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

Source: http://www.brookhavenhospital.com/files/2011/09/eating-disorders.pdf