Lecture on Eating Disorders DANIEL STEIN, M.D.

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Lecture on Eating DisordersDANIEL STEIN, M.D.

• Anorexia nervosa (AN) - history, definition,
  clinical description
• Bulimia nervosa (BN) definition, clinical
  description
• Physical laboratory findings in AN and BN
• Epidemiology of AN and BN
• Etiology - genetic, biological, socio-cultural,
  psychological, familial
• Treatment of AN and BN- ambulatory vs.
  inpatient treatment cognitive-behavioral,
  family, biological treatments
• Prognosis

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References Fairburn Cg, Marcus MD, Wilson GT
Cognitive-behavioral therapy for binge eating and
bulimia nervosa A comprehensive treatment
manual. In Fairburn CG, Wilson TG (Eds), Binge
eating Nature, assessment and treatment (pp
361-404). New York Guilford Press, 1993. Cooper
Z, Fairburn CG, Hawker DM Cognitive-behavioral
Treatment of Obesity A Clinician Guide. New
York Guilford Press, 2003.
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History of anorexia nervosa

• Medieval period Holy anorexia
• 1698 First documentation (Thomas Morton)
• 1873 First clinical descriptions (Laséque,
  Gull)
• 1900-1930 Biological causes (Simmonds Syndrome)
• 1900-1960 Psychoanalytic explanations (oral
  impregnation)

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History of anorexia nervosa

• 1970th H. Bruch Severe Ego Pathology
• disturbances in
  body image
• overall
  personality disturbance
• alexythymia (not
  Bruchs term)
• disturbance in
  interoceptive awareness
• ineffectiveness
• 1979 First description of bulimia nervosa
• 1982 description of two types of anorexia
  nervosa
• restricting type
• 
  purging/bingeing-purging type
• 1993 First descriptions of binge eating
  disorder as a separate entity

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Diagnostic Criteria of anorexia nervosa (AN)
(DSM-IV)

• Refusal to maintain body weight at or above a
  minimally normal weight for age and height (85
  of expected body weight), or failure to reach
  expected weight (85 of expected body weight)
  during period of growth
• Fear of gaining weight or becoming fat even
  though underweight
• Disturbance in body perception, or undue
  influence of weight/ shape on self-evaluation, or
  denial of seriousness of low weight
• In post-menarcheal females, amenorrhea absence
  of at least three consecutive menstrual cycle (in
  33 AN appears before menarche)

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Clinical description of anorexia nervosa

• Pre-morbid features ? perfectionism,
  inhibition, conformity, obsessionality,
  ineffectiveness, harm avoidance, ? self-esteem
• Diet ? in quantity
• type of food (bad food, good
  food)
• number of meals
• Eating eating-related behaviors highly
  obsessional
• ? physical activity highly obsessional

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Clinical description of anorexia nervosa

• Usually prolonged period before discovery
  (denial, treatment refusal by patient, family
  problems that reduce parental awareness)
• Anorexia nervosa (AN) usually starts as
  restricting
• 30-50 of restricting AN ? purging/bingeing-
  purging AN or bulimia nervosa

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Physical changes in anorexia nervosa

• Amenorrhea, ? sexual development
• Fatigue (? BMR)
• Bradycardia, hypotension, hypothermia
• Osteoporosis, ? bone density, ? peripheral
  muscles, cardiomyopathy
• Yellow skin due to Hypercarotenemia (? T3)

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Physical changes in anorexia nervosa

• Lanugo
• Peripheral edema (? albumin, inappropriate ADH
  secretion)
• ? cognitive function (sometimes continuing
  after recovery)
• ? spontaneous abortions, small for date
  deliveries (even when recovered)

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Mortality in anorexia nervosa

• Lifetime mortality restricting anorexia nervosa
  5-10
  (illness complications suicide)
• Lifetime mortality bingeing/purging anorexia
  nervosa 10-20
  (illness complications suicide)

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Laboratory changes in anorexia nervosa

