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Hanipsych, biology of eating disorder


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Hanipsych, biology of eating disorder

  1. 1. Biology of eating Disorders Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.Psychiatry Prof. PsychiatryProf. Psychiatry Chairman of Psychiatry DepartmentChairman of Psychiatry Department Beni Suef UniversityBeni Suef University Supervisor of Psychiatry DepartmentSupervisor of Psychiatry Department El-Fayoum UniversityEl-Fayoum University APA memberAPA member
  2. 2. HistoryHistory • In Western Europe of the 12In Western Europe of the 12thth and 13and 13thth centuries,centuries, “miracle“miracle maidens,” or women who starved themselves, were highlymaidens,” or women who starved themselves, were highly regarded, and their behavior was imbued with religiousregarded, and their behavior was imbued with religious interpretations.interpretations. • Catherine of Siena (1347 – 1380), whose complete controlCatherine of Siena (1347 – 1380), whose complete control over her food intake was seen as a sign of religious devotion,over her food intake was seen as a sign of religious devotion, was regarded as a saint (Heywood, 1996).was regarded as a saint (Heywood, 1996). • ““Holy anorexia” was, however, short-livedHoly anorexia” was, however, short-lived • By the 16By the 16thth century the Catholic Church began to disapprovecentury the Catholic Church began to disapprove of asceticism.of asceticism. • Some anorexics were subsequently viewed as witchesSome anorexics were subsequently viewed as witches (Brumberg, 2000).(Brumberg, 2000).
  3. 3. History cont’d • First cases reported in 1689 by RichardFirst cases reported in 1689 by Richard Morton –Morton – “wasting” disease of nervous“wasting” disease of nervous etiology in one male and one femaleetiology in one male and one female (Gordon, 2000).(Gordon, 2000). • The first formal description of AN, however, isThe first formal description of AN, however, is credited to Sir William Gull, physician tocredited to Sir William Gull, physician to Queen Victoria, who in 1868 named theQueen Victoria, who in 1868 named the disorder anorexia hysterica, emphasizingdisorder anorexia hysterica, emphasizing what he believed to be its psychogenicwhat he believed to be its psychogenic
  4. 4. History: Bulimia NervosaHistory: Bulimia Nervosa • Bulimia Nervosa (BN), by contrast, was first clinicallyBulimia Nervosa (BN), by contrast, was first clinically described in 1979described in 1979 • Historical accounts date to 1398, whenHistorical accounts date to 1398, when “true“true boulimus” was described in an individual having anboulimus” was described in an individual having an intense preoccupation with food and over eating atintense preoccupation with food and over eating at very short intervals, terminated by vomiting (Stein &very short intervals, terminated by vomiting (Stein & Laakso, 1988).Laakso, 1988). • The word bulimia is derived from Greek and meansThe word bulimia is derived from Greek and means “ravenous hunger,” quite the opposite of anorexia.“ravenous hunger,” quite the opposite of anorexia.
  5. 5. The Celebrity Thin IdealThe Celebrity Thin Ideal
  6. 6. The Impact of Media • 90% of all girls ages 3-11 yrs have a Barbie Doll • If Barbie were a real woman, her measurements would be 38-18-33 • The body type portrayed in advertising as the ideal is possessed naturally by only 5% of females • The diet industry came on the scene in the 1960’s
  7. 7. Barbie and BodiesBarbie and Bodies • Seven feet tallSeven feet tall • 38 inch chest38 inch chest • 21 inch waist21 inch waist • 36 inch hips36 inch hips • VirtuallyVirtually unattainable for anunattainable for an adult womanadult woman
  8. 8. Eating Disorders and Cross- Cultural Influences • Eating disorders more prevalent in industrialized societies which emphasize thinness. – US, Canada, Japan, Europe • As countries become more “westernized”, eating disorders increase. • When women from countries with low prevalence rates more to countries with higher prevalence rates, prevalence increases. • Variations in assessment methods and diagnostic criteria make it difficult to be certain about differences in prevalence rates from country to country.
