Transcript Eating Disorders

Eating Disorders
Zaid B. Malik, MD
University Of Arkansas for Medical
Sciences.
Overview
Types
Diagnostic Criteria
Etiology
Complications
Rx
Types ??
What does she remind you of?
And this ?
And this…
Or this…
DSM-IV-TR Eating Disorder
Anorexia Nervosa
Bulimia Nervosa
Binge- eating Disorder ( classified as Eating
Disorder NOS)
Basic Concept of ED
Disordered pattern of eating, accompanied
by distress, disparagement, preoccupation
and / or distortion associated with one’s
eating, weight or body shape.
Etiology
Multi factorial, with both genetic and
environmental contributing risk factors.
Genetic , Biological ( Serotonin, Nor
epinephrine, dopamine, hypothalamic
dysfunction, and thyroid dysfunction.
Social ( dysfunctional family system as
whole, can involve sexual abuse hx.
Western society promote a drive for
thinness, participation in sports that
emphasize weight restriction
Individual use of obsessive eating behavior
as a replacement for normal adolescent
pursuits of social and sexual functioning.
Individual feeling under excessive control
of their parents.
Individuals are unable to interpret body
hunger signal because of early experience
of inappropriate feeding.
Course ?
Course…..
50 % of individuals with Anorexia and
Bulimia nervosa make a full recovery where
as 30% partially recover and 20 % follow a
chronic course.
* Individuals with BED have a slightly
favorable outcome.
* Mortality rate with AN is 0.6 % annually.
Epidemiology
Which one is more prevalent??
AN or BN or BED
EPIDEMIOLOGY…..
PREVELENCE: AN is the least prevalent
ED, affecting aprox. 0.3 % young adult
females. BN affect aprox. 1 % of young
adult females and BED affect aprox. 2.6 %
of young adults.
Demographics
Which gender is more likely to have which
ED…
DEMOGRAPHICS
Typically affect young adult females with
85 to 95 % of cases of AN and BN and
approximately 60 % of cases of BED
occurring among females.
Onset
What start early, AN / BN / BED
ONSET
AN is slightly earlier than BN, both
generally begin in adolescence, however
both can occur at much older age.
Onset of BED tends to be slightly later,
generally beginning in late adolescent or
early twenties.
Mean age of onset for AN is 17 with a
bimodal peak at ages, 12 and 18, onset after
40 is un common.
SOCIOCULTURAL FACTORS.
Reported all over the globe, but more
prevalent in industrialized and or/
Westernized societies. Several
epidemiologic studies have linked
immigration, modernization and
urbanization to risk.
Anorexia Nervosa
DIAGNOSTIC FEATURES OF
AN
Refusal to maintain a body weight at or
above a minimally normal weight for age
and height.( Below 80th %tile)
Intense fear of gaining weight or becoming
fat, even though underweight.
Disturbance in a way in which one’s body
weight or shape is experienced.
In postmenarcheal females, amenorrhea ( i.e
absence of at least three consecutive
menstrual cycles)
YOU HAVE TO HAVE ALL OF THESE
TO DIAGNOSE
ANOREXIA NERVOSA
OR THE DIAGNOSIS IS…..
ED NOS
What are subtypes ?
SUBTYPES
RESTRICTING TYPE: Person not
regularly engaged in binge- eating or
purging behavior)
BINGE-EATING/ PURGING TYPE:
Person has regularly engaged in binge
eating or purging behavior.
** Individuals typically have a normal
appetite until the illness progresses to
dangerous level of emaciation.
Food restriction represents a drug of choice.
Self worth often become tied to the ability
to achieve and maintain an emaciated state.
Typical Anorexic Feast….
Alternating b/w the restricting and binge
eating type is possible.
Physical and Lab findings
What do you expect, from head to toe and
lab work up??
PHYSICAL AND LAB
FINDINGS
VITAL SIGNS: Bradycardia, hypotension,
hypothermia.
CVS: QTc widening, CHF, Edema,
Dehydration, Orthostasis, Impaired
perephral circulation.
GI : Impaired motility, Elevated LFT’s,
Elevated serum amylase, Erosion of tooth,
Mallory Weiss Syndrome.
Hematological : Pancytopenia, leukopenia,
anemia)
Renal: Calculi, Elevated BUN
Endocrine: Decreased T 3 and T 4,
Decreased Estrogen in females and
Testosterone in males.
Musculoskeletal : Osteoporosis, wasting.
Dermatological: Dry yellow skin, lanugo
hair, hair loss, calluses on dorsum of hand
( Russell Sign).
