Eating Disorders Flashcards
What is an eating disorder?
An undue preoccupation with body image leading to impaired intake.
(Except, not quite…)
The basics
Disordered behavior…
Disordered thinking…
Disordered physiology…
What is it not?
Depression often involves appetite changes
Paranoia in schizophrenia can involve food avoidance
Medical conditions can lead to weight loss.
– DM type 1, thyroid dysfunction, malabsorbtion
Neglect often involves poor intake
Poverty involves poor intake
The Eating disorders
Anorexia Nervosa
- Restricting type
- Binge/purge type
Bulimia Nervosa
Binge Eating Disorder
Other specified/unspecified Eating Disorder
Binge?… purge?
Binge =
Limited period ( ~2 hrs ) with intake significantly greater than others would consume in similar circumstance
Sense of lack of control over eating in episode
Not as fun as it sounds: Almost always followed by guilt, sadness, disgust
Purge =
Self-induced vomiting or misuse of laxatives, diuretics, or enemas
Vomiting is used by 90% of patients
Anorexia Nervosa criteria
Restriction of energy intake relative to requirements, leading to significantly low weight
- Below a BMI of 18.5
Intense fear of gaining weight or getting fat, or persistent weight loss behavior despite medical starvation
Significant disturbance in perception of shape or weight of body
Anorexia subtypes
Restricting type
- In last 3 months, has not engaged in recurrent binge eating or purging.
- This means, weight loss is achieved through diets, fasts, excessive exercise
- Usually attempting to consume less than 300 kcal/day with no fat
- Relentless exercise
- Often high-achievers
Binge/purge type
- In last 3 months, has engaged in recurrent binges and/or purges
- Represents a failure to adhere to pure anorexic goals
- Less “self-control”, more substance use and impulsivity
Anorexic patients are split roughly 50/50
anorexia Epidemiology
Most common onset 14-18
About 1% of adolescent females
F:M ratio >10:1
Higher in modeling, ballet, cross-country
Anorexia: Why?
Biologic
Higher concordance in monozygotic twins than dizygotic
Mood disorders are more common in family
Social
Heterosexual women and gay men – equally high
Heterosexual men and lesbian women – lower risk
anorexia - Psychodynamic (or Mommie dearest)
Often close family, but domineering and lacking in empathy
Family where “excellence” is demanded
Patients lack a sense of autonomy and selfhood
Self-starvation = discipline, self-mastery
Wrest control of self from (often) mother
Rigid and perfectionistic (ego-syntonic)
Loss of appetite?
Anorexia is Greek for “loss of appetite”
Complete misnomer
Anorexics spend vast majority of time thinking about food.
- Collecting food, hiding it, making meals for others, reading recipes, rearranging it on the plate
anorexia - A lot of stuff decreases
Social isolation and secrecy
- So much time thinking and engaging in behaviors, yet no one else “gets it”
Marked decrease in sex accompanies onset
Usually loved ones drag patients to treatment
anorexia Psychiatric Comorbidities
65% of patients meet MDD criteria 35% meet Social Anxiety criteria 25% meet OCD criteria 12% meet GAD criteria 80% are single
anorexia complications
sad, moody, bab memory, fainting, brain chemistry
hair thins, gets brittle
low BP, slow HR, palpitations
anemia
weak muscles, swollen joints, fractures, osteoporosis
kidney stones, failer
low potassium, magnesium, sodium
constipation, bloating
amenorrhea, bone loss,
easy bruising, dry skin, fine hair all over body, cold intolerance, yellow skin, brittle nails
Lowered cognition, anhedonia / apathy Cold intolerance Bradycardia Reduced thyroid metabolism (low T3) Low LH and FSH, estrogen/testosterone Delayed sexual development Osteoporosis, hypocalcemia - fractures Lanugo Chronic dehydration and constipation Plus purging complications as below
Anorexia treatment
Weight normalization
Treat physical complications
CBT
Distorted body image
Low self-esteem
Destructive coping strategies
SSRIs for comorbid depression and anxiety
SGAs are often used for obsessive thinking and wt gaing
Family therapy
Achieving Long term remission
anorexia- To admit, or not to admit,…
Hospitalize if:
Under BMI of 17
Evidence of organ system failure
HR under 40 bpm, orthostatic hypotension, temp under 97°, glucose under 60, BP under 80/50
Hypokalemia, hypophosphatemia, hypomagnesemia
Comorbid psychiatric condition requiring hospitalization (i.e. depression w/ SI)
(
Failing outpatient efforts
Prognosis - anorexia
Age of onset strongly affects prognosis
Adult onset = age of symptom onset after 18 years old
Adolescent Onset Prognosis 5 years post treatment > 70% full recovery 25% other specified E.D. 5% meet criterion for full syndrome No deaths reported
Adult Onset Prognosis 4 years post treatment 15% fully recovered 40% “good” outcomes Weight within 85% of expected Regular menstruation 40% enduring morbid food and weight preoccupation 5% dead
Lifetime mortality 25%
5.6% per decade
Death 2° medical complications of starvation and suicide
Bulimia Nervosa
Recurrent binge eating with inappropriate compensatory methods to avoid weight gain.
