Understanding Eating Disorders: Overview, Classification, and Clinical Features

1. Scott Hall drscotthall@doctors.net.uk Eating DisordersAn overview

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

4. ?floating hypothesis • ?distinct entities

5. Anorexia Nervosa (conceptualisation) • Medicoclinical (Lasegue, Gull) • Sociocultural (Brumberg) • Tools (EAT, EQ)

9. 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

10. Epidemiology 2 • Is it increasing? Rochester, Mn • Changing social norms • Asking a different question : “Are eating disorders (generally) increasing?”

20. 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 family’s 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/P&S gain/etc.

22. Systemic Psychopathology ?significance • Over-enmeshment • Overprotective • Rigidity • Involvement of sick child in parental conflicts • Lack of resolution

23. 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

27. 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

28. Clinical features 2The biological syndrome • HPA dysgregulation • Ammenorrhoea • Physical features • BMI criteria • Differential diagnosis

29. 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

33. 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

35. 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

37. Predisposing • Demographics • Environmental • Psychiatric • Perfectionism • Family history of substance abuse

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

39. 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

40. Comorbidities • MDD • Anxiety disorders • D&A • Personality traits/disorder • AN • Obesity • *Type I diabetes

41. Physical Complications • Menstrual irregularity in 25% • Purging related • Laxitive/diuretic related • Dental

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

44. Drugs in ED • Fluoxetine – binge/compulsive behaviour • Olanzapine* • Topiramate • Zonisamide • Sibutramine (adverse CV side effects) • Rimonabant

45. Questions/Discussion