  9. 9. Statistics • Over one-half of teenage girls and one- third of teenaged boys use unhealthy weight control behaviors such as skipping meals, smoking, fasting, vomiting, or taking laxatives
  10. 10. Some statisticsSome statistics • Eating disorders have increased threefold in the last 50 years • 10% of the population is afflicted with an eating disorder • 90% of the cases are young women and adolescent girls • Up to 21% of college women show sub-threshold symptoms • 61% of college women show some sort of eating pathology
  11. 11. Statistics • Americans spend over $40 billion on dieting and diet related products each year
  12. 12. Messages about FoodMessages about Food What messages have you received (from parents, peers, media, etc.) about food? How are messages about food different for women and men?
  13. 13. Eating Disorders • Anorexia Nervosa –Restricting Type –Binge Eating/Purging (Bulimic) Type • Bulimia Nervosa –Purging Type –Nonpurging Type • Eating Disorder NOS
  14. 14. AnorexiaAnorexia Risk of Death: The Deadliest of all Psychological Disorders
  15. 15. Anorexia vs. Bulimia • Denies abnormal eating behavior • Introverted • Turns away food in order to cope • Preoccupation with losing more and more weight • Recognizes abnormal eating behavior • Extroverted • Turns to food in order to cope • Preoccupation with attaining an “ideal” but often unrealistic weight
  16. 16. Body Mass Index • Weight in kg divided by height in m2 • NORMAL BMI : 18 to 24 years of age BMI < 18 : suspect malnutrition BMI 24 to 30 : overweight BMI 30 to 40 : obesity BMI above 40 = morbid obesity
  17. 17. Obesity • Defined as 20% over ideal body weight or BMI > 30 • Not an eating disorder per se and unlike an eating disorder is not an mental illness. However, many people who binge eat become obese and can have mental health problems • 1/3 of NYC public high school students are overweight or obese
  18. 18. What does our weight cost? • Direct CostsDirect Costs • Indirect CostsIndirect Costs • 1995 = $99 billion1995 = $99 billion • 2000 = $117 billion2000 = $117 billion • Most of the cost associated with obesity is dueMost of the cost associated with obesity is due to type 2 diabetes, coronary heart disease, andto type 2 diabetes, coronary heart disease, and hypertension.hypertension.
  19. 19. Why are we so overweightWhy are we so overweight?? • GenesGenes • DietDiet • ExerciseExercise • Nutrition EducationNutrition Education • Social (single parent, no time to prepare meals,Social (single parent, no time to prepare meals, etc.)etc.)
  20. 20. Vicious Cycle of Bulimia
  21. 21. 22Chapters: 1. Neurodevelopmental Disorders 2. Schizophrenia Spectrum & Other Psychotic Disorders 3. Bipolar & Related Disorders 4. Depressive Disorders 5. Anxiety Disorders 6. Obs-Compulsive & Related 7. Trauma- & Stressor-Related 8. Dissociative Disorders 9. Somatic Symptom Disorders 10.Feeding & Eating Disorders 11.Elimination Disorders 12.Sleep/Wake Disorders 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse-Control & Conduct Disorders 16. Substance Related & Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders 20. Other Mental Disorders 21. Medication-induced Movement… Med Effects 22. Other Conditions (v codes)
  22. 22. Feeding and Eating Disorders: Cont… Pica and Rumination Disorder: • Criteria has been revised to allow diagnosis for individuals of all ages. Avoidant/Restrictive Food Intake Disorder: • Previously feeding disorders of infancy or early childhood. • Criteria is significantly expanded making it a broader category to capture a wider range of clinical presentations.
