eating disorders & alcoholism laurie mccormick, md assistant professor, psychiatry university of...

Eating Disorders & Eating Disorders & AlcoholismAlcoholism

Laurie McCormick, MD Laurie McCormick, MD Assistant Professor, PsychiatryAssistant Professor, Psychiatry

University of IowaUniversity of Iowa

© AMSP

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Eating Disorders - Common but Difficult to Identify

5% of US population has an ED~ 1% AN ♀>> ♂

~ 3% BN ♀>♂

~ 1% BED ♀=♂

80% of US ♀ - dissatisfied with body

50% ♀ / 25% ♂ - on a diet any given day

© AMSP

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Disordered Eating Continuum

1/3 of dieters → pathological dieting; 1/4 of pathological dieters → EDs

2/3 ♀ + 1/3 ♂ teens - unhealthy wt control

1/5 ♀ + 1/10 ♂ – very unhealthy wt control

Shame/secretiveness ≠ identification

© AMSP

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Alcohol Use Disorders Are Common

© AMSP

%/yr

(Lifetime)

Hazardous 25

Abuse5

(15)

Dependence5

(10)

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Mortality/Morbidity of EDs & AUDs

© AMSP

EDs - ↑ mortality rate of all psychiatric ds

AN - most deadly psychiatric illness

BN - electrolyte disturbance

AUDs - 3-4X ↑ in early death Health related (stroke, cancer, heart ds) Accidents Suicide

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This Lecture Reviews

Definitions

Relationships

Screening & identification

Treatment & management

© AMSP

What are Eating Disorders?

© AMSP7/31

http://www.youtube.com/watch?v=QSqtVDIwnHo

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Anorexia Nervosa (AN)

Weight - refusal to keep weight ~ 85% expected

Amenorrhea

Fear of gaining weight

Evaluation of self - influenced by weight/shape

* 30% cross over to BN over time

© AMSP

9/31

Bulimia Nervosa (BN)

Binge eating – recurrently

Inappropriate compensation

Compensation - 2X/wk x 3 mo’s

Evaluation of self - influenced by body image

Not occurring during AN

* Rarely cross-over to AN

© AMSP

10/31

Eating Disorder – NOS (ED-NOS)

Sub-threshold AN or BN

Binge eating disorder (BED) Eating large amounts of food in <2hrs

Distress from lack of control while eating

Eating when not hungry

Guilt from overeating

No compensatory behaviors

Occurs ≥ 2X/wk x 3 mo’s© AMSP

11/31

Alcohol Abuse / Dependence

© AMSP

Dependence12-months of 3: - Tolerance - Withdrawal - use - ↓ ability to quit - time using alcohol - ↓ social activities - Continued use

Abuse

12-months of 1:

- ↓ obligations

- Hazardous situations

- Legal problems

- Interpersonal problems

- Not alcohol dependence

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Definitions √

Relationships



© AMSP

13/31

Can EDs + AUDs Co-Occur?

2X ↑ risk of AUD w/ BN, not AN (only in ♀)

Alcohol related problems > alcohol use

♀ BN & risk of AUD 50% - ED before AUD 40% - AUD before ED 10% onset of AUD & ED at the same time

© AMSP

14/31

ED + AUD Comorbidity

Anxiety → ↑ risk AUDs & EDs

↑ risk of BN + AUD in ♀= impulsivity, novelty seeking, immature defenses

Comorbid AUD + ED = worse outcome? Only in AN

© AMSP

Sociocultural Model for EDs Sociocultural Model for EDs

Pressure to be thin

Thin-idealinternalization

Body dissatisfaction

Dieting (restraint)

Negative affect Exercise

Binge/purge

Low self-esteem

Neuroticism

© AMSP 15/31

Depression

16/31

Food Addiction = Motivation & Reward

© AMSP

↓ Dopamine- DRD2 A1 allele

↑ Opiate- Mu G allele- Kappa 1 long allele

Ventral

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Genetic & Environmental Risk Factors

Genetic +/-

Environment +/-

© AMSP

18/31


Definitions √

Relationships √



© AMSP

19/31

Patient Health Questionnaire (PHQ)

16 sets of questions Sections 6-8: (9 questions) - ED Sections 9-10: (7 questions) - AUD

“Feel you can’t control what or how much you eat?”

“Do you ever vomit?”

Overall accuracy - 85% Sensitivity to detect - 75% Specificity for the illness - 90%

© AMSP

20/31

Eating Disorder Examination (EDE-Q)

28 item questionnaire (6-pt scale)

“Trying to limit food to influence shape/weight?”

“In the past month, lose control over eating?”

Sensitivity - 80% Specificity - 80%

© AMSP

21/31

AUDIT – Alcoholism Screening

10-item questionnaire (5-pt scale)

1. How often do you have a drink of alcohol?

2. How many drinks of alcohol in one occasion?

3. Do you ever have 6 or more on a given day?

Score of > 8/50 = hazardous drinking

Sensitivity to detect: ~ 80%

Specificity for disease: 80%© AMSP

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ED Complaints & Findings

Physical findings: Emaciated appearance Enlarged salivary/parotid glands

Complaints: Constipation Gastroesophageal reflux disease Dental caries/broken teeth Menstrual irregularity

© AMSP

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Stages of Treatment

© AMSP

Identification

Intervention - brief intervention - motivational interviewing

Inpatient - detoxification - weight stabilization - break binge/purge cycle

Day treatment/outpatient - rehabilitation - psychopharmacology - cognitive behavioral tx

Outpatient - relapse prevention

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Initial Intervention

Directive brief interventions

Motivational interviewing Feed back on risks Responsibility for change Advice Menu of treatment options Empathetic interaction Self-efficacy enhancement

© AMSP

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Meds for ED - Limited Efficacy

© AMSP

Fluoxetine

(Prozac)

Topiramate

(Topamax)

Cognitive Behavioral

Therapy

↓ purge √ √

↓ binge √ √ √

↓ weight √ √

↑ abstinence

(>12 mos)

√

28/31

Meds for AUDs - Limited Efficacy

© AMSP

Naltrexone Acamprosate Topiramate

↓ urges √ √ √

↓ drinks √ √ √

↓ relapse √ √ √

↑ abstinence

(>12 mos)

√ √ √

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Meds for Combined ED + AUD

Naltraxone Inconsistent findings

Acamprosate ↓ cravings for food & alcohol in AUD

Topiramate ↓ heavy drinking days by 50% in AUD ↓ weight in BED by 7lbs - 21 wks ↓ weight by 5kg in 16 wks

© AMSP

30/31

Psychotherapeutic Interventions

Family therapy for AN in adolescents

Cognitive behavioral therapy (CBT) Improves outcome in EDs Improves outcome in AUDs

Group therapy/support groups

© AMSP

eating disorders & alcoholism laurie mccormick, md assistant professor, psychiatry university of...

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