Eating Disorders

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Eating Disorders

  1. 1. Eating Disorders
  2. 2. Three Categories: <ul><li>Anorexia Nervosa </li></ul><ul><li>Bulimia Nervosa </li></ul><ul><li>Bing Eating Disorder </li></ul>
  3. 3. Eating Disorders In General <ul><li>Main Etiological Factors: </li></ul><ul><li>Family history of: </li></ul><ul><li>1) eating disorder </li></ul><ul><li>2) affective disorder </li></ul><ul><li>3) substance abuse </li></ul><ul><li>4) obesity </li></ul><ul><li>Personal History of: </li></ul><ul><li>1) affective disorder </li></ul><ul><li>2) obesity </li></ul><ul><li>3) sexual abuse </li></ul>
  4. 4. Etiology Continued: c) History of disturbed family relations and /or parenting d) Parental over-concerns about dieting, eating and body shape and weight
  5. 5. Etiology of Eating Disorders Ties in Strongly With a Persons Beliefs About: <ul><li>- Self Esteem </li></ul><ul><li>- Attractiveness </li></ul><ul><li>- Beauty </li></ul><ul><li>- The “Relational Self” </li></ul>
  6. 6. Taking A Look at Diagnosing <ul><li>History Taking </li></ul><ul><li>MSE </li></ul><ul><li>“ Ruling Out” </li></ul><ul><li>May lead to delays in treatment and co-morbidity </li></ul><ul><li>Medical Assessment-good for understanding </li></ul><ul><li>consequences and complications and decision </li></ul><ul><li>making about treatment. Is NOT necessarily used </li></ul><ul><li>for diagnosis. </li></ul>
  7. 7. DSM-IV Criteria DSM-IV Handout <ul><li>Anorexia Nervosa </li></ul><ul><li>Bulimia Nervosa </li></ul>
  8. 8. Risk Factors That Increase Probability of Eating Disorders <ul><li>Gender: >females than males by 6-10:1 </li></ul><ul><li>Age: Teens & 20’s mostly </li></ul><ul><li>Location: Western Societies that value thinness </li></ul><ul><li>Personality: Anorexia- sensitive, self-critical </li></ul><ul><li>persevering </li></ul><ul><li>Bulimia- unstable mood, impulsive </li></ul><ul><li>dramatic features </li></ul><ul><li>Family History: depressive illness, obesity, eating </li></ul><ul><li>disorders </li></ul><ul><li>Interest Groups: Ballet dancers, wrestlers, models, </li></ul><ul><li>jockeys, gymnasts </li></ul>
  9. 9. Risk Factors Continued: <ul><li>Sexual Orientation: Gay males (not lesbians), </li></ul><ul><li>heterosexual females </li></ul><ul><li>Critical Sensitizing Events: Teasing, criticism for </li></ul><ul><li>overweight, especially comments </li></ul><ul><li>by mothers, coaches, peers, </li></ul><ul><li>occasional iatrogenic onset </li></ul><ul><li>Onset of Drive for Thinness: 40% by age 9 or 10 in </li></ul><ul><li>girls </li></ul><ul><li>Racial Group: Caucasians > African Americans but </li></ul><ul><li>depends on valuation of thinness </li></ul>
  10. 10. Eating Disorders Have Considerable: <ul><li>* Morbidity and Mortality </li></ul><ul><li>* Relatively High Rates of Relapse </li></ul><ul><li>All Eating Disorders Share a Common Theme: </li></ul><ul><li>Body Shape & Body Image </li></ul>
  11. 11. Caveot <ul><li>Symptoms of Starvation Resemble </li></ul><ul><li>Symptoms of Depression: </li></ul><ul><li>Dysphoria </li></ul><ul><li>Anhedonia </li></ul><ul><li>Poor sleep </li></ul><ul><li>Decreased energy </li></ul><ul><li>Decreased concentration </li></ul><ul><li>Decreased libido </li></ul><ul><li>Socially withdrawn </li></ul>
  12. 12. Anorexia Nervosa (AN) <ul><li>Relatively Rare </li></ul><ul><li>High Mortality </li></ul><ul><li>Sensitive, self critical, persevering perfectionist </li></ul><ul><li>Obcessional, introverted, overly formalistic </li></ul><ul><li>(refer to hand-out) </li></ul><ul><li>Characteristics </li></ul><ul><li>Symptoms </li></ul><ul><li>Physical Findings </li></ul>
