and avoidant personality Obsessive compulsive and avoidant personality

stylestyle Perfectionistic, obsessive, harm avoidant traitsPerfectionistic, obsessive, harm avoidant traits Family dynamics: enmeshment, anxiety, Family dynamics: enmeshment, anxiety, over-achieversover-achievers Troubles with major life transitionsTroubles with major life transitions an attempt to regress, avoid developmentan attempt to regress, avoid development Difficulty managing and expressing angerDifficulty managing and expressing anger Cognitive distortionsCognitive distortions Ego-syntonic nature of diseaseEgo-syntonic nature of disease

Psychological Correlates of Bulimia Psychological Correlates of Bulimia NervosaNervosa

Poor self conceptPoor self concept Chaotic developmental history, parental Chaotic developmental history, parental

deficitdeficit ambiguous communication stylesambiguous communication styles Affective regulation problemsAffective regulation problems Cognitive distortionsCognitive distortions Ego-dystonic nature of diseaseEgo-dystonic nature of disease Impulsivity, substance abuse, self harm, Impulsivity, substance abuse, self harm,

sexual acting out, shop liftingsexual acting out, shop lifting

Distorted BeliefsDistorted Beliefs

There are “good” foods and “bad” foods.There are “good” foods and “bad” foods. If I am fat, no one will love me.If I am fat, no one will love me. If I eat too much, I need to get rid of it by purging.If I eat too much, I need to get rid of it by purging. If I eat this piece of cheesecake, I will be able to see it on If I eat this piece of cheesecake, I will be able to see it on

my body tomorrow.my body tomorrow. You can never be too rich or too thin.You can never be too rich or too thin. Thinness equals happiness.Thinness equals happiness. Using laxatives gets rid of all the food.Using laxatives gets rid of all the food. Purging gets rid of all the food.Purging gets rid of all the food. My worth is my weight.My worth is my weight. It is more important to be thin than anything else.It is more important to be thin than anything else. Everyone hates fat people.Everyone hates fat people. Men like women who are skinny.Men like women who are skinny.

Recovery BeliefsRecovery Beliefs My worth is not my weight.My worth is not my weight. My body is an instrument, not an ornament.My body is an instrument, not an ornament. When I treat my body well, by eating 3 balanced meals per When I treat my body well, by eating 3 balanced meals per

day and exercising moderately, my body will find its own day and exercising moderately, my body will find its own set-point weight.set-point weight.

People come in all kinds of shapes and sizes. I don’t have to People come in all kinds of shapes and sizes. I don’t have to try to mold my body into a standard set by the media or try to mold my body into a standard set by the media or fashion industry.fashion industry.

I need some fat in my diet in order to have soft skin, shiny I need some fat in my diet in order to have soft skin, shiny hair, and be able to become pregnant some day. hair, and be able to become pregnant some day.

I can enjoy having a more curvy body, instead of striving for I can enjoy having a more curvy body, instead of striving for thinness. thinness.

I am unique and special due to my inner qualities.I am unique and special due to my inner qualities. Perfectionism only leads to disappointment, not happiness.Perfectionism only leads to disappointment, not happiness.

Goal of Psychological TreatmentGoal of Psychological Treatment

Help pt to adjust to their personality Help pt to adjust to their personality traits/temperamenttraits/temperament

Reduce anxiety through use of Reduce anxiety through use of positive coping skillspositive coping skills

Reduce “eating disorder voice” and Reduce “eating disorder voice” and develop a “recovery voice.”develop a “recovery voice.”

Increase focus on inner qualities to Increase focus on inner qualities to define self, rather than physical define self, rather than physical

traits like thinness.traits like thinness.

Important initial Important initial assessment/screening assessment/screening issues/tools in EDS issues/tools in EDS

See Screening HandoutSee Screening Handout

Screening QuestionsScreening Questions

How many diets have you been on in How many diets have you been on in the past year? the past year?

