HM Medical Clinic


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,