  23. 23. Feeding and Eating Disorders: Cont… Anorexia Nervosa: • The requirement for amenorrhea has been eliminated. • Clarity and guidance: how to judge if an individual is at “significantly low weight” has been added. • Criterion B has been expanded to include not only “overtly expressed fear of weight gain” but also “persistent behavior that interferes w/ weight gain”.
  24. 24. Feeding and Eating Disorders: Cont… Bulimia Nervosa : • The only change is the reduction in the required minimum average frequency of binge eating & inappropriate compensatory behavior frequency from twice to once weekly for 3 months.
  25. 25. Feeding and Eating Disorders: Cont… Binge Eating Disorder: • Elevated to main body of manual from appendix B in DSM-IV. • The only change is the minimum average frequency of binge eating required for diagnosis is once weekly over the last 3 months (identical to frequency criterion for bulimia nervosa).
  26. 26. Causes of Eating Disorders • Personality Traits • Genetics • Environmental Influences • Biochemistry
  27. 27. Personality Traits • Low self-esteem • Feelings of inadequacy or lack of control in life • Fear of becoming fat • Depressed, anxious, angry, and lonely feelings • Disobey • Keep feelings to themselves • Perfectionists • Achievement oriented – Good students – Excellent athletes – Competitive careers
  28. 28. Personality traits contribute to the development of eating disorders because: • Food and the control of food is used as an attempt to cope with feelings and emotions that seem overwhelming • Having followed the wishes of others... – Not learned how to cope with problems typical of adolescence, growing up, and becoming independent • People binge and purge to reduce stress and relieve anxiety • Anorexic people thrive on taking control of their bodies and gaining approval from others • Highly value external reinforcement and acceptance
  29. 29. Genetic Factors May Predispose People to Eating Disorders *Studies Suggest: • Increased risk of anorexia nervosa among first-degree biological relatives of individuals with the disorder • increased risk of mood disorders among first-degree biological relatives of people with anorexia, particularly the binge-eating/purging type. • Twin studies – concordant rates for monozygotic twins is significantly higher than those for dizygotic twins. • Mothers who are overly concerned about their daughter’s weight and physical attractiveness might cause increase risk for development of eating disorders. • Girls with eating disorders often have brothers and a father who are overly critical of their weight.
  30. 30. Environmental Factors - Interpersonal and Social • Interpersonal Factors – troubled family and personal relationships – difficulty expressing emotions and feelings – history of being teased or ridiculed based on size or weight – history of trauma, sexual, physical and/or mental abuse • 60-75% of all bulimia nervosa patients have a history of physical and/or sexual abuse
  31. 31. Etiology: Biological Theory • Biological theories focus on the role of the hypothalamus (the region concerned with the regulation of body functions, such as temperature, weight, appetite, & general homeostasis); support for this theory comes from neurotransmitter studies showing an increase in Corticotropin Releasing Factor (CRF) in the CSF of anorexic patients • When administered to rats, CRF leads to a reduction in food intake, feeding time, & feeding episodes; it also leads to an increase in grooming time & grooming episodes • The occurrence of amenorrhea before weight loss also suggests a hypothalamic disturbance (occurs in 20% of patients)
  32. 32. Hypothalamus • Neurotransmitter links to these eating disorders stem from studies done primarily on the hypothalamus. • Specifically, the ventromedial and lateral hypothalamus have been shown to govern eating behavior in humans, as well as in many laboratory animals. • The ventromedial hypothalamus has been called the satiety center. When this part of the brain is stimulated eating behavior stops, correlating to a feeling of being satiated. Conversely the lateral hypothalamus, when stimulated, correlates to eating behavior.
  33. 33. • When operating properly these two areas operate to keep the body at a specific body weight, termed the set point. • Damage to either of these regions causes the set point to be altered. Eating will then reflect the new set point, thus, if it is lower then normal the animal can literally starve themselves to death.
  34. 34. • Decreasing the level of epinephrine in the ventromedial hypothalamus of rats was correlated with their exhibiting anorexic type behaviors. • That is, they would adopt a low rate of eating, increase their rate of activity, reduce their carbohydrate intake, and rebound with overeating.