Do you think you should be dieting? Do you think you should be dieting? Are you dissatisfied with your body Are you dissatisfied with your body

size? size? Does your weight affect the way you Does your weight affect the way you

think about yourself? think about yourself?

Introduction to TreatmentIntroduction to Treatment

NEEDSNEEDSmet by the eating disorder:met by the eating disorder:

Safety/Survival: Safety/Survival: reduction of anxietyreduction of anxiety

Love/Belonging: Love/Belonging: best friendbest friend

Freedom: Freedom: no one can take the e.d. awayno one can take the e.d. away

Power/control/importance: Power/control/importance: feeling superior, feeling superior, weight loss as an accomplishmentweight loss as an accomplishment

Fun/relaxation/release: Fun/relaxation/release: endorphins endorphins

released by purgingreleased by purging

Case Study: TomCase Study: Tom

A Major Truth: Feelings A Major Truth: Feelings Follow Thoughts & ActionsFollow Thoughts & Actions

Needs

Thoughts

Want Choices

Feelings

Physiology

Actions

Group Therapy Group Therapy

Structured on-site mealStructured on-site meal Milieu therapy/ use of groupMilieu therapy/ use of group CBT/DBTCBT/DBT Process groupProcess group Nutritional counselingNutritional counseling Body image groupBody image group Art TherapyArt Therapy Relaxation, meditationRelaxation, meditation

Power of the GroupPower of the Group

Reduce isolationReduce isolation Enhance accountabilityEnhance accountability Shame reductionShame reduction Encourage each otherEncourage each other Forward momentum of the groupForward momentum of the group Establish healthy group normsEstablish healthy group norms How group leader uses group to How group leader uses group to

enhance individual growthenhance individual growth

Individual TherapyIndividual Therapy

Affect regulation and toleranceAffect regulation and tolerance ImpulsivityImpulsivity Externalization of self worthExternalization of self worth Feelings of ineffectiveness, inadequacyFeelings of ineffectiveness, inadequacy Rejection sensitivityRejection sensitivity DBTDBT PMD and dietitianPMD and dietitian

Family TherapyFamily Therapy

Required with AdolescentsRequired with Adolescents Maudsley Family TherapyMaudsley Family Therapy Systemic Family TherapySystemic Family Therapy CouplesCouples

UCSD Eating Disorder IOPUCSD Eating Disorder IOP(Individual and Family Therapy by appointment)(Individual and Family Therapy by appointment)

Mon.Mon. Tues.Tues. Wed.Wed. Thurs.Thurs. Fri.Fri.Adult and Teen Adult and Teen Process GroupsProcess Groups

Adult Art Adult Art TherapyTherapy

MeditationMeditation

SnackSnack

Dialectical Dialectical Behavioral Behavioral TherapyTherapy

Goal Setting Goal Setting GroupGroup

Cognitive Cognitive Behavioral Behavioral TherapyTherapy

Adult Adult Mindfulness Mindfulness Based Stress Based Stress ReductionReduction

OrOr

Teen Art Teen Art TherapyTherapy

Dinner Meal and Dinner Meal and Nutrition Nutrition EducationEducation

Treatment Team Treatment Team for all Stafffor all Staff

Goal SettingGoal Setting Dinner MealDinner Meal

Process MealProcess Meal

Goal SettingGoal Setting

Common Management IssuesCommon Management Issues

Denial, resistanceDenial, resistance Lack of insight and motivation for Lack of insight and motivation for

treatmenttreatment Failure to learn from experienceFailure to learn from experience Adolescent – anxious parents, Adolescent – anxious parents,

conflictsconflicts Adults – family burn outAdults – family burn out Ambivalence: pt wants to recover, Ambivalence: pt wants to recover,

but does not want to gain any weightbut does not want to gain any weight

Expected IssuesExpected IssuesPatients and FamiliesPatients and Families

Obsessive anxiety – much reassurance and Obsessive anxiety – much reassurance and discussing details of carediscussing details of care

