Working with Eating Disorder Patients

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Working with Eating Disorder Patients

• Elise Curry Psy.D.
• Program Manager
• UCSD IOP
• Terry Schwartz MD
• Medical Director UCSD Eating Disorders Program
• Asst Clinical Professor UCSD

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Structure of 3 day training

• Day 1 Intro to ED assessment and treatment
• Day 2 and 3 More specifics how to, therapy
  modalities, special populations

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Anorexia Nervosa

• Most homogenous psychiatric disorder
• 90-95 female
• Onset teenage years puberty
• Monotonous puzzling symptoms
• Poor response to treatment
• Highest mortality rate
• 50 to 80 contribution of genes

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DSM IV Criteria for Anorexia Nervosa

• Preoccupation with body shape, weight/size
• lt85 ideal BW
• Fear of becoming fat despite low weight
• Loss of 3 consecutive periods in women
• Types restricting,binge/purge,purge

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DSM IV criteria for Bulimia Nervosa

• Recurrent episodes of binge eating, characterized
  by eating an excessive amount of food within a
  discrete period of time and by a sense of lack of
  control over eating during the episode
• Recurrent inappropriate compensatory behavior in
  order to prevent weight gain, such as
  self-induced vomiting or misuse of laxatives,
  diurética, enemas, or other medications
  (purging) fasting or excessive exercise
• The binge eating and inappropriate compensatory
  behaviors both occur, on average, at least twice
  a week for 3 months
• Self-evaluation is unduly influenced by body
  shape and weight

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Diagnostic challenges in EDs (ED NOS)

• BN vs. AN binge/purge type
• Sandy is 5 ft tall and weighs is 80 lbs. She has
  regular periods and no body distortion. She is 16
  yrs old.
• Sally purges normal meals, but does not binge.
• Tom thinks he needs to gain weight. He uses
  exercise to purge. He binges 2 times per week and
  then goes running.
• Shelly chews and spits her food several times a
  day

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Possible Signs of an Eating Disorder

• Preoccupation with food/weight
• Dramatic weight loss or gain
• Chronic dieting
• Feels cold all the time
• Dental problems
• History of ballet, wrestling, or modeling
• Disgusted by red meat or desserts

• Has difficulty eating with people
• Cuts out food groups
• Becomes vegetarian/vegan as a teen
• Uses bathroom after meals
• Wears baggy clothes or layers
• Cooks for other excessively
• Excessive exercise

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Scope of The Problem

• Prevalence increasing
• AN .5-2
• BN 3-4
• AN BN More common westernized cultures
• 10 of eating disordered individuals in treatment
  are male
• 5-20 of AN patients die (disorder or suicide)

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Primary Causes of Death in Patients with Eating
Disorders
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Scope of the problem continued

• One of the highest death rates from any mental
  health condition (AN)
• Increasing incidence in elementary age children
  (8-11 year old)
• The incidence of bulimia in 10-39 year old women
  TRIPLED between 1988 and 1993.
• There has been a rise in incidence of anorexia in
  young women 15-19 in each decade since 1930.

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Ethnic Diversity in EDs

• Minnesota Adolescent Health Study found that
  dieting was associated with weight
  dissatisfaction, perceived overweight, and low
  body pride in all ethnic groups (Story et al,
  1997).
• Among the leanest 25 of 6th and 7th grade girls,
  Hispanics and Asians reported significantly more
  body dissatisfaction than did white girls.
  Robinson et al (1996)

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Cultural Issues

• More common in Westernized Societies
• Historically self starvation reported prior to
  19th century (religious/spiritual reasons)
• Cultural importance placed on thinness
• Less common in cultures where roundness is sign
  of fertility, health, prosperity
• Hong kong, India AN w/o fear of fat.
• Many individuals in our culture, for a number of
  reasons, are concerned with their weight and
  diet. Yet less than half of one percent of all
  women develop anorexia nervosa, which indicates
  to us that societal pressure alone isnt enough
  to cause someone to develop this disease, said
  Kaye.

