Overview of
Eating Disorders
Alexis Polles, MD
Kirstie Alley
Mary Kate Olson
Princess Dianna
Outline
• Eating Disorder
Definitions
• Our Philosophy
• Medical/Psychiatric Issues
– Co-morbidity
• Diagnostic Instrument...
DSM-IV-TR Descriptions of
Eating Disorders
• The Eating Disorders are characterized by
severe disturbances in eating behav...
Disturbance in Self-Regulation
• The use of food in one’s body to solve
psychological conflicts
Our Philosophy from the
Psychiatric Medical Perspective
• Eating disorders are a group of illnesses
exhibiting a progressi...
Nutritional/Exercise Perspective
• An integrated approach combining spirituality,
psychotherapy, pharmacology, nutrition a...
Trauma and Victimization
• Bulimic link
• Sexual assault is not causal, but is a non-
specific risk factor
Brewerton Reviews
(AACAP, 1997/Natl Women’s Study)
• 1. Is CSA associated with BN? Yes
• 2. Is CSA > in BN than AN? Yes
• ...
National Women’s Study
• Random telephone survey of the general
– population of women
• Victimization included
– completed...
PTSD in the NWS
• 37% of those with BN had PTSD at some
point
• 12% of those in the general pop. had PTSD
at some point
• ...
Functions of the ED in
Victimization
• Regulation of emotional states or
interpersonal conflicts (numbing)
• Avoidance/esc...
Therapy Perspective
• Multidisciplinary team approach with a deep
spiritual emphasis allows clients to connect to
their in...
STAGES OF ADDICTION
USE
Loss of Control and Choice
EARLY
MIDDLE
LATE
NON-ADDICTION
Control and Choice
Occasional relief ea...
Adult Feeling Disease Phases
I. Learns Mood Swing
II. Seeks Mood Swing
III. Harmful Dependence
IV. Using Eating Disorder B...
Anorexia Nervosa
• A progressive and potentially fatal illness with
the highest mortality rate of any psychiatric
illness ...
Anorexia Nervosa
• Associated Descriptive Features:
– Plays with food or has rituals with food
– Guilt or shame about eati...
Anorexia Nervosa
• Associated Medical Issues:
– Laboratory
– Cold intolerance
– Constipation
– Abdominal pain
– Lethargy
–...
Anorexia Nervosa
• Other Features:
– More prevalent in industrial societies
– Rarely begins before puberty
– Onset between...
Human StarvationHuman Starvation
• Sleep disturbance
• Weakness
• GI disturbance
• Decreased BMR
• Decreased libido
• Decr...
2001 NEDA Stats on Men
• 25% American men are on diets
• 41% Men dissatisfied with their weight
• 70% College-age men diss...
Bulimia Nervosa
• Is a potentially devastating disease which is
characterized by:
– Recurrent episodes of binge eating
• E...
Bulimia Nervosa
• Associated Descriptive Features:
– Typically within the normal weight range
– Likely to be overweight pr...
Bulimia Nervosa
• Associated Medical Issues:
– Laboratory (Frequent low potassium)
– Dental erosions
– Parotid gland enlar...
Eating Disorder NOS
– AN with regular menses
– AN with normal weight
– BN that occurs less than twice a week
for less than...
Binge Eating Disorder
• Recurrent episodes of binge eating
• Binges have at least 3
– Eating more rapidly than normal
– Ea...
Binge Eating Disorder
• Associated Descriptive Features:
– May be triggered by depression and anxiety
– May feel numb or s...
Prevalence of Overweight and Obesity
in U.S. Women: BMI >25 Ages >20*
50.7% All women
49.2% White
65.85% Black
47.4% White...
Women and Weight Gain:
Risks and Consequences
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitab...
Obesity in Women:
Consequences for Children
In addition to:
• Low family income
• Lower cognitive stimulation
• High fat/c...
Childhood Predictors of
Adult Obesity
Strong associations found:
– Parental fatness:
• Whether due to genes or lifestyle i...