Perfectionism – not good enoughPerfectionism – not good enough Stress and conflicts over eating, weight, Stress and conflicts over eating, weight,

control, meal plan etc.control, meal plan etc. Over-exercise Over-exercise Undermining treatment: i.e. taking the pt Undermining treatment: i.e. taking the pt

runningrunning

Countertransference IssuesCountertransference Issues

Feeling angry at the patient for not Feeling angry at the patient for not recoveringrecovering

Thinking this is “willful” behaviorThinking this is “willful” behavior Blaming the parentsBlaming the parents Feeling incompetentFeeling incompetent Giving up hope for the patientGiving up hope for the patient Not taking the disorder seriouslyNot taking the disorder seriously

Coping with Countertransference Coping with Countertransference IssuesIssues

Practice patient acceptance: The Practice patient acceptance: The average recovery rate is 7 years.average recovery rate is 7 years.

Have compassion for the suffering Have compassion for the suffering

of the patient.of the patient. See their behavior as part of the See their behavior as part of the

disorder, not personal toward you.disorder, not personal toward you. Practice good self-care. Practice good self-care.

Overview of biological Overview of biological underpinnings of EDSunderpinnings of EDS

Genetic Correlates in Anorexia Genetic Correlates in Anorexia NervosaNervosa

Family and twin studiesFamily and twin studies Serotonin receptor geneSerotonin receptor gene Variation in Dopamine 2 receptor Variation in Dopamine 2 receptor

genegene Chrom 1 and 10Chrom 1 and 10 Family history of OCD, OCPD, ANFamily history of OCD, OCPD, AN

Genetic Correlates of Bulimia Genetic Correlates of Bulimia NervosaNervosa

Twin studiesTwin studies 5ht2A receptor alteration5ht2A receptor alteration Family history of affective, anxiety, Family history of affective, anxiety,

substance abuse d/osubstance abuse d/o

Neuroendocrine Correlates of Neuroendocrine Correlates of Anorexia Nervosa Anorexia Nervosa

Serotonin (5HT2A receptor)Serotonin (5HT2A receptor) Dopamine Dopamine Endogenous opiate response to Endogenous opiate response to

starvationstarvation Hypothalamus dysfunction (satiety, Hypothalamus dysfunction (satiety,

amenorrhea)amenorrhea)

Neuroendocrine correlates of Neuroendocrine correlates of Bulimia NervosaBulimia Nervosa

Serotonin (5HT1A receptor)Serotonin (5HT1A receptor) Endogenous opiate response to binge Endogenous opiate response to binge

purgepurge

Neuropsychiatric correlates of Neuropsychiatric correlates of Eating DisordersEating Disorders

Iowa gambling task: AN vs CW: Iowa gambling task: AN vs CW: Differences seen on fMRIDifferences seen on fMRI

AN: Neuropsych testing: difficulties AN: Neuropsych testing: difficulties with set shifting, flexibilitywith set shifting, flexibility

AN: Detail focus, to the point of AN: Detail focus, to the point of missing global (Janet Treasure)missing global (Janet Treasure)

AN vs BNAN vs BN Use in clinical practiceUse in clinical practice

Cognitive FlexibilityCognitive Flexibility

Anorexia NervosaAnorexia Nervosa Perceptual rigidityPerceptual rigidity Cognitive rigidityCognitive rigidity

ANAN Weight recoveryWeight recovery

No changesNo changes

ANAN Full recoveryFull recovery Partial improvement in Partial improvement in

cognitive flexibility cognitive flexibility taskstasks

Bulimia NervosaBulimia Nervosa Slowness in cognitive Slowness in cognitive

shifting tasks shifting tasks Fluctuations in Perceptual Fluctuations in Perceptual

task task

Psychiatric co morbidityPsychiatric co morbidity

PSYCHIATRIC COMORBIDITY: PSYCHIATRIC COMORBIDITY: Anorexia NervosaAnorexia Nervosa

affective disordersaffective disorders anxiety disordersanxiety disorders psychotic disorderspsychotic disorders personality disorderspersonality disorders Substance abuse Substance abuse

