800-767-4411 welcome rogers treats children, adolescents and adults with: anxiety disorders eating...
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800-767-4411rogershospital.org
Welcome
Rogers treats children, adolescents and adults with:• Anxiety disorders• Eating disorders• Mood disorders• Substance use disorders
Eating Disorders:An Overview
Brad E.R. Smith, M.D.Medical DirectorEating Disorder ServicesRogers Memorial Hospital
Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Other Specified Feeding or Eating Disorder– Atypical anorexia nervosa, bulimia with low frequency, binge
eating with low frequency, purging disorder, night eating disorder
• Unspecified Feeding or Eating Disorder
Illness, Not Choice
• Combination of longstanding behavioral, emotional, psychological, interpersonal, biological and social factors.
• Natural size and shape largely determined by genetics, so fighting that can lead to unhealthy practices.
• 20 million women and 10 million men suffer from clinically significant eating disorder at some time in their life.
• Highest mortality rate of any psychiatric disorder
Anorexia Nervosa: Criteria (DSM-5)
• Restriction of energy intake relative to requirements, leading to significantly low body weight
• Intense fear of gaining weight or becoming fat, even though underweight
• Disturbed way in which body weight or shape is experienced, undue influence of weight on self-evaluation, or denial of seriousness of low weight
Anorexia: Subtypes
• Restricting type: no binge eating or purging behavior (purge is vomiting or misuse of laxatives, diuretics, enemas) in past 3 months
• Binge-eating/purging type: regularly engaged in binge-eating or purging behavior in past 3 months
Anorexia Severity Specifiers
• Mild: BMI less than or equal to 17
• Moderate: BMI between 16 and 16.99
• Severe: BMI between 15 and 15.99
• Extreme: BMI less than 15
Anorexia: Demographics
• Prevalence: 0.4% of late adolescent to early adult females meet full criteria. Subthreshold rates higher. Limited data in male populations.
• Age of Onset: mean is 17 y.o., possibly bimodal at 14 and 18 y.o.
• Mortality: 5% per decade
Anorexia: Etiology/Course
• Often begins after stressful life event (transition to college)
• Recovery after single episode, fluctuating course of recovery and relapse, chronic deterioration over years
• Increased risk among first degree biological relatives with Anorexia Nervosa and mood disorders
• Increased risk in occupations/avocations that encourage thinness: modeling, elite athletes, dancing
Anorexia: Medical Complications
• Whole Body: low weight, dehydration, hypothermia, cachexia, weakness, fatigue
• Cardiovascular: palpitations, lightheadedness, dizziness, weakness, SOB, chest pain, cold extremities, bradycardia, orthostatic, weak pulse
• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, neuropathy
• Endocrine: fatigue, cold intolerance, diuresis, hypothermia
Anorexia: Medical Complications, cont.
• GI: vomit, pain, bloating, constipation, distension with meals, parotid swelling, dental caries, diarrhea
• GU: changes in urinary volume
• Hematology: fatigue, cold intolerance, bruising
• Immune: low white blood cells, reduced febrile response to infections
• Integument: changes in hair, hair loss, dry/brittle hair, yellow skin, lanugo, acne
• Muscular: weakness, aches, cramps, muscle wasting
• Pulmonary: reduced aerobic capacity, wasting of respiratory muscles
• Reproductive: arrested development of sex characteristics and psychosexual maturation, loss of libido, loss of menses, regression of sex characteristics, fertility problems, pregnancy complications
• Skeletal: bone pain, short stature and arrested skeletal growth, osteopenia, osteoporosis
Anorexia: Medical Complications, cont.
Bulimia Nervosa: Criteria (DSM-5)
• Recurrent binge eating episodes– Eating large amount in period of time compared to normal
– Sense of lack of control during episode
• Recurrent compensatory behavior to prevent weight gain (vomiting, laxatives, diuretics, enemas, meds, fasting, overexercise)
• Once per week for three months
• Self-evaluation unduly influenced shape, weight
• Not exclusively during anorexia
Bulimia: Severity Specifiers
• Mild: 1-3 episodes of compensatory behaviors per week
• Moderate: 4-7 episodes of compensatory behaviors per week
• Severe: 8-13 episodes of compensatory behaviors per week
• Extreme: 14 or more episodes of compensatory behaviors per week
Bulimia: Demographics
• Prevalence: 1-1.5% in adolescent and young adult females, 0.1-0.3% in males. Subthreshold symptoms higher.
• Age of Onset: late adolescence or early adulthood
• Mortality: 2% per decade
Bulimia: Etiology/Course
• Often begins during or after dieting
• Chronic or intermittent
• Increased risk if Bulimia Nervosa, a mood disorder, or substance abuse in relatives
• Cross-over to Anorexia Nervosa: 10-15%
Bulimia: Medical Complications
• Cardiovascular: weakness, palpitations, arrhythmias
• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, peripheral neuropathy
• GI: heartburn, reflux, blood in vomit, pain, constipation, bloating, gastric or esophageal rupture, perforation, enlarged salivary glands, esophageal erosions, pancreatitis, colonic dysmotility
• Integument: scarring on dorsum of hand (Russell’s sign), petechia, conjunctival hemorrhages after vomit
Bulimia: Medical Complications, cont.
