Eating Disorders Dr. J. David Moore ValueOptions Medical Director

Assessment and Treatment of Eating Disorders

The Failure To Thrive

Weighing The Statistics ƒ Anorexia, bulimia and binge eating disorders are serious illnesses which affect more than 3 million Americans. ƒ Untreated eating disorders lead to heart damage, depression, permanent health damage, or suicide. ƒ A recent study showed that more than half of all college students knew someone with anorexia or bulimia.

Weighing the Statistics As many as one in every 100 young women suffer from eating disorders (ED), with an incidence of 1-2% among American women. ƒ Onset most often in teens and 20s. ƒ Early onset patients (ages 7-12) have more obsessional behavior and depression. ƒ Children often present with physical symptoms such as nausea, abdominal pain, feeling full, or being unable to swallow. ƒ Children’s weight loss can be rapid and dramatic ƒ Children with ED may suffer from delayed growth and especially prone to osteopenia and osteoporosis.

Weighing The Statistics Anorexia Nervosa • 90-95% are women. • One of the most common psychiatric diagnoses in young women. • 5-20% will die prematurely with risk increasing proportionally with the longevity of the illness. • One of the highest death rates of any mental health condition. • Typically appears in early to midadolescence.

Weighing The Statistics Bulimia Nervosa • 80% female. • 1- 3% of middle and high school girls and 1- 4% of college age women. • Prevalence not clear. • Can be of normal or heavier than average weight. • History of depression not uncommon. • Complex schedules or rituals to provide opportunities for binge-and-purge sessions.

Weighing The Statistics Eating Disorder N.O.S. • Eating Disorder NOS is not uncommon in eating disorder programs. • These are more heterogeneous patients with sub-syndromal cases of AN or BN. • The nature of treatment is based on the symptom profile and severity of impairment and not the DSM-IV Diagnosis.

Weighing The Statistics • Eating Disorder, N.O.S.(Continued) • Includes Binge Eating Disorder which is not an approved DSM-IV diagnosis: • Binge eating • Obesity common • Body image dissatisfaction • More frequent in adults than adolescents

Underlying Causes Causative Factors • Family and cultural pressures • A single traumatic event • A two to 3 year period of unusual stress or pain with several events in a short time • An extended period of emotional pain • The onset of a mood disorder

Underlying Causes Causative Factors (Continued) • Having been a very sensitive child in a family in which there was emotional pain not acknowledged or discussed. These families may be very religious with much time spent in those activities. • A controlling environment that results in the patient giving up her own identity while the pain increases to the point of not being able to do it anymore. • Lack of validation of feelings where feeling a certain way is considered wrong, selfish, bad, or crazy.

Underlying Causes Causative Factors (Continued) • Emotional pain is at such a level of intensity that the patient is unable to manage it in a healthy way. • Inability to express feelings directly • Lack of model for closeness, support, or resolution of conflict. • Lack of necessary tools to handle negative emotions or talk about them • Development of focus on the body or food • Looking for an external source and solution to emotional pain

Underlying Causes • Path 1- Leads to intake of food to excess as a source of comfort and nurturing that is consistent, reliable, and ever present. This results in compulsive eating. • Path 2 – Leads to restriction of food intake and/or binging and purging with resultant weight loss. With positive comments from others about the weight change, the person feels positive attention for something that is within her control. The increased focus on exercise, dieting, weight loss, or purging, results in a blunting of the emotional pain.

Underlying Causes Genetics and biology • Genetic predisposition. • One study in Maudsley Hospital in London suggests variations in the gene for serotonin receptors that influence appetite. • Those with Anorexia are in a continual state of feeling acute stress—“fight or flight.” • Dr. Walter Kaye examined a number of recovered Bulimia patients who demonstrated abnormally high serotonin with normal dopamine and noreprinephrine.

Underlying Causes Genetics and Biology (cont.) • Serotonin is involved in many behaviors such as hunger, sleep, sexual response, impulse control, aggressive behavior and anger, depression, anxiety and perception. • Low levels could contribute to depression and may be increased in binging with resultant sense of well-being.