Benefits of
Modest (5 – 10%) Weight Loss
• Lowers TC, triglycerides, LDL, BP and left
ventricular mass
 Blood glucose in...
Recommended Dietary Intake
Reduces Disease Risk
• Study of 42,254 women assigned a “score” based on #
servings from the di...
Risk Factors for Men
• Childhood obesity
• Family history
• Psychiatric co-morbidity
• Alcohol and substance abuse
• Gende...
Psychiatric Co-morbidity
• Commonly occurring Axis I co-morbidity:
– Major Depression
– Anxiety Disorders
• OCD, Social Ph...
Assessment Tools
• General physical exam (include labs)
• Nutritional consultation
• BMI/% body fat
• Interview
• Written ...
BMI
• Body Mass Index Score
–Less than 19 % Underweight
–19%-25% Desirable Range
–25%-30% Overweight
–30% + Obese
BMI = (
...
Approximately 13%
Kate Moss
Approximately 15%
Courtney Cox
Approximately 18.5%
Meg Ryan
Approximately 19.5%
Lower Healthy
Tony Braxton
Approximately 25%
Upper Healthy
Jennifer Lopez
Approximately 28%
O...
Jennifer Lopez
Approximately 28%
Overweight
Ricki Lake
Approximately 30%
Borderline Obese
Camyrn Manhiem
Approximately 39%...
Assessment Instruments
• EDI III– Self Report
• Questionnaire on Eating and Weight—Revised
• DSM
Review of Information on Healthy Eating
• For those of you who watch what you eat... Here's the final
word on nutrition an...
Goals of Treatment
• Restoring healthy eating patterns.
• Restoring healthy body weight.
• Identifying and treating underl...
General Treatment PrinciplesGeneral Treatment Principles
• Diagnostic evaluation
• Relative chronology
• Potential functio...
General Treatment Principles
• Normalizing brain function
– Nutritional rehabilitation
– Abstinence from substance abuse/d...
Intensive TherapyIntensive Therapy
• CBT
• DBT
• IPT
• Family Therapy
• Psychodynamic/experiential
• 12 step recovery mode...
Overview of Eating Disorders
Overview of Eating Disorders
Overview of Eating Disorders
Overview of Eating Disorders
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Overview of Eating Disorders

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Eating disorders are a group of illnesses exhibiting a progressive course of distorted thinking and behaviors. They are characterized by loss of control over one’s relationship with food and eating. These illnesses have developmental, biological, familial, and socio-cultural roots. Recovery is about achieving balance and healthy nurturance in one’s life.

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  • Ansell Key published landmark data in “The Biology of Human Starvation” in the 1950s. He studied a group of conscientious objectors in the late 40’s. They were on semi-starvation diets for a period of six months and they were studied in depth psychologically, medically, every way they knew how before, during, and after this period of starvation.
    What they found are a list of symptoms that are very similar to what we see in eating disorders. If we start with the physical changes there are sleep disturbances, weakness, and gastrointestinal disturbances. We know that starvation causes a functional gastro-paresis. It delays gastric emptying and contributes to a lot of the stomach symptoms you hear your clients complaining of. I do use Reglan.
    There is decreased basal metabolic rate, decreased sexual interest, and decreased energy.
    You may notice that here are 2 or 3 symptoms of major depression, and there are others to come.
    Then there are cognitive changes including decreased concentration, poor judgment, and apathy.
    And then we have emotional-social changes including depression, anxiety, irritability and anger. One percent of the subjects actually became psychotic.
    There was also social withdrawal.
    The person would meet criteria for major-depressive disorder; but it is entirely due to the effects of starvation.
    Lastly, attitudes and behaviors toward food were significantly affected.
    There was food preoccupation, collecting recipes, and cookbooks, unusual eating habits, increased consumption of coffee, tea, spices, and weird mixtures, and most importantly – binge eating. Starvation leads to binge eating.
    Even in people with normal weight bulimia nervosa, we know it’s important to normalize eating in order to prevent binge eating.
