1

Eating Disorders

Based on DSM-IV-TR and APA Practice Guidelines unless otherwise

indicated. As of 1 Feb 2013.

2

Hormone

• Q. What human hormone signals the brain to cease eating? Where does it originate in the body?

3

Hormone

Ans. Leptin from fat cells signals the brain to cease eating.

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Hormone

• Q. What human hormone signals the brain to eat? Where does it originate?

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Hormone

Ans. Ghrelin from the stomach signals the brain to eat.

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Ghrelin in anorexia nervosa

Ghrelin level in anorexia nervosa?

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Ghrelin in anorexia nervosa

Ghrelin is usually highly elevated in anorexia nervosa.

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DX

• DSM-IV-TR criteria for anorexia nervosa?

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DX

• Ans.• 1] < 85% of expected weight• 2] Intense fear of gaining weight• 3] Disturbance is the way in which one’s body weight or

shape is experienced• 4] In women, amenorrhea for 3 consecutive months.• Two Types:• Restricting type: current episode with no binge

eating/purging.• Binge eating/Purging type: current episode with binge

eating/purging.

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Types - 1

Q. What are the two types?

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Types - 2

Ans:

• Two Types:

• Restricting type: current episode with no binge eating/purging.

• Binge eating/Purging type: current episode with binge eating/purging

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Cultural Impact

• Q. What cultural factors contribute to the prevalence of anorexia nervosa?

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Cultural Impact

Ans. More common in:

• Industrial societies

• Where food is abundant

• Where thinness is considered attractive

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Gender

• Ans. Percentage men?

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Gender

• 10 % are men.

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Prevalence/Age of Onset

• Q. Prevalence in the United States?

• Q. What is the age of onset?

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Prevalence/Age of Onset

• 0.5% in the US

• DSM-IV-TR: 14-18 years most common age of onset.

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“severe malnutrition”

Q. Definition of “severe malnutrition”?

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“severe malnutrition”

Ans. <70% standard body weight.

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Suicide

Q. What co-morbid psychiatric disorders increase chances of suicide in people with anorexia nervosa?

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Suicide

Ans. Substance-abuse/dependence.

[Independent of co-morbidity, there is at least one major report that has eating disorders as having the highest rate of suicides of any psychiatric disorder. So, depending on the wording of the question, “anorexia nervosa” may be the correct answer as to the psychiatric disorder with highest suicide rate.]

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Comorbidity

Q. Most common three comorbid psychiatric disorders, other than substance-related disorders, with eating disorders?

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Comorbidity

• Depression – 65%

• Social Phobia – 34%

• OCD – 26%

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Differential Diagnoses

• Q. List some of the more important differential diagnoses [other than the co-occurring just listed in the prior slides].

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Differential Diagnoses

• Bulimia Nervosa

• Medical Conditions like brain tumor or cancer

• Somatization Disorder

• Schizophrenia

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Levels of care

Q. In communities with comprehensive eating disorder programs, what are the five levels of care?

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Levels of care

Ans.

1. Outpt

2. Intensive outpt

3. Partial

4. Residential

5. Inpt

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Levels of care and weight

Q. While rigid rules as to weight are to be avoided, in general, for the five levels of care on the prior screen, what level of care suggests what level of care?

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Levels of Care - weight

Ans.

1. Outpt = >85% of desired weight

2. Intensive outpt = > 80% of desired weight

3. Partial = >75%

4. Residential = <85%

5. Inpt = <75%

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Hospitalization

• Q. Under what circumstances should someone with anorexia nervosa be hospitalized? List five.

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Ans. Hospitalization

Ans.

• 1] Rapid and persistent decline in weight despite outpt or partial hospitalization treatment.

• 2] Presence of additional stressors that lead to more inability to eat, e.g., a bad GI viral illness

• [see next slide]

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Hospitalization

Ans. continued.

• 3. Prior history of anorexia weight loss that led to instability.

• 4. Comorbid psychiatric illnesses that, given both, require hospitalization.

• 5. Comorbid somatic illnesses that, given both, require hospitalization.

• [Suicidal also might be an answer]

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General or Psych ward?