Nutritional Changes: Electrolyte
disturbances, parotid gland enlargement.
( Chickmuck face )
WORKUP
Complete physical and psychiatric exam.
Lab studies
Psychological Testing ( MMPI, Eating
Attitudes Test, Eating Disorder Inventory )
Co morbidity
Which diagnostic spectrum do you think
will be most common with AN??
COMORBIDITY
BN ( variable )
Substance Use ( 26%)
MDD ( 50- 75 %)
Anxiety ( 50- 75 %)
Personality D/O ( up to 50 % )
TREATMENT
GOALS: Restore and maintain at least a
minimal adequate body weight, reduce
complicating factors, improve the
willingness to correct the anorexia through
therapy.
Consider HOSPITALIZATION, if weight
below 20 to 30 % normal, sever medical
complications.
No medications are FDA approved.
Prozac, Thorazine, Zyprexa, Periactin,
ReVia, ECT may be helpful.
*Favorable factors
Admission of hunger
Good insight
Greater level of maturity and self esteem.
Illness onset b/w age 13 and 18.
Patient’s Question
Doctor, what is my target weight? OR
How do I know I am at a good weight?
Is it my BMI that indicate that I am at a
good weight?
Most important land mark is when, Body
physiologic functions return to normal…
Resumption of menses is very good
indication of return of physiologic
functions…
Bulimia Nervosa
DIAGNOSTIC CRITERIA FOR
BN
Recurrent episode of Binge eating ( Eating
in a discrete period of time and a sense of
lack of control over eating )
Recurrent compensatory behavior in order
to prevent weight gain
Binge and inappropriate compensatory
behavior occurring at least twice a week for
3 months.
Self evaluation is unduly influenced by
body shape and weight.
The disturbance does not occur exclusively
as a part of AN
So if some one is binging five times a week
for 2 months, is that not BN..
NO
What if its once a week for 6 months…
NO
What is it???
ED NOS
So what if I Binge twice a week for 3
months, but never purge.. Do I have BN
NO…
BED… ( we will talk about it in a bit..)
Sub types of BN
??
SUB TYPES
PURGING: Regularly involved in self
induced vomiting or misuse of laxative,
diuretics and enemas.
NON PURGING TYPE: Has other
inappropriate compensatory behaviors like
fasting, excessive exercise etc.
* There are a few physical findings.
Individuals are usually of normal or near
normal weight.
Individuals typically choose food that are
sweet and high in caloric value.
Depression usually follow binging and is
ameliorated by purging, followed by guilt..
Self induced emesis is the most common
purging technique ( 80 to 90 % )
Individuals with bulimia nervosa unlike
anorexia nervosa have an interest in
physical attractiveness, sexual issues nad a
greater interest in recovery.
Medical Complications
Dehydration
Vomiting induces swelling of parotid glands
Mallory- Weiss Syndrome
Dental Caries
Electrolyte Imbalance
Mild elevation in serum amylase.
* Epidemiology
Life time prevalence 1 to 3 %
Average age of onset 18, with age range of
12 to 40.
Prognosis if significantly better than AN
COMORBIDITY
MDD, Bipolar D/O
Anxiety
Substance abuse ( 33 – 60 %)
Borderline PD ( 25- 48 %)
AN ( variable)
TREATMENT
CBT
Antidepressants ( especially when
combined with CBT )
Prozac ( FDA Approved), TCA’s,
Trazadone, Ondensetron, Topiramate,
ReVia.
T 3 or adding Topamax.
***** NO WELLBUTRIN***** :
associated with increased risk of grand mal
seizures.
BINGE EATING DISORDER
DIAGNOSTIC CRITERIA
Impaired control over repeated food binges
and distress over this loss of control.
Absence of compensatory mechanism.
* Individuals are often over weight.
* Individuals often hide their eating habits.
* Despite their eating habit ( at least 2
binges per week or at least 2 days a week)
individuals have a fear of being fat, an
intense pre occupation with thought of food,
weight and becommign thin.
EPIDEMIOLOGY
1.5 to 3 %
TREATMENT
CBT
Luvox, Celexa, Prozac, Zoloft.
Topamax
Sibutramine ( Meridia) a seratonin and
norepinepherine reuptake inhibitor, FDA
approved for obesity, can be helpful.
CONCLUSION
ED are common among young adult
women, although they can affect both man
and women, and can occur from childhood
into old age. They are often associated with
co morbid psychiatric illness as well as
some life threatening medical conditions.
Successful treatment require collaborative
team management ( medical, psych,
nutritional interventions)
Questions...