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EATING DISORDERS Review Lecture, 2011

EATING DISORDERS Review Lecture, 2011. Dr. Clare Roscoe Assistant Professor University of Ottawa croscoe@cheo.on.ca. Eating Disorders Overview. Epidemiology Diagnosis Understanding Eating Disorders Etiology, Risk Factors, and Power Medical Complications Principles of Treatment Outcome.

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EATING DISORDERS Review Lecture, 2011

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  1. EATINGDISORDERSReview Lecture, 2011 Dr. Clare Roscoe Assistant Professor University of Ottawa croscoe@cheo.on.ca

  2. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  3. Epidemiology: • Prevalence A.N. 0.5-1% B.N. 1-3% EDNOS 3-10% • ♀ : ♂ 10 : 1 • Onset • A.N. : 13-20 yrs (peaks at 14 and 18 yrs) : 5% present after 20 years of age • B.N. : 16.5-19 yrs old

  4. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  5. Types of Eating Disorders • Anorexia Nervosa • Restricting Type • Binge-Eating/Purging Type • Bulimia Nervosa • Purging Type • Nonpurging Type • Eating Disorder NOS

  6. Definitions: Anorexia Nervosa A. Refusal to maintain body weight Body weight <85% of expected B. Intense fear of gaining weight C. Distorted body image - or Undue influence of weight on self-worth, - or Denial of seriousness of the low weight D. Amenorrhea: the absence of at least 3 consecutive menstrual cycles

  7. Anorexia Nervosa cont’d • Specify: • Restricting Type • Binge-Eating / Purging Type Purging - Vomiting - Laxatives - Diuretics - Enemas

  8. Bulimia Nervosa A. Recurrent Binge Eating: • Eating a very large amount of food in a discrete period of time 2. Lack of control during the episode B. Recurrent Compensatorybehavior to prevent weight gain (vomiting, laxatives, fasting, over-exercising…)

  9. Bulimia Nervosa • A. and B. occur at least: • 2x / week for 3 months • Self-worth unduly influenced by shape and weight • Not A.N.

  10. A binge is almost always the result of dieting and food restriction. Purging is the result of: Fear of weight gain Shame caused by the loss of control over eating Restrict Binge Purge The Bulimic Cycle

  11. Bulimia Nervosa Cont.. • Specify: • Purging Type • Nonpurging Type Purging - Vomiting - Laxatives - Diuretics - Enemas

  12. Eating Disorder NOS (EDNOS) Patient does not meet all the criteria for an eating disorder. For example: • A.N. with normal periods • Frequent purging but no binge-eating and above 85%ile for weight

  13. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  14. Understanding Eating Disorders • Up to 90% of teenage girls will go on a diet. What happens to the 5%, (and the boys), that go on to develop Eating Disorders?

  15. The Development of an ED Need to Gain Control / Feel Better Dieting Stressors Sense of Achievement Increased Dieting • Vulnerable Youth • Risk factors • Comorbidities • Low self-esteem Snowballing of behaviours Eating Disorder

  16. Risk Factors for AN

  17. Risk Factors for BN

  18. Co-Morbidity of A.N.: • >50% Depression (i.e. #1 comorbidity) • 50% Anxiety Disorders (esp. OCD, GAD, and Social Phobia) • Perfectionism • “Cluster ‘C’ P.D. traits, e.g.. OCPD (rigidity, restraint, obsessiveness)

  19. Comorbidity of B.N.: • Depression >50%, #1 comorbidity • Anxiety in >50% (esp. GAD and Social Phobia) • Impulsivity/risk-taking behaviors • Substance Abuse • Borderline Personality Disorder traits • PTSD • Bipolar Spectrum disorders

  20. E.D. Spectrum • A.N.-------------A.N./B-P--------------B.N. • Perfectionistic Chaotic • Compliant Unstable moods • Anxious Substance abuse • Sensitive Impulsive • Possible OCPD Possible BPD

  21. Eating Disorders come from: • Feeling “not good enough”

  22. The Development of an ED Need to Gain Control / Feel Better Dieting Stressors Sense of Achievement Increased Dieting Snowballing of behaviours • Vulnerable Youth • Risk factors • Comorbidities • Low self-esteem Powerful Eating Disorder

  23. i.e. What makes an Eating Disorder so Strong?