  • The recommendation to treat overweight and obesity is based not only on the evidence that shows overweight is associated with increased morbidity and mortality, but also on RCT evidence that weight loss reduces risk factors for disease. Thus, weight loss may help control diseases worsened by overweight and obesity and may also decrease the likelihood of developing these diseases.
    Some benefits associated with weight loss include the following:
    Decreased cardiovascular risk.
    Decreased glucose and insulin levels.
    Decreased blood pressure.
    Decreased LDL-cholesterol and triglycerides and increased HDL-cholesterol.
    Decreased severity of sleep apnea.
    Reduced symptoms of degenerative joint disease.
    Improved gynecological conditions.
  • I want to talk about general principles in treating co-morbidity with eating disorders.
    A diagnostic evaluation is the starting point. DSMIV diagnosis is not everything, but it does help to guide you on your decision tree about treatment approaches. It provides a road map.
    Try to identify the relative chronology of these disorders: which are primary, which are secondary; which are concurrent, which are ongoing.
    As you identify these diagnoses, also begin to sort out any potential functional links between these disorders.
    Most of the time, you want to treat concurrently, with the emphasis being on treating the most dangerous issues first.
    It is also necessary to normalize brain function as much as possible before you can do any kind of meaningful psychotherapy or pharmacological therapy. Until very low weight anorexics begin to eat and maintain their weight, psychotherapy doesn’t have much effect.
    Re-feeding has to be the first stage followed by intensive psychotherapy and then the maintenance phase.
    Let’s take a look at what happens with starvation.
  • Once we attain the nutritional rehabilitation and abstinence detox from substances, then we can move into the next phase of treatment, which is the intensive psychotherapy phase. Cognitive behavioral therapy has the best scientific validity behind it in terms of how to approach eating disorders, though the studies with CBT are often in select populations without a lot of the co-morbidity seen in much of clinical practice.
    Interpersonal therapy has also been shown to be helpful, studies being primarily done in bulimia nervosa.
    Family therapy we know to be important especially in anorexia nervosa of early onset.
    Psychodynamic and experiential psychotherapies certainly have an important role but efficacy has not been studied well and has to be placed at the right time in treatment.
    12-step or recovery model approaches are also beneficial, though not studied well.
    Psychopharmacology also plays an important part, though it should be adjunctive to other approaches and not the only treatment given.
    Most often, especially with co-morbid disorders, clinicians will use a combination of approaches, involving all of these kinds of treatment interventions.
  • Overview of Eating Disorders

    1. 1. Overview of Eating Disorders Alexis Polles, MD
    2. 2. Kirstie Alley
    3. 3. Mary Kate Olson
    4. 4. Princess Dianna
    5. 5. Outline • Eating Disorder Definitions • Our Philosophy • Medical/Psychiatric Issues – Co-morbidity • Diagnostic Instruments • Treatment Goals
    6. 6. DSM-IV-TR Descriptions of Eating Disorders • The Eating Disorders are characterized by severe disturbances in eating behavior. • Three Diagnostic Categories = Form – Anorexia Nervosa Restricting Type or Binge Eating/Purging Type – Bulimia Nervosa Purging Type or Non-Purging Type – Eating Disorder NOS Binge Eating or Compulsive Overeating, etc. • Function is attempt at self-regulation.
    7. 7. Disturbance in Self-Regulation • The use of food in one’s body to solve psychological conflicts
    8. 8. Our Philosophy from the Psychiatric Medical Perspective • Eating disorders are a group of illnesses exhibiting a progressive course of distorted thinking and behaviors. They are characterized by loss of control over one’s relationship with food and eating. These illnesses have developmental, biological, familial, and socio-cultural roots. Recovery is about achieving balance and healthy nurturance in one’s life. Alexis Polles, M.D.