• Anemia, leucopenia
• ? glucose, ? cholesterol (due to ? T3)
• Disturbances in liver function tests
• ? Mg, zinc
• TSH, T4 normal, ? T3
• Hypercarotenemia (? T3)
• Most changes related to starvation, reversible

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Laboratory changes in anorexia nervosa

• ? response to ADH
• ? FSH, LH, estrogens, testosterone (males)
• ? CRH, cortisol
• ? endogenous opiates
• ? leptin, neuropeptides
• ?brain volume, gray, white matter changes
• Most changes related to starvation, reversible

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Diagnostic Criteria of bulimia nervosa (BN)
(DSM-IV)

• Recurrent episodes of binge-eating, characterized
  by 1. Eating in a discrete period of time an
  amount of food that is definitively larger than
  most people would (e.g., 1000 calories in 30
  minutes). 2. Lack of control over eating during
  binge.
• Recurrent inappropriate compensatory behaviors to
  prevent weight gain (purging self-induced
  vomiting, misuse of laxatives, diuretics, enemas,
  or other medications, fasting, excessive
  exercise)
• Bingeing purging occur at least 2 twice a week
  for 3 months.
• Undue influence of weight/ shape on
  self-evaluation
• Not associated with low weight for age and height
  (i.e., not occurring exclusively during AN
  episodes).

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Clinical description of bulimia nervosa
Bingeing

• Planning ahead
• Obsessional planning
• Bingeing high calorie food (sweet, fat)
• ? pace compared to normal eating
• Feeling that one is bingeing (sense of lack of
  control, unable to stop) automatic,
  dissociation (bingeing in front of TV)
• Hiding binges

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Clinical description of bulimia nervosa
Bingeing

• Between binges ? of food intake (weight
  fluctuations)
• Stress, negative feelings ? bingeing
• In binges eating until feeling full/uncomfortable/
  pain
• Immediately following binge ? dysphoria,
  later ? dysphoria, disgusted, guilty
• Bingeing not associated with hunger
• Binges ? late in evening/night (D.D DSPS)

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Clinical description of bulimia nervosa Purging

• Self-induced vomiting 80-90
• Immediately following vomiting ? dysphoria,
  later ? dysphoria, disgusted, guilty
• Laxatives, enemas 30

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Physical changes in bulimia nervosa

• ? parotid glands (due to vomiting)
• ? gastric dilatation (due to binges)
• Congestive heart failure (due to binges)
• Irregular menstruation
• Peripheral edema (inappropriate ADH secretion)
• Erosion of dental enamel
• Lifetime mortality 10

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Laboratory changes in bulimia nervosa

• Hypokalemia, metabolic alkalosis (? HCL ?
  bicarbonate) (due to vomiting)
• Hyponathremia, metabolic acidosis
  (laxative-induced)
• ? parotid diastase (due to vomiting)
• Most changes related to starvation, reversible

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Multi-impulsive bulimia nervosa

• ? rates of a combination of several
• impulsive behaviors
• Multiple purging behaviors (self-induced
  vomiting laxatives)
• Substance use disorders
• Impulse control disorders (kleptomania,
  gambling)
• Suicidal behavior, self-mutilation
• Promiscuity
• Borderline personality disorder

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Epidemiology

• Lifetime Prevalence
• Anorexia nervosa 0.2 1
• Bulimia nervosa 1 4
• Binge Eating Disorder not known (apparently ?
  than BN)
• Partial eating disorders 5 15

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Epidemiology

• Anorexia nervosa (AN) mainly adolescents
• Bulimia nervosa (BN) mainly young adults
• Binge Eating Disorder - mainly young adults
• AN BN males 5-10
• In recent years ? males
• ? age of onset

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CURRENT CONCEPTS OF THE SOCIO-CULTURALMODEL IN
ANOREXIA NERVOSA (AN)

• Messages and norms that are of importance for the
  development of AN
• Social influences of body image and perception
  