  24. Why so powerful? Understanding the Eating Disorder • Effects of starvation • Meaning of the Illness • Poor Insight

  25. Effects of Starvation • Ancel Keys, University of Minnesota, during WWII • Psychologically “Normal” men, with superior “psychobiological stamina”  Semi-starvation (lost 25% body weight)

  26. Effects of Starvation • Change of Eating Habits • Started to eat in silence, prolonged time, unusual mixing of food • Social Changes • Men became withdrawn, decrease wish to socialize • Less humour • Cognitive Changes • Impaired concentration • Impaired comprehension and judgment

  27. Effects of Starvation • Emotional Changes • Depression, • Irritability, • Frequent outbursts of anger, • Extreme mood swings, • High levels of anxiety (including nail biting), • Almost 20% experienced extreme emotional deterioration (some hospitalized), • Most changes persisted through refeeding, became worse for some

  28. The Meaning of the Eating Disorder • The Eating Disorder is one thing I am good at • Not eating allows me to feel in control of my life • Not eating allows all my other worries to go away • The Eating Disorder makes me feel powerful, special and in control • The Eating Disorder means I don’t have to grow up • Eating means I am weak and a failure • The Eating disorder is who I am

  29. Poor Insight and Denial

  30. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  31. Medical Complications of Eating Disorders • Starvation • Body shutting down one system at a time • Purging

  32. Medical Complications of Eating Disorders

  33. Medical Complications

  34. Medical Complications

  35. Labs in Eating Disorders: •  • BUN (dehydration) • Amylase (vomiting) • Cholesterol • (starvation) •  • Na, K, CL (vomiting/laxatives) • LH, FSH, estrogen (starvation) • RBCs (starvation) • WBCs (starvation) • T3

  36. Clinical features of a Patient at Higher Risk of Death • Very low weight at admission • Bradycardia • No medical follow-up • Longer duration of illness • Multiple purging methods • Chronic self-harm or suicide attempts • Amphetamine or cocaine use • Severe alcohol abuse

  37. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  38. Principles of Treatment for E.D.’s: • Start with a thorough assessment • Biopsychosocial formulation • Specialized, multidisciplinary treatment team (physician, dietician, therapist…) • A psychological illness with medical and nutritional consequences • Importance of medical and psychological aspects of treatment together 3. Importance of Education

  39. Treatment of Anorexia Nervosa: • Medical and Nutritional: • reversal of the effects of starvation; re-feeding • “food is the medicine” • meal plan, “mechanical eating” • medical management and weighing • No medication found to be effective; (recent use of atypical antipsychotics); SSRI’s not effective at low weight

  40. Treatment of A.N. cont’d: • Psychological • Therapeutic Alliance • Supportive, compassionate, empathic • Understanding the illness, education • Externalize the illness, lift blame and shame, challenging ED • Motivational techniques; exploring pros and cons, comparing to OCD • Exploring and treating co-morbidities

  41. Treatment of A.N. cont’d: • Family Therapy for Children and Adolescents (evidence based) • CBT; IPT; motivational therapy; groups

  42. Treatment of A.N. cont’d: • Inpatient vs. Day Treatment Programs vs. Outpatient (stepped-care approach) • Treatment of co-morbidities e.g.. anxiety, depression

  43. Treatment of Bulimia Nervosa: • Use of high-dose SSRIs (Prozac) • CBT (manualized); IPT; Groups • Importance of a meal plan • Psychoeducation • Treatment of co-morbidities, e.g.. substance abuse, PTSD...

  44. Eating Disorders Overview • Epidemiology • Diagnosis • Understanding Eating Disorders • Etiology, Risk Factors, and Power • Medical Complications • Principles of Treatment • Outcome

  45. Outcome for AN • High morbidity and mortality (among highest of all psychiatric illnesses) • Mortality: 5-20% • 50% suicide • 50% medical complications

  46. Outcome for AN • Prognosis in Adolescents: • 50-70% full recovery in 5 years • 10-20% develop chronic AN • Prognosis in Adults: • 50% “recover” • 25% intermediate outcome • 25% poor outcome

  47. Outcome for B.N. • Better treatment outcomes compared to A.N. • Up to 70% recover with treatment • 15-20% intermediate outcome • 10-15% continue to do poorly

  48. Outcome cont’d: • Better prognosis associated with: • onset (and treatment) before age 15 yrs • treatment within 3 years of onset of illness • weight recovery within 2 years of treatment • Worse Prognosis associated with: • later age of onset, longer duration of illness, previous hospitalizations, greater individual and family disturbance

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