Q. When should you hospitalize pt on general medical ward? When on psychiatry ward?

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General or psych ward

Ans.

1. Depends on the skills of the two units.

2. Depends on how pressing are the pt’s non-psychiatric medical needs.

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Physical exam foci

Q. In doing the physical examination, what to focus on?

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Physical exam foci

Ans.

1. Dehydration

2. Acrocyanosis

3. Lanugo

4. Salivary gland enlargement

5. Russell’s sign

6. Sexual development in younger pts looking for less than expected development

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Acrocyanosis

Q. What is acrocyanosis?

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Acrocyanosis

Ans. Acrocyanosis is circulatory disorder in which the hands are cold and blue.

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Russell’s sign

Q. What is Russell’s sign?

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Russell’s sign

Ans. Abrasions or scars on the back of the hands. These suggest manual attempts at self-vomiting.

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Physical Exam

• Q. What physical examination findings suggests a need for hospitalization?

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Physical Exam

• Ans. Results that suggest hospitalization are:

• 1. P < 40

• 2. BP < 90/60

• 3. Temp < 97.0

• 4. Signs of dehydration

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Lab tests

• Q. Lab tests that suggest a need to hospitalize?

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Lab tests

Ans.

• Lab tests that suggest a need to hospitalized:

• 1. k < 3.0

• 2. electrolyte imbalance

• 3. Lab tests that suggest hepatic, renal or cardiovascular signs of deterioration.

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Hospital discharge andweight level

Q. What weight level can be the sole criterion for discharge from the hospital?

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Hospital discharge andweight level

Ans. Weight level should “never” be used as the sole criterion for hospital discharge.

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Essential on discharging

Q. What is essential to establish when the pt is discharge from the hospital?

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Essential on discharging

Ans. Discharge document should state where and when the pt will next be seen. {This answer will fit any discharge of any disorder as Joint Commission and CMS [Medicare] expect this continuity with all psychiatric discharges.}

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Partial program indications

Q. When are partial programs indicated?

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Partial program indications

Ans.

1. Need for structure to gain weigh

2. Need to prevent compulsive exercising

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Partial programs

Q. How intense, i.e., how many hours/week, should a partial program be?

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Partial program

Ans. At least five 8-hour days/week. So, a 40 hour week.

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Indications for residential program

Q. What are the indications for residential programs

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Indications for residential program

Ans.1. >75% and <85% desired weight [but some

flexibility on this requirement is desired]2. Medically stable, does not need IVs,

nasogastric feedings or multiple daily lab tests.3. Not planning suicide.4. Cooperative with highly structured program5. Needs close supervision of meals and exercise6. Can’t live at home for geographic reasons or

because of family conflicts.

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Complications

• List as many of the ten or so complications as you can, complications that are related to weight loss?

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Wt. loss related complications - 1

Ans.• cachexia, • prolonged QT interval, • PVC’s, • bloating, • constipation,• amenorrhea

• [see next slide]

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Wt loss complications - 2

• lanugo,

• leucopenia,

• zinc deficiency (abnormal taste sensation),

• osteoporosis

• sudden death

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Purging-related complications

• Q. Purging-related complications?

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Purging-related complications

Ans. • hypomagnesemia, • hypokalemic hypochloremic alkalosis, • salivary gland inflammation• pancreatic inflammation,• Amylase, • erosion of frontal teeth enamel, • seizures, • mild cognitive disorder

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Long range goals

Q. Long range treatment goals in the treatment of anorexia nervosa?

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Long –range Treatment Goals

Ans.

• 1] “healthy weight”

• 2] For females, weight at which menses and ovulation return.

• 3] For men, weight at which normal sex drives and testosterone return to normal level.

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Gender and therapist

Q. Should choice of therapist’s gender be an issue?

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Gender and therapist

Ans. Yes, it should be attended to in selecting health care clinician.

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Monitoring

Q. What should be monitored in eating disorder programs?

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Monitoring

Ans.1. Food intake2. Fluid intake and output3. Electrolytes, including phosphorus4. Edema5. Weight 6. Congestive heart failure7. Constipation and bloating

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Q. Weight gain goal while in hospital?