Underlying Causes Genetics and Biology (cont.) • If too much serotonin is present, there may be a constant sense of anxiety that would be reduced by self starvation given the sense of regaining control. • Restricting and binging can also lead to a disruption in serotonin levels adding to an existing problem or creating a new one. • Studies suggest there are genetic predispositions to serotonin disruptions that run in families.

Underlying Causes Other Factors • The way the person was taught to cope with their emotions. • How they were taught to communicate. • Their general sense of self-esteem. • Possible issues of physical, emotional or sexual abuse. • History of addiction in patient or family.

Differential Diagnosis

Anorexia, Bulimia or Eating Disorder NOS

• Diagnostic Overview: The Renfrew Center

Differential Diagnosis

Differential Diagnosis Symptom Comparison

Anorexia Nervosa Warning Signs • Dramatic weight loss • Preoccupation with weight, food, calories, fat grams and dieting • Food restrictions • Anxiety about gaining weight or being “fat” • Denial of hunger • Development of food rituals • Avoidance of mealtimes or situations involving food. • Excessive rigid exercise regimen • Withdrawal from usual friends and activities • Primary focus on food, calories, weight loss, dieting

Anorexia Nervosa Primary Symptoms ƒ Refusal to maintain body weight or above a minimally normal weight for height, body type, age and activity level. ƒ Intense fear of weight gain or being “fat”. ƒ Feeling fat or overweight despite dramatic weight loss. ƒ Loss of menstrual periods in girls and women postpuberty. ƒ Extreme concern with body weight and shape.

Bulimia Nervosa Warning Signs • Disappearance of food or presence of wrappers and containers indicating consumption of large amounts of food • Frequent trips to the bathroom, signs or smells of vomiting, presence of wrappers or packages of laxatives or diuretics • Excessive exercise regimen • Unusual swelling of cheeks or jaw area • Calluses on the back of the hands and knuckles from self-induced vomiting

Bulimia Nervosa Warning Signs (cont.) • Discoloration or staining of teeth • Complex lifestyle schedules or rituals to make time for binge and purge cycles • Withdrawal from usual friends and activities • Weight, dieting and control of food are primary concerns • Weight normal or high • Frequent dieting and exercise • Severe binges two times per week for at least three months

Bulimia Nervosa Warning Signs (cont.) • Intake of thousands of calories with high sugar, carbohydrates and fat • Eat so rapidly that food may not be chewed or tasted • Binge ends when interrupted or falling asleep or stomach pain • Pain or fear of weight gain leads to purging or Laxative use several times a day or week

Bulimia Nervosa Primary Symptoms • Eating large amounts of food in short periods of time, often secretly, without regard to hunger or fullness and to the point of feeling out of control while eating • Following these binges with some form of purging or compensatory behavior to make up for the excessive calories taken in: purging, laxatives, diuretics, fasting, and or compulsive exercise • Extreme concern with body weight and shape

Binge Eating Disorders Primary Symptoms •

Frequent episodes of eating large quantities of food in short periods of time often secretly without regard to feelings of hunger or fullness

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Feeling out of control during binges

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Eating large quantities of food rapidly without really tasting the food

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Eating alone

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Feelings of shame, disgust, or guilt after a binge

Assessment of the Patient and Family Patient and Family History • • • • •

Parenting Styles Family Boundaries Environmental Influences Patient’s Developmental History Stressor History

Perceptions – Negative Voices • The voices of their own self-hate and lack of self-worth. • Ego syntonic in nature • They are described as “loud thoughts”, “my own head”, or “voices • May go to the point of saying the world would be better without them and they deserve a life of pain • Convince them they have no will power

Assessment of the Patient and Family Perceptions (Cont.) – Negative Voices • Tell them they are weak when they have eaten. • Tell them “no one will ever love you”. • Learning to not listen to them can be like killing their best friend. • Recovery depends on learning to love themselves and the voices fight hard to keep that from happening. • These should be the focus of the CBT. – Distorted Cognitions • “I’m Fat”. • “I’m a horrible person”.

