Psychiatry of EDs 2021.pptx

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Psychiatry Of Eating Disorders
By Heba Essawy MD., CEDS.,
Prof of Psychiatry
International Chapter chair –Egypt Iaedps
Head of Eating Disorders Clinics
Medical school
Ain Shams University
Cairo- Egypt

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Background
• Eating disorders is a devastating disorder
• Psychiatric comorbidities with Eds have recently emerged as
significant clinical, public health and research issues
• Recognizing and treating these comorbidities improves outcomes
for the eating disorders and treating an Eating Disorders can
significantly improve other conditions as well
Blinder et., al., 2006

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Background
• Because psychiatric comorbidities occur so often with Eds , it is
critically important to properly diagnose and understand the
relationship between these mental health issues to ensure a lasting
recovery
• The high prevalence of these conditions means that treatment
should include a comprehensive screening for a range of mental
disorders and a plan addressing multiple diagnosis

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Roadmap
• 1-Identification of the most common forms of comorbidity with
Eds that might present to the clinicians
• 2-Recognition of the confounding effects of starvation and
unstable eating on either diagnosis , adverse effects and response
to treatment of the comorbidity
• 3-Discuss the different pharmacological approaches for treatment
of comorbid mental disorders with Eds

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Importance of identification of Psychiatric
comorbidity in Eds
• Failure to recognize and treat comorbidities can have
catastrophic repercussions .
• To improve the treatment of Eds , it is important to
understand the timelines and sequencing of the onset of
psychiatric comorbidities and to consider the potential
impact of comorbidities have on diagnosis , treatment and
prognosis of the Eds
Bernstein et., al., 2014

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Correlation of Psychiatric comorbidity in Eds
• Individuals with EDs very often have comorbid medical and or
psychiatric condition.
• Almost 97% of female inpatients with Eds were found to have one
or more Comorbid diagnosis
• Clinical studies reported that between 55% - 98% of individuals
with AN met the criteria for another psychiatric disorder
• 88% of Individuals with BN met the criteria for another psychiatric
disorder
• In AN, mortality is 18 times higher when another significant
psychiatric disorders as depression is present
Hughes et., al., 2013

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Biological correlation of Eds and comorbid
psychiatric disorders
• Alterations in frontostriatal brain areas in Eds and depression
• Higher gray matter volumes in the right putamen / globus
pallidus in Binge eating Disorders
• Lower volume in the medial orbitofrontal ,dorsomedial and the
dorsolateral prefrontal cortecis are characterized in cases of
purging and depression
Zuo Zhang et., al., 2020

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Dual diagnosis in Eating Disorders
• The most frequent comorbid psychiatric disorders are :
- Depression
- Anxiety
- Substance abuse disorder
- OCD
• - Borderline personality Disorder
• - Post traumatic stress disorder ( PTSD)

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1-Eating Disorders and Depression: Statistics
• The most frequent comorbid psychiatric disorders are MDD,
• Lifetime prevalence of comorbid depression in Eds is 94%
• Depression affects equally patients with AN, BN or Eating
Disorders not otherwise specified (EDNOS)
• Elise in 2021, concluded that AN patients, had greater clinical
severity when they had comorbid disorder as MDD,GAD, SP over
their lifetime
Elise et.,al., 2021

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1- Eating Disorders and Depression: Statistics
• Up to 65.5% of individuals suffering from BED self report a life
prevalence of MDD
• 32.8 % of BED patients are diagnosed as Depression

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Challenges of Eating Disorders and Depression :
Diagnosis
• It is difficult to make an accurate diagnosis of depression in AN or
BN due to the confounding effects of starvation , as starvation may
contribute to depressive symptoms
• AN clients identify their mood is abnormal , flat or empty mood or
extreme labiality of mood
• The vegetative symptoms energy, libido and sleep are all
disrupted on account of starvation
• Cognitively, the patient experience helplessness or hopelessness,
but this often due to the chronic nature of their condition

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Challenges of Eating Disorders and Depression :
Onset and Prognosis
• Studies of the onset of Eds and depression suggest that Eds tend to
precede the development of depression , and depressed mood
improves with weight restoration
• Prognosis : Comorbid depression may predict a longer course of
illness or contribute to the development and intensity of Eds
symptoms
• Hughes, et., al., 2013

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2-Eating Disorders and Anxiety Disorders :Statistics
• Anxiety disorders co-occur in more than half (56%)of Ed cases
• Life time prevalence of OCD are around 40% in patients with Eds
- OCD rituals, affecting 56% of individuals with AN cases
• Social phobia was prevalent as in 20% of AN cases
• Panic Disorder affect 11% of Eds cases
• Generalized Anexity Disorder is prevalent in 10% of Eds patients
• PTSD occur in 13% in Eds patients
Kaye et., al., 2004. Bulik et.,al., 2002

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Eating Disorders and OCD :Diagnosis
• OCD represents a complex challenge, in AN
• Diagnostically
1- Ritualistic activities ( exessive exercise and repetitive weighting)
that involved food should not be counted when diagnosing OCD as
these are part of Eds
2- Perfectionist is a major trait for AN patients , a character trait
that persists even after weight restoration
3- Patients with OCPD and Eds may be mistaking as OCD

