Lesson 4

Roadmap
 Anorexia Nervosa  Diagnosis

 Bulemia Nervosa 
Epidemiology
 Binge-eating disorder
 Medical risks
 Obesity
 Etiology
 Treatment

 prognosis
Risk Factors for EDs
 Perfectionism for AN
 Early Puberty
 Failed attempts to lose weight
 Athletics
 Beginning a diet
 Family history of eating disorder, substance abuse or
mood disorder
Diagnosis AN (DSM-5):
 Restriction of energy intake relative to
requirements leading to a significantly low body
weight in the context of age, sex.
 Intense fear of gaining weight or becoming fat,
or persistent behavior that interferes
with weight gain.
 Disturbance in one's body weight or shape ,
persistent lack of recognition of the seriousness
of low body weight
 Specif y:

 Restricting type
 Purging type/Binge Eating.
Subtypes AN (DSM-5):

Restricting Type: during last 3months, the person has

not engaged in recurrent episodes of binge eating or
purging behavior
Binge-Eating/Purging Type: during last 3 months, the
person engaged in
recurrent episodes of binge eating or purging behavior
Epidemiology:
 Life
0.5- 3.7%
time prevalence
0.5- 1%
 Girls from 14- 18ys
30 - 50%
 A N and BN 3-8%
 Death
10-30years.
 Age:
Sp. After stress
 Risk : 1: 20
 M:F ratio modeling –
ballet dancers.
 I n professions
Medical Complication
 Death (hypokalemia , starvation, sudden cardiac death)
 Hypometabolic state (bradycardia, hypotension, hypothermia)
 Dehydration
 Arrhythmia, heart failure.
 Bone loss
 Peripheral edema
 Delayed sexual maturity
 Hair loss, brittle hair, Lanugo.
 On recovery: Re-feeding syndrome
Etiology

(kristinaschwerin
et.al.2010)
Eating Disorder Inventory (EDI)
 The EDI is a 64 item, self-report for the
assessment of psychological and behavioral traits
common in anorexia nervosa (AN) and bulimia.
 EDI consists of eight sub-scales measuring: 1)
Drive for Thinness, 2) Bulimia, 3) Body
Dissatisfaction, 4) Ineffectiveness, 5)
Perfectionism, 6) Interpersonal Distrust, 7)
Interoceptive Awareness ,8) Maturity Fears
Anorexia Nervosa: Treatment
 Determine inpatient vs. day treatment vs. outpatient
 Multidisciplinary teams are ESSENTIAL!
 Primary care provider
 Psychiatrist
 Individual therapist
 Family therapist
 Nutritionist

 1st: weight restoration

 2nd: psychological
 3rd: maintinance (long-term)
Medical Admission Criteria
 <75% ideal body weight
 Hypothermia T<36
 Bradycardia HR<50 while awake, <45 asleep
 Orthostasis-drop in sbp >10, increase in
HR>35
 Dehydration
 Severe hypokalemia (<2-3 mmol/L) or other
electrolyte abnormality
 Acute medical complication
 Severe depression/suicidality– Psychiatric
admit
 Refractory to outpatient treatment
Anorexia Nervosa: Therapy
 Best
evidence is for family-based treatment
(Maudsley approach)
 Who: younger patients who live at home, intact
family
 Philosophy: no-blame, family did not cause anorexia;
family is the best resource to help her get better
 Elevate family’s anxiety about the gravity of the illness.
Empower parents to do whatever they need to do to get the
anorexic to eat. Align siblings with the patient for
support. Externalize the anorexia.
 “Family Meal”
 O n ce weight-restored:explore the family dynamics and
psychological issues.
Anorexia Nervosa: Medications
 No approved medication treatments for Anorexia Nervosa

 Prozac (or other SSRI) for co-morbid depression or anxiety

 Low-dose Atypical Antipsychotics off-label for near-

psychotic thinking that is characteristic of anorexia,
Zyprexa may help with weight gain
- problem: informed consent for risks of weight gain
ANOREXIA NERVOSA
Prognosis:
 40% → recover.