Assessment of the Patient and Family Perceptions (Continued) – Distorted Cognitions • “I wish I could be as skinny as them.” • Black and white thinking. • Compliments are met with invalidating remarks about themselves. • Want to take on control of the world around them. • “I deserve this.” • What is seen in the mirror is not reality. • “It’s my own fault.” • “My problems don’t matter.”

Comorbidity: Substance Abuse Substance Abuse • Common among women with ED. • 22.9% of Bulimia Nervosa patients meet criteria for alcohol abuse. • SA is less common in those restricting than those with binge-purge cycles. • One study found bulimic women seven times more likely to develop SA than restricting anorectic patients. • SA raises the incidence of wider impulsivity such as shop lifting, suicide gestures, laxative abuse • SA results in longer hospitalizations and reduced compliance with treatment. • Concurrent treatment is the treatment of choice.

Comorbidity: Mental Health Mood and Anxiety Disorders • Present in a high percentage of ED patients seeking treatment. • Nutritional deficiency and weight loss predispose patients to depressive symptoms. • Comorbid (Depression and ED) patients have more anxiety, guilt, and obsessionality but less social withdrawal and lack of interest than depressed patients without ED. • Presence of comorbid depression at onset of treatment has no predictive value for outcomes. • Antidepressant medication may improve the ability of depressed ED patients to be involved in therapy.

Comorbidity: Mental Health • Lifetime prevalence of anxiety disorders higher for both AN and BN. • With AN patients, social phobia and OCD are most common. • For the BN patients, social phobia, simple phobia and OCD are most common. • Overanxious disorders of childhood commonly precede the onset of eating disorders. • These comorbid disorders should be addressed concurrently.

Personality Disorders ƒ AN patients more likely to have Cluster C. ƒ BN more likely to display features of cluster B disorders, particularly impulsive, affective, and narcissistic trait disturbances.

Comorbidity: Mental Health • Borderline PD seems to be associated with more disturbance in eating attitudes, hospitalizations, and suicide and SIB. • Borderline PD associated with poorer treatment outcome and higher levels of psychopathology at follow up. • Necessitates long term clinical focus on the Personality Disorder, the interpersonal relationships, and Eating Disorder symptoms.

Post Traumatic Stress Disorder ƒ One national survey revealed a 37% lifetime rate of PTSD in women with BN. ƒ There are higher rates of abuse in patients with BN. ƒ These must be addressed in the treatment of the ED.

Comorbidity: Medical Conditions Type 1 Diabetes Mellitus • Eating disorder symptoms are more common in women with Diabetes. • Comorbidity with Diabetes requires closer contact between providers. • Rates of diabetic complications are greater in patients with eating disorders. • Diabetics with eating disorders often under dose their insulin to lose weight.

Comorbidity: Medical Conditions Pregnancy • Inadequate nutritional intake, binge eating, purging by various means, and use or abuse of teratogenic medications (e.g. Lithium, Benzodiazepines, Depakote) can result in fetal and/or maternal complications. • Care usually requires collaboration of psychiatrist and obstetrician specializing in high risk pregnancies. • Greater number of birth complications. • Higher rate of LBW babies. • More difficulties in feeding their babies and young children than mothers without eating disorders.

Assessment Tools

When to Hospitalize •

Points for hospitalization: • Rapid or persistent decline in oral intake • Decline in weight despite maximally intensive outpatient or partial hospitalization interventions • Presence of additional stressors (viral infection) that may interfere with eating • Prior knowledge of weight where instability occurred • Cormorbid psychiatric problems that merit hospitalization

Treatment Planning and Design

“ Oh, it is the error of our day that the physician separates the soul from the body.” Plato

Treatment Planning and Design Assessing and monitoring symptoms and behaviors • Initial careful assessment of symptoms and behaviors • Family history of diagnoses, how they deal with the illness, and general attitudes toward eating, exercise, and appearance • PE by a physician familiar with eating disorders with emphasis on vital signs, physical and sexual growth and development • Initial assessment takes hours and may need to be done over time