PSYCHIATRIC COMORBIDITY: Bulimia PSYCHIATRIC COMORBIDITY: Bulimia NervosaNervosa

affective disordersaffective disorders anxiety disordersanxiety disorders ICDsICDs personality disorderspersonality disorders Substance abuseSubstance abuse

Psychiatric symptoms in AN and BNPsychiatric symptoms in AN and BN

Premorbid onset Premorbid onset ““Best little girl in the world”Best little girl in the world” Majority have childhood anxiety disorder that precedes onset AN, Majority have childhood anxiety disorder that precedes onset AN,

BNBN Childhood negative self-evaluation, perfectionism, rule bound, Childhood negative self-evaluation, perfectionism, rule bound,

inflexible, obsessive personalityinflexible, obsessive personality

Persistent symptoms after recoveryPersistent symptoms after recovery Obsessions - body image, weight, foodObsessions - body image, weight, food Obsessions - perfectionism, symmetry, exactnessObsessions - perfectionism, symmetry, exactness Anxiety, harm avoidanceAnxiety, harm avoidance

Behaviors are exaggerated by malnutritionBehaviors are exaggerated by malnutrition Differences Between AN and BNDifferences Between AN and BN

Novelty seeking BN > AN, BN extremes of over- and under-controlNovelty seeking BN > AN, BN extremes of over- and under-control

Anxiety Disorders (AD)Anxiety Disorders (AD)Lifetime and Premorbid RatesLifetime and Premorbid Rates

StudyStudy EDED nn Lifetime ADLifetime AD AD before EDAD before ED

Deep 95Deep 95 ANAN 2424 68%68% 58%58%

Bulik 97Bulik 97 ANAN 6868 60%60% 54%54%

Bulik 97Bulik 97 BNBN 116116 57%57% 54%54%

Godart 00Godart 00 ANAN 2929 83%83% 62%62%

Godart 00Godart 00 BNBN 3434 71%71% 62%62%

Kaye 04Kaye 04 AN,BNAN,BN 672672 64%64% 61%61%

23% OCD23% OCD

13% social phobia13% social phobia

Lifetime OCD Diagnosis in AN, Lifetime OCD Diagnosis in AN, BNBN

0

10

20

30

40

50

60

AN (n 619) AN BN (n 515) BN (n 282)

Perc

ent w

ith D

iagn

osis

Price Foundation Genetic Collaborative StudyTotal 1416 subjects

DSM IV, SCID I, Y-BOCS MS/PhD Clinical Interview N. America, England, Germany

DiagnosisDiagnosis Range Range

ANAN 10 – 62%10 – 62%

AN BNAN BN 10 – 66%10 – 66%

BNBN 00 – 43 %– 43 %

Review of LiteratureReview of LiteratureGodart 2002Godart 2002

General population rate OCD: 1-3% of adults; 2-4% of children General population rate OCD: 1-3% of adults; 2-4% of children (Grados 97, Riddle 98; Serpell 02)(Grados 97, Riddle 98; Serpell 02)

Obsessive-Compulsive Personality Obsessive-Compulsive Personality Disorder (OCPD) Diagnoses in ED Disorder (OCPD) Diagnoses in ED

from Clinical Interviewer Assessmentfrom Clinical Interviewer AssessmentCassin S, von Ranson K: Personality and eating disorders: a decade in review Cassin S, von Ranson K: Personality and eating disorders: a decade in review

Clin Psychol RevClin Psychol Rev 2005;25(7):895-916 2005;25(7):895-916

SubjectsSubjects Range of OCPDRange of OCPD

RANRAN 2 – 30%2 – 30%

BNBN 2 – 19%2 – 19%

Important Medical issues in Important Medical issues in treatment of EDstreatment of EDs

Physical Complications of Anorexia NervosaPhysical Complications of Anorexia Nervosa

