Eating Disorders

Natalia Ortiz MD
Associate Professor of Clinical
Psychiatry
Lewis Katz-Temple University
Natalia.Ortiz@tuhs.temple.edu
 Eating Disorders

I declare that I have no personal nor

familial conflict of interest affecting this
lecture
 Eating Disorders
Objectives
 1. To identify the diagnostic criteria for
anorexia, bulimia nervosa and binge
eating disorder
 2. To identify the medical complications
associated with eating disorders
 3. To learn what are the effective
treatments used for eating disorders
 Anorexia Nervosa
 Diagnosis (DSM-V):

 Restriction of energy intake relative to requirements, leading to

significant body weight (age/sex/dev and health).

 Intense fear gaining w./ fat even though underweight.

 Body Image Disturbance: way bw/shape is experienced; bw

influence on self-evaluation or denial of seriousness of current
low BW.
 Anorexia Nervosa
 Types (sxs x past 3 months): restricting or
binging/purging.

 Severity: BMI(kg/m2)
• Mild >17
• Moderate 16-16.99
• Severe 15-15.99
• Extreme <15
 Anorexia Nervosa
 Body Image Disturbance:
 Of Perception: views selected body parts as unrealistic big.
Predictive of tx outcome.
 Of Cognition (dissatisfaction): w/ shape, - physical
appearance, thinness is 1ary source of value.
 Of Behavior: body image avoidance, “checking behavior”,
avoids anxiety about body (e.g. swim).

 Eating Behavior:
 Eats what is perceived as “safe, good” food.
 Rituals (to reduce anxiety): cutting food small pieces, mixing
foods, cover taste food w/ excess condiments; too slow/fast; w/
fingers, diluting, bread w/ fork.
 Anorexia Nervosa
Epidemiology
 Incidence: 10:1 per 100,000 (women:men/year in
western)
 Prevalence: 0.3-0.7 % young adult females

 Onset: early adolescence

 Course: 50 % full recovery, 30% partial; 20% chronic.
 10% in 10 y; 20% in 20 y: will die from medical

complications or suicide

 Mortality rate: 0.6 %/year

 Anorexia Nervosa
Etiology
 Genetics: 50 %
 Pre-morbid personalities: OCD, anxious, avoidant, perfectionist,
pleasers, avoid affects and risks, avoid conflict, prefer
predictable environments, ruminate, like routines, have
difficulties with change.
 Will like to stand out
 12 times more chance if mom/sister w/ AN

 Sociocultural: different ethnic and socioeconomic

backgrounds; more prevalent in western.
 Thiness ideal: self-control and power
 Medical Complications
 Nutritional Assessment:

 Body mass index (BMI) = weight (kg)/Height (m)2

• Normal range: 20-25
• Underweight: 17.5-20
• Anorexic <17.5

 % Expected body weight (EBW):

• Women: [100 lb. for 1st 5 feet + 5 lb./inch above 5 feet] +-
10%
• Men: [106 lb. for 1st 5 feet + 6 lb./inch above 5 feet]+-10%
 Medical Complications
 Endocrine: amenorrhea (low FSH, LH), osteoporosis (low estrogen/Ca),
euthyroid sick syndrome (T4 to T3), increase GH & cortisol, decrease ADH
secretion; infertility; cold int; large parotids.

 GI: constipation, int. diarrhea, small stomach,delayed g emptying; high

LFTs (fatty liver), gastric distention, h amylase, low albumin; low Zn & Mg;
high cholesterol
 CV: small L ventricle; low CO; bradycardia; hypotension; arrhythmias.

 Renal: high BUN, low GFR; edema; renal calculi; electrolytes’

abnormalities ( Na, K, phosphorus).
 Hemato: anemia, leukopenia, thrombocytopenia, lymphocytosis, low
complement; bm atrophy.
 Skin: carotenemia; lanugo; thin hair; dry skin.
 Neuro: “pseudoatrophy”; low production of NE and serotonin;
hypothermia.
 Anorexia Nervosa
DDx
 MDD
 Schizophrenia
 Medical:
malignancies, hyperthyroidism,
gastroparesis
 Treatment:
Re-feeding Process
 Avoid Bulimia Nervosa: 50 % pts AN
 Increase 2 lbs/wk
 Zn (100 mg/d), Ca (1g/day), MV.
 PO phosphate: avoid deficits.
 Monitor edema, vol.overload.
 Hormone replacement or OCP if <70% IBW w/ osteop.
 Psycho-education; see psychotherapies
 Check fears about food
 Dev. responses to hunger/satiety
 No psychopharmacology
 Bulimia Nervosa
 DSM-IV criteria:
A. Recurrent episodes of binge eating characterized by
both of the following:

A. Eating, in a discrete period of time (e.g. within 2

hr period), more than most people eat during
similar period and under similar circumstances.

B. A sense of lack of control over eating during the

episode.
 Bulimia Nervosa
DSM-V
B. Recurrent inappropriate compensatory behavior in order to
prevent weight gain (e.g. vomiting, laxatives, diuretics,
enemas), fasting or excessive exercise

C. Behaviors occur at least 1/wk for 3 months.

D. Self-evaluation influenced by body shape and weight

E. The disturbance does not occur exclusively during episodes of

anorexia nervosa
 Bulimia Nervosa
 Severity: (# episodes/week)
 Mild 1-3
 Moderate 4-7
 Severe 8-13
 Extreme 14 or more
 Bulimia Nervosa
 Epidemiology: (pre) 1-3 % of young women;
(in) 15 women:0.5 male per 100,000/year.