Treatment Planning and Design Treatment Plan Requirements • Medical care and monitoring • Psychosocial interventions • Nutritional counseling and medication management when appropriate • Risk assessment at time of diagnosis

Treatment Planning and Design Psychotherapy Constructs • Anorexia Nervosa and Bulimia Nervosa will not go away on their own. • These are complex illnesses that require a careful multidisciplinary treatment approach. • Treatment must address the medical, psychological, dental, psychiatric and nutritional needs of the patient. • The Treatment team should include specialists in ED. • Treatment may include individual and group therapy, peer support groups, nutritional counseling, medication and behavioral therapy.

Treatment Planning and Design Psychotherapy (Cont.) • Understanding the emotions that trigger the disorder • Correcting distorted self-image • Overcoming morbid fear of weight gain • Changing obsessive-compulsive behavior regarding food and eating

Treatment Planning and Design The Treatment Plan Focus • Nutritional management and counseling • Psychopharmacological treatment • Enhancement of self-esteem • Improved sense of control • Reducing binging and purging behaviors • Reducing obsessive thinking and compulsive behaviors

Courses Of Treatment Phases of Treatment • Restoring weight lost to severe dieting and purging • Treating psychological disturbances (distorted body image, low self-esteem, and interpersonal conflicts) • Achieving long-term remission and rehabilitation or full recovery – Early diagnosis and treatment increase the treatment success rate. – SSRIs have been shown to be helpful for weight maintenance and resolving. – Mood and anxiety symptoms associated with anorexia

Course of Treatment Therapeutic interventions ƒ Cognitive behavioral ƒ Interpersonal ƒ Individual/Group/Family

Psychotropic medications ƒ Primarily SSRIs ƒ May prevent relapse

Family Involvement ƒ Essential to learn to communicate verbally rather than through food. ƒ Family involved throughout treatment to learn about the goals, the condition, and the functions the disorder serves for the patient and the family.

Course of Treatment Psychotherapeutic Issues in Psychiatric Management • The clinician should attempt to build trust, establish mutual respect, and develop a therapeutic relationship. • The clinician is encouraging the thing those with eating disorders are most afraid of-weight gain. • Eating Disorders can invoke counter transference including demoralization and an excessive need to change the patient. • Gender and cultural differences may significantly influence the course of treatment.

Course of Treatment Psychotherapeutic Issues in Psychiatric Management (Cont.) • Sexual abuse victims stir a profound need to rescue the patient, with loosening of therapeutic structure, loss of therapeutic boundaries, and a sexualized transference. • Interventions create anxiety. • If unrecognized, the counter transference can lead to unethical treatment on the part of the therapist. • CLEAR boundaries are critical.

Course of Treatment Care Coordination and Collaboration With Other Clinicians • The Psychiatrist’s role is to coordinate and oversee treatment. • The Treatment Team should coordinate care with nutritional counseling, working with the family, and various individual and group therapies. • Collaborate with general physicians and dentists when appropriate. • If not in an eating disorders program, education and training is critical to success.

Specific Treatment Guidelines for Anorexia Nervosa Nutritional Rehabilitation • • • • •

Establish healthy target weights. Restore weight. Normalize eating patterns. Achieve normal perceptions of hunger and satiety. Correct biological and psychological sequelae of malnutrition.

Accomplish this through: • Controlled weight gain (2-3 lb./week IP, .5-1 lb./week OP). • Intake levels around 1000-1600kcal/day and progressively increased. • During weight gain phase- up to 2300-4000 kcal/day for some patients.

