icm eating disorders

Restricting Subtype
Binge Eating/Purging Subtype

*Refusal to maintain body weight at or above a minimally normal level
*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 the body weight or shape on self-evaluation or denial of seriousness of low weight
*Ammenorrhea in postmenarcheal females

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). Please note that this does not include weight loss due to a medical condition, insufficient availability of food, etc. Low weight alone does not mean a person has anorexia; there must be an active refusal to work toward a normal body weight.

This often involves catastrophic thoughts related to weight gain such as “no one would want to be my friend if I gained weight”

The person may still see “areas of fat” or may insist that he/she is “fine” even when clearly emaciated. The person may see weight/shape as the central determinant of success.

Please note that if the patient is taking oral contraceptives, she may continue to menstruate.

During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting, misuse of laxatives, diuretics, enemas, etc.) This is the type of Anorexia people tend to be most familiar with. Individuals may restrict down to several hundred calories/day or less.

During the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior. The important point to note here is that not all patients who binge and purge meet criteria for Bulimia. If their weight drops below 85% of the expected level, the diagnosis is Anorexia – Binge-Eating/Purging Type.

*if male has all symptoms except period, he gets diagnosis
*if female has all symptoms except still has period, she doesn't get diagnosis

Purging type
Non-purging type

*Recurrent episodes of binge eating
*Recurrent inappropriate compensatory behavior in order to prevent weight gain
*Binge eating and compensatory behavior occur on average at least twice each week for three months
*Self-evaluation is unduly influenced by body shape and weight
*The disturbance does not occur during episodes of anorexia nervosa

*a. 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.
exception: Thanksgiving- everyone overeats!
*b. A sense of 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

Inappropriate compensatory behavior does NOT just refer to vomiting. A person who runs 4 hours after a binge in order to rid him/herself of the food is engaging in inappropriate compensatory behavior.

If frequency is lower, the person may meet criteria for an Eating Disorder, NOS.

Feelings of guilt or worthlessness may be associated with eating behavior.

the diagnosis is Anorexia Nervosa, Binge/Purge type NOT Bulimia.

Engages regularly in self-induced vomiting, misuse of laxatives, diuretics or enemas

fasting or exercise used as compensatory behaviors, but self-induced vomiting, etc. are not regularly used.

*Most frequent ages of onset are 14 and 18
*90% of those diagnosed are female
*Usually members of upper SES levels
*Prevalence in women from adolescence to early adulthood is about 1%

It is believed that the age 14 peak in onset is believed to be primarily due to the stresses associated with puberty and beginning high school. The age 18 peak is believed to be primarily due to the stresses involved in the transition to adulthood.

number of males with Anorexia Nervosa has been increasing in recent years. This may in part be due to historical under-diagnosis of eating disorders in males, but is also likely due in part to increasing pressure on males to have a certain body type or make weight classes for certain sports such as wrestling.

we can estimate about 0.1%.

*Mean age of onset is 17-19
*90% of those diagnosed are female
*Prevalence in women from adolescence to early adulthood is 1-3%

anorexia

Such behavior may include “social binging and purging” as part of a sorority or athletic team culture, or may involve experimentation with maladaptive methods of weight control that are either sporadic or quickly abandoned.

Environmental Factors:
-cultural influences
-family factors
-risk factors
and Biological Factors
-genetics
-disturbances in serotonin and norepinephrine

Girls are trading their boyish little girl bodies for women’s figures and will in the process, gain weight. The average girl sees about a 15-pound weight gain and an increase in body fat percentage. Girls may notice that their favorite clothes no longer fit, and become concerned that they are getting fat. This can especially be a problem if the girl has crappy "friends"

have become more and more extreme during the past decades. The theme seems to be the thinner the better, and the thinner you are the more beautiful, popular, and successful you will be. Women, in particular, who are very healthy, normal weights, can begin to feel inadequate and overweight when comparing themselves to models and actresses. Men are not immune to this pressure; for men, the pressure tends to be toward having very close to 0% body fat; every muscle should be defined and visible.

more conforming, obsessive, perfectionistic, socially inhibited and emotionally constrained than comparison individuals.

poor impulse control, acting out behavior, low frustration tolerance, chronic depression, and affective lability than comparison individuals.

Social definitions of attractiveness
Cultural interpretation of physical changes of adolescence and culturally based social expectations of adolescence

Overcontrolling/enmeshed family
Family emphasis on weight/shape/diet
Family discord

controlling- ex: kid says they want to be a teacher and family freaks out and says, "No!!! You don't make enough $ as a teacher!"

normal weight parent and normal weight siblings , but really big kid or +40 lbs in ~6 mos

Traumatic separations, losses
ex: separated from friends
Abuse
Engaging in an activity that emphasizes body shape/low weight ex: cheerleading/gymnastics
Dieting

such as a messy break-up or parental divorce, losses, or family discord may lead to a feeling of loss of control, and may lead to an effort to attempt to gain control in another area such as eating. In other cases, eating disorder symptoms serve the function in a family of drawing attention from problems such as parental conflict. After all, how can parents fight about finances when their child is starving him/herself? In this way, in addition to having a sense of gaining control over eating, the adolescent may realize the impact of their symptoms on the family system, and may feel a sense of control in the family as well.

such as sexual abuse, in the etiology of eating disorders has been extensively studied. Current research suggests that abuse may be a risk factor for general psychopathology rather than specifically eating disorders.