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Media Stats

• The average young adolescent watches 3 to 4 hours
  of TV per day (Levine, 1997).
• A study of 4,294 network television commercials
  revealed that 1 our of every 3.8 commercials send
  some sort of attractiveness message, telling
  viewers what is or is not attractive (as cited in
  Myers et al, 1992). These researchers estimate
  that the average adolescent sees over 5,260
  attractiveness messages per year.
• Another study of mass media magazines discovered
  that womens magazines had 10.5 times more
  advertisements and articles promoting weight loss
  than mens magazines did (as cited in Guillen
  Barr, 1994).

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Drive for thinness and dieting

• Girls who diet frequently are 12 times as likely
  to binge as girls who dont diet
  (Neumark-Sztainer,2005).
• Most fashion models are thinner than 98 of
  American women (Smolak, 1996).
• The average American woman is 54 tall and
  weighs 140 lbs. The average model is 511 and
  weighs 117 lbs.
• 35 of normal dieters progress to pathological
  dieting. Of those, 20-25 progress to partial or
  full syndrome eating disorders (Shisslak Crago,
  1995).
• 95 of all dieters will regain their lost weight
  in 1 to 5 years (Grodstein, et al., 1996).
• Americans spend over 40 billion on dieting and
  diet related products each year (Smolak, 1996).

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Body Image

• How you see yourself when you look in the mirror
  or when you picture yourself in your mind.
• What you believe about your own appearance
  (including your memories, assumptions, and
  generalizations).
• How you feel about your body, including your
  height, shape, and weight.
• How you sense and control your body as you more.
  How you feel in your body, not just about your
  body.
• NEDA website

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Negative body image

• A distorted perception of your shape you
  perceive parts of your body unlike how they
  really are.
• You are convinced that only other people are
  attractive and that your body size or shape is a
  sign of personal failure.

• You feel ashamed, self-conscious, and anxious
  about your body.
• You feel uncomfortable and awkward in your body.
• NEDA website

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Positive body image

• A clear, true perception of your shape you see
  various parts of your body as they really are.
• You celebrate and appreciate your natural body
  shape and you understand that a persons physical
  appearance says very little about their character
  and value as a person.

• You feel proud and accepting of your unique body
  and refuse to spend an unreasonable amount of
  time worrying about food, weight, and calories.
• You feel comfortable and confident in your body.
• NEDA website

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Childhood Symptoms OC Personality Traits
Percentage of Individuals With Traits
of Patients
Anderluh MB, et al. Am J Psychiatry.
2003160(2)242-247.
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Psychological Correlates of Anorexia Nervosa

• Poor self concept
• Obsessive compulsive and avoidant personality
  style
• Perfectionistic, obsessive, harm avoidant traits
• Family dynamics enmeshment, anxiety,
• over-achievers
• Troubles with major life transitions
• an attempt to regress, avoid development
• Difficulty managing and expressing anger
• Cognitive distortions
• Ego-syntonic nature of disease

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Psychological Correlates of Bulimia Nervosa

• Poor self concept
• Chaotic developmental history, parental deficit
• ambiguous communication styles
• Affective regulation problems
• Cognitive distortions
• Ego-dystonic nature of disease
• Impulsivity, substance abuse, self harm, sexual
  acting out, shop lifting

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Distorted Beliefs

• There are good foods and bad foods.
• If I am fat, no one will love me.
• If I eat too much, I need to get rid of it by
  purging.
• If I eat this piece of cheesecake, I will be able
  to see it on my body tomorrow.
• You can never be too rich or too thin.
• Thinness equals happiness.
• Using laxatives gets rid of all the food.
• Purging gets rid of all the food.
• My worth is my weight.
• It is more important to be thin than anything
  else.
• Everyone hates fat people.
• Men like women who are skinny.