Specific Treatment Guidelines for Anorexia Nervosa Accomplishing Nutritional Rehabilitation (Continued) • Vitamin and Mineral supplements (especially phosphorus) • Medical Monitoring during re-feeding • May include temporary supplementation or replacement of regular food with liquid food supplements • May require parenteral or nasogastric feeding for brief periods • Education, ongoing support, and helping patients deal with concerns about weight gain and body image changes

Specific Treatment Guidelines for Anorexia Nervosa Psychosocial Interventions • Must incorporate an understanding of psychodynamic conflicts, cognitive development, psychological defenses, the complexity of family relationships, and the presence of other psychiatric disorders. • Understand and cooperate with nutritional and physical rehabilitation. • Understand and change the behaviors and dysfunctional attitudes related to the eating disorder. • Understand what they have been through

Specific Treatment Guidelines for Anorexia Nervosa Psychosocial Interventions • Developmental, family, and cultural antecedents of the illness • How the illness may have been a maladaptive attempt to cope and emotionally self-regulate • How to avoid or minimize risks of relapse • How to better deal with salient developmental and other important life issues in the future • How to improve interpersonal and social functioning

Specific Treatment Guidelines for Anorexia Nervosa Psychosocial Interventions • Address comorbid psychopathology and psychological conflicts that reinforce or maintain ED behaviors • Are an overlap of different treatment interventions with mixture of individual, milieu, group, family, couples treatment employing emotional nurturance, behavioral interventions, cognitive, interpersonal, and psychodynamic psychotherapy approaches.

Specific Treatment Guidelines for Anorexia Nervosa Medications • Antidepressants are effective as part of an initial program for most patients. • Can reduce symptoms of binge eating and purging • May prevent relapse in patients in remission • SSRIs are safest • Most helpful with symptoms of depression, anxiety, obsessions, impulse disorder symptoms, or for patients who have failed or had suboptimal response to just psychosocial therapeutic interventions

Specific Treatment Guidelines for Anorexia Nervosa Medications (Continued) • Tricyclics and MAOIs are used in typical doses as used for depression. • Some research reports the best responses are with a combination of antidepressants and cognitive behavioral therapy. • Low doses of novel antipsychotics with SSRIs are being used to treat the more obsessional and compulsive patients. • Anxiolytics have been used before meals to reduce anticipatory anxiety concerning eating.

Specific Treatment of Bulimia Nervosa Nutritional Rehabilitation Goals • Reduce binge eating and purging • Establish a pattern of regular, non-binge meals • Increase caloric intake and expand macronutrient selection • Reduce behaviors related to the eating disorder • Minimize food restriction and correct nutritional deficiencies • Increase the variety of foods eaten • Encourage healthy exercise patterns

Specific Treatment of Bulimia Nervosa Psychosocial Treatment – Goals vary and can include: • Reducing or eliminating binges and purging • Improving attitudes related to the eating disorder • Minimizing food restriction • Increasing the variety of foods eaten • Treatment of comorbid conditions and clinical features associated with eating disorders

Specific Treatment of Bulimia Nervosa Psychosocial Treatment (cont.) • Addressing developmental issues, identity formation, body image concerns, self-esteem, sexual and aggressive difficulties, affect regulation, gender role expectations, family dysfunction, coping styles, and problem solving • Cognitive behavioral therapy has been most studied with evidence of efficacy • Interpersonal, psychodynamically oriented, or psychoanalytic approaches are also used

Specific Treatment of Bulimia Nervosa Psychosocial Treatments (cont.) • Group therapy including dietary counseling and management with more frequent sessions on the front end • Family and marital therapy especially with adolescents living with parents or patients with marital discord • Parenting help and interventions for women with children • Support groups helpful but restrictive 12-step programs controversial

Specific Treatment of Bulimia Nervosa Medications • Goals are to reduce frequency of disturbed eating behaviors, alleviate symptoms such as depression, anxiety, obsessions, or certain impulse disorder symptoms. • Antidepressants have helped even with patients without evidence of depression. • Reductions in binge eating and vomiting have been found in 50-75% of patients. • Antidepressants improve comorbid disorders and complaints such as mood and anxiety symptoms.