  35. 35. Biochemical Factors • Chemical imbalances in the neuroendocrine system – these imbalances control hunger, appetite, digestion, sexual function, sleep, heart and kidney function, memory, emotions, and thinking • Serotonin and norepinephrine are decreased in acutely ill anorexia and bulimia patients – representing a link between depression and eating disorders • Excessive levels of cortisol in both anorexia and depression – caused by a problem that occurs in or near the hypothalamus
  36. 36. Etiology: Biological Theory (2( • There is also evidence of a central neurotransmitter system dysregulation affecting 5HT, DA, and NOREPI; the strongest evidence supports reduced NOREPI activity and turnover • Vomiting leads to an increase in DA levels which reinforces/rewards the vomiting behavior • Theories of serotonergic hyperfunctioning in anorexia and serotonergic hypofunctioning in bulimia are attractive but don’t explain why SSRIs are sometimes helpful for both
  37. 37. • This indicates that bulimics may have a faulty satiation response center. • A desire to feel satiated may cause the bulimic to try to flood their brain with tryptophan, by overeating on sugars which will lead to this precursor. • The successful treatment of bulimia with SSRIs suggests the importance of serotonin in eating disorders.
  38. 38. • Anorexic patients, on the other hand, may have overactive serotonerigic response centers, leading to a need to reduce the levels of serotonin in their brains by restricting their food intake. • Actually, excessive levels of serotonin are correlated with a nervous, jittery feeling. Self-starvation may be an attempt to rid the body of this uncomfortable feeling.
  39. 39. • Low serotonin levels have been linked to depression which is a commonly concurrent disorder in people with eating disorders. • Both eating disorders and depression can be seen as disorders that occur when the I-function, a sense of self, is not in agreement with external reality. • For example, the depressed person often has a feeling of helplessness, hopelessness, and exceedingly low self esteem regardless of their actual situation in life.
  40. 40. • A person suffering from anorexia or bulimia feels they are overweight when in fact they are underweight (anorexia( or of normal weight (bulimia(. The I-function has somehow adopted an unhealthy self image. • The body presented by the I-function to the self is not the same body which others see. • Researchers looking for biological treatments for these disorders are in effect looking for ways to bring the I-function's body image into agreement with the body as seen by the outside world. • Ultimately, the I-function must be a conglomeration of neurons whose arrangement was determined through genetic programming. • As neurons communicate by neurotransmitters an aberrant neurotransmitter system could affect the I-function, and therefore self perception. • Possible reasons for the faulty neurotransmitter system range from genetic to environmental influences.
  41. 41. • Success of drug therapies suggest that the I-function can be positively affected by artificial augmentation of the neuro-chemical environment. • Treatment with anti-depressant medication correlates with an increase in self esteem among depressed individuals. • That is, an I-function which was previously supplying a poor self image can be changed, allowing for a healthier, more accurate view of the self. • A bulimic's or anorexic's I-function may also be positively affected by drugs which can change its neuro-chemical environment. • In this chemical fashion relief may be found for affected individuals.
  42. 42. • Two newly discovered hormones, orexin A and orexin B, are connected with feeding behavior in rats. • By modulating feelings of hunger and satiety the scientists can influence how much a rat eats. • Following injection of these hormones into the lateral hypothalamus the rats were found to immediately begin eating eight to ten times more food than normal. • Following up on this finding they measured elevated hormone levels when the rat was starved. • These researchers have not yet been able to see if a decrease of orexin A and B result in decreased appetites.
  43. 43. • A few sources suggested that anorexics are addicted to fasting, apparently because of the chemical changes brought on by starvation. • The opioids, enkephalins and endorphins are found to be at elevated levels in the spinal fluid of patients with anorexia. • It is unclear however, whether or not the starving was caused by, or was the cause of, these elevated opioid levels. • Some studies have found that drugs which inhibit the functioning of these opioids cause anorexic patients to gain weight.