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Recovery Beliefs

• My worth is not my weight.
• My body is an instrument, not an ornament.
• When I treat my body well, by eating 3 balanced
  meals per day and exercising moderately, my body
  will find its own set-point weight.
• People come in all kinds of shapes and sizes. I
  dont have to try to mold my body into a standard
  set by the media or fashion industry.
• I need some fat in my diet in order to have soft
  skin, shiny hair, and be able to become pregnant
  some day.
• I can enjoy having a more curvy body, instead of
  striving for thinness.
• I am unique and special due to my inner
  qualities.
• Perfectionism only leads to disappointment, not
  happiness.

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Goal of Psychological Treatment

• Help pt to adjust to their personality
  traits/temperament
• Reduce anxiety through use of positive coping
  skills
• Reduce eating disorder voice and develop a
  recovery voice.
• Increase focus on inner qualities to define self,
  rather than physical
• traits like thinness.

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Important initial assessment/screening
issues/tools in EDS

• See Screening Handout

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Screening Questions

• How many diets have you been on in the past year?
  
• Do you think you should be dieting?
• Are you dissatisfied with your body size?
• Does your weight affect the way you think about
  yourself?

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Introduction to Treatment
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NEEDSmet by the eating disorder

• Safety/Survival reduction of anxiety
• Love/Belonging best friend
• Freedom no one can take the e.d. away
• Power/control/importance feeling superior,
  weight loss as an accomplishment
• Fun/relaxation/release endorphins
• released by purging

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Case Study Tom
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A Major Truth Feelings Follow Thoughts Actions
Thoughts
Actions
Needs
Want Choices
Feelings
Physiology
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Group Therapy

• Structured on-site meal
• Milieu therapy/ use of group
• CBT/DBT
• Process group
• Nutritional counseling
• Body image group
• Art Therapy
• Relaxation, meditation

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Power of the Group

• Reduce isolation
• Enhance accountability
• Shame reduction
• Encourage each other
• Forward momentum of the group
• Establish healthy group norms
• How group leader uses group to enhance individual
  growth

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Individual Therapy

• Affect regulation and tolerance
• Impulsivity
• Externalization of self worth
• Feelings of ineffectiveness, inadequacy
• Rejection sensitivity
• DBT
• PMD and dietitian

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Family Therapy

• Required with Adolescents
• Maudsley Family Therapy
• Systemic Family Therapy
• Couples

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UCSD Eating Disorder IOP(Individual and Family
Therapy by appointment)
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Common Management Issues

• Denial, resistance
• Lack of insight and motivation for treatment
• Failure to learn from experience
• Adolescent anxious parents, conflicts
• Adults family burn out
• Ambivalence pt wants to recover, but does not
  want to gain any weight

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Expected IssuesPatients and Families

• Obsessive anxiety much reassurance and
  discussing details of care
• Perfectionism not good enough
• Stress and conflicts over eating, weight,
• control, meal plan etc.
• Over-exercise
• Undermining treatment i.e. taking the pt running

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Countertransference Issues

• Feeling angry at the patient for not recovering
• Thinking this is willful behavior
• Blaming the parents
• Feeling incompetent
• Giving up hope for the patient
• Not taking the disorder seriously

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Coping with Countertransference Issues

• Practice patient acceptance The average recovery
  rate is 7 years.
• Have compassion for the suffering
• of the patient.
• See their behavior as part of the disorder, not
  personal toward you.
• Practice good self-care.

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Overview of biological underpinnings of EDS
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Genetic Correlates in Anorexia Nervosa

•  
• Family and twin studies
• Serotonin receptor gene
• Variation in Dopamine 2 receptor gene
• Chrom 1 and 10
• Family history of OCD, OCPD, AN
•  

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Genetic Correlates of Bulimia Nervosa

• Twin studies
• 5ht2A receptor alteration
• Family history of affective, anxiety, substance
  abuse d/o

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Neuroendocrine Correlates of Anorexia Nervosa

• Serotonin (5HT2A receptor)
• Dopamine
• Endogenous opiate response to starvation
• Hypothalamus dysfunction (satiety, amenorrhea)