 30% → continue with milder

course.
 30% chronic cases.
Risk of death
→  Suicide
Cardiac arrest
Malnutrition

 > 3 years of illness: prognosis is poor

Diagnostic Criteria for Bulemia Nervosa DSM-5
 A . Recurrent episodes of binge eating:
(1) Eating large amount in a discrete period of
time
(2) lack of control over eating
B. Recurrent compensatory behavior in order
to prevent weight gain.
C. Binge eating and inappropriate compensatory
behaviors is at least once a week for 3 months.
Bulemia: Epidemiology
 Lifetime Prevalence
 1.5% women
 0.5% men

 Prevalence of binge-purge behaviors:

 13% girls
 7% boys
Bulemia: Etiology

Family dynamics

Individual
Temperament
(ie. impulsive)

Societal, cultural

Media factors biological

Medical Complication
 Electrolyte abnormalities
 Dental – loss of enamel, chipped teeth, cavities
 Parotid enlargement
 Conjunctival hemorrhages
 Calluses on dorsal side of hand (Russel’s sign)
 Esophagitis

 hematemesis
 Latxative-dependent: cathartic colon, melena, rectal
prolapse
Bulemia: Treatment
 Multidisciplinary team
 Primary care provider
 Psychiatrist
 Family therapist
 Nutritionist
 Evidence based : CBT + Antidepressant
(SSRI)
Bulemia: Treatment (Therapy)
 Family therapy is a good option if patient is young
and still lives at home (But not as much evidence as
for Anorexia)
 Interpersonal therapy (IPT) (short-term treatment
focused on life transitions)
 Psychodynamic Psychotherapy (good for long-term
results in people with chronic depressive and
personality symptoms)
 Nutrition plan, exercise, physical activity
Bulemia:
 High-dose Fluoxetine/Prozac (SSRI) – very good
Medicaions
evidence!
 Sertraline/Zoloft (SSRI) – some good evidence
 Buproprion/Wellbutrin (other antidepressant)
– contraindicated! (risk of seizures if history of
purging)
 Topiramate/Topomax (mood stabalizer,
promotes weight loss) – some good evidence, but
use with caution esp if low-weight
Bulemia: Prognosis
 33% remit every year
 But another 33% relapse into full criteria
Adolescent-onset better prognosis than adult-onset
 Death-rate = 1%
Binge Eating Disorder
Binge Eating Disorder- Diagnosis
Also needs 3 of the following:
 Eating much more rapidly than normal
 Getting uncomfortably full
 Large
amounts of food when not physically
hungry
 Eating
alone because embarrassed about how
much one is eating
 Feelingdisgusted with oneself, depressed, or
guilty when over-eating
DSM-5 Diagnostic Criteria for Binge Eating
Disorder
 Eating, in a discrete period of time , large amount
 Lack of control over eating during the episode
 B i n geeating occurs, on average, at least once a week
for three month
Binge Eating Disorder:
Epidemiology
 Most common eating disorder
 Lifetime prevalence:
 3.5% women
 2% men
Binge Eating Disorder:
Treatment (Medication)
 SSRI
 h i gh dose reduces binge behavior short-term
 but doesn’t help weight loss

 Topomax, Zonisamide (anticonvulsants, mild

mood stabalizer)
 Helps binge reduction
 Helps weight loss
 Caution for adverse effects, high discontinuation
rates
Binge Eating Disorder:
Treatment (Therapy)
 Therapies either prioritize…
 Weight loss
 Binge-reduction

 Neither (ie. relationships, depression etc)

 G ro u p psychotherapy
 T h e re
is little evidence that obese individuals who
binge should receive different therapy than obese
individuals who do not binge
Any questions?
 Heba Essawy MD
Website www. Hebaessawy.com
Facebook Dr.heba essawy
Email essawi_h@yahoo.com