Eating Disorders

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Eating Disorders Adjustment Disorders

• RCS 6931
• June 7, 2007
• Steven R. Pruett, Ph.D.

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Eating Disorders

• Severe disturbances in eating behavior
• DSM-IV contains 3 different eating disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Eating Disorder NOS
• Eating Disorders not included in DSM-IV
• Obesity
• What about Pica Rumination?
• Not considered eating disorderssee disorders
  usually first diagnosed in infancy/childhood or
  adolescence.

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Anorexia Nervosa 307.1

• Individuals refuses to maintain a minimally
  normal body weight.
• Person weighs less than 85 of normal weight for
  persons age and height.
• Individuals have an intense fear of gaining
  weight
• Perceive themselves to be fat and unattractive
• Fear of fat does not go away with weight loss.
• Weight loss is perceived a great achievement and
  a sign of self-discipline.
• Self-esteem is based largely on body shape and
  weight.

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Anorexia Nervosa

• Usually weight loss is accomplished by not eating
  much food
• Other methods
• Purging
• Vomiting
• Laxatives
• Diuretics
• Exercise

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Anorexia Nervosa

• Usually deny any serious medical implications
  that is resultant from malnutrition.
• In females that are postmenarcheal, amenorrhea is
  common due to low estrogen (caused by low
  follicle-stimulating hormone FSH and
  luteinizing hormone LH)

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Anorexia Nervosa

• People with Anorexia are usually brought to
  professional attention by family members
  following weight loss.
• It is rare for individuals with this condition to
  complain about weight loss.
• Individuals with this condition frequently lack
  insight or have significant denial of the
  problem and are generally poor historians.

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Anorexia Nervosa

• Subtypes
• Restricting Type
• Attempt to lose weight primarily by dieting or
  excessive exercise.
• Binge-Eating/Purging Type
• Has regularly engaged in binge eating or purging
  (or both) during the current episode.
• Most people with Anorexia Nervosa who binge also
  purge.
• Some people do not binge-eat but regularly purge
  after eating small amounts of food.

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Anorexia Nervosa

• Associated conditions
• Depressed mood
• Diminished interest in sex
• Some OCD features
• Related unrelated to food.
• Strong need to control ones environment
• Inflexible thinking
• Perfectionism
• Limited social spontaneity

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Anorexia Nervosa

• Other physical issues
• Leukopenia and mild anemia are common
• Dehydration
• Cardiac
• Sinus Bradycardia
• Arrhrythmias
• Increase ventricular/brain ratio secondary to
  starvation
• Electrolyte disturbances

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Anorexia Nervosa

• Far more common among industrialized nations
  where there is an abundance of food AND it is
  considered to be attractive (particularly for
  females) to be thin.
• Most common in US, Canada, Europe, Australia,
  Japan, New Zealand, and South Africa.
• Little epidemiological research for other
  cultures.
• 90 of all individuals with Anorexia Nervosa are
  females.

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Anorexia Nervosa

• Rarely begins before puberty
• When illness begins between ages 13 18 there is
  a better prognosis.
• Lifetime prevalence among females is 0.5.
• Among males it is .05.
• Homosexuality
• Sports that require low weight (e.g. jockeys,
  wrestling)
• Reverse Anorexia

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Anorexia Nervosa

• Course
• Typically beings in mid-late adolescence
• Rarely occurs in females over age 40.
• Onset may be associated with stressful event
• Outcome course is variable
• Some will resolve after a single episode
• Some will change from restricting type to
  binge-eating/purging type after the 1st 5 years
  of onset.
• Hospitalization may be required to restore weight
  and fluid/electrolyte balance.
• Of those admitted to hospitals long-term
  mortality due to Anorexia Nervosa is 10

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Anorexia Nervosa

• Increased risk among first-degree blood relatives
• Twin studies.
• Diagnostic Criteria
• Morrison p. 389, DSM-IV-TR p. 589.
• Treatment
• Conjoint family therapy (for patients
• Behavioral Family Systems Therapy
• CBT
• SSRIs

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Bulimia Nervosa 307.51

• Periods of binge-eating (can be large amounts of
  starches or sweets)
• To prevent increases in body weight and shape the
  individual compensates by vomiting, exercising,
  using laxatives /or diuretics.
• Individuals are frequently ashamed of their
  eating disorder and try to cover it up.
• Binge-eating is done in secret or inconspicuously
  as possible.
• Binge-eating may or may not be planned.

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Bulimia Nervosa

• Binge-eating
• May reduce dysphoria a little BUT
• Self disparaging thoughts and depressed mood
  frequently follow a binge.
• Is frequently accompanied by a sense of lack of
  self-control.

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Bulimia Nervosa

• Purging
• Most common method of purging in 80-90 of cases
  is vomiting.
• Effects of vomiting is
• Relief from discomfort from binge-eating
• Prevent weight gain
• Sometimes vomiting becomes a goal in itself
• Infrequently individuals will use laxatives and
  diuretics enemas.