• The thin body ideal
• Denigration of obesity
• Importance of weight and appearance for
  success and self-esteem
• (e.g., ? Weight is critical for ?
  self-esteem we can change our life with dieting
  physical activity all-American woman)

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SUPPORT FOR THE ROLE OF THE SOCIO-CULTURALMODEL
IN ANOREXIA NERVOSA

• AN does not appear in all cultures but in
  specific groups (e.g., young females, who are
  particularly influenced by weight-related social
  norms)
• AN ? in Western than non-Western cultures
• ? incidence of AN in recent years that
  parallels ? influence of weight-related social
  norms

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SUPPORT FOR THE ROLE OF THE SOCIO-CULTURALMODEL
IN ANOREXIA NERVOSA

• ? rate of AN in specific vulnerable
  sub-populations (e.g., dancers)
• Recent appearance of AN in places only recently
  exposed to Western weight-related social norms
  (e.g., Fiji Islands, Curacao)
• Young females at risk to develop disordered
  eating will adopt more rigidly weight-related
  social norms expressed by media, family/peers

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Heritability of anorexia nervosa (AN) and bulimia
nervosa (BN(

• Family studies ? rates of AN, BN, ED-NOS in 1st
  degree relatives of AN BN patients
• Twin studies ? concordance rates of AN, BN, or
  both in monozygotic twins in whom the afflicted
  twin has AN or BN
• compared to dyzygotic twins
• Heritablity estimates for AN BN
• 0.54-0.80

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Findings supporting genetic transmission in
eating disorders (EDs)

• ? rates of ?/? weight in 1st degree relatives
  of AN BN patients
• Limited influence of shared environmental
  factors in the variance of disordered eating
  among family members
• Genotypic influences may determine the nature
  of experiences to which the individual is
  attracted (non-shared environment)
• Infrequency of full-blown EDs in the face of
  robust cultural influences

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Biological aspects of eating disorders

• ? food intake (hunger)
• endogenous opioids, neuropeptide Y, NE,
  grhelin, adiponectin
• ?food intake (satiety)
• cholecystokinin, leptin, 5HT
• High rates of dissatisfaction with weight shape
  in young female adolescents young adults
• BUT
• AN BN relatively rare

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Differences in rates of eating disorders between
females males Psychological, sociocultural
biological factors

• ? importance of weight shape in females
• Females more influenced by media societal
• directives
• ? food more available to women
• ? in number of fat cells in females but not
  males during puberty
• Centrifugal (females) vs. centripetal (males)
  weight increase

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Lifetime comorbid disorders in Eating Disorders
(EDs)

• Depressive disorders
• Prevalence 40-80
• Not necessarily associated with starvation
  bingeing/purging
• ? prevalence in 1st degree relatives of patients
  with eating disorders

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Lifetime comorbid disorders in Eating Disorders
(EDs(

• Substance use disorders (SADs)
• 50 of BN AN-P/BP patients
• ? prevalence of SADs in 1st degree relatives of
  patients with BN AN-P/BP who also have SADs

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Lifetime comorbid disorders in Eating Disorders
(EDs)

• Anxiety disorders
• Social phobia panic disorder 30 80
• ? prevalence of panic disorder in 1st degree
  relatives of patients with AN BN
• ? prevalence of social phobia in 1st degree
  relatives of patients with AN

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Lifetime comorbid disorders in Eating Disorders
(EDs)

• Obsessive compulsive disorder
• 10-70 in anorexia nervosa
• 5-45 in bulimia nervosa
• obsessive compulsive symptoms in acutely ill
  recovered patients symmetry, ordering,
  perfectionism
• ? prevalence of obsessive compulsive disorder in
  1st degree relatives of patients with AN BN

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Psychological factors personality disorders
(PDs) and personality features in eating
disorders (EDs)