Specific Treatment of Bulimia Nervosa Medications (Continued) • Improved interpersonal functioning has been demonstrated as well. • Medications found in double blind studies to have been efficacious are: – Tricyclics such as Imipramine, desipramine, and amitriptyline – Prozac – MAOIs – Trazadone – (Bupropione is not recommended because of seizures in purging bulimic patients)

Expected Outcomes Chronicity of Eating Disorders • Those with chronic course of AN (>10 years) are unable to maintain a healthy weight and have chronic depression, obsessionality and social withdrawal. • These require individualized Treatment Planning and careful case management. • Consultation with other specialists, repeated hospitalizations, PHP, residential care, 1:1 or group, medication trials, and at times, ECT are needed for this population • Goals need to emphasize small progressive steps and fewer relapses.

Expected Outcomes Chronicity of Eating Disorders (Continued) • More frequent OP contact and support may reduce hospitalizations • Communication among professionals very important in these cases • Target may be to achieve a safe weight compatible with life rather than a healthy weight • Focus on quality of life rather than eating and weight

Expected Outcomes HEALTH CONSEQUENCES • Changes in heart muscle resulting in bradycardia and hypotension with increased risk for heart failure • Reduction of bone density with dry brittle bones (osteoporosis) • Muscle loss and weakness • Severe dehydration, with resultant kidney failure • Fainting, fatigue, and overall weakness • Dry hair and skin, hair loss common • Growth of lanugo (downy layer of hair) all over the body as an effort to keep the body warm

Expected Outcomes if Untreated Anorexia Nervosa » » » » » » » » » » » »

Malnutrition Dehydration Heart damage Liver damage Infertility Personality changes Kidney damage Osteoporosis Damage to the immune system Starvation Permanent health damage Death

Expected Outcomes if Untreated Bulimia Nervosa » Chronic inflammation and sore throat » Swollen salivary glands in neck and below jaw » Cheeks and face become puffy » Tooth enamel wears away » Tooth decay especially front teeth secondary to stomach acid » Chronic laxatives lead to chronic colon irritation and loss of minerals. » Kidney problems secondary to diuretic use. » Dehydration and loss of needed electrolytes and minerals needed for the nervous system and muscles.

Expected Outcomes Eating Disorder NOS (Binge Eating Disorders ) » » » » » »

» » » » »

Hypertension High cholesterol Heart disease as a result of elevated triglycerides Secondary diabetes Gallbladder disease Electrolyte imbalance caused by dehydration and loss of potassium and sodium from the body secondary to purging Potential for gastric rupture Inflammation and possible rupture of the esophagus from frequent vomiting Tooth decay and staining from stomach acids Laxative abuse causing chronically irregular bowel movements and constipation Peptic ulcers and pancreatitis

References •

American Psychiatric Association. (2001). Clinical Resources; Practice Guidelines for the Treatment of Patients With Eating Disorders. Washington D.C.

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Anorexia & Bulimia: Sign’s and Symptoms. [Electronic data base]. (2001). The Renfrew Center. Philadelphia P.A.

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Disordered Eating: When Food Takes Control. [Electronic data base]. (1999). North Dakota: Prairie Public Broadcasting Inc..

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National Eating Disorders Association. (2001). Anorexia Nervosa. (ED Info Text Pages). Seattle Washington.

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National Eating Disorders Association. (2001). Anorexia Nervosa in Males. (ED Info Text Pages). Seattle Washington.

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National Eating Disorders Association. (2001). Binge Eating Disorders. (ED Info Text Pages). Seattle Washington.

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National Institute of Mental Health. (2001). Eating Disorders: Facts About Eating Disorders and the Search for Solutions (NIH Publication No. 01-490). Washington D.C.: U.S. Government Printing Office.

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What is an Eating Disorder. [Electronic data base]. (1996-2000). Eating Disorder Recovery Online. Tucson Arizona.

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What Causes Eating Disorders?. [Electronic data base]. (1996-2000). Eating Disorder Recovery Online. Tucson Arizona.

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What are ED’s?. [Electronic data base]. (2002). Something Fishy: Website on Eating Disorders. Holbrook N.Y.

Conclusion

“ I am crying because my pain is gone and I am not yet used to living without it” …… Anais Nin