  44. 44. Why do we eat? The hypothalamus is the controller stimulated by: • OREXIGENIC PEPTIDES (appetite inducers) e.g. agouti-protein and neuropeptide Y • ANOREXIGENIC PEPTIDES (appetite suppressants) e.g. melano-cortin which, with effects on specific receptors (MC1R(, decreases food intake and increases energy expenditure
  45. 45. Central Controls are Influenced by Circulating HORMONES: • INSULIN: provides signals related to blood glucose levels • LEPTIN: signaling consistency of body fat stores and, in addition • The GUT HORMONES
  46. 46. The GUT HORMONES • GRELIN: secreted by the stomach fundus (when empty( increases appetite and hence food intake (orexigenic( • NO: nitric oxide (not a hormone but dilates the empty stomach hence very orexigenic( • CHOLECYSTOKININE and PEPTIDE YY3-36: secreted by endocrine lining cells of the distal gut and colon when food present hence appetite suppressants (anorexigenic( Can these hormones be manipulated therapeutically? Not easily! ANY LOSS OF BODY FAT stimulates a defensive system which acts in order to RESIST THE LOSS OF FAT IN CONCLUSION: the GUT TALKS to the BRAIN ‫بتصوصو‬ ‫بطنه‬ ‫عصافير‬ ‫بيقولك‬
  47. 47. Thorough Medical Assessment • Physical Exam – Check weight – Blood pressure, pulse, and temperature – Heart and lungs – Tooth enamel and gums • Nutritional assessment/evaluation – Eating patterns – Biochemistry assessment—how chemistry with eating disorders contributes to additional appetite decline and decreased nutritional intake
  48. 48. Thorough Medical Assessment • Lab & other diagnostic tests – Blood tests – X-rays – Other tests for heart and kidneys • Interviews – History of body weight – History of dieting – Eating behaviors – All weight-loss related behaviors – Past and present stressors – Body image perception and dissatisfaction
  49. 49. Treatment Strategies For Eating Disorders
  50. 50. Treatment Strategies: • Ideally, treatment addresses physical and psychological aspects of an eating disorder. • People with eating disorders often do not recognize or admit that they are ill – May strongly resist treatment – Treatment may be long term • E.D. are very complex and because of this several health practitioners may be involved: – General practitioners, Physicians, Dieticians, Psychologists, Psychiatrists, Counselors, etc. • Depending on the severity, an eating disorder is usually treated in an: – Outpatient setting: individual, family, and group therapy – Inpatient/Hospital setting: for more extreme cases
  51. 51. Anorexia Treatment • Three main phases: – Restoring weight lost – Treating psychological issues, such as: • Distortion of body image, low self-esteem, and interpersonal conflicts. – Achieving long-term remission and rehabilitation. • Early diagnosis and treatment increases the treatment success rate.