Organ SystemOrgan System SymptomsSymptoms Lab Test ResultsLab Test Results

1. Whole body1. Whole body Weakness, Weakness, lassitudelassitude

Low weight/body mass index, Low weight/body mass index, low body fat percentage low body fat percentage

2. CNS2. CNS Apathy, poor Apathy, poor concentrationconcentration

CT: ventricular enlargement; CT: ventricular enlargement; MRI: decreased gray and white MRI: decreased gray and white mattermatter

3. CV 3. CV Pre-syncope, Pre-syncope, palps, dyspnea, palps, dyspnea, weakness, cold weakness, cold extremities, extremities, chest painchest pain

ECG: sinus bradycardia, other ECG: sinus bradycardia, other arrhythmia, QTc prolongation; arrhythmia, QTc prolongation; cardiac echo (consider): MVP, cardiac echo (consider): MVP, silent pericardial effusionsilent pericardial effusion

Physical Complications of Anorexia Nervosa; Cont.Physical Complications of Anorexia Nervosa; Cont.


4. Muscular4. Muscular Weakness, Weakness, muscle muscle achesaches

Muscle enzyme abnormalities in Muscle enzyme abnormalities in severe malnutritionsevere malnutrition

5. Reproductive5. Reproductive Prepubertal Prepubertal psychosex-psychosex-ually ually

Hypoestrogenemia; prepubertal Hypoestrogenemia; prepubertal patterns of LH, FSHpatterns of LH, FSH

6. Endocrine, 6. Endocrine, metabolicmetabolic

Fatigue, cold Fatigue, cold intolerance, intolerance, diuresis, diuresis, vomitingvomiting

Elevated cortisol; euthyroid Elevated cortisol; euthyroid sick; dehydration; electrolyte sick; dehydration; electrolyte abnormalities; low phos on abnormalities; low phos on refeeding; hypoglyc.(rare)refeeding; hypoglyc.(rare)

Physical Complications of Anorexia Nervosa; Cont.Physical Complications of Anorexia Nervosa; Cont.


7. GI7. GI Vomiting, abdom. Vomiting, abdom. pain, bloating, pain, bloating, constipationconstipation

Delayed gastric Delayed gastric emptying; occas. abnl emptying; occas. abnl LFTsLFTs

8. Renal8. Renal Pitting edemaPitting edema Elevated BUN; renal Elevated BUN; renal failurefailure

9. Skeletal9. Skeletal Bone pain w/ Bone pain w/ exerciseexercise

X-ray/bone scan w/ stress X-ray/bone scan w/ stress fx; DEXA w/ osteopenia fx; DEXA w/ osteopenia or osteoporosisor osteoporosis

Physical Complications of Bulimia NervosaPhysical Complications of Bulimia Nervosa

Organ systemOrgan system SymptomsSymptoms Lab Test ResultsLab Test Results

1. Metabolic1. Metabolic Weakness; Weakness; irritabilityirritability

Dehydration; serum Dehydration; serum electrolytes: ↓K+, electrolytes: ↓K+, ↓Cl alkalosis w/ ↓Cl alkalosis w/ vomiting; ↓Mg, ↓K+, vomiting; ↓Mg, ↓K+, ↓Phos w/ laxative ↓Phos w/ laxative abuseabuse

2. GI2. GI Abdom. pain; Abdom. pain; constipation; constipation; bloating; reflux bloating; reflux

Physical Complications of Bulimia Nervosa; cont.Physical Complications of Bulimia Nervosa; cont.