  13. 13. Bulimia Nervosa (BN) <ul><li>Essential Features: </li></ul><ul><li>* overvaluation of weight and shape </li></ul><ul><li>* dietary restriction </li></ul><ul><li>* binging </li></ul><ul><li>* purging </li></ul><ul><li>* age of onset approximately 19 </li></ul><ul><li>Two Sub-Categories: </li></ul><ul><li>Purging Type Non-Purging Type </li></ul><ul><li>laxatives exercise to compensate </li></ul><ul><li>Induced vomiting fasting </li></ul>
  14. 14. Bulimia Nervosa-continued <ul><li>(refer to handout) </li></ul><ul><li>Clinical and Physical Features </li></ul><ul><li>There exists similar incidences of co-morbidity in </li></ul><ul><li>Bulimia Nervosa as in Anorexia Nervosa: </li></ul><ul><li>* depression </li></ul><ul><li>* anxiety particularly OCD </li></ul><ul><li>* alcohol and drug abuse </li></ul><ul><li>* personality disorders </li></ul><ul><li>Persons with BN are more: impulsive, dramatic, unstable moods (Mehler & Andersen, 1999) </li></ul>
  15. 15. Binge Eating Disorder (BED) <ul><li>Essential Features: </li></ul><ul><li>* Eating large amounts of food in short period </li></ul><ul><li>* Loss of control during the binge </li></ul><ul><li>* Associated with 3 or more of the following: </li></ul><ul><li>a) eating more rapidly than normal </li></ul><ul><li>b) eating until uncomfortably full </li></ul><ul><li>c) eating large amounts when not hungry </li></ul><ul><li>d) eating alone/hiding </li></ul><ul><li>e) feeling disgusted, depressed, guilty after </li></ul><ul><li>over-eating </li></ul>
  16. 16. Binge Eating continued: <ul><li>* The binge occurs minimum 2x/week for duration </li></ul><ul><li>of 6 months </li></ul><ul><li>* Not associated with purging, fasting, or </li></ul><ul><li>excessive exercise </li></ul><ul><li>BED also associated with co-morbidity (60%) </li></ul><ul><li>* Major Depression </li></ul><ul><li>*Obsessive Compulsive Disorder </li></ul><ul><li>* Panic Disorder </li></ul><ul><li>*Substance Abuse </li></ul><ul><li>* 35% have personality disorder </li></ul>
  17. 17. Assessment of Eating Disorders <ul><li>Medical History </li></ul><ul><li>Screening Questions </li></ul><ul><li>Physical Exam </li></ul><ul><li>Signs and Symptoms </li></ul>
  18. 18. Assessment Continued <ul><li>Common GI Symptoms with Weight Loss: </li></ul><ul><li>* bloating </li></ul><ul><li>* nausea </li></ul><ul><li>* constipation </li></ul><ul><li>* heartburn </li></ul><ul><li>* abdominal pain </li></ul><ul><li>* diarrhea </li></ul>
  19. 19. Assessment Continued <ul><li>Common GI Symptoms with Bulimia: </li></ul><ul><li>* vomiting related </li></ul><ul><li>a) heartburn, hoarseness, sore throat, </li></ul><ul><li>dysphagia, (difficulty swallowing), </li></ul><ul><li>odynophagia (pain on swallowing) </li></ul><ul><li>* Purging related </li></ul><ul><li>a) diarrhea, abdominal cramping </li></ul>
  20. 20. Assessment Continued <ul><li>(Handouts) </li></ul><ul><li>Recommended Laboratory Tests </li></ul><ul><li>Lab Results Indicating Possible Eating Disorder </li></ul><ul><li>Common Lab Abnormalities </li></ul><ul><li>Electrolytes (Serum and Urinary) </li></ul>
  21. 21. Differential Diagnosis for Eating Disorders <ul><li>Anorexia Nervosa: </li></ul><ul><li>hyperthyroidism </li></ul><ul><li>diabetes mellitus </li></ul><ul><li>malignancies – lymphoma, stomach cancer </li></ul><ul><li>chronic infection – TB, AIDS, fungal diseases </li></ul><ul><li>cystic fibrosis </li></ul><ul><li>Inflammatory bowel disease – Crohn’s, colitis </li></ul><ul><li>chronic pancreatitis </li></ul><ul><li>malabsorption syndromes </li></ul><ul><li>psychiatric disorders associated with weight loss </li></ul>
  22. 22. Differential continued <ul><li>Bulimia Nervosa </li></ul><ul><li>Inflammatory bowel disease </li></ul><ul><li>peptic ulcer disease </li></ul><ul><li>parasitic intestinal infections </li></ul><ul><li>chronic pancreatitis </li></ul><ul><li>hypothalmic lesions or tumors </li></ul><ul><li>diverticulum </li></ul><ul><li>scleroderma or other connective tissue disorder </li></ul><ul><li>with GI involvement </li></ul>
