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Microsoft powerpoint - eating disorders2006
Chisoo Choi, M.D. Brookhaven Hospital
"There were times I felt fat. I had a distorted image of myself" Ana Carolina Reston
Learning Objectives Diagnostic criteria Differential diagnosis Medical consequences Treatment approach Psychotropic medications
Learning Objectives Identify 3 major types of eating disorders List the diagnostic criteria for each Determine the healthy weight & BMI Discuss the bio-psychosocial etiology of Identify the medical consequences Discuss the treatment approaches Understand the appropriate use of psychotropic medications
Anorexia Nervosa: History "Nervous loss of appetite" a misnomer Refusal to maintain adequate body weight Followers of St. Jerome starving ca. 900 AD Saint Catherine of Sienna, Italy had anorexia Richard Morton: "A Nervous Consumption" in his 1689 textbook, A Treatise of Consumption Sir Wm Gull in 1874 paper, coined the term "Anorexia Nervosa" Schilder: "Body Image" Anorexia Nervosa: History Hilde Bruch, M.D.
Eating Disorders: Obesity, Anorexia Nervosa & the Person Within (1973) The Golden Cage: The Enigma of Anorexia AN: relentless pursuit of excessive thinness; self-starvation=struggle for autonomy, competence and self-respect Body image disturbance Interoceptive disturbance: misinterpretation of internal sensation like hunger Feelings of ineffectiveness & loss of control Anorexia Nervosa (307.1) Bulimia Nervosa (307.51) Binge Eating Disorder (307.50) Anorexia Nervosa: Diagnosis Refusal to maintain adequate weight: less than 85% of ideal body weight Intense fear of weight gain Body-image distortion: "feels fat" even when obviously under weight Amenorrhea for 3 cycles 2 types: restricting, purging Ideal Body Weight Women: 100 Lbs for 5 ft height; add 5 Lbs for each additional inch Men: 106 Lbs for 5 ft height; add 6 Lbs for each additional inch BMI (Body Mass Index)= wt/ht2 in Kg/m2 Anorexia (85% 0f IBW) < 17.5 Conversion formula: wt (Lbs)/ ht2 (inches) x 703 Bulimia Nervosa: Diagnosis Binge eating: > twice a week for 3 months Eating large amount & sense of lack of control over eating Purging: vomiting, laxatives, diuretics, excessive exercise to prevent weight gain Preoccupation: with body size, shape Self-evaluation: unduly influenced by body shape / weight 2 types: purging, non-purging Binge Eating Disorder: Diagnosis Binge eating with lack of control At least twice weekly for 6 months Marked distress regarding binging Other symptoms: Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts when not hungry Eating alone because of feeling embarrassed about eating Feeling disgusted, depressed or guilty after eating Anorexia Nervosa: Epidemiology Onset: bimodal (age of puberty 12-15 and late teen - early 20's) 0.5% of adolescent females in US No racial differences Worldwide phenomenon (not just Western) Bulimia Nervosa: Epidemiology Onset: late teens – mid-20's 1 – 5% of adolescent females in US Eating Disorders in Men Higher prevalence of homosexuality among men with eating disorders Less co-morbid depression / anxiety than Higher prevalence of alcohol dependence Lower rate of sexual abuse than women Body image distortion is different in men Body Image Distortion "Missing America" a study by Johns Hopkins School of Public Health BMI (body mass index) of Miss Americas from 1920 –1999. (Normal= 19 – 25) "At this rate, the BMI of Miss America could reach zero in about 320 years…" Times Magazine, April 3, Anorexia Nervosa & Bulimia: Etiology Twin of a woman: odd ratio 10.7 for AN, 9.0 for BN Human Genome Project: no specific gene defect found yet; AGRP (Agouri-related protein): a chemical messenger to stimulate appetite, in chromosome 16, was defective in 11% Brain Biochemistry / Neurotransmitters Decreased 5-HIAA (serotonin metabolite) & MHPG (NE metabolite) in CSF of women with AN & BN Tryptophan (precursor of serotonin) - free diet caused lowering of mood, sense of loss of control in eating among bulimics: decrease in serotonin activity may trigger cognitive and mood disturbances associated with BN Anorexia Nervosa & Bulimia: Etiology Anorexia Nervosa & Bulimia: Etiology Family Dynamics Mothers are often blamed: seen as dominating & powerful Fathers are noted to be distant, withholding affection especially as the girl matures Chaotic family dynamics: unresolved conflicts and rigid coping skills and communication forms: Dinner table and food become the battle ground for parental conflict Lack of healthy parental model of effective use of assertive methods of expressing anger (one tend to be aggressive while the other passive or passive-aggressive) Parental pressure to lose weight at young age Childhood sexual abuse & incest Anorexia Nervosa & Bulimia: Etiology Personal development issues Psychoanalytic theory (not helpful): AN is a defense against development into a mature and sexual women. BN: binging is oral equivalent of impregnation desire, and purging the repudiation of this unwanted conflict Psychological development (Dr. Hilde Bruch): AN: Powerlessness & Perfectionism BN: Deprivation & Dependency ("Emptiness inside") Societal Factors "Biggest disease is feeling unwanted. People need to be loved. Without it, they die" Anorexia Nervosa: differential diagnosis Affective disorder: depression, bipolar Personality disorder: Schizophrenia (paranoid