Eating Disorders

1. Eating Disorders Jess P. Shatkin, MD, MPH Director of Education and Training New York University School of Medicine NYU Child Study Center

2. Learning Objectives • Residents will be able to: • Distinguish between Anorexia and Bulimia Nervosa • Describe the primary clinical findings in Anorexia and Bulimia Nervosa • Identify rational diagnostic evaluation methods for affected children and adolescents and their families • Determine evidence-based treatments for patients affected by Eating Disorders

3. Facts and Stats • Among normal weight female teens, 40-60% view themselves as too heavy • Up to 60% of female teens diet regularly • Over 50% of teens exercise in order to improve their shape or lose weight • Approximately 45% of female teens smoke cigarettes to control weight • Most female teens are preoccupied with their food intake • 70% of girls report that body shape is important to their self-esteem (Strober and Schneider, 2005).

4. History • In Western Europe of the 12th and 13th centuries, “miracle maidens,” or women who starved themselves, were highly regarded, and their behavior was imbued with religious interpretations. • Catherine of Siena (1347 – 1380), whose complete control over her food intake was seen as a sign of religious devotion, was regarded as a saint (Heywood, 1996). • “Holy anorexia” was, however, short-lived • By the 16th century the Catholic Church began to disapprove of asceticism. • Some anorexics were subsequently viewed as witches and burned at the stake (Brumberg, 2000).

5. History cont’d • First cases reported in 1689 by Richard Morton – “wasting” disease of nervous etiology in one male and one female (Gordon, 2000). • The first formal description of AN, however, is credited to Sir William Gull, physician to Queen Victoria, who in 1868 named the disorder anorexia hysterica, emphasizing what he believed to be its psychogenic origins.

6. History: Anorexia Nervosa • Gull later changed the name to “nervosa” to avoid confusion with hysteria • Although quite descriptive, the word anorexia is a misnomer, as the term literally means “lack of appetite,” which is, in fact, rare. • Not simply a product of the modern society • Both Anorexia Nervosa and Bulimia Nervosa patients share an intense preoccupation with body weight and shape

7. History: Bulimia Nervosa • Bulimia Nervosa (BN), by contrast, was first clinically described in 1979 • Historical accounts date to 1398, when “true boulimus” was described in an individual having an intense preoccupation with food and over eating at very short intervals, terminated by vomiting (Stein & Laakso, 1988). • The word bulimia is derived from Greek and means “ravenous hunger,” quite the opposite of anorexia. • Much less has been historically made of bulimic behavior, and consequently, we have significantly less knowledge of this disorder.

8. Eating Disorders • Anorexia Nervosa • Restricting Type • Binge Eating/Purging (Bulimic) Type • Bulimia Nervosa • Purging Type • Nonpurging Type • Eating Disorder NOS

9. Anorexia Nervosa • Diagnosis requires: • Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) • Intense fear of gaining weight or becoming fat, even though underweight • Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight • In post-menarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration)

10. AN: Characteristics • The discrepancy between weight and perceived body image is key to the diagnosis of anorexia; anorexic patients delight in their weight loss and express a fear of gaining weight • Have changes in hormone levels which, in females, result in amenorrhea (if the weight loss occurs before puberty begins, sexual development will be delayed and growth might cease) • Feel driven to lose weight because they experience themselves as fat, even when at a subnormal weight • Intensely afraid of becoming fat and preoccupied with worries about their body size and shape • Direct all their efforts towards controlling their weight by restricting their food intake, but may also binge eat, self induce vomiting, misuse laxatives or diuretics (purging behaviors), exercises excessively or misuse appetite suppressants

11. Bulimia Nervosa • Diagnosis requires: • Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances • a lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months • Self-evaluation is unduly influenced by body shape and weight • The disturbance does not occur exclusively during episodes of Anorexia Nervosa

12. BN: Characteristics • Frequent episodes of binge eating, during which they consume a large amount of food within a short period of time • Feels overwhelmed by the urge to binge and can only stop eating once it becomes too uncomfortable to eat any more • Feels guilty, anxious and depressed, because they have been unable to control their appetite any they fear weight gain • Tries to regain control by getting rid of the calories consumed ( the most common method is vomiting, but they might misuse laxatives, diuretics or appetite suppressants, fast or excessively exercise

13. Subclassification • 2 major subtypes of anorexia: • (1) Restricting Type: fasting, introverted, decreased risk of substance abuse, family conflict is covert • (2) Bulimic Type: binge eating or purging, more volatile, family frequently disengaged, prone to substance abuse • 2 major subtypes of bulimia: • (1) Purging Type: self-induced vomiting or use of laxatives, diuretics, or enemas • (2) Nonpurging Type: use of other compensatory mechanisms, such as fasting or excessive exercise

14. Denies abnormal eating behavior Introverted Turns away food in order to cope Preoccupation with losing more and more weight Recognizes abnormal eating behavior Extroverted Turns to food in order to cope Preoccupation with attaining an “ideal” but often unrealistic weight Anorexia vs. Bulimia