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Bulimia Nervosa

• Individuals may fast for over a day or exercise
  excessively to compensate for binge-eating.
• These individuals will place inordinate emphasis
  on body shape weight in their self-evaluation.
• May closely resemble anorexia nervosa with fear
  of gaining weight and desire to lose weight
  dissatisfaction with their bodies.
• Diagnosis of Bulimia Nervosa should not be given
  if it occurs during an episode of Anorexia
  Nervosa
• Subtypes Purging and Nonpurging

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Bulimia Nervosa

• Physical issues
• Recurrent vomiting leads to significant and
  permanent loss of dental enamel.
• Menstrual irregularity or amenorrhea sometimes
  occurs in females with Bulimia Nervosa.
• Laxative dependency
• Rectal prolapse, esophageal tears, gastric
  ruptures

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Bulimia Nervosa

• Like Anorexia Nervosa, Bulimia Nervosa occurs in
  industrialized countries and 90 of the
  individuals are female.
• Males with Bulimia Nervosa have a higher
  incidence of premorbid obesity than females.
• Lifetime prevalence 1-3 in females. 0.1
  0.3 in males.

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Bulimia Nervosa

• Usually begins in late adolescence or early
  adulthood.
• Binge eating usually occurs following a period of
  dieting.
• Disturbed eating behavior frequently last for
  several years.
• Course can be chronic or intermittent.
• Over longer-term cases the symptoms appear to
  diminish.
• Periods of remission 1 year are associated with
  a better long-term prognosis.

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Bulimia Nervosa

• Diagnostic Criteria
• Morrison p. 392 DSM-IV-TR p. 594.
• Treatment
• CBT
• Interpersonal Therapy
• Conjoint psychopharmacotherapy??

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Eating Disorder NOS 307.50

• Represents nearly 60 of all eating disorders.
• Binge-eating disorder
• Obesity??
• Anorexia Nervosa with regular menses
• Anorexia Nervosa with regular weight
• Bulimia Nervosa frequency occurs less than twice
  a week or for a duration of less than 3 mos.
• Chewing spitting out (but not swallowing) food.

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Eating Disorder NOS

• Treatment
• Binge-eating
• CBT
• Interpersonal therapy
• DBT
• Behavioral weight loss and very low calorie diet
• Pharmacotherapy
• Sibutramine (Anti-obesity)
• Topiramate (anti-seizure)
• Rapid relapse?

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Adjustment Disorders

• Symptoms must occur within 3 months after the
  onset of the stressor(s).
• Reaction has to be in excess of an expected
  reactions given the nature of the stressor.
• Must cause a significant impairment
• Does not apply to Bereavement
• Must resolve within 6 mos of termination of
  stressor
• Should mention stressor in Axis IV.

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Adjustment Disorders

• Each subtype of adjustment disorder has its own
  code.
• With Depressed Mood 309.0
• Dominant feeling of depressed mood, sadness,
  hopelessness, tearfulness.
• With Anxiety 309.24
• Symptoms manifest nervousness, worry, or
  jitteriness.
• With Mixed Anxiety and Depressed Mood 309.28
• Both depressed mood and nervousness symptoms are
  present

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Adjustment Disorders

• With Disturbance of Conduct 309.3
• Predominant manifestation is a disturbance of
  conduct violation of rights of others, or major
  age-appropriate norms/rules (e.g. truancy,
  vandalism, fighting, defaulting on legal
  responsibilities, etc).
• With Mixed Disturbance of Emotions and Conduct
  309.4
• Both conduct and emotional symptoms (depression
  /or anxiety) are present
• Unspecified 309.9
• Other maladaptive reactions e.g., social
  withdrawal, physical complaints, work or academic
  inhibition.

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Adjustment Disorders

• Specifiers
• Acute indicate persistence of symptoms for less
  than 6 months
• Chronic symptoms have lasted longer than 6
  months.
• Since for adjustment disorders symptoms cannot
  last more than 6 months after the termination of
  the stressor you can only use Chronic when the
  stressor is chronic in nature or the stressor has
  some enduring consequences.

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Adjustment Disorders

• Prevalence
• Relatively common
• 2-8 of children and adolescents and elderly
• 12 of general hospital inpatients who are
  referred for mental health consultation
• 10 30 of mental health outpatients
• 50 for special populations (e.g. following
  cardiac surgery).

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Adjustment Disorders

• Course
• Begins 3 mos of onset of stressor last no
  longer than 6 mos after stressor or consequences
  have ceased.
• Persistence of Adjustment Disorder and/or
  progression to more severe mental disorder (Major
  Depression) maybe more likely in children and
  adolescents vs. adults.

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Adjustment Disorders

• Diagnostic Criteria
• Morrison, p. 455 DSM-IV-TR, p. 683.
• Treatment
• Generally psychopharmacology is not used.
  However, some sort-term anxiolytics
  (benzodiazepines) might be given for insomnia or
  anxiety control.
• Psychotherapy
• Solution focused therapy to help the patient deal
  more effectively with the stressor.
• Family therapy (particularly if the individual is
  an adolescent).