Organ systemOrgan system SymptomsSymptoms Lab Test ResultsLab Test Results

3. Oropharyngeal3. Oropharyngeal Dental decay; Dental decay; swollen cheeksswollen cheeks

X-rays confirm X-rays confirm erosion of dental erosion of dental enamel; elevated enamel; elevated serum amylaseserum amylase

4.CV and muscular 4.CV and muscular (in ipecac abusers) (in ipecac abusers)

Palpitations; Palpitations; weaknessweakness

Cardiomyopathy and Cardiomyopathy and arrhythmias; arrhythmias; peripheral myopathy peripheral myopathy

Amenorrhea and OsteopeniaAmenorrhea and Osteopenia Most serious complication of prolonged Most serious complication of prolonged

amenorrhea is osteopenia, or reduced bone massamenorrhea is osteopenia, or reduced bone mass Degree of osteopenia depends on age of onset Degree of osteopenia depends on age of onset

and duration of amenorrheaand duration of amenorrhea Adolescence is critical time for bone mass Adolescence is critical time for bone mass

acquisitionacquisition Approx 60% of peak bone mass is accrued during Approx 60% of peak bone mass is accrued during

adolescenceadolescence Little net gain in bone mass after 2 yrs post-Little net gain in bone mass after 2 yrs post-

menarchemenarche Peak bone mass achieved by end of second Peak bone mass achieved by end of second

decadedecade

Osteopenia and OsteoporosisOsteopenia and Osteoporosis

Osteopenia refers to decreased quantity of Osteopenia refers to decreased quantity of normally mineralized bonenormally mineralized bone

Osteoporosis is clinical syndrome Osteoporosis is clinical syndrome consisting of decreased bone mass, consisting of decreased bone mass, disruption in normal bone architecture disruption in normal bone architecture with decreased bone strength, with decreased bone strength, pathological fractures, pain and disabilitypathological fractures, pain and disability

Osteoporosis defined as greater than 2.5 Osteoporosis defined as greater than 2.5 SD below the mean for young adult SD below the mean for young adult womenwomen

Osteopenia 1-2.5 SD below young adult refOsteopenia 1-2.5 SD below young adult ref

Bone Density and FracturesBone Density and Fractures

Each SD decrease in bone density Each SD decrease in bone density doubles the fracture riskdoubles the fracture risk

DEXA is most widely used method for DEXA is most widely used method for measuring bone densitymeasuring bone density

May be compared with age-matched May be compared with age-matched children and adolescents (Z scores)children and adolescents (Z scores)

Prevalence of Bone Loss in AN (N=130)

(Grinspoon et al, Ann Int Med, 2000)

0

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60

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Osteopenia

Osteoporosis

Undernutrition: – Low lean body mass– Reduced calcium and Vitamin D

intake– IGF-I deficiency

Hormonal: – Estrogen deficiency– Resistance to growth hormone (GH)– Elevated cortisol (stress hormone)– Deficiency of other hormones

• Testosterone• Dehydroepiandrosterone (DHEA)

Mechanisms of Bone Loss Mechanisms of Bone Loss in ANin AN

Bone Loss Treatment Bone Loss Treatment StrategiesStrategies

No therapies proven effective for bone No therapies proven effective for bone loss in women with AN. loss in women with AN.

Estrogen:Estrogen:Decision on estrogen individualized, but Decision on estrogen individualized, but no convincing data that estrogen alone no convincing data that estrogen alone increases bone density in AN population.increases bone density in AN population.

Potential therapies under study:Potential therapies under study:– IGF-IIGF-I– DHEADHEA– TestosteroneTestosterone– BisphosphonatesBisphosphonates

Osteoporosis TreatmentOsteoporosis Treatment

Weight gainWeight gain Calcium supplementation improves Calcium supplementation improves

bone mass (1500-2000mg/day)bone mass (1500-2000mg/day) Vitamin DVitamin D Moderate weight-bearing exercise Moderate weight-bearing exercise

increases bone massincreases bone mass When medically stable, wt bearing When medically stable, wt bearing

exercises 3-4 times per weekexercises 3-4 times per week

Is there a benefit to treatment ofIs there a benefit to treatment ofAmenorrhea Amenorrhea

Drugs Drugs – Appearance of normal mensesAppearance of normal menses

AN – abnormalities driven by malnutritionAN – abnormalities driven by malnutrition Drugs are NOT substitute for nutritionDrugs are NOT substitute for nutrition

– Illusion that problem is “solved” Illusion that problem is “solved” ? Ineffective or harmful? Ineffective or harmful

