Recent advances in Eating disorder

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aneroxia nervosa, bulemia nervosa , binge eating , diet, overeating , obesity , treatment psychotherapy .

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Recent advances in Eating disorder

  1. 1. Heba Essawy , MD Professor of Psychiatry Ain Shams University
  2. 2. Roadmap Anorexia Nervosa Bulemia Nervosa Binge-eating disorder Obesity Diagnosis Epidemiology Medical risks Etiology Treatment prognosis
  3. 3. Risk Factors for EDs  Perfectionism for AN  Early Puberty  Failed attempts to lose weight  Athletics  Beginning a diet  Family history of eating disorder, substance abuse or mood disorder
  4. 4. Diagnosis of Anorexia Nervosa DSM IV Refusal to maintain 85% of ideal body weight Intense fear of becoming fat Body image distortion; undue influence of weight on self evaluation; denial of risks of low weight Amenorrhea (in post-menarchal females) Purging-type Restricting-type
  5. 5. Proposed DSM V changes “less than minimally expected” instead of 85% ideal body weight Remove “refusal” (pejorative) Add “behavior” to avoid weight gain, since many patients deny fear of gaining weight Remove amenorrhea Subtyping be for current episode
  6. 6. Diagnosis AN (DSM-5):  Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex.  Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain. Disturbance in one's body weight or shape , persistent lack of recognition of the seriousness of low body weight Specify: Restricting type Purging type/Binge Eating.
  7. 7. Subtypes AN (DSM-5): Restricting Type: during last 3months, the person has not engaged in recurrent episodes of binge eating or purging behavior Binge-Eating/Purging Type: during last 3 months, the person engaged in recurrent episodes of binge eating or purging behavior
  8. 8. Epidemiology: Life time prevalence 0.5- 3.7%  Girls from 14- 18ys 0.5- 1% AN and BN 30 - 50% Death 3-8% Age: 10-30years. Risk : Sp. After stress M:F ratio 1: 20 In professions modeling – ballet dancers.
  9. 9. Medical Complication  Death (hypokalemia , starvation, sudden cardiac death)  Hypometabolic state (bradycardia, hypotension, hypothermia)  Dehydration  Arrhythmia, heart failure.  Bone loss  Peripheral edema  Delayed sexual maturity  Hair loss, brittle hair, Lanugo.  On recovery: Re-feeding syndrome
  10. 10. Etiology (kristinaschwerin et.al.2010)
  11. 11. Eating Disorder Inventory (EDI)  The EDI is a 64 item, self-report for the assessment of psychological and behavioral traits common in anorexia nervosa (AN) and bulimia.  EDI consists of eight sub-scales measuring: 1) Drive for Thinness, 2) Bulimia, 3) Body Dissatisfaction, 4) Ineffectiveness, 5) Perfectionism, 6) Interpersonal Distrust, 7) Interoceptive Awareness ,8) Maturity Fears
  12. 12. Anorexia Nervosa: Treatment  Determine inpatient vs. day treatment vs. outpatient  Multidisciplinary teams are ESSENTIAL!  Primary care provider  Psychiatrist  Individual therapist  Family therapist  Nutritionist  1st : weight restoration  2nd : psychological  3rd : maintinance (long-term)
  13. 13. Medical Admission Criteria  <75% ideal body weight  Hypothermia T<36  Bradycardia HR<50 while awake, <45 asleep  Orthostasis-drop in sbp >10, increase in HR>35  Dehydration  Severe hypokalemia (<2-3 mmol/L) or other electrolyte abnormality  Acute medical complication  Severe depression/suicidality– Psychiatric admit  Refractory to outpatient treatment
  14. 14. Anorexia Nervosa: Therapy Best evidence is for family-based treatment (Maudsley approach) Who: younger patients who live at home, intact family Philosophy: no-blame, family did not cause anorexia; family is the best resource to help her get better Elevate family’s anxiety about the gravity of the illness. Empower parents to do whatever they need to do to get the anorexic to eat. Align siblings with the patient for support. Externalize the anorexia. “Family Meal” Once weight-restored: explore the family dynamics and psychological issues.
  15. 15. Anorexia Nervosa: Medications  No approved medication treatments for Anorexia Nervosa  Prozac (or other SSRI) for co-morbid depression or anxiety  Low-dose Atypical Antipsychotics off-label for near- psychotic thinking that is characteristic of anorexia, Zyprexa may help with weight gain - problem: informed consent for risks of weight gain
  16. 16. ANOREXIA NERVOSA Prognosis:  40% → recover.  30% → continue with milder course.  30% → chronic cases. Risk of death  Suicide Cardiac arrest Malnutrition  > 3 years of illness: prognosis is poor
  17. 17. Bulemia Nervosa – DSM IV Recurrent episodes of binge-eating (eating larger amounts of food than others would eat in a discrete- 2 hour- period of time, with a sense of lack of control) recurrent inappropriate compensatory behavior (vomitting, laxatives, excessive exercise, etc) Both occur at least 2x/wk for 3 months Self-evaluation is unduly influenced by body shape or weight (purging type, non-purging type)