*concern/displeasure concerning body weight
*efforts to control weight

*Genetic factors seem to explain about 50% of variance in liability for eating disorders
*Traits involving need for control may be heritable
*Eating attitudes and behavior seem to have a heritable component
*Deficits in hunger/satiety may be heritable

Disturbances in serotonin and norepinephrine
Both regulate mood and eating behavior
Both can be disrupted by disordered eating, and disturbances in these neurotransmitters can lead to disordered eating
*individuals with Bulimia Nervosa may have lower levels of serotonin, and may be compensating by increasing intake of carbohydrates (binge foods tend to be high in carbohydrates). This theory is supported by the relative efficacy of SSRIs in treatment of Bulimia Nervosa.
*Medications tend to be not as effective in the treatment of Anorexia Nervosa as they are for Bulimia Nervosa

Mood Disorders
Anxiety Disorders
Personality Disorders
Substance Abuse

yes- ppl in study w/ restricted diet had changed: mood, physiology, social/emotional changes, worse cognitive decision making, physical

High comorbidity – 20-80%
AN can precede Major Depression (MDD)– Starvation produces chemical changes
Twin studies suggest unique and shared genetic components for AN and MDD
Relatives of AN patients have a higher rate of MDD than the general population

High comorbidity
MDD can be a result of altered neurotransmitter levels due to disordered eating
Altered neurotransmitter levels can lead to disordered eating
Seems to have some shared genetic component with MDD

About 50% of those with AN also have an anxiety disorder
Can be a physiological result of starvation, but typically, the anxiety disorder comes before AN appears

Anxiety disorders almost always precede BN
Most likely there are shared genetic factors between BN and anxiety disorders
Bingeing may have the effect of temporarily reducing anxiety

In patients with Bulimia Nervosa, Cluster B personality disorders tend to be the most common. These include, Antisocial, Borderline, Narcissistic, and Histrionic. Patients with Anorexia Nervosa commonly display at least features of either Cluster B, or Cluster C (Avoidant, Dependent, Obsessive-Compulsive).

Higher rate of substance abuse among ED patients than general population
No research backs up popular notion that ED’s are a form of addiction – they are more closely related to mood and anxiety disorders
All psychiatric diagnoses carry a higher risk of substance abuse
In some cases, substance use starts as part of a weight control effort (e.g. nicotine, caffeine, amphetamines, cocaine)

a. Fluids, electrolytes and kidneys: volume depletion, decreased chloride, increased bicarbonate, decreased potassium, and edema
b. Endocrine system: abnormal thyroid, abnormal hypothalamic-pituitary-gonadal axis, abnormal hypothalamic-pituitary-adrenal axis, abnormal menses, delayed puberty, growth retardation
c. Cardiovascular system: hypotension, bradycardia, congestive heart failure, EKG abnormalities, cardiomyopathy
d. Pulmonary system: pneumomediastinum, aspiration pneumonitis
e. Hematological system: anemia, leukopenia, thrombocytopenia, abnormal cytokines
f. Gastrointestinal system: salivary gland hypertrophy, hyperamylasemia, esophagitis, slowed gastric emptying, pancreatitis, constapation, cathartic colon
g. Bones and metabolism: Osteoporosis, decreased calcium, decreased phosphorous, decreased magnesium, increased cholesterol
h. Skin: hair loss, lanugo, dry skin, “Russel’s sign” (lesions on dorsum of hand)
i. Teeth: enamel erosion
j. Neurological system: enlarged ventricles, abnormal brain imaging studies, abnormal EEG

a. Diabetes – A warning sign is blood sugar that becomes erratic in a patient who had been well controlled. Some patients find that by letting their blood sugar run high, they can lose weight.
b. Cystic Fibrosis – Patients may omit enzymes in an effort to lose weight.
c. Crohn’s disease – Patients may omit steroids to keep weight under control

Physical exam and laboratory tests as appropriate
Comprehensive Psychiatric Interview
Eating Disorder Specific Questions
Nutritional evaluation

dieting history, exercise, current and history of other attempts to control weight, binge history

eating disorders

Self-Monitoring
Prescription of Regular Eating Patterns
Eliminating Dieting and Forbidden Foods
Teaching Problem Solving Skills
Cognitive Restructuring
Exposure/Desensitization to feared situations

Building alliance tends to take time
Giving rationale for restoring nutrition – motivational interviewing
Introduce experimental model of change
Meal planning/prescribing eating patterns
Behavioral interventions including relaxation training, and level system
Cognitive interventions

In BN, 70% see a reduction in bingeing and purging
In AN, no consistent benefit has been found

70% of BN patients treated with 60mg of fluoxetine (Prozac) saw a reduction in symptoms
Findings have been mixed for AN

BN – theory was that since anxiety triggers binges, anxiolytics would reduce bingeing – not supported!
AN – investigated use during “refeeding” – not effective, but did lead to abuse of the substances!

about as well as a placebo

Futility of purging methods
Complications of eating disorders
Ways to increase positive feelings about one’s body

Dietary fat is not immediately stored as body fat
Every calorie taken in does not have to be burned off by activity (education about basal metabolic rate)
Realistic estimates of nutritional needs