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Neuroendocrine correlates of Bulimia Nervosa

• Serotonin (5HT1A receptor)
• Endogenous opiate response to binge purge

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Neuropsychiatric correlates of Eating Disorders

• Iowa gambling task AN vs CW Differences seen on
  fMRI
• AN Neuropsych testing difficulties with set
  shifting, flexibility
• AN Detail focus, to the point of missing global
  (Janet Treasure)
• AN vs BN
• Use in clinical practice

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Cognitive Flexibility

• Anorexia Nervosa
• ? Perceptual rigidity
• ? Cognitive rigidity
• AN Weight recovery
• No changes
• AN Full recovery
• Partial improvement in cognitive flexibility
  tasks

• Bulimia Nervosa
• Slowness in cognitive shifting tasks
• Fluctuations in Perceptual task

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Psychiatric co morbidity
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PSYCHIATRIC COMORBIDITY Anorexia Nervosa

• affective disorders
• anxiety disorders
• psychotic disorders
• personality disorders
• Substance abuse 

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PSYCHIATRIC COMORBIDITY Bulimia Nervosa

• affective disorders
• anxiety disorders
• ICDs
• personality disorders
• Substance abuse

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Psychiatric symptoms in AN and BN

• Premorbid onset
• Best little girl in the world
• Majority have childhood anxiety disorder that
  precedes onset AN, BN
• Childhood negative self-evaluation,
  perfectionism, rule bound, inflexible, obsessive
  personality
• Persistent symptoms after recovery
• Obsessions - body image, weight, food
• Obsessions - perfectionism, symmetry, exactness
• Anxiety, harm avoidance
• Behaviors are exaggerated by malnutrition
• Differences Between AN and BN
• Novelty seeking BN gt AN, BN extremes of over- and
  under-control

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Anxiety Disorders (AD)Lifetime and Premorbid
Rates
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Lifetime OCD Diagnosis in AN, BN
Price Foundation Genetic Collaborative
StudyTotal 1416 subjects DSM IV, SCID I, Y-BOCS
MS/PhD Clinical Interview N. America, England,
Germany
Review of Literature Godart 2002
General population rate OCD 1-3 of adults 2-4
of children (Grados 97, Riddle 98 Serpell 02)
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Obsessive-Compulsive Personality Disorder (OCPD)
Diagnoses in ED from Clinical Interviewer
AssessmentCassin S, von Ranson K Personality
and eating disorders a decade in review Clin
Psychol Rev 200525(7)895-916
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Important Medical issues in treatment of EDs
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Physical Complications of Anorexia Nervosa
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Physical Complications of Anorexia Nervosa Cont.
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Physical Complications of Anorexia Nervosa Cont.
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Physical Complications of Bulimia Nervosa
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Physical Complications of Bulimia Nervosa cont.
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Amenorrhea and Osteopenia

• Most serious complication of prolonged amenorrhea
  is osteopenia, or reduced bone mass
• Degree of osteopenia depends on age of onset and
  duration of amenorrhea
• Adolescence is critical time for bone mass
  acquisition
• Approx 60 of peak bone mass is accrued during
  adolescence
• Little net gain in bone mass after 2 yrs
  post-menarche
• Peak bone mass achieved by end of second decade

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Osteopenia and Osteoporosis

• Osteopenia refers to decreased quantity of
  normally mineralized bone
• Osteoporosis is clinical syndrome consisting of
  decreased bone mass, disruption in normal bone
  architecture with decreased bone strength,
  pathological fractures, pain and disability
• Osteoporosis defined as greater than 2.5 SD below
  the mean for young adult women
• Osteopenia 1-2.5 SD below young adult ref

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Bone Density and Fractures

• Each SD decrease in bone density doubles the
  fracture risk
• DEXA is most widely used method for measuring
  bone density
• May be compared with age-matched children and
  adolescents (Z scores)

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Prevalence of Bone Loss in AN (N130)
(Grinspoon et al, Ann Int Med, 2000)
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Mechanisms of Bone Loss in AN