Binge, and compensation, average once a week for at least 3 months
Self-evaluation unduly influenced by weight or shape
bulimia epidemiology
1-4% lifetime prevalence in females
Onset is usually late teens to early twenties
Bulimia: why?
Biologic
Serotonin: linked to satiety
- SSRIs decrease binging and purging, and depression
Increased rate of Bulimia in first degree relatives
Psychodynamic
Less superego control
More outgoing, impulsive, emotional lability
Engage in substance use and destructive sexual relations
Significant BPD-associated traits
Often view family as conflictual, neglectful, and rejecting
More often, dislike the disordered eating
- “Ego-dystonic”
“Anxious” + “Ox hunger”
Disorder is less “controlled”
- Failed attempt at anorexia
- Binges as “breakthrough eating”
- Eating as self soothing in times of stress
Binge is soothing
- High calorie, sweet, soft/smooth
- Secret, fast, and not always chewed
Binges provoke panic state
- Pt proves to self “lack of control”
Bulimia complications
Dehydration and electrolyte disturbances
- Laxatives can lead to metabolic acidosis
- Vomiting can lead to a metabolic alkalosis
- – Also chipped teeth and enlarged parotids
- – Leads to renal excretion of K+
Low magnesium and elevated amylase
Often have irregular menses
Treatment - bulimia
Psychotherapy: 50% symptom reduction
Cognitive Behavioral Therapy
* most effective form of short-term intervention
Psychodynamic
Psychotherapy
- Useful once binge/purge symptoms improve
- Targets both E/D and broader personality issues
Family Therapy
- Very important for adolescents
Meds: SSRIs
- Fluoxetine is FDA approved
- Decreases behaviors substantially
For best results: Combine CBT and SSRI
Prognosis - bulimia
Most have episodic course
At 3 months post-treatment
- ~ 70% achieved remission
10 yrs. post-treatment
- 60% Fully Recovered
- 10% E.D. NOS
- 30% Still meet diagnostic criteria
Binge eating disorder
Recurrent binge eating (weekly in 3 mos)
No compensation in any way
Binges are associated with:
- Eating much faster than normal
- Get uncomfortably full
- Very large amounts when not hungry
- Eating alone due to embarrassment
- Post-binge disgust, depressed, guilty
Marked distress regarding binge eating
binge eating epidemiology
Most common Eating Disorder
- Females: 4% Males: 2%
50% of pts are obese
Present in 25% of pts seeking care for obesity
Present in >50% of pts with severe obesity (BMI >40)
binge eating Treatment
CBT
SSRIs
Self-help groups (OA)
When trying to diagnose binge eating…
Why is person showing disordered eating?
- Undergoing chemo, stroke, paranoia, depression?
Look at BMI
- BMI is will take you a long way
Look for complications from behavior
Social
Western societies emphasize thinness and exercise
Visual media exposes 300M people to pictures of a few thousand very thin women, creating a false norm
Is the desire to be found attractive by men “pathologic”?
- Heterosexual women and gay men – higher risk
- Heterosexual men and lesbian women – lower risk
Go west, young woman
As the incidence of overweight and obesity rise, so does the incidence of eating disorders.
As countries become more “Westernized”, eating disorders rates increase
When women from countries with a low prevalence move to countries with higher prevalence, their rates of eating disorders increase
Prevalence in adolescent girls from Fiji increased significantly after exposure to television
Four out of five U.S. women are dissatisfied with their appearance
Start them young…
42% of girls age 6 to 9 “want to be thinner”
In 1970 the average age a girl started dieting was 14;
by 1990 the average age dropped to 8 years old
One half of 4th grade girls are on a diet
- And stated they felt better about themselves when adhering to a diet
90% of female high school juniors & seniors diet, yet only one out of ten high school girls are overweight
Overall - 62% of girls & 29% of boys are dieting,
yet only 6.9% of these girls and 14.2% of the boys actually overweight
Psychiatric comorbidities
Substance Abuse
- 23-40% with Bulimia
- 12-18% with Anorexia
Sexual Abuse
- 20-50% both Bulimia and Anorexia
Avoidant Personality D/O
- Both Anorexia and Bulimia
Obsessive/Compulsive Personality D/O
- Anorexia Nervosa
Borderline Personality D/O
Bulimia Nervosa
The Shame game
All of these groups struggle with body-centered shame.