– Menses – regulated by complex Menses – regulated by complex neuroendocrine circuits neuroendocrine circuits

Medical evaluation for Anorexia Medical evaluation for Anorexia NervosaNervosa

Assess for co morbidityAssess for co morbidity Screening labs: electrolytes, Ca++, Screening labs: electrolytes, Ca++,

Mg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UAMg+, Phos, BUN/Cr, CBC, LFTs, TFTs, UA Bone density (DEXA) Bone density (DEXA) EKGEKG

REFEEDING COMPLICATIONSREFEEDING COMPLICATIONS

Normal foodNormal food– Peripheral edemaPeripheral edema– Bloating or discomfortBloating or discomfort– RefluxReflux– Rare gastric dilitationRare gastric dilitation

Nasogastric feedingNasogastric feeding– Seldom indicatedSeldom indicated– Nasal, esophageal erosionNasal, esophageal erosion

Central hyperalimentationCentral hyperalimentation– Rarely indicatedRarely indicated– Pneumothorax, infection, metabolic disturbancesPneumothorax, infection, metabolic disturbances

Nutritional Restoration and Weight Gain Nutritional Restoration and Weight Gain in ANin AN

Starvation and weight loss – ego Starvation and weight loss – ego syntonicsyntonic

Increased dysphoria before and during Increased dysphoria before and during mealsmeals

Food and weight obsessions and ritualsFood and weight obsessions and rituals– Stereotypic food choices, ritualized eating, Stereotypic food choices, ritualized eating,

calorie countingcalorie counting– Delusionary quality Delusionary quality – Nothing else is more important Nothing else is more important

Requirements for weight gain in Requirements for weight gain in anorexia nervosa anorexia nervosa

excess calories (over maintenance) to excess calories (over maintenance) to gain 1 kggain 1 kg

StudyStudy caloriescalories

Russell and Russell and Mezey. 1962Mezey. 1962

7525 7525 + + 585585

Walker et al 1979Walker et al 1979 6401 6401 + + 16271627

Dempsey et alDempsey et al 9768 9768 ++ 4212 4212

Forbes et al 1984Forbes et al 1984 5340 5340 ++ 1850 1850

Kaye et al 1988Kaye et al 1988 8301 8301 ++ 2272 2272

Eating behavior in AN – After weight Eating behavior in AN – After weight restoration restoration

Hypermetabolic after weight Hypermetabolic after weight restorationrestoration– RAN need 50 to 60 kcal/kg/dayRAN need 50 to 60 kcal/kg/day– BAN need 40 to 50 kcal/kg/dayBAN need 40 to 50 kcal/kg/day– 50 kg women = 2000 to 3000 kcal/day50 kg women = 2000 to 3000 kcal/day

Probably normalizes in long termProbably normalizes in long term Probable contribution to high rate of Probable contribution to high rate of

relapse relapse

Medical evaluation for Bulimia Medical evaluation for Bulimia NervosaNervosa

Assess for comorbidityAssess for comorbidity Screening labs: electrolytes, Ca++, Mg+, Screening labs: electrolytes, Ca++, Mg+,

Phos, BUN/Cr, CBC, LFTs, TFTs, UAPhos, BUN/Cr, CBC, LFTs, TFTs, UA EKGEKG DentalDental

Pharmacology for ANPharmacology for AN

SSRIsSSRIs Atypical antipsychotic medicationsAtypical antipsychotic medications Meds tried and failed for appetite Meds tried and failed for appetite

enhancementenhancement GI meds to aid physical symptomsGI meds to aid physical symptoms

Pharmacology for BNPharmacology for BN

Serotonin re-uptake inhibitorsSerotonin re-uptake inhibitors AEDs (topiramate, ?zonisamide)AEDs (topiramate, ?zonisamide) AntipsychoticsAntipsychotics Mood stabilizersMood stabilizers reglan, H2 blockersreglan, H2 blockers

