Eating Disorders An overview

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Eating DisordersAn overview

• Scott Hall
• drscotthall_at_doctors.net.uk

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Classification

• AN/BN/EDNOS ?BED ?OBESITY
• ICD 10
• DSM IV
• Subtypes

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• ?floating hypothesis
• ?distinct entities

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Anorexia Nervosa (conceptualisation)

• Medicoclinical (Lasegue, Gull)
• Sociocultural (Brumberg)
• Tools (EAT, EQ)

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Epidemiology

• Overall quite rare
• Lifetime prevalence 0.2-0.6
• ?Changing the BMI parameters
• Depends on the population studied
• Pre-pubertal incidence
• Fenwick Is much more common in the wealthier
  classes of society than those who have to procure
  their bread by daily labour

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Epidemiology 2

• Is it increasing? Rochester, Mn
• Changing social norms
• Asking a different question Are eating
  disorders (generally) increasing?

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Aetiology

• Rapid cultural change not 1st/3rd world
• The teenager
• Life events (multiaxial confounders)
• Family factors (Minuchin The sick child plays an
  important role in the familys pattern of
  conflict avoidance and this role is an important
  source of reinforcement of symptoms
• Good girls A sparrow in a golden cage Bruch
• Cognitive model
• Learning theory/modelling/PS gain/etc.

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Systemic Psychopathology ?significance

• Over-enmeshment
• Overprotective
• Rigidity
• Involvement of sick child in parental conflicts
• Lack of resolution

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Aetiology 2

• Janet elaborate manifestation of OCD
• ?epiphenomenon of PD (BN cf AN)
• ?begins psychological and becomes increasingly
  biological as starvation ensues
• Genetics (St Georges twin study 56 vs 7)
• Neurotransmitters the satiety cascade
• As with all mental disorder - multifactorial

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Clinical Features/Assessment

• 2 syndromes
• Importance of collateral hx (denial)
• Hx food intake, weight, exercise, behaviours,
  menstrual
• Psychopathology Beliefs, avoidance,
  magersucht, body image, achievement,
  distortion/disparagement, guilt
• Screening for comorbidity

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Clinical features 2The biological syndrome

• HPA dysgregulation
• Ammenorrhoea
• Physical features
• BMI criteria
• Differential diagnosis

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Complications

• Starvation syndrome (Mn study)
• Think biological, psychological and social!
• Fluids/electrolytes/CVS
• Cx related to purging
• Metabolic (hypoglycaemia)
• Myopathy / osteoporosis
• Haematological
• Temperature regulation
• The re-feeding syndrome
• Paediatric

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MSKR CVS RESP NEURO HAEM/MET
Myopathy Rhabdomyolysis Osteopaenia Osteomalacia Cardiomypathy Arrythmias Failure Failure to wean Delirium Seizures Encephalopathy Impaired oxygen release Haemolysis Leucocyte dys Met acidosis Glucose intolerance
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Management

• Outpatient
• Inpatient
• MDT approach What is the role of the
  psychiatrist?
• MHA
• Stepped care
• CR130
• Psychosocial interventions
• CBTe - Fairburn
• FT
• Psychdynamic/analytic Crisp, Bruch

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BN

• A new disorder est 1979 (Russell)
• An ominous variant of AN
• Uncontrolled overeating, compensatory behaviours,
  phobia BUT within normal range for BMI
• Chronic course (cf AN)
• 1 females 16-35

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Predisposing

• Demographics
• Environmental
• Psychiatric
• Perfectionism
• Family history of substance abuse

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Associations

• AN
• Past psychiatric history (BPAD, depression)
• Self harm
• Personality traits
• Important to distinguish from AN

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Psychopathology/observation

• Dieting (obsessional in nature)
• Exclusion of other means to evaluate self
• Guilt (when rules broken)
• Behaviours purging, laxitives, diuretics
• Most of which are largely ineffective
• Sense of achievement post purge
• Core - overconcern, preoccupation, OVI re shape
  and weight
• Phobia
• Low self worth/esteem ?conceptualise as self harm

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Comorbidities

• MDD
• Anxiety disorders
• DA
• Personality traits/disorder
• AN
• Obesity
• Type I diabetes

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Physical Complications

• Menstrual irregularity in 25
• Purging related
• Laxitive/diuretic related
• Dental

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Management

• NICE
• AD
• CBTe
• Other modalities (IPT, SFT)
• Stepped care

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Drugs in ED

• Fluoxetine binge/compulsive behaviour
• Olanzapine
• Topiramate
• Zonisamide
• Sibutramine (adverse CV side effects)
• Rimonabant

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Questions/Discussion