  18. 18. Proposed DSM V changes Change frequency of compensatory behaviors from 2x/week to 1x/week Deletion of non-purging subtype, because it more closely resembles binge-eating disorder
  19. 19. Diagnostic Criteria for Bulemia Nervosa DSM-5 A. Recurrent episodes of binge eating: (1) Eating large amount in a discrete period of time (2) lack of control over eating B. Recurrent compensatory behavior in order to prevent weight gain. C. Binge eating and inappropriate compensatory behaviors is at least once a week for 3 months.
  20. 20. Bulemia: Epidemiology Lifetime Prevalence 1.5% women 0.5% men Prevalence of binge-purge behaviors: 13% girls 7% boys
  21. 21. Bulemia: Etiology Media factors Individual Temperament (ie. impulsive) biological Family dynamics Societal, cultural
  22. 22. Medical Complication Electrolyte abnormalities Dental – loss of enamel, chipped teeth, cavities Parotid enlargement Conjunctival hemorrhages Calluses on dorsal side of hand (Russel’s sign) Esophagitis hematemesis Latxative-dependent: cathartic colon, melena, rectal prolapse
  23. 23. Bulemia: Treatment  Multidisciplinary team Primary care provider Psychiatrist Family therapist Nutritionist  Evidence based : CBT + Antidepressant (SSRI)
  24. 24. Bulemia: Treatment (Therapy) Family therapy is a good option if patient is young and still lives at home (But not as much evidence as for Anorexia) Interpersonal therapy (IPT) (short-term treatment focused on life transitions) Psychodynamic Psychotherapy (good for long-term results in people with chronic depressive and personality symptoms) Nutrition plan, exercise, physical activity
  25. 25. Bulemia: Medicaions High-dose Fluoxetine/Prozac (SSRI) – very good evidence! Sertraline/Zoloft (SSRI) – some good evidence Buproprion/Wellbutrin (other antidepressant) – contraindicated! (risk of seizures if history of purging) Topiramate/Topomax (mood stabalizer, promotes weight loss) – some good evidence, but use with caution esp if low-weight
  26. 26. Bulemia: Prognosis 33% remit every year But another 33% relapse into full criteria Adolescent-onset better prognosis than adult-onset Death-rate = 1%
  27. 27. Binge Eating Disorder – DSM IV (only in appendix) Episodic intakes of larger than typical amounts of food Episodes occur in brief (<2 hrs) periods of time Subjectively, sense of loss of control while eating At least 2 days/week for 6 months
  28. 28. Binge Eating Disorder- Diagnosis Also needs 3 of the following: Eating much more rapidly than normal Getting uncomfortably full Large amounts of food when not physically hungry Eating alone because embarrassed about how much one is eating Feeling disgusted with oneself, depressed, or guilty when over-eating
  29. 29. Proposed DSM-V changes That binge eating disorder should become a free- standing diagnosis, rather than only in the appendix Less Frequency: once a week for 3 months
  30. 30. DSM-5 Diagnostic Criteria for Binge Eating Disorder  Eating, in a discrete period of time , large amount  Lack of control over eating during the episode Binge eating occurs, on average, at least once a week for three month
  31. 31. DSM-5 Diagnostic Criteria for Binge Eating Disorder BE are associated WITH : 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling hungry 4. feeling disgusted with oneself, depressed, or very guilty afterwards
  32. 32. Binge Eating Disorder: Epidemiology Most common eating disorder Lifetime prevalence: 3.5% women 2% men
  33. 33. Binge Eating Disorder: Medical Risks Less acute risk than with restrictive eating patterns Long-term risks significant: the many organ systems affected by obesity, shortened life-span, etc
  34. 34. Binge Eating Disorder: Etiology Media factors genetic Individual Temperament (ie. impulsive) biological Family dynamics Societal, cultural
  35. 35. Binge Eating Disorder: Treatment (Medication) SSRI high dose reduces binge behavior short-term but doesn’t help weight loss Topomax, Zonisamide (anticonvulsants, mild mood stabalizer) Helps binge reduction Helps weight loss Caution for adverse effects, high discontinuation rates
  36. 36. Binge Eating Disorder: Treatment (Therapy) Therapies either prioritize… Weight loss Binge-reduction Neither (ie. relationships, depression etc) Group psychotherapy There is little evidence that obese individuals who binge should receive different therapy than obese individuals who do not binge
  37. 37. Binge Eating Disorder: Psychosocial Support Family need help with co-dependency Weight loss programs Weight watchers, Jenny Craig, etc. 12-step Self help groups Food Addicts in Recovery Anonymous Overeaters Anonymous
  38. 38. Any questions? Heba Essawy Website www. Hebaessawy.com Facebook Dr.heba essawy Email essawi_h@yahoo.com

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