  52. 52. Eating Disorder Treatment • Medical Treatment – Medications can be used for: • Treatment of depression/anxiety that co-exists with the eating disorder • Restoration of hormonal balance and bone density • Encourages weight gain by inducing hunger • Normalization of the thinking process – Drugs may be used with other forms of therapy • Antidepressants (SSRI’s) – May suppress the binge-purge cycle – May stabilize weight recovery
  53. 53. Eating Disorder Treatment • Individual Therapy – Allows a trusting relationship to be formed – Difficult issues are addressed, such as: • Anxiety, depression, low self-esteem, low self-confidence, difficulties with interpersonal relationships, and body image problems – Several different approaches can be used, such as: • Cognitive Behavioral Therapy (CBT) – Focuses on personal thought processes • Interpersonal Therapy – Addresses relationship difficulties with others • Rational Emotive Therapy – Focuses on unhealthy or untrue beliefs • Psychoanalysis Therapy – Focuses on past experiences
  54. 54. Current Opinion in Psychiatry A Review of Eating Disorders in Males Anu Raevuori, Anna Keski-Rahkonen, Hans W. Hoek DisclosuresCurr Opin Psychiatry. 2014;27(6):426-430. • Abstract • Purpose of review Research in eating disorders in males has been active lately compared to the past. This review aims to provide an overview of the recently published studies of eating disorders in males. • Recent findings Publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition has outlined more sex-neutral diagnostic criteria for eating disorders. Data of socioeconomic factors, prenatal influences, clinical characteristics, assessment, and mortality for eating disorders have been reported independently for males. Unlike in females, higher parental education showed no association with eating disorders in males, but twin or triplet status and lower gestational age at birth had an independent association with anorexia nervosa in males. Contrary to earlier suggestions, no differences in eating disorder symptoms such as binging, vomiting, or laxative abuse were observed between the sexes. • Yet, males tended to score lower on eating disorder symptom measures than females. High rates of premorbid overweight and higher BMIs at various stages of eating disorders have been confirmed repeatedly. • Higher age and lower BMI at admission, and restrictive anorexia nervosa subtype predicted fatal outcome for anorexia nervosa in males. • Summary Contemporary research provides grounds for improved recognition, diagnosis, and treatment for males suffering from eating disorders.
  55. 55. ‫واسمه‬ ‫نفسى‬ ‫مرض‬ ‫بقى‬ ‫السيلفى‬ ‫كده‬ ‫خل ص‬ ‫سيلفيتيس‬ HEALTH & MEDICINE, HUMAN INTEREST, INTERNATIONAL AMERICAN PSYCHIATRIC ASSOCIATION MAKES IT OFFICIAL: ‘SELFIE’ A MENTAL DISORDER MARCH 31, 2014 Chicago, Illinois – The American Psychiatric Association (APA) has officially confirmed what many people thought all along: taking ‘selfies’ is a mental disorder.
  56. 56. APA said there are three levels of the disorder: Borderline selfitis : taking photos of one’s self at least three times a day but not posting them on social media Acute selfitis: taking photos of one’s self at least three times a day and posting each of the photos on social media Chronic selfitis: Uncontrollable urge to take photos of one’s self round the clock and posting the photos on social media more than six times a day Types of Selfitis
  57. 57. According to the APA, while there is currently no cure for the disorder, temporary treatment is available through Cognitive Behavioral Therapy (CBT). The other good news is that CBT is covered under Obamacare. This is unwelcome news for Makati City in the Philippines, especially for its mayor, Junjun Binay, son of the incumbent vice president. Makati was recently named selfie capital of the world by Time Magazine. The mayor even organized a ticker tape parade after his city was bestowed the rare honor.
  58. 58. Medscape Medical News > Psychiatry More Than 50% of Antipsychotics Prescribed Off Label Liam Davenport, December 30, 2014 More than half of the prescriptions for antipsychotics in the United Kingdom are prescribed to individuals with no diagnosis of a serious mental illness (SMI), a major study of primary care records has revealed. Investigators at University College London also found that off-label antipsychotic prescribing is more likely to occur in women, older people, and socially and economically disadvantaged individuals.
  59. 59. More Than 50% of Antipsychotics Prescribed Off Label Serious Side Effects International and national guidelines urge caution concerning the use of antipsychotics; for patients who do not have a diagnosis of psychosis, their use is recommended only in a limited number of cases. The drugs are associated with serious adverse effects, including extrapyramidal symptoms with first-generation antipsychotics and weight gain and lipid/glucose dysregulation with second- generation agents. Moreover, antipsychotics may be linked to increased rates of stroke and all-cause mortality in patients with dementia. However, the researchers note that the drugs may be prescribed off label, potentially to "augment antidepressants in complex or treatment-resistant cases of obsessive compulsive disorder, anxiety and personality disorders."