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Eating Disorders and Anxiety disorders : Onset
• Anxiety Disorders commonly had their onset in childhood before
the onset of Eds , raising the possibility they are vulnerability
factor for developing AN or BN
• The emergence of Eds as a coping mechanism is supported by the
research that OCD and other Anxiety disorders arise during
childhood predating the development of Eds cases
• Early onset anxiety disorders may represent a genetically – based
pathway toward the development of an Eds

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Eating Disorders and Anxiety disorders : Sequencing
• Excessive fear about certain events or situations may lead into
excessive concerned about eating , shape and weight and may
subsequently lead into the development of disordered eating
behaviors
• The fear that serves as the base of OCD may also lead Eds clients
to strive to perfection in figure , weight or control via highly
structured rules around food , exercise or purging .
Pallister&Waller ,2008

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3- Eating Disorders and Post Traumatic Stress
Disorder : Statistics
• PTSD is a commom comorbidity with Eds
• PTSD is present in 50% for the restricting forms of AN
• PTSD is over 80%for the binge-purging AN
• Rates of PTSD tend to increase with severity of Eds

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4-Eating Disorders and Substance Use Disorder
Statistics
• SUD is associated with 25% of clients with Eds
• Lifetime prevalence of alcohol abuse and dependence ranges
from 17% in the restricting AN to 46% in BN
• SUD is used as suppressor of Appetite in Anorexics
• Substance abuse may serve self- medicating function as an
attempt to alleviate the anxiety and distress that often underlies
disorders eating
Kay et., eal., 1996

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Challenges in Treatment of Eds and Comorbid
psychiatric disorders
• Depression
• OCD
• PTSD
• SUD

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Eating Disorders and Depression Treatment:
pharmacotherapy
• There is little evidence on which treatment work best for people
with Eds and comorbidity
• In treating ,AN and BN with comorbid depression any
Antidepressant is acceptable except of Brupropion which can be
associated with seizures with Binge Eating and or purging
• The benefit of older Antidepressants such as Tcas and MAOIs
need to be carefully weighted against their less favorable
adverse effect profiles and risk when taken
Blake Woodside 2006

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pharmacotherapy
• Dosages used should be those for depression in other setting
• Fluoxetine,paroxitine and citalopram should be started at
20mg/day, Sertraline at 100mg/day,Venlafaxine at 75mg/day
• It is not necessary to reduce the dosage of the antidepressant on
the basis of patient s weight
• Patients of very low weight may need to given lower dosages
than normal if they experience significant adverse effects
• It is very important to provide an adequate dosage of the drug in
question

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pharmacotherapy
• Eds patients have to be informed that complete resolution of
mood is unlikely to be resolute of underlying eating disturbance
• The antidepressant is not having much effect on underlying
anorexic symptomatology
• Patients with AN will not fully respond to AD until they are
weight-restored

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BED and Depression Treatment
• Psychotherapy
- CBT
- Interpersonal therapies
• Psychopharmacological treatment for BED :
- For binging and weight : Topiramate and or Naltroxane
- For appetide regulation :sibutramine
- For obssesive thought : Lisdexamfetamine
- For Anxiety anf Depression : SSRIs , SNRIs, vortioxitine
Sanchez ,et.,al., 2015 Gonda ,et.,al., 2019

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Impact of Eating Disorders and OCD : Treatment
• Little responses on OCD either using pharmacotherapy or
psychotherapy until changes have begun to occur in the core
symptoms of the Eds
• Once changes have started , treatment with AD is the first line of
attack
• Start with typtical dosage ofAD either Fluxetine , paroxitine,
citalopram 20mg/ day ( not necessary to reduce the dose on
account of the patients )

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Impact of Eating Disorders and OCD : Treatment
• If a decision is made to increase the dosage of AD, it should be
raised to the highest dosage that can be tolerated by the patients
• Clinicians should resist the urge to increase the dosage of the AD
in patients whose eating is not improving
• Addition of very small dose of Antipsychotic as an augmentation
agent as this will be more intense and rapid response than AD
alone ( as Resperidone in 0.5-2mg/day)

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Impact of Eating Disorders and PTSD : Treatment
• It is not recommended to provide the usual lines of treatment
both an AD and Benzodiazepines as this a wrong choice because
the patient will report a dramatic but transient in anxiety and
immediately begin the escalate the dosage
• Low dosage of Atypical antipsychotic is preferably used instead
of Bz ( Quetiapine 12.5mg three times a day, resperidone 0,5 mg)
• Some patients may require higher dosages, up to 150-200mg of
quetiapine per day
• Clinicians should always try to use the lowest possible dosages

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Impact of Eating Disorders and SUD : Treatment
• In SUD comorbidity with Eds, it demands treatment as an urgent
priority
• It is advisable to try to “dry out” the patient before attempting
any significant treatment for Eds , 30 –day residential treatment
facilities attached to ongoing follow-up where the clinicians are
much aware of the patient s ED
• Pharmacological treatments for SUD are not recommended

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Conclusion
• Failure to recognize and treat comorbidities
-Place an individual who has recovered from an Eating
disorder at greater risk of relapse when faced with acute stressor
trauma
- Many patients need assistance with multiple disorders ,
integrative therapy provides the best option for long- term
physical and mental health for Eds patients

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Thank you

Psychiatry of EDs 2021.pptx

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