• Anorexia nervosa restricting type
• ? rates of pre-morbid avoidant, dependent,
  obsessive compulsive, narcissistic PDs
• ? rates of pre-morbid conformism, rigidity,
  inhibition, harm-avoidance, perfectionism, low
  self-esteem, selflessness, alexithymia
• Secondary vs. primary anorexia nervosa

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Psychological factors personality disorders
(PDs) and personality features in eating
disorders (Eds)

• Anorexia nervosa purging type bulimia nervosa
• ? rates of pre-morbid narcissistic, borderline,
  antisocial PDs
• ? rates of pre-morbid impulsivity, novelty
  seeking
• Difference between uni-impulsive and
  multi-impulsive BN
• Importance of sexual abuse (not necessarily
  ? rates of PTSD)

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Family factors in eating disorders (EDs(

• The Psychosomatic Family (Anorexia Nervosa)
  (Minuchin, 1978)
• Enmeshment overly close relationship between
  IP mother, father distant
• Overprotection
• Lack of distinct boundaries between parents
  children subunits (parental child)
• Conflict avoidance
• Illness of IP maintains conflict avoidance
• Rigidity of family structure hampers change

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Outcome of eating disorders (EDs(
Eating disorders are chronic mean duration for
recovery 4-7 years 30-50 relapse rate in BN
after 6 months-6 years
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Factors associated with negative outcome of AN

• Earlier onset in adolescent patients (not
  definite), particularly prepubertal
• Onset in adulthood compared to adolescence
• ? duration of illness
• ? duration until receiving treatment
• Severe disturbance in body image

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Factors associated with negative outcome of AN

• Obsessionality in eating physical exercise
• Appearance of bingeing/purging symptoms in
  restricting AN
• Illness starts at normal vs. overweight
• Comorbid DSM Axis I Axis II disorders
• Maladaptive relations with family members
• Decreased social skills

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Treatment

• Multidimensional interventions (pediatrician,
  psychiatrist, psychologist, dietician, social
  worker, nurse, art therapist, school)
• Ambulatory ? day/partial treatment ? Inpatient
• Behavioral weight restoration program

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Treatment

• Indications for hospitalization
• severe weight ? (30 IBW)
• rapid weight ?
• 
  
• failure of ambulatory treatment
• 
  
• severe pathology in family
• suicidality

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Treatment

• Psychotherapy dynamic anorexia nervosa
• Cognitive behavioral bulimia nervosa,
  
  binge eating disorder
• Family therapy in adolescent non-chronic
  patients (particularly AN, but also BN)
• SSRIs bulimia nervosa, binge eating disorder
• only weight restored anorexia nervosa
  to decrease relapse

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Principles of cognitive behavioral treatment
(CBT) in eating disorders Three
stages 1. Psychoeducation on cognitive model
Introduction of behavioral techniques to
replace
maladaptive with adaptive behavior Cognitive
technique to modify dysfunctional cognitions
.2  3. Maintenance of change, relapse prevention
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Evidence based family therapy for adolescent
anorexia nervosa (AN) (Dare Isler, 1997 Lock
et al, 2001)

• Structured, focused, time-limited (treatment
  manual)
• Mobilization of adolescent family for therapy
• Family not he source of AN, but is the best
  resource for change
• Psychoeducation

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Evidence based family therapy for adolescent
anorexia nervosa (AN) (Dare Isler, 1997 Lock
et al, 2001)

• Active, consistent, non-blaming parental
  involvement in nutritional rehabilitation.
• ? parental efficacy is important for adolescent
  development.
• Family has a meal in the presence of therapist
  direct observation food considered medication
• Upon ? in weight focus transfers to age
  appropriate developmental tasks (adolescent
  gradually takes control over her life)
• Relapse prevention

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Evidence based family therapy for adolescent
anorexia nervosa (AN) (Dare Isler, 1997 Lock
et al, 2001)

• Contraindications for parental involvement in
  nutritional rehabilitation
• Maladaptive families
• deteriorates parent- adolescent relationship
• if ineffective - ? motivation
• Not recommended in the case of binging,
  self-induced vomiting