    9. 9. Nutritional/Exercise Perspective • An integrated approach combining spirituality, psychotherapy, pharmacology, nutrition and exercise are all necessary to ensure recovery from an eating disorder. Size and food issues are only the bandages that cover the underlying wounds of low self-esteem, trauma, poor communication, and the need for control. These issues need to be addressed in order for real healing to occur. Ralph Carson, Ph.D., RD
    10. 10. Trauma and Victimization • Bulimic link • Sexual assault is not causal, but is a non- specific risk factor
    11. 11. Brewerton Reviews (AACAP, 1997/Natl Women’s Study) • 1. Is CSA associated with BN? Yes • 2. Is CSA > in BN than AN? Yes • 3. Is CSA a specific risk factor? No • 4. Is CSA associated with severe BN? No
    12. 12. National Women’s Study • Random telephone survey of the general – population of women • Victimization included – completed rape, molestation, attempted assault – aggravated assault • 54% with BN experienced at least one • 31% without BN experienced at least one
    13. 13. PTSD in the NWS • 37% of those with BN had PTSD at some point • 12% of those in the general pop. had PTSD at some point • 22% in BED • Purging may prevent healing and resolution • Rape without PTSD, 2% had BN • Rape with PTSD, 10.4% had BN
    14. 14. Functions of the ED in Victimization • Regulation of emotional states or interpersonal conflicts (numbing) • Avoidance/escape • Analgesia, self-punishment, self-blame • Repetition compulsion • Addictive cycle
    15. 15. Therapy Perspective • Multidisciplinary team approach with a deep spiritual emphasis allows clients to connect to their internal conflicts of fear, control and perfectionism. With the support of a dedicated, competent staff, clients are able to develop hope for change and transition into recovery, where they find healthy connections to their bodies, and spiritual connections to the disowned self. This allows for healing in all their relationships. Mary Bellofatto, MA, LMHC, CEDS, CP, PAT
    16. 16. STAGES OF ADDICTION USE Loss of Control and Choice EARLY MIDDLE LATE NON-ADDICTION Control and Choice Occasional relief eating or fasting Onset of memory fuzziness Feelings of guilt Initial avoidance of family and friends Decrease ability to stop Inability to determine feelings of fullness Grandiose and Passive/Aggressive Behaviors Urgency for food and compensatory behaviors Geographical escapes Loss of other interest Change in tolerance Work and money problems Severe relational issues Physical deterioration Spiritual deterioration Severe impairment in thinking Indefinable fears Nearly constant obsession/compulsion
    17. 17. Adult Feeling Disease Phases I. Learns Mood Swing II. Seeks Mood Swing III. Harmful Dependence IV. Using Eating Disorder Behavior to Feel Normal Adolescent Feeling Disease Phases I. Learns Mood Swing II. Seeks Mood Swing III. Harmfully Involved IV. Harmfully Dependent “I’m ugly and fat and don’t fit in”.
    18. 18. Anorexia Nervosa • A progressive and potentially fatal illness with the highest mortality rate of any psychiatric illness characterized by: – Refusal to maintain body weight (BMI less than 17.5 or 85% IBW) – Intense fear of weight gain or becoming fat – Judges self harshly by weight or shape – In postmenarcheal females, amenorrhea (3 cycles)
    19. 19. Anorexia Nervosa • Associated Descriptive Features: – Plays with food or has rituals with food – Guilt or shame about eating – Difficulty eating in public – Sensitivity to cold temperatures – Depression and irritability – Socially withdrawn – Perfectionism – Overly controlled social and emotional life
    20. 20. Anorexia Nervosa • Associated Medical Issues: – Laboratory – Cold intolerance – Constipation – Abdominal pain – Lethargy – Increased energy – Low blood pressure – Dry Skin/Yellow Skin (hypercarotenemia) – Edema – Dental erosions – Scars on the back of hands – Osteoporosis – Decreased estrogen
    21. 21. Anorexia Nervosa • Other Features: – More prevalent in industrial societies – Rarely begins before puberty – Onset between 14 and 18 – Rarely starts after age 40 – Significant number of those with restricting type develop binge eating – Long term mortality is over 10% and death usually due to starvation, suicide or electrolytes – There is a familial pattern – Significantly higher concordance rates for monozygotic vs dizygotic twins
