Eating Disorders: An Overview

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Eating Disorders: An Overview

Julie Lesser, MD Medical Director Beth Brandenburg, MD

Associate Medical Director

Center for the Treatment of Eating Disorders

Children’s Hospitals and Clinics of Minnesota Abbott Northwestern Hospital

Outline

ÌWe are an evidence-based, specialty program focusing on outpatient treatment using two main models:

ÌFBT (Family Based Therapy)

ÌCBT-E (Cognitive Behavioral Therapy-Enhanced) ÌOur model includes

ÌOngoing staff education and training

ÌSupervision with treatment developers (Lock and Fairburn)

ÌMeasures of outcomes, tracking of key interventions

ÌWe see outpatients of all ages

ÌOutpatient clinic - 910 Medical Building in Minneapolis ÌOur inpatient units:

ÌChildren’s Hospital - up to age 21 (based on developmental level) ÌAbbott Northwestern Hospital - adults

Center for the Treatment of

Eating Disorders (CTED)

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Accounts of fasting Catholic Saints in 14thcentury

“Anorexia nervosa” introduced by Sir William Gull in

1874

Gerald Russell named “Bulimia nervosa” in 1979

Historical Review

Ancel Keys, et al

Recruited 36 conscientious objectors in 1944

During 24 week starvation period, diet adjusted to achieve loss of 25% of body weight

Followed by rehabilitation phase

Minnesota Starvation Study

Weakness Cold sensitivity Decrease in: temperature pulse respiration Fatigue Sleep problems

Physical Effects of Starvation

Edema Hair loss

Decreased sexual interest Poor concentration

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Preoccupation with food Social withdrawal Depression, emotional

distress Eating rituals Food cravings

Behavioral Effects of Starvation

Vicarious pleasure in

watching others eat Increased fluid consumption Compulsive gum chewing Hoarding, obsessiveness 8 | © 2013 Cultural influences Gender Genetic factors Psychosocial factors

**Families do not cause eating disorders

What causes eating disorders?

Perfectionism

Low self esteem

Anxiety and mood disorders

Negative life events

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Persistent disturbance of eating or eating related behaviors resulting in altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning

Diagnostic criteria provided for Anorexia Nervosa

Bulimia Nervosa Binge-Eating Disorder

Avoidant/Restrictive Food Intake Disorder (ARFID) Pica

Rumination Disorder

Unspecified or Other Specified Eating Disorder

DSM 5: Feeding and Eating

Disorders

Significantly low body weight Mild: BMI >17

Moderate: BMI 16 – 16.99 Severe: BMI 15 – 15.99 Extreme: BMI <15

Fear of fatness or persistent behavior that interferes with weight gain

Body image disturbance or persistent lack of recognition of the seriousness of the current low body weight Restricting type or binge-eating/purging type

Anorexia Nervosa

Peak age of onset 14 – 18

Lifetime prevalence 0.9% for women in U.S.

High rates of mood and anxiety disorders

Highest mortality rate of any psychiatric disease 5-10% 10 year mortality rate

Mortality rate increases 5.6% per decade that an individual remains ill

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Recurrent binge eating

Recurrent purging (vomiting, misuse of laxatives, diuretics or other medications, fasting or excessive exercise) Episodes of binge eating/purging on average at least 1

time per week for 3 months

Over-evaluation of shape and weight Not anorexia nervosa

Bulimia Nervosa

Peak age of onset 16 to 22

2 to 3 % of young women

Elevated rates of depression, bipolar disorder, anxiety disorders, substance use disorders, and personality disorders

Bulimia Nervosa cont.