• Q. When hospitalized, what is a reasonable weight gain goal for most of the pts?

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Ans. Weight gain goal while in hospital

• 2-3 lbs/week

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Weight gain as an outpt

Q. What is the desired weight gain of a pt who is being treated as an outpt?

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Weight gain goalswhile an outpt:

Ans. ½ to 1 lb/week

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Nutritional needs

Q. In addition to a well balanced diet, what are the beginning kcal for a typical pt in treatment? What kcal for weight gain? What for weight maintenance?

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Nutritional needs

Ans. Begin at 30-40 kcal/kg/d [1,000 - 1,600 kcal] and increase periodically until the kcal/d leads to weight gain, usually means 70-100 kcal/day.

After desired weight is attain, 40-60 kcal/kg/d is the usual desired level.

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Supplements

Q. What supplements are used in eating disorder programs?

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Supplements

Ans.

1. Vitamins

2. Minerals, especially phosphorus

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Rapid weight gain

Q. Your pt gains weight very rapidly. What should be your concern?

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Rapid weight gain

Ans. Fluid overload.

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Suspected of over-hydration

Q. How to evaluate if you suspect your pt is over-hydrating?

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Suspected of over-hydration

Ans. At morning weighing, obtain urine sample and check for specific gravity.

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Persistent vomiters – lab test

Q. What lab test is recommended to identify persistent vomiters?

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Persistent vomiters – lab test

Ans. Obtain K+ level. It is often low with such pts, sometimes dangerously low.

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Physical activity

Q. With eating disorders, the level of physical activity, in general, should be?

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Physical activity

Ans. Physical activity should be consistent with food intake.

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Exercise program

Q. Once the pt weight has been achieved, what is the goal of an exercise program?

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Exercise program

Ans. The exercise program should be focused on physical fitness, not on expending calories.

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Treatments - 1

• Q. What is status of CBT, family therapy and psychodynamic therapy?

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Treatments - 2

• CBT – effective for weight gain

• Family Therapy – Often used

• Psychodynamic Therapy – not very successful due to resistance, but there are anecdotal reports of success. Also recent reports suggest psychodynamic psychotherapy can be useful in [see next screen]

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Treatments - 3

Continued on usefulness of psychodynamic, in addressing:

Transference

Symptom symbolism

Key conflicts

Narcissistic vulnerabilities

Relational dynamics

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Family therapy

Q. Under what circumstances should family therapy be considered

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Family therapy

Ans. While could be useful with anyone, it is especially likely to be helpful with children and adolescent pts.

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Olanzapine in anorexia nervosa

Use of olanzapine in anorexia nervosa?

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Olanzapine - 2

Olanzapine has been shown to be effective in raising the body mass index and reduce obsessionality, including obsessional thoughts about food. Olanzapine is one of the most potent appetite stimulants known, and causes the body to preferentially store fat. [next slide has references]

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Olanzapine -- references

• Brambilla, Francesca; Garcia, Cristina Segura; Fassino, Secondo; Daga, Giovanni Abbate; Favaro, Angela; Santonastaso, Paolo; Ramaciotti, Carla; Bondi, Emilia et al. (2007). "Olanzapine therapy in anorexia nervosa: psychobiological effects". International Clinical Psychopharmacology 22 (4): 197–204. doi:10.1097/YIC.0b013e328080ca31. PMID 17519642.

• ^ Bissada H, Tasca GA, Barber AM, Bradwejn J (2008). "Olanzapine in the treatment of low body weight and obsessive thinking in women with anorexia nervosa: a randomized, double-blind, placebo-controlled trial". The American Journal of Psychiatry 165 (10): 1281–8. doi:10.1176/appi.ajp.2008.07121900. PMID 18558642.

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Medications

Q. Name medications shown to reduce desire of these pts to lose weight?

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Medications - 2

Ans. There are no medications that have been shown to decrease the pt’s desire to lose weight.

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Nasogastric Feeding - 1

Q: Status of nasogastric feeding in pts with anorexia nervosa?

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Nasogastric feeding - 2

Ans. Pt refuses to eat and requires life-preserving nutrition.

Improved results when combined with CBT.