    22. 22. Human StarvationHuman Starvation • Sleep disturbance • Weakness • GI disturbance • Decreased BMR • Decreased libido • Decreased energy • Decreased concentration •Poor judgment •Apathy •Depressed mood •Anxiety •Irritability •Anger •Psychosis •Social withdrawal •Disturbed attitude toward food
    23. 23. 2001 NEDA Stats on Men • 25% American men are on diets • 41% Men dissatisfied with their weight • 70% College-age men dissatisfied w/body image • 32% College males dieting past 6 months • 50% High-school freshmen dieting past 6 months • 28% Boys / 40% Adolescent males trying to gain weight • 1 Million boys and men have eating disorders
    24. 24. Bulimia Nervosa • Is a potentially devastating disease which is characterized by: – Recurrent episodes of binge eating • Eating in a discrete period of time an amount of food which is definitely larger than what most people would eat. • Sense of lack of control over eating – Recurrent compensatory behaviors to prevent weight gain • Laxative, diuretics, enemas, fasting, exercise, other drugs – Behavior occurs on average twice a week for 3 months – Self-evaluation unduly influenced by body shape and weight – Types • Purging type = vomiting, diuretics, enemas • Non-purging type = fasting, exercise
    25. 25. Bulimia Nervosa • Associated Descriptive Features: – Typically within the normal weight range – Likely to be overweight prior to onset – Increased frequency depressive symptoms and low self-esteem – Increased frequency anxiety symptoms – Binge eating frequently begins during an episode of dieting – Periods of remission longer than 1 year have better long term outcome – Familial pattern with bulimia, mood disorders, substance abuse and possibly obesity
    26. 26. Bulimia Nervosa • Associated Medical Issues: – Laboratory (Frequent low potassium) – Dental erosions – Parotid gland enlargement – Scars on back of hand – Menstrual irregularities – Fatal problems can include esophageal tears, gastric rupture, and cardiac arrhythmias – Rectal prolapse
    27. 27. Eating Disorder NOS – AN with regular menses – AN with normal weight – BN that occurs less than twice a week for less than 3 months – Chewing and spitting out but not swallowing food – Binge ED
    28. 28. Binge Eating Disorder • Recurrent episodes of binge eating • Binges have at least 3 – Eating more rapidly than normal – Eating until uncomfortably full – Eating large amounts when not physically hungry – Eating alone due to embarrassment – Feeling disgusted, depressed or very guilty after overeating • Marked distress regarding binge eating • Occurs 2 days a week for 6 months • No regular use of compensatory behaviors
    29. 29. Binge Eating Disorder • Associated Descriptive Features: – May be triggered by depression and anxiety – May feel numb or spaced out during a binge – Grazing with no planned meal times – Many have been on multiple diets – Usually overweight
    30. 30. Prevalence of Overweight and Obesity in U.S. Women: BMI >25 Ages >20* 50.7% All women 49.2% White 65.85% Black 47.4% White, non-Hispanic 66.0% Black, non-Hispanic 65.9% Mexican American * NIH Guidelines, September 1998, pg 69S – from NHANES III data 1988-94 Low-income or low-educated US women more likely to be obese than those with higher socioeconomic status. Low-income or low-educated US women more likely to be obese than those with higher socioeconomic status. Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    31. 31. Women and Weight Gain: Risks and Consequences Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    32. 32. Obesity in Women: Consequences for Children In addition to: • Low family income • Lower cognitive stimulation • High fat/calorie intake • Avid T.V. watching • Maternal obesity: best predictor of childhood obesity 1. USDA, Nutrition Insights, May 1999 Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    33. 