15. Eating Disorders NOS • Likely to be similar to people with AN or BN but not quite meet the diagnostic criteria • Might vomit after eating small amounts of food • Might chew food and then spit it out • Might binge eat, but not attempt to get rid of the calories consumed (this behavior is now called Binge Eating Disorder [BED], the phrase compulsive eating is sometimes used, but has never been adequately defined)

16. Obesity • Defined as 20% over ideal body weight or BMI > 30 • Not an eating disorder per se and unlike an eating disorder is not an mental illness. However, many people who binge eat become obese and can have mental health problems • 1/3 of NYC public high school students are overweight or obese

17. What is a healthy weight? • Body Mass Index (BMI) is the best currently accepted measure • BMI (kg/m²) = (pounds x 703) ÷ height in inches² or = kilograms ÷ height in meters² • BMI Parameters • Underweight = < 18.5 • Normal weight = 18.5 – 24.9 • Overweight = 25 – 29.9 • Obese = > 30 • These next slides show 20 years of obesity in the United States

31. Why are we so overweight? • Genes • Diet • Exercise • Nutrition Education • Social (single parent, no time to prepare meals, etc.)

32. What does our weight cost? • Direct Costs • Indirect Costs • 1995 = $99 billion • 2000 = $117 billion • Most of the cost associated with obesity is due to type 2 diabetes, coronary heart disease, and hypertension.

33. Epidemiology • More likely than a true increase in these disorders in recent years is that the public is more aware of them • The prevalence rate of anorexia is 0.5-1%; incidence <0.1% • The prevalence rate of bulimia is 3-8% in females 12 – 40 y/o; incidence <0.1% • The prevalence of both disorders for men is about one-tenth that for women

34. Epidemiology (2) • Individual symptoms characteristics of each disorder (such as binge eating, purging, or fasting) are far more common than the disorders themselves • The typical age of onset is adolescence or young adulthood (peaks at 14 – 15 y/o and again at 18 y/o) • These disorders are thought to be more prevalent among higher SES; anorexia in particular is uncommon in poorly developed countries and had been rare among blacks in the US for years; although now there is minimal difference among ethnic groups in America

35. Comorbidity • Anorectics face an increased risk of depression, anxiety d/o (especially OCD & Social Phobia), and personality d/o (cluster C in anorectic restrictors; cluster B and C in anorectic bulimics) • Bulimics face an increased risk of depression; anxiety d/o may also be increased • The lifetime prevalence of substance abuse/dependence among bulimics (particularly alcohol and stimulants) is at least 30% (25% among all patients with an eating disorder) • The diagnosis of a personality d/o among bulimics is not uncommon (especially Borderline PD)

36. Etiology • There are numerous, as yet unproven theories, as to why people develop anorexia • Early psychological theories proposed that anorexia represents a phobic avoidance to food and an association with the sexual tensions generated during puberty • Psychodynamic formulations have suggested that anorexic patients have fantasies of oral impregnation • Social theories stress the importance of conforming to the American ideal of youth, beauty, and slimness

37. Etiology (2) • Modern psychological theories stress that these patients are avoidant of maturational challenges which are perceived as insurmountable; concretization and avoidance of psychological discord follow thereafter • They aim for the antithesis of puberty – these kids are unprepared and exert control by not eating, thereby staying young and immature; they experience profound self-loathing, along with the illusion of competence because of the ability to follow rules

38. Etiology (3) • Family theory suggests that AN results from a cry for help from a child enmeshed in a conflicted and disfunctional family (Minuchin et al, 1978) • Unconscious collusion among family members perpetuates the child’s symptoms because focus on the child defuses the parental conflicts. • Cognitive-behavior theory, meanwhile, proposes that individuals are rewarded by peers and society for being slender, which for some can be sufficiently powerful to maintain the illness despite the health risks. • Finally, the social and cultural emphasis upon being thin and the associated pressures that are overtly and covertly placed upon children are believed to contribute in some way to the genesis of Eating Disorders (Brumberg, 1988).

39. Etiology: Biological Theory • Biological theories focus on the role of the hypothalamus (the region concerned with the regulation of body functions, such as temperature, weight, appetite, & general homeostasis); support for this theory comes from neurotransmitter studies showing an increase in Corticotropin Releasing Factor (CRF) in the CSF of anorexic patients • When administered to rats, CRF leads to a reduction in food intake, feeding time, & feeding episodes; it also leads to an increase in grooming time & grooming episodes • The occurrence of amenorrhea before weight loss also suggests a hypothalamic disturbance (occurs in 20% of patients)

40. Etiology: Biological Theory (2) • There is also evidence of a central neurotransmitter system dysregulation affecting 5HT, DA, and NOREPI; the strongest evidence supports reduced NOREPI activity and turnover • Vomiting leads to an increase in DA levels which reinforces/rewards the vomiting behavior • Theories of serotonergic hyperfunctioning in anorexia and serotonergic hypofunctioning in bulimia are attractive but don’t explain why SSRIs are sometimes helpful for both

41. Etiology: Genetics • Eating Disorders are familial. • The risk of AN among mothers and sisters of probands is estimated at 4% or about eight times the rate among the general population (Strober et al, 2000). • A large twin registry study appears to confirm that BN and AN are related. This study found that the co-twin of a child with AN was 2.6 times more likely to have a diagnosis of BN than were co-twins of children without an Eating Disorder (Walters and Kendler, 1995). • Twin studies confirm a genetic link. Studies of identical or monozygotic twins show concordance of up to 90% for AN and 83% for BN (Kaye et al, 2000). • Nearly all women in Western society diet at some point in adolescence or young adulthood, yet fewer than 1% develop AN.