• Metabolic: weight fluctuations, muscle cramping, pitting edema
• Muscular: weakness, myopathy (worst in ipecac users)
• Oropharyngeal: dental decay, pain in pharynx, swollen cheeks and neck, dental caries
• Reproductive: fertility problems, spotty menstrual periods
• Skeletal: bone pain, arrested skeletal growth, osteopenia or osteoporosis
Binge Eating Disorder: Criteria (DSM-5)
• Recurrent episodes of binge eating
• 3 or more: eat more rapidly, uncomfortably full, large amounts despite no hunger, eating alone due to embarrassment, disgusted with oneself/depressed
• Marked distress
• 1 day/week for 3 months
• No use of compensatory behaviors
Binge Eating Disorder: Severity Specifiers
• Mild: 1-3 episodes per week
• Moderate: 4-7 episodes per week
• Severe: 8-13 episodes per week
• Extreme: 14 episodes per week
Binge Eating Disorder: Demographics
• Prevalence: 1.6% females, 0.8% males
• Age of onset: late adolescence or early adulthood
Binge Eating Disorder: Etiology/Course
• Dieting often follows onset of illness
• Remission rates higher than Bulimia or Anorexia
• Cross-over to other eating disorders not as common
• Increased risk for obesity and associated complications
Co-morbid disorders in eating disorder patients
Depression 70% life time prevalence
Anxiety63% life time prevalence
40% OCDSocial phobia 20%
Alcohol abuse and/or dependence
Anorexia Nervosa 17%Bulimia Nervosa 46%
Posttraumatic stress disorder 13%
Substance Use Comorbidity
• Anorexia: estimates vary between restricting type vs binge/purge type, lower than BN and BED
• Bulimia Nervosa: 22.9% have alcohol abuse
• Binge Eating Disorder: 57% males and 28% females with lifetime substance abuse
• Associated with higher rates of impulsivity---shoplifting, self-injury, suicidal behaviors, laxative abuse
• Holderness et al, 1994 indicated 50% of ED patients had some form of substance abuse/dependence compared to 9% of general population
Suspected Eating Disorder?
• Any signs of the medical complications listed previously
• Significant weight changes
• Family reports
• Behaviors
What to Look for:
Behaviors
• Obsessively counting calories/nutritional content
• Cutting food into small pieces, hiding food, unusual combinations of condiments
• Gum, ice, candy
• Loose clothing
• Bathroom during or after meals
• Long time to eat
How to Approach
• Express concerns in non-judgmental way
• Offer information on illness/complications
• Avoid “triggering” terms – fat, healthy, better
• Ask open-ended questions
Choice
• Developing an eating disorder is not a choice….recovery is
Treatment: Levels of Care
• Comprehensive team: therapists, dietitian, primary care physician, psychiatrist
• Outpatient
• Intensive Outpatient
• Partial Hospital Program
• Residential Treatment Center
• Inpatient – ED Hospital– Medical/Surgical Hospital
Treatment: Types of Interventions
• Nutritional rehabilitation
• Psychotherapy– Individual, group– CBT, DBT, IPT, psychodynamic, family
• Medications– Antidepressants– Antipsychotics– Anxiolytics– Topiramate
Treatment: Efficacy
• Early intervention has best success– 70% of adolescents who received treatment had full
recovery at 5 yrs
• Adult hospitalized patients 4 yrs later – 44% good outcomes– 28% intermediate– 24% poor– 5% died
Drawing from other fields
• Community support
• Peer support (12 step programs)
• Transitional living
• Group homes
• Using legal system
• Earlier recognition
Resilience for Recovery
• Optimism
• Facing fear
• Moral compass, ethics, and altruism
• Spirituality and religion
• Social support
• Role models
• Training: physical health
• Brain fitness
• Cognitive and emotional flexibility
• Meaning, purpose, growth• Steven Southwick, M.D. and Dennis Charney, M.D.
Male Case Example
• 36 y.o. P.A. ---health care professional
• Started in HS, first admitted in past year---denial, covering up, deceit
• Going through divorce---high impact on family
• Lost job---high impact on work
• Wife wanted another child---testosterone level low
• Restricting primarily----a man restricts
• Started out trying to eat healthy for sports---slippery slope
• 5’11” admit weight 103 (BMI 14.5)---thinks he is overweight
Male Case Example (cont’d 1)
• Mood down---deficiency in protein leads to low neurotransmitter, meds cannot work
• Alcohol use at half pint of hard alcohol---numb self, calorie intake uncommon
• Started binge and purge---idea that starvation leads to binge
• Hypokalemia---supplement electolytes, high risk of arrhythmia
• Liver enzyme elevation---alcohol or ED
• One child age 5---nearly apathetic to being away from
• Edema with refeeding---fluid shifts, cardiac overload
• Pulse 42---cardiac dysfunction
Male Case Example (cont’d 2)
• Mother professor, father engineer---loving, professional parents can have child with ED
• Hiding food, deny even when caught---deceit and denial
• Grabbed excessive equal at AA meeting, presented completely innocent---deceit and denial
• NG tube for weeks, turning off---deceit
• Meals take long time, rituals---OCD high comorbidity
• Insurance MD thinks “must be something else”---severe ED is its own illness
• Compliance improved with insurance threatening to cut out---sometimes the insurance may help
Male Case Example (cont’d 3)
• 800 mg of quetiapine---distorted thinking unphased
• Able to improve compliance (i.e. when insurance threatening)---behavioral component of this leads to misperceptions
• Went on to RTC, improving---even very complex situations can improve
Resources
• Rogers Memorial Hospital:rogershospital.org
• National Eating Disorder Association (NEDA):nationaeatingdisorders.org
• National Association of Anorexia and Associated Diseases (ANAD): anad.org
800-767-4411rogershospital.org
Thank you
Rogers’ Eating Disorder Services are offered at these Wisconsin locations:• Oconomowoc
• Milwaukee (West Allis)
• Madison
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