There are potential harms to nasogastric feeding, so not recommended for normal wait pts.

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Bulimia

Q. DSM-IV criteria?

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Bulimia

• DSM-IV:• 1] Recurrent binging• 2] Recurrent inappropriate compensatory

actions, such as self-induced vomiting• 3] Above two occur, on average, 2x/week for at

least 3 months• See next slide

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DX continued

• 4] self-evaluation is unduly influenced by body image

• 5] Above does not occur within episode of anorexia nervosa

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Types of bulimia- ?

What are the types of bulimia?

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Types of bulimia - answer

• Two types:

• Purging: current episode with regular self induced vomiting or use of laxatives, diuretics, and enemas.

• Non-purging: current episode using other means like fasting or exercise.

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Family therapy - 1

Q. Role of family therapy?

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Family therapy - 2

Ans. Valuable, especially for adolescents.

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Bulimia

• Q. What psychotherapies are recommended for bulimia?

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Ans. Psychotherapies for bulimia are

• 1. CBT has most evidence. If asked for “treatment of choice,” CBT is the correct answer.

• 2. Interpersonal has some evidence, a choice if CBT fails.

• 3. Psychodynamic therapy my be helpful once pt is improving.

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Preferred Class of medsfor bulimia?

Q. What is the preferred class of meds for bulimia?

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Meds for bulimia

Ans. SSRIs [fluoxetine is FDA approved]

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Meds - Bulimia

• Q. SSRI dosing with this disorder?

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Meds - Bulimia

• SSRIs are often prescribed at higher doses than with pts with MDD.

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Meds

• Q. What about TCAs for bulimia?

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Meds

Ans.

• Cautious because of suicidal potential with these pts.

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Meds for bulimia

• Q. What about MAOIs being used with bulimia?

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Meds -- MAOIs

Ans.

• Should be avoided because of the potential of binge eating.

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Meds - Bulimia

Q. What about Li with bulimia?

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Meds - Bulimia

Ans. Vomiting makes it difficult to maintain the desired blood levels.

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Meds for bulimia

Q. What about using bupropion?

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Meds - Bulimia

Ans. Don’t use bupropion because of increased chances of seizures.

[Some think this is not correct, but the above is still the answer usually expected.]

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Bulimia

Q. Highest remission rates in bulimia achieved with what treatment approaches?

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Bulimia

Ans. Highest treatment results achieved with combination of psychotherapy and meds. Nutritional counseling will be needed with some.

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Group therapy for bulimia

Q. What would be goal of group therapy for people with bulimia?

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Bulimia – Group Therapy

Ans. Probably has many uses given the pt’s needs. “To reduce shame” is probably a use that is appropriate for every pt.

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FDA approved for bulimia?

Q. FDA approved for bulimia?

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FDA approved for bulimia:

Ans. Fluoxetine

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Meds

• Q. What meds are recommended for weight restoration per se in eating disorders?

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Meds for weight restoration

Ans. None established for that specific purpose. But if the pt is also depressed, has OCD or another anxiety disorder, then, obviously, an SSRI would help the pt maintain their weight.

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Hospitalization - Bulimia

Q. Under what conditions should someone with bulimia be hospitalized?

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Hospitalization - Bulimia

Ans. Not a common need, but consider hospitalization when:

• 1] Disorder still at severe level after outpt treatment.

• 2] Pt has serious, concurrent general medical illness.

• 3] Suicidal• 4] Pt has another psychiatric disorder that

merits hospitalization on its own.

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Binge eating disorder essential characteristics - 1

Q: Essential features?

128

Essential characteristics - 2

Ans: Recurrent episodes of binge eating associated with subjective and behavioral indicators of impaired control over, and significant distress about binge eating AND

Lacking signs of bulimia.

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Treatment of binge eating disorder - 1

Q: Treatment?

130

Treatment – 2

Ans.

1.CBT, individually or group

2.Meds:

imipramine

citalopram/escitalopram

topiramate

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Binge Eating Disorder – meds - 1

Q: status of sibutramine?

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Bing Eating Disorder – meds - 2

Ans. Sibutramine has been withdrawn from US markets after FDA withdrew its approval.