42. The Highly Familial Nature of Anorexia Nervosa (Strober, 2000)

43. Support for A Primary Role of Fear and Anxiety Related Traits in AN • Comorbidity with anxiety disorders • major anxiety syndromes occur in upwards of 80% of AN patients, roughly 4 times the rate in the general female population • Association with ‘anxious’ personality phenotype – tendency toward greater restraint, caution, regimentation, and perfectionism compared to persons without AN

44. Anxiety in FamiliesStavro et al (submitted)

45. AN: Risk Factors & Prognosis • Risk factors for AN: puberty; perfectionistic personality; family h/o affective, OCD, and Anxiety D/O; impaired family interactions, stressful life events (e.g., sexual abuse, beginning college, leaving home, etc.) • Prognostic indicators for AN: age of onset (12 - 18 is better b/c prior to 18 y/o families can mandate treatment; prior to 12 y/o is bad prognosis); bulimic/purging symptoms lead to a worse prognosis (restrictors do better); chronicity of illness (>6 years of illness with little treatment benefit); weight at treatment; repeated hospitalizations; poor social functioning

46. BN: Risk Factors & Prognosis • Risk Factors for BN: dieting, puberty, transitions (e.g., college, new job, relationship break-up), various jobs (athletes, actors, models), anorexia, impulsivity, anxiety, • Favorable Prognostic Indicators for BN: younger age at onset; higher social class, and family history of alcohol abuse

47. Clinical findings (1) • A repertoire of behaviors in the pursuit of weight loss (e.g., extreme dieting, adopting unusual diets or vegetarianism, refusal to eat with family or in restaurants, etc.) • Patients show an unusual interest in food that belies their fear of gaining weight (e.g., collecting recipes, preparing elaborate meals for others, developing an interest in nutrition) • Many patients begin to abuse laxatives, diuretics, or stimulants in an effort to lose more weight • Anorexic patients commonly develop an intense, almost obsessive interest in physical exercise and have strict work-out routines

48. Clinical findings (2) • Bulemics tend to carry on their behavior in private, often with foods high in calories or carbohydrates • The binge may at first bring feelings of relief from tension, which is followed by guilt and feelings of disgust • Some patients abuse emetics (e.g., ipecac) • About 10% of bulimics steal food by shoplifting or other means • Clinical lore states that patients with anorexia tend to have above-average scholastic achievement, are highly perfectionist, and come from achievement oriented families; they often have poor sexual adjustment, which has suggested to some that anorexia represents an attempt to prolong childhood and escape the responsibilities of adulthood • Anorectic families are characterized as non-conflictive, intrusive (e.g., parents answer for patient), overly protective, rigid, and inflexible

49. Clinical findings (3) • Bulimic families are characterized as notable for a lack of parental affection, negative/hostile and disengaged interactions, parental impulsivity, alcoholism, obesity, and chaos • The anorexic temperament is classically risk avoidant, emotionally restrained, compliant/conventional, perseverative, perfectionistic, with decreased resiliency, and preferring order and routine • With severe weight loss, other physical changes may develop (hypothermia, dependent edema, bradycardia, HOTN, lanugo, osteoporosis, brain atrophy) • Hormonal abnormalities in anorexia may include elevated growth hormone and plasma cortisol levels and reduced gonadotropin levels (along with low FSH, LH, and estrogen); T3 may be reduced, but T4 and TSH are often normal. Increased corticotropin CSF levels may act as a potent anorectic which ironically perpetuate anorexia by further decreasing appetite

50. Clinical findings (4) • Bulimic patients often develop calluses on the dorsal surface of their hands (self-induced vomiting), dental erosion and carries, esophageal erosion, lanugo hair, enlarged parotid glands (chipmunk face secondary to increased amylase), bradycardia, hypotension, and arrhythmias (secondary to hypokalemia) • Medical complications in bulimics may include hypocalcemia, hypochloremia, or hypokalemia (secondary to vomiting and/or laxative/diuretic abuse); metabolic alkalosis; electrolyte disturbances (arrhythmias, lethargy, weakness, seizures); serum transaminase levels may increase reflecting fatty degeneration of the liver; parotid gland enlargement and elevated amylase; elevated serum amylase may develop; elophageal tears (uncommon) can be life threatening