delusion) Anxiety disorders, OCD (food rituals) Stimulant abuse (cocaine, methamphetamine, caffeine, Ritalin) Medical disorders (hyperthyroidism, neoplasm, diabetes, mal-absorption, chronic infection incl. AIDS, TB) differential diagnosis Affective disorder: depression, bipolar Personality disorder Anxiety disorders, OCD Medical disorders (severe GERD, PUD, delayed gastric emptying, diabetic gastroparesis, malabsorption, GI tumor, brain tumor, severe vertigo, migraine headache, medications including cancer chemotherapy, hypothyroidism, acute febrile illness and chronic infections) Anorexia Nervosa: medical consequences Low BP, HR, cardiac output, syncope Endocrine changes (amenorrhea, low E , FSH, LH = return to pre-pubertal state, lanugo hair, osteoporosis) Anemia, leukopenia, thrombocytopenia Delayed gastric emptying ("shrinking" of stomach) Dehydration, constipation Fatty liver changes (elevated liver enzymes) medial consequences Parotid gland hypertrophy ("chipmunk face") Dental enamel loss Esophagitis, gastritis, Mallory-Weiss tear, esophageal rupture Severe hypokalemia, cardiac arrhythmia Metabolic alkalosis (due to vomiting & laxative abuse) Aspiration pneumonia Cardiac failure (with use of ipecac syrup) medical consequences Diabetes mellitus Leg edema, possibly CHF Osteoarthritis (knees, lumbar spines), ataxia & falls Hyperlipidemia, with increased risk of ASHD, CVA Obstructive sleep apnea Daytime hypersomnolence "Pickwickian Syndrome" Hypoventilation, COPD Multifactorial Treatment Approach: Anorexia Nervosa & Bulimia Nervosa Nutritional support (malnutrition, dehydration) Caloric needs: 15 Kcal/Lb of IBW (for 5'5" women, IBW is 100 + 5 x 5 = 125 Lb, and 15 x 125 = 1875 Kcal) Nutritional knowledge is frequently poor & distorted Hypokalemia, delayed gastric emptying, nausea, purging, esophagitis, gastritis, constipation, laxative abuse Psychological issues Depression, anxiety, denial, distorted body image, low self-esteem, self-abusive behavior Cognitive behavioral therapy & Psychotropic medications Psychotropics: SSRI Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro) All block reuptake of 5-HT Fewer side effects compared to TCA, MAOI Be careful when treating children Psychotropics: SSRI Fluoxetine Bulimia Nervosa Collaborative Study Group 387 patients with bulimia nervosa were divided to 3 groups (placebo, 20mg or 60mg Fluoxetine) Fluoxetine was effective in reducing the episodes of binge eating & purging.
High dose (60mg) group showed better response than low dose (20mg) group. Archive of General Psychiatry 1992 Psychotropics: others Nefazodone (Serzone) Venlafaxine (Effexor) Duloxetine (Cymbalta) Bupropion (Wellbutrin, Wellbutrin SR) Mirtazapine (Remeron) Olanzapine (Zyprexa) Topramate (Topamax) Nefazodone (Serzone) Blocks post-synaptic 5-HT receptor which causes potentiation at 5-HT receptor (to improve depression & anxiety) No clinical trials for eating disorder Warning: rare risk of hepatic failure Not popular (no longer listed on PDR) Venlafaxine (Effexor) Dual action antidepressant (5-HT & NE) Inhibits reuptake of serotonin & norepinephrine at presynaptic transporter sites, increasing 5-HT & NE at post-synaptic receptors Effexor XR (Extended Release Capsule) Elimination T1/2 : 5hr (V), 11hr (ODV) A small study of patients with AN: improved BMI from 15.7 to 18.3 in 6 mo.
Duloxetine (Cymbalta) Dual action antidepressant (5-HT & NE) May help reduce painful physical as well as emotional symptoms of depression Safer than TCAs (like Amitriptyline) but with similar analgesic effects? Watch for hepatotoxicity Bupropion (Wellbutrin) Antidepressant with actions on NE & D 1988 multicenter study for bulimia nervosa Bupropion was effective in reducing binging & Increased risk of seizure* in bulimic patients (seizure rate 5.8% vs 0.4% non-bulimics on Tx) Bupropion is relatively contraindicated in patients with bulimia or anorexia* Mirtazapine (Remeron) Antidepressant increases serotonin by blocking post-synaptic Anxiolytic effect (like Nefazodone) No headache / GI side effects (binds 5-HT ) Antihistamine effect (sedation, weight gain) Olanzapine (Zyprexa) Atypical antipsychotic Binds to post-synaptic 5-HT & D Side effects: weight gain, possibly diabetes Topiramate (Topamax) (gamma-amino-butyric No side effect of increased appetite (often causes weight loss) Particularly useful for bulimia nervosa & binge eating disorder Bruch, H. (1973). Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. New York, Basic Books Bruch, H. (1978). The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, MA, Harvard University Press Gross, M. (1982). Anorexia Nervosa. Lexington, MA, Collarmore Press Garner, D.M., & Garfinkel, P. (1997) Handbook of Treatment for Eating Disorders, 2nd ed. New York, Guilford Press Sobel, S.V. (2004) Eating Disorders. Sacramento, Chisoo Choi, M.D. Brookhaven Hospital
J Arch Mil Med. 2015 August; 3(3): e30057. DOI: 10.5812/jamm.30057 Published online 2015 August 24. Assessment of Consensus-Based Pharmacological Therapies in Irritable Seyed Reza Abtahi 1,*; Parvin Zareian 11Department of Physiology and Pharmacology, School of Medicine, AJA University of Medical Sciences, Tehran, IR Iran*Corresponding author: Seyed Reza Abtahi, Department of Physiology and Pharmacology, School of Medicine, AJA University of Medical Sciences, Tehran, IR Iran. Tel: +98-2188337909,