 Etiology:

 Serotonin and norepinephrine

 Endorphin: high in purging type
 High achievers, respond to social pressure
 Many are depressed and have family hx of
depression; higher conflict in families
 More angry and impulsive than A.N
 Bulimia Nervosa
Personality Traits
Difficulty w/ trust (few relationships), lack of
boundaries
• Shoplifting, drugs and alcohol dep, emotional
lability, self-destructive sexual behaviors
• Ego-dystonic binging
• Difficulties separating from caretakers (absence of
transitional objects during child.)
 Binging: wish fuse with caregiver
 Purging: wish separation
 Bulimia Nervosa
 Behaviors:

 Binge: not chewed (fast), dissociative, sweets

 Compensatory behavior: decreases guilt, anxiety, sadness,

bloated sensations and fear of wt gain after binge.

 Weight is variable, usually normal

 Can have other eating behaviors: struggle w/ meal (rituals), pica

 Bulimia Nervosa
Medical Complications
Hypokalemia
 Hypochloremic alkalosis, hypomagnesemia
 Gastric and esophageal tears (rare)
 Cardiomyopathy: ipecac
 Cardiac arrhythmias
 Hyperamylasemia, GI obstruction, gastroparesis, GI bleed,
erosions, ulcers
 Peripheral edema, renal failure
 Irregular menstruation
 Hypotension and bradycardia at times
 Starvation might be not obvious
 Caries
 Russell’s sign
 Bulimia Nervosa
 Comorbidities:

 Mood d/o
 Anxiety d/o
 Substance-related d/o
 Personality d/o
 Impulse control d/o
 Dissociative d/o
 Bulimia Nervosa
 Differential Dx:

 AN purging type
 CNS tumors
 Kluver-Bucy syndrome: visual agnosia, compulsive
licking and biting, examination of obj with mouth,
inalibity to ignore any stimulus, placidity, altered
sexual behaviors and dietary habits (high).
 Klein-Levin syndrome: hypersomnia (2-3 wks) and
hyperphagia; men>women; adolescents
 Borderline: can binge eat
 Bulimia Nervosa
Course and Prognosis

 Course: variable

 If Tx: 50% improvement, 30% (p), 20 % (c)

 Waxing waning

 Hospitalized pt: 1/3 doing well after 3 years, > 1/3 some
improvement, 1/3 poor (chronic)
 Prognosis dep. On medical complications
 Bulimia Nervosa
 Treatment:

 Psychotherapy: individual w/ CBT; group; family tx

 Identify and tx comorbidities
 Inpt: if med complications or psych dangerousness.

 CBT:
• Identify thoughts, feelings and behaviors leading to
sxs
• Behavioral contract to control those
• Splitting of food: bad food is vomited
 Bulimia Nervosa
Treatment
 Medications:

• Ssris e.g. fluoxetine 60-80 mg

• Imipramine, desipramine, trazodone and maois:
helpful
• Carbamazepine, li: can help comorbidities only
• Naltrexone (200-300 mg/day)
• Ondansetron (24 mg/day in 6 doses)
 Binge Eating Disorder
(DSM-V)
 A. Recurrent episodes of binge eating:
 Short time, large meal
 Lack of control

 B. Episode associated with at least 3:

 Faster than normal
 Uncomfortably full
 Large meal when not hungry
 Alone since embarrassed
 Disgusted about self, depressed or guilty afterwards
 Binge Eating Disorder
(DSM-V)
 C. Marked distress regarding binge eating
 D. Episodes 1/wk x3 mo.
 E. No use of compensatory behaviors. Not part
of A. N. or B.N.
 Binge Eating Behavior
 Severity: (#episodes/wk)
 Mild 1-3
 Moderate 4-7
 Severe 8-13
 Extreme 14 or more
 Binge Eating Disorder
 Characteristics:

 10 % with Hx of BN
 Prevalence: 2 % women, 0.8% male
 ¼ of obese pts have BED
 Usually presents for tx in the 40’s
 Emotional eating

 Risk factors: parental dep; obesity; exp. – comments

shape/ w and eating.

 Comorbidities: anxiety, depression; DM, HTN,

hyperlipidemia, sleep apnea, CAD
 Eating disorders and trauma
 To numb feelings by binging or starving

 To cleanse themselves by purging

 To punish self by starving

 Treatment eating disorders
 Psychotherapy:

 Family Therapy
 Interpersonal Psychotherapy
 Cognitive Behavioral Therapy
 Group Therapy
 Exercise Therapy
 Psychodynamic Psychotherapy
 References
 References:
 1.APA Publishing DSM-5. 2013.
 2. Briber, S; Leavy, P; Quinn, C.E.; Zoiro, J. “The mass
marketing of disordered eating and eating disorders: The
social psychology of women, thinness and culture.
Women’s studies international forum. Vol. 29(2). Mar-Apr
2006, 208-224. (PsycInfoHesse Ovid)
 3. Gardfinkel, P.E., Garner, D.M. Handbook for treatment
of eating disorders. 1997. 2nd edition. Gulford Press.
 References
 4. Kaplan H.I. and Sadock, B.J. Comprehensive
Textbook of Psychiatry. “Eating Disorders”. 9th edition,
2009. (R2 online, Temple School of Medicine”.
 5. Mitchell, J. E.a; Crow, S.b. “Medical complications of
anorexia nervosa and bulimia nervosa”. Current opinion
in Psychiatry. 19(4): 438-443, July 2006. (Journals Ovid
Full Text).
 6. Soderster, P; Bergh, C; Zandir, M. “Understanding
eating disorders”. Hormones and behavior. Vol. 50(4).
Nov. 2006, 572-578. (PsycInfo Ovid).