Methods of TreatmentMethods of Treatment

A.A. Regular Weight restorationRegular Weight restoration• 2 to 3 lbs/wk inpatient2 to 3 lbs/wk inpatient• 1 to 2 lbs/wk day-hospital1 to 2 lbs/wk day-hospital• 1 lb/wk outpatient1 lb/wk outpatient

B.B. Nutritional TeachingNutritional Teaching• Provide patient supportProvide patient support• Prevention from vitamin and mineral Prevention from vitamin and mineral

deficiencydeficiency• Prevention of osteoporosisPrevention of osteoporosis

Aim for high CaAim for high Ca++++ intake intake Vitamin D to aid in CaVitamin D to aid in Ca++++ absorption; vegetarians may absorption; vegetarians may

need supplementsneed supplements Eat iron-containing foods, especially important for Eat iron-containing foods, especially important for

vegetariansvegetarians

Integrated treatment programsIntegrated treatment programs

Multidisciplinary treatment teamMultidisciplinary treatment team

Program managerProgram manager PsychiatristPsychiatrist Therapists with ED trainingTherapists with ED training Registered DietitianRegistered Dietitian Internist/PediatricianInternist/Pediatrician

AN: Hospital vs Outpatient TreatmentAN: Hospital vs Outpatient TreatmentFrom American Psychiatric Association Guidelines for From American Psychiatric Association Guidelines for

the Treatment of Eating Disorders the Treatment of Eating Disorders

OutpatientOutpatient InpatientInpatient

WeightWeight >85%>85% < 75%< 75%

Medical complicationsMedical complications nonenone HR, BP, K etcHR, BP, K etc

Suicidal, comorbid psych Suicidal, comorbid psych d.o. d.o.

Not presentNot present severesevere

Motivation, insight, Motivation, insight, cooperationcooperation

yesyes nono

Excessive exercise, Excessive exercise, purging, etcpurging, etc

minimalminimal severesevere

Stress, family dynamicsStress, family dynamics minimalminimal severesevere

Local ED treatment Local ED treatment resourcesresources

availableavailable nonenone

Referral to Higher level of careReferral to Higher level of care

Pt is failing lower level.Pt is failing lower level. Pt’s weight loss is continuing in spite Pt’s weight loss is continuing in spite

of treatmentof treatment Pt is unable to stop bingeing/purging.Pt is unable to stop bingeing/purging. Pt’s physical symptoms warrant Pt’s physical symptoms warrant

greater supervision (fainting, greater supervision (fainting, dehydration, heart palpitations)dehydration, heart palpitations)

Pt is resisting current level of carePt is resisting current level of care

Specific LOC ConsiderationsSpecific LOC Considerations

OP: high motivation, >85% IBWOP: high motivation, >85% IBW IOP: moderate motivation, >80%IBWIOP: moderate motivation, >80%IBW PHP: >75%PHP: >75% RTC: clinical issuesRTC: clinical issues IP: <75% IBW, psych co morbid severe (SI)IP: <75% IBW, psych co morbid severe (SI) UCSD Intensive Family Therapy programUCSD Intensive Family Therapy program Legal controversyLegal controversy

Outcome Data for EDsOutcome Data for EDs

Data mixed results due to design of Data mixed results due to design of studiesstudies

AN 10 yr: 50% rec, 20-30% improved AN 10 yr: 50% rec, 20-30% improved but still symptomatic, 10-20% but still symptomatic, 10-20% chronic, up to 10% mortalitychronic, up to 10% mortality

BN 10yr: 50%-70% rec, 30% some BN 10yr: 50%-70% rec, 30% some improvement, 20% chronic improvement, 20% chronic

Outcomes for EDSOutcomes for EDS

Some studies show ave of 7 years to Some studies show ave of 7 years to recrec

Less than 1 year of treatment has Less than 1 year of treatment has poorer prognosispoorer prognosis

Chronicity, OCPD, purging in AN Chronicity, OCPD, purging in AN associated with worse outcomeassociated with worse outcome

Documents

Working with Eating Disorder Patients