33. Childhood Predictors of Adult Obesity Strong associations found: – Parental fatness: • Whether due to genes or lifestyle is unknown1 – Birth weight: • Increased fatness with higher birth weight1 – Timing and rate of maturation: • Early menarche (before 11 yrs) in girls doubled chances of being overweight • Highest prevalence in early-maturing black girls2 1. Parsons TJ, et al, Int J Obesity (1999) 23, Supp 8, S1-107 2. Adair LS, Gordon-Larsen P. Am J Pub Hlth April 2001, Vol 91, No 4;642-644 Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    34. 34. Benefits of Modest (5 – 10%) Weight Loss • Lowers TC, triglycerides, LDL, BP and left ventricular mass  Blood glucose in type II diabetics • Improves HDL cholesterol, lower back pain, reflux, lower extremity arthralgias, obstructive sleep apnea • Often can decrease medications for obesity- related conditions NHLBI Guidelines, June 1998 Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    35. 35. Recommended Dietary Intake Reduces Disease Risk • Study of 42,254 women assigned a “score” based on # servings from the dietary guidelines • Of those who followed the guidelines: 30% less likely to die of any cause 40% less likely to die of cancer (colon, breast, endometrial, and gallbladder) 33% less likely to die of heart disease 42% less likely to die of stroke Kant et al, JAMA 2000 Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust
    36. 36. Risk Factors for Men • Childhood obesity • Family history • Psychiatric co-morbidity • Alcohol and substance abuse • Gender dysphoria and sexual orientation (Gay and Bi-sexual males over represented) • Weight related sports (Gymnast, runners, body-builders, rowers, wrestlers, jockeys, dancers and swimmers)
    37. 37. Psychiatric Co-morbidity • Commonly occurring Axis I co-morbidity: – Major Depression – Anxiety Disorders • OCD, Social Phobia, PTSD – Substance Abuse/Dependence except in restricting AN – Somatoform Disorders • Body Dysmorphic Disorder • Axis II – BN and Cluster B (Borderline) – AN and Cluster C (Avoidant, OCPD)
    38. 38. Assessment Tools • General physical exam (include labs) • Nutritional consultation • BMI/% body fat • Interview • Written instruments
    39. 39. BMI • Body Mass Index Score –Less than 19 % Underweight –19%-25% Desirable Range –25%-30% Overweight –30% + Obese BMI = ( Weight in Pounds (Height in inches) x (Height in inches) ) x 703
    40. 40. Approximately 13% Kate Moss Approximately 15% Courtney Cox Approximately 18.5%
    41. 41. Meg Ryan Approximately 19.5% Lower Healthy Tony Braxton Approximately 25% Upper Healthy Jennifer Lopez Approximately 28% Overweight
    42. 42. Jennifer Lopez Approximately 28% Overweight Ricki Lake Approximately 30% Borderline Obese Camyrn Manhiem Approximately 39% Obese
    43. 43. Assessment Instruments • EDI III– Self Report • Questionnaire on Eating and Weight—Revised • DSM
    44. 44. Review of Information on Healthy Eating • For those of you who watch what you eat... Here's the final word on nutrition and health. It's a relief to know the truth after all those conflicting medical studies: • 1. The Japanese eat very little fat and suffer fewer heart attacks than the British or Americans. • 2. The Mexicans eat a lot of fat and suffer fewer heart attacks than the British or Americans. • 3. The Japanese drink very little red wine and suffer fewer heart attacks than the British or Americans. • 4. The Italians drink excessive amounts of red wine and suffer fewer heart attacks than the British or Americans. • 5. The Germans drink a lot of beer and eat lots of sausages and fats and suffer fewer heart attacks than the British or Americans.
    45. 45. Goals of Treatment • Restoring healthy eating patterns. • Restoring healthy body weight. • Identifying and treating underlying emotional issues. • Developing coping strategies for dealing with day-to-day stressors.
    46. 46. General Treatment PrinciplesGeneral Treatment Principles • Diagnostic evaluation • Relative chronology • Potential functional links • Treat concurrently • Normalize brain function -Re-feed -Psychotherapy -Maintenance
    47. 47. General Treatment Principles • Normalizing brain function – Nutritional rehabilitation – Abstinence from substance abuse/dependence • Acute withdrawal
    48. 48. Intensive TherapyIntensive Therapy • CBT • DBT • IPT • Family Therapy • Psychodynamic/experiential • 12 step recovery models • Psychopharmacology • Trauma based

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