  23. 23. Differential Continued <ul><li>Binge-Eating Disorder </li></ul><ul><li>temporal lobe or limbic seizures </li></ul><ul><li>lesions of the hypothalamus, frontal lobe, </li></ul><ul><li>or temporal lobe </li></ul><ul><li>degenerative neurologic conditions i.e.: Pick </li></ul><ul><li>disease, Alzheimer disease, Huntington </li></ul><ul><li>disease, Parkinson disease </li></ul>
  24. 24. Clinical Pearls <ul><li>Anorexics are proud of their weight loss </li></ul><ul><li>Bulimic behavior is usually shameful or guilt-producing </li></ul><ul><li>Binge–Eating usually occurs in the obese and in older patients (ages 30s-50s) </li></ul><ul><li>Eating Disorders in older people are usually complicated by concurrent medical or psychiatric </li></ul><ul><li>Once EA is diagnosed, assess for psychiatric disorders as well as medical consequences as both these usually occur </li></ul>
  25. 25. Treatment for Eating Disorders <ul><li>Goals: * nutritional rehabilitation and a “set point” weight maintenance </li></ul><ul><li>* Normal eating behavior </li></ul><ul><li>* Healthy thinking about weight </li></ul><ul><li>* Appropriate treatment plan with behavioral and pharmacological therapies </li></ul><ul><li>* Increased family awareness </li></ul><ul><li>* Relapse prevention with continued treatment </li></ul>
  26. 26. Treatment Continued <ul><li>Mental Health treatments: </li></ul><ul><li>* Cognitive Behavioral Therapy (CBT) </li></ul><ul><li>* antidepressants </li></ul><ul><li>* self help plus brief therapy </li></ul><ul><li>* Interpersonal therapy (IP) </li></ul><ul><li>* Dialectic Behavioral Therapy (DBT) </li></ul>
  27. 27. Mental Health Treatment <ul><li>Cognitive Behavioral Therapy-superior to others </li></ul><ul><li>* Phase I : focus on regular eating </li></ul><ul><li>(3 meals/day plus 2 snacks regardless if </li></ul><ul><li>hungry or not) </li></ul><ul><li>* Phase II : Modification of thoughts involving </li></ul><ul><li>diet and body shape </li></ul><ul><li>* Phase III : Relapse Prevention </li></ul>
  28. 28. Treatment Model: Cognitive Maintenance (specifically for BN)
  29. 29. When to Use Antidepressant? <ul><li>Agras (2001) demonstrated that if patient does not have 70% reduction in symptoms by week 4 of CBT, he recommended initiating SSRI (Fluoxetine). Beginning dose 20 mg and titrate in 2-4 days to 60mg. </li></ul><ul><li>Use of antidepressants rational is linked to affective disorders. Possible role of serotonin in feeding behaviors (  serotonin =satiety) </li></ul><ul><li>Patients on 60mg Fluoxetine showed 80% response rate within two weeks of treatment </li></ul>
  30. 30. Physical Complications of BN <ul><li>Metabolic: * weakness, poor skin turgor, dehydration </li></ul><ul><li>Gastrointestinal: * abd pain, blood in vomit </li></ul><ul><li>Reproductive: * fertility problems, scanty menses, possible hypoestrogenemic </li></ul><ul><li>Oropharyngeal: * dental decay, erosion of dental enamel painful throat, swollen cheeks & neck (painless), enlarged salivary glands </li></ul><ul><li>Cardiomuscular: * weakness, palpitations, cardiomyopathy, cardiac abnormalities </li></ul>
  31. 31. Physical Complications of AN <ul><li>CNS: * apathy, poor concentration, depressed, irritable, cognitive impairment </li></ul><ul><li>Cardiovascular: * palpitations, dizziness, SOB, chest pain, cold extremities, irregular pulse, BP changes </li></ul><ul><li>Skeletal: * bone pain, point tenderness, arrested skeletal growth </li></ul><ul><li>Muscular: * weakness, muscle aches, muscle wasting, </li></ul><ul><li>Endocrine: * fatigue, cold intolerance, hypothermia </li></ul><ul><li>Hematologic: * rare bruising, clotting abnormalities </li></ul><ul><li>GI: vomiting, abd pain, bloating, constipation, pitting edema, abnormal bowel sounds </li></ul>

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