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Dealing with Eating Disorders in Family Medicine

Collaborative Mental Health Care Network April 17, 2004

Colleen Flynn, MD, FRCPC

Teaching Objectives

• Present a conceptual model of ED as it applies to diagnostic criteria and treatment approach

• Discuss “setpoint theory” and its therapeutic application in the treatment of ED

• Discuss an approach to caring for adults with ED in family medicine

Learning Objectives

• Increase recognition of ED symptoms via a conceptual model

• Understand role of dieting in the perpetuation of ED

• Develop a stepped approach to the management of adults with ED

Conceptualizing Eating Disorders Russell, G. Bulimia Nervosa: An ominous variant of anorexia nervosa. Psychol Med 1979:9;429-48

Psychopathology / Cognitive Distortion

Behavioural Disturbance Compensatory Consequence

Anorexia Nervosa (DSM IV)

•Intense fear of gaining weight even though underweight.

•Refusal to maintain weight at minimally normal level for age & height (85% expected)

•Amenorrhea in postmenarcheal females.

Restricting Type and Binge-Eating/Purging Type

•Disturbance in way one’s body size is experienced or undue

influence on self-evaluation or denial of seriousness of current low weight.

Bulimia Nervosa (DSM IV)

•Self-evaluation is unduly influenced by body shape and weight.

•Recurrent episodes of binge

eating. 1.Eating in a discrete time period an amount larger than most.

2. A sense of lack of control

inappropriate compensatory behaviour in order to prevent weight gain.

Purging Type and Nonpurging Type

•Recurrent

•Frequency: 2 / week

Eating Disorder, NOS (DSMIV)

• Partial syndrome Anorexia Nervosa• Partial syndrome Bulimia Nervosa• Binge Eating Disorder• Chews and Spits• Night Binge Eating

Screening Questions

• Are you unhappy with your body weight?• Are you dieting? • Have you lost weight?• Do you experience binge eating?• Do you purge after eating?• Do you feel your exercise is out of control?Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John

Hopkins, 1999.

Prevalence• AN: 0.5 - 1% Woodside, DB. A review of Anorexia Nervosa and Bulimia

Nervosa. Curr Probl Pediatr; 1995;25:67-89.

• BN: 1.1% full syndrome2.3% partial syndrome

Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan, Woodside. Bulimia Nervosa in a Canadian community sample. Amer J Psych; 1995;152:1052-8.

• BED: 25% of medically obese patients Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John Hopkins, 1999.

Comorbid Psychiatric Illness(50-70%)

• Mood Disorders• Panic Disorder• Generalized Anxiety Disorder• Obsessive Compulsive Disorder• Post Traumatic Stress Disorder• Alcohol / Drug Abuse• Personality Disorders

Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John Hopkins, 1999.

Regulation of Body Weight

• Dieting

• Setpoint theory

• Evidence of Setpoint theory and the effects of starvation on behaviour.

Implications of Dieting forEating Disorders

• In N. America 80% girls, 10% boys on diets by age 13 Mellin, Irving, Scully. Prevalance of disordered eating in

girls. J Amer Dietetic Ass 1992:92;851-3.• Dieters - 3.3 times more likely to binge eat

and 5.7 times more likely to vomitJones, Bennett, Olmsted, Lawson, Rodin. Disordered eating attitudes and behaviours in teenaged girls: a school-based study. CMAJ Sept 4, 2001; 165(5):547-52.

• Dieting schoolgirls at one year showed 20% had progressed to an ED as opposed to 3% ofnondieters Patton, Johnson-Sabine, Wood, Mann, Wakeling. Abnormal eating attitudes in London schoolgirls. Psychol Med 1990:20;383-94.

Heritability Estimates of Various Conditions

• Breast Cancer 45%• Coronary Artery Disease 49%• Epilepsy 50%• Alcoholism 57%• Hypertension 57%• Schizophrenia 68%• Height 80%• Weight 81%Stunkard et al. A twin study of Obesity. JAMA 1986:256;51-4.

Setpoint Theory

• The body is biologically programmed to weigh a certain amount

• The body defends a certain weight that is unique to each individual

• A number of factors determine what one’s natural weight will be

The Keys Study: Keys et al (1950), The biology of human starvation.

Minneapolis,University of Minnesota Press

• Scientists wanted to establish the best way to refeed people who had starved in Europe as a result of WWII

• 100 men volunteered, 40 with exceptional physical & psychological health selected

• 24-week period of dietary restriction with goal to lose 25% of body weight

Keys StudyFindings Before Semi-Starvation

• Subjects were pleasant, well-adjusted, active

• Were not weight & shape preoccupied

Keys StudyFindings During Experiment

• Decreased BMR, lowered body temperature• bradycardia, hypotension• Lethargy• Impaired concentration & judgment• Reduced libido

Keys StudyFindings During Experiment

• Withdrawn, depressed• Irritability, mood swings• Nail biting• Preoccupied with food• Increased use of salt, spices, coffee, tea,

chewing gum, cigarettes

Keys StudyDuring the Refeeding Phase

• Increase in hunger immediately following a large meal

• Consumption of enormous quantities of food without feeling satisfied

• Subjects did not skyrocket into obesity

graph

Significance of the Keys Study

• Challenges the popular notion that body weight is easily altered if one has enough “willpower”

• Demonstrates that the body has a strong biological drive to defend its target weight or setpoint.