Binge-Eating Disorder

Recurrent episodes of bring eating

Episodes are associated with 3 (or more) of: Eating much more rapidly than normal Eating until feeling uncomfortably full

Eating large amounts of food when not feeling physically hungry Eating alone because of feeling embarrassed about how much is

consumed

Feeling disgusted, depressed or very guilty after a binge Marked distress regarding binge eating is present

Occurs, on average, at least 1 time/week for 3 months

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Avoidant/Restrictive Food

Intake Disorder (ARFID)

Eating or feeding disturbance disallowing appropriate nutritional and/or energy needs associated with one (or more) of:

Significant weight loss

Significant nutritional deficiency

Dependence on enteral feeding or oral supplements

Marked interference with psychosocial functioning

Not better explained by lack of available food or associated culturally sanctioned practice

Not anorexia or bulimia and there is no evidence of a disturbance in one’s body image

Not attributable to a concurrent medical condition or mental disorder

Avoidant/Restrictive Food

Intake Disorder (ARFID)

Differentiating the feeding disturbance (examples):

Apparent lack of interest in eating or food

Avoidance based on the sensory characteristics of food

Concern about aversive consequences of eating

GI problems/pain

Vomiting

Choking

Clinically significant distress or impairment in, social, occupational, or other important areas of

functioning predominate but do not meet full criteria for any of the disorders

Used when the clinician chooses not to specify the

reason criteria are not met

Includes presentations in which there is insufficient information (e.g., in emergency room settings)

Unspecified Feeding or Eating

Disorders (307.50)

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Atypical AN (all criteria for AN are met, except despite the significant weight lose the individuals weight is within or above the normal range)

Subclinical BN or BED (all criteria for BN are met, not meeting frequency criteria)

Purging Disorder (recurrent purging to influence weight or shape, and may include misuse of laxatives and other medications in the absence of binge-eating)

Night Eating Syndrome (recurrent episodes of night eating causing distress and impairment and not better explained by other disorders or medication affects)

Other Specified Feeding or Eating

Disorder (307.59)

Low blood pressure/pulse, risk of arrhythmias Osteoporosis, fractures

Brain volume loss

Delayed growth and development Delayed gastric emptying, gastroparesis Muscle wasting

Lanugo on body, loss of hair from scalp Decreased body temperature, hypothermia

Medical Complications of

Eating Disorders

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Brain Volume Loss

Hypoglycemia

Elevated LFT’s

Low phosphorous

Leukopenia, anemia

Mitral valve prolapse

Secondary amenorrhea

Medical Complications of Eating

Disorders

Dehydration

Electrolyte abnormalities (potassium)

Erosion of dental enamel

Esophageal tears,

rupture

Complication of feeding severely malnourished patients

Low phosphorous

Seizures Heart failure

Arrhythmias

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Close monitoring of electrolytes (particularly phosphorous), cardiac status

Start with 1500 kcal diet, gradually increase to 3,000 – 4,000

Weight regain no more than 2 to 3 pounds per week

Avoid use of total parenteral nutrition

Preventing Refeeding Syndrome

Necessary for patients with very low weight or medical instability

APA guidelines

Multidisciplinary approach

Inpatient Treatment

Child and Adolescent Inpatient

Admission Criteria

ÌWeight <75% of est. healthy body

weight

ÌRapid weight loss even if weight

is not less than 75% below the

normal weight ÌRefusal to eat ÌHeart rate <50 bpm ÌBlood pressure <80/50 ÌOrthostatic hypotension (with an

increase in pulse of 20>bpm or a

drop in BP of >10‐20 mm Hg/min

from supine to standing)

ÌHypokalemia, hypophosphatemia or

hypomagnesemia ÌDehydration ÌHypothermia

ÌSymptomatic hypoglycemia ÌUncontrolled vomiting or hematemesis ÌCardiac arrhythmia

ÌSyncope

ÌLack of improvement or worsening

despite outpatient treatment ÌSuicide intent, plan or high level of risk

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Adult Inpatient Admission

Criteria

ÌWeight <75% of estimated

healthy body weight (usually BMI

<16) ÌHeart rate <40 bpm ÌSymptomatic orthostatic hypotension ÌBlood pressure <90/60 ÌPotassium <3 mEq/L

ÌElectrolyte imbalance (including

hypophosphatemia) ÌDehydration ÌHypothermia ÌSymptomatic hypoglycemia ÌUncontrolled vomiting or hematemesis ÌCardiac arrhythmia ÌLack of improvement or

worsening despite outpatient

treatment

ÌSuicide intent and suicide plan or

other factors suggesting a high

level of suicide risk (which may

indicate need for psychiatric

hospitalization, but if medically

compromised should be admitted

to medical unit on 1 to 1 patient

monitoring)

Psychotherapy

Family based therapy Multi-family therapy Cognitive behavioral therapy Interpersonal therapy

Cognitive remediation therapy (adjunctive treatment)

Medications

Inpatient treatment

Residential treatment, levels of care

Treatment of Eating Disorders

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Developed at Maudsley Hospital in London Key interventions

Agnostic about etiology, medical model

Collaborative weighing

Parental and sibling alliances

Family meal

Phases of treatment

Separation of illness from the child

Goal to have child eating independently and maintaining an

ideal, expected BMI at the 50th_percentile

Parents play an active role in helping to restore the child’s weight, then transition the control over eating back to the child and encourage normal adolescent development

Family Based Therapy cont.

Over half of adolescent AN patients are recovered

at the end of FBT, with further improvement at later follow up.

In older studies, 75 – 90% are fully weight recovered at 5 year follow-up

Currently the first line treatment for Anorexia nervosa in children and adolescents

Family Based Therapy cont.

Cognitive Behavioral Therapy

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Collaborative weighing Regular eating Self monitoring

Making a cognitive formulation

Problem solving and emotion regulation strategies

Addressing maintaining factors including interpersonal problems, core low self esteem and clinical perfectionism

More involvement of parents in the adolescent protocol

Key Interventions of CBT-E

20 to 40 weeks of individual therapy

Applicable to all types of eating disorders 2/3 of patients with BMI >17.5 recovered at end of

treatment, sustained at 1 year follow-up

Emerging data for patients with AN

Adults and adolescents with 50% recovery at 1 year f/u

Studied in adolescents as young as age 13

CBT-E

Interpersonal World

Mood

Evidence based therapy for Depression in adults and adolescents

Effective for Bulimia nervosa Manual exists for Anorexia nervosa

Key interventions Interpersonal inventory Problem solving Motivational strategies

Interpersonal Therapy

Nutritional Status Fo rm ulat ion

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Fluoxetine 60 mg/day

FDA approved

Effective in reducing binge eating and purging

Topiramate

Odansetron

Medications for Bulimia Nervosa

SSRI’s for comorbid depression or anxiety disorders

Olanzapine may be effective in decreasing

obsessionality

No medications have been shown to improve weight

regain

Medications for Anorexia Nervosa

Practice guidelines

2/3 relapse rate

Consideration of comorbid conditions

Need for tracking and publishing outcomes

What is the role of partial

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Sample Weight Graph: 14yo Female

14.5 15.5 16.5 17.5 18.5 19.5 4/4 5/14 6/23 8/2 9/11 10/2111/30 1/9 2/18 3/30 5/9 6/18 7/28 9/6 Inpatient Family-Based Therapy

Cognitive Behavioral Therapy-Enhanced

BMI Graph: 21yo

15 16 17 18 19 20 11/1 1/1 3/1 5/1 7/1 9/1 11/1 1/1 3/1

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Outpatient Clinic Team

Collaborative Care:

Patient follows with primary care/referring provider Psychiatrists Julie Lesser, MD Beth Brandenburg, MD Jill Gorius, MD Therapists Joan Valente, PhD Melissa Adler, LICSW

Georgia Banks, LICSW

Tina Welke, LICSW

Cindy Gieseke, LICSW

Lindsey Utzinger, PsyD Dietician

Libby Johnson, RD Administrative

Traci Horejsi, Clinic Coordinator

Pamela Coleman, LPN, Lynnae Sniker, MA

Only hospital-based programs in MN offering immediate access to medical stabilization and specialists

Inpatient teams:

Staff training based on Janet Treasure’s New Maudsley Method Separate units for children and adults

Inpatient Teams at

Children’s and Abbott

Hospitalists Psychiatrists Physical Therapy Social Work Psychologists Integrative Medicine

NursesChild Life

Contact information

ÌOutpatient clinic ÌP: 612‐813‐7179 ÌF: 612‐813‐7190

ÌFor child and adolescent referrals

ÌChildren’s Physician Access: 612‐343‐2121

ÌAdult referrals

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