• The body is not simply “reprogrammed” at a lower setpoint once weight loss has been achieved

Keys StudyImplications for Eating Disorders

• Many symptoms are a result of starvation

• Symptoms are not restricted to food & weight but extend to virtually all areas of psychological & social functioning

A Stepped Approach to Treating Eating Disorders

Psychopathology / Cognitive Distortion

Behavioural Disturbance Compensatory Consequence

A Stepped Approach to Treating Eating Disorders

• Therapeutic mileau

• Recognizing the stage of treatment– Living safely with the illness

– Working toward symptom interruption

– Relapse prevention

Therapeutic Mileau

• Empathic, non-judgemental, non-blaming

• Be aware of personal preference / bias / prejudice and avoid enactment

• Support treatment philosophy of setpoint theory and weight regulation

Stage 1:Living Safely with the Illness

• Safety

• Living with illness

Safety(Goal = keep them alive)

• Monitoring for the physical complications of semi-starvation, purging and refeeding

• High risk: - severe or rapid weight loss-increased frequency of symptoms

• Emaciated patients may be young but their bodies can be as frail as some 90 year olds

• Responding to psychological crisis

Living with the Illness

• Nonspecific supportive psychotherapy• Understanding egosyntonic aspects• Enhancing egodystonic aspects• Expanding activities and social connections• Education around ED and consequences• Negotiating small changes in symptoms• Pharmacotherapy

Stage 2: Working toward Symptom Interuption

• Education• Nutritional rehabilitation

– Non-dieting approach• Motivational enhancement techniques• ED specific CBT / IPT / family therapy • Behavioural therapy to address symptoms• Pharmacotherapy

Education

• Illness and diagnosis• Physical and psychological complications• Precipitating and perpetuating factors• Setpoint theory and weight regulation• Role of starvation in the binge / purge cycle• Normalized eating• Coping strategies

The Non-Dieting Approachand Structured Eating

• 3 meals & 1-3 snacks daily• Daily caloric intake: about 2000 calories• Food = Medicine, needs regular dosing• Eat by the clock• Plan ahead to avoid undereating / overeating• No forbidden / phobic / “bad” foods• All foods can fit

Cognitive Behaviour Techniques

• Self-monitoring of symptoms including time of day, type of meal, intake, urges, symptoms

• Examine symptoms by exploring connections between the situation, feelings and automatic thoughts

• Develop behavioural strategies

Behavioural Strategies

• Self soothing activities• Coping phrases• Delay• Distraction• Problem solving• Limit setting

Stage 3: Relapse Prevention

• Examining “slip ups”

• Reinforcing learned strategies

• Addressing underlying psychopathology

Pharmacotherapy

• SSRI anti-depressants:– Prozac– Paxil– Zoloft– Celexa

• Uses:– binge urges– co-morbid mood and anxiety illnesses

Anti-depressants & Anorexia Nervosa

• Do not work in underweight, emaciated individuals

• Some evidence of usefulness in weight-restored individuals to prevent relapse

Anti-depressants & BulimiaNervosa Fluoxetine Bulimia Nervosa Collaborative Study Group. Fluoxetine in the treatment of Bulimia Nervosa. Arch. Gen. Psych. 1992:49;139-47.

• 60% reduction in symptoms of bingeing and purging

• High doses often needed• Effective as an adjunct to other treatments• Effect not related to treatment of depression• After response, continue for at least one

year

Pharmacotherapy: Anxiolytics

• Benzodiazepines or low dose antipsychotics

• May be helpful for short term use (eg. treating anxiety before meals)

• Antipsychotics may help weight restoration in AN by decreasing eating disordered thoughts

Pharmacotherapy: GI

• Prokinetic agent to help with symptoms of bloating, reflux and abdominal pain after eating (eg. domperidone)

• Constipation: avoid stimulant laxatives (including sennakot)– Bulk agents: psyllium fiber– Osmotic agents: lactulose, GoLYTELY, Peglyte

Outcome• AN: Mortality - 5% at 5-8 years, 20% at 20 years

Full Recovery - 32 - 71% over 20 yearsChronicity - 20% over 20 years

• BN: Mortality: 5% over 2-5 yearsRecovery: 20 - 25% continuously well

20 - 25% continuously illWoodside , DB. A review of Anorexia Nervosa and Bulimia Nervosa.

Curr Probl Pediatr; 1995;25:67-89

• BED: significantly better outcome than BNStriegel-Moore, Wilson, Wilfley, Elder, Brownell. Binge-eating in an obese community sample. Int J Eat Disord; 1998;23:27-38

Suggested Resources

• Eating disorders: a guide to medical care and complications. P. Mehler & A. Andersen.

• Turning Points: A psychoeducational program for overcoming and eating disorder. R. Davis & W. Phillips. Distributed through NEDIC.

• The overcoming bulimia workbook. R. McCabe, T. McFarlane & M. Olmsted.

• Overcoming binge eating. C. Fairburn.• Gurze eating disorders resource catalogue.

www.bulimia.com (800)-756-7533.