• Undernutrition
• Low lean body mass
• Reduced calcium and Vitamin D intake
• IGF-I deficiency
• Hormonal
• Estrogen deficiency
• Resistance to growth hormone (GH)
• Elevated cortisol (stress hormone)
• Deficiency of other hormones
• Testosterone
• Dehydroepiandrosterone (DHEA)

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Bone Loss Treatment Strategies

• No therapies proven effective for bone loss in
  women with AN.
• EstrogenDecision on estrogen individualized,
  but no convincing data that estrogen alone
  increases bone density in AN population.
• Potential therapies under study
• IGF-I
• DHEA
• Testosterone
• Bisphosphonates

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Osteoporosis Treatment

• Weight gain
• Calcium supplementation improves bone mass
  (1500-2000mg/day)
• Vitamin D
• Moderate weight-bearing exercise increases bone
  mass
• When medically stable, wt bearing exercises 3-4
  times per week

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Is there a benefit to treatment ofAmenorrhea

• Drugs
• Appearance of normal menses
• AN abnormalities driven by malnutrition
• Drugs are NOT substitute for nutrition
• Illusion that problem is solved
• ? Ineffective or harmful
• Menses regulated by complex neuroendocrine
  circuits

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Medical evaluation for Anorexia Nervosa

• Assess for co morbidity
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA
• Bone density (DEXA)
• EKG
•  

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REFEEDING COMPLICATIONS

• Normal food
• Peripheral edema
• Bloating or discomfort
• Reflux
• Rare gastric dilitation
• Nasogastric feeding
• Seldom indicated
• Nasal, esophageal erosion
• Central hyperalimentation
• Rarely indicated
• Pneumothorax, infection, metabolic disturbances

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Nutritional Restoration and Weight Gain in AN

• Starvation and weight loss ego syntonic
• Increased dysphoria before and during meals
• Food and weight obsessions and rituals
• Stereotypic food choices, ritualized eating,
  calorie counting
• Delusionary quality
• Nothing else is more important

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Requirements for weight gain in anorexia nervosa
excess calories (over maintenance) to gain 1 kg
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Eating behavior in AN After weight restoration

• Hypermetabolic after weight restoration
• RAN need 50 to 60 kcal/kg/day
• BAN need 40 to 50 kcal/kg/day
• 50 kg women 2000 to 3000 kcal/day
• Probably normalizes in long term
• Probable contribution to high rate of relapse

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Medical evaluation for Bulimia Nervosa

• Assess for comorbidity
• Screening labs electrolytes, Ca, Mg, Phos,
  BUN/Cr, CBC, LFTs, TFTs, UA
• EKG
• Dental
•  
•  

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Pharmacology for AN

• SSRIs
• Atypical antipsychotic medications
• Meds tried and failed for appetite enhancement
• GI meds to aid physical symptoms

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Pharmacology for BN

• Serotonin re-uptake inhibitors
• AEDs (topiramate, ?zonisamide)
• Antipsychotics
• Mood stabilizers
• reglan, H2 blockers

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Methods of Treatment

• Regular Weight restoration
• 2 to 3 lbs/wk inpatient
• 1 to 2 lbs/wk day-hospital
• 1 lb/wk outpatient
• Nutritional Teaching
• Provide patient support
• Prevention from vitamin and mineral deficiency
• Prevention of osteoporosis
• Aim for high Ca intake
• Vitamin D to aid in Ca absorption vegetarians
  may need supplements
• Eat iron-containing foods, especially important
  for vegetarians

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Integrated treatment programs

• Multidisciplinary treatment team
• Program manager
• Psychiatrist
• Therapists with ED training
• Registered Dietitian
• Internist/Pediatrician

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AN Hospital vs Outpatient TreatmentFrom
American Psychiatric Association Guidelines for
the Treatment of Eating Disorders
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Referral to Higher level of care

• Pt is failing lower level.
• Pts weight loss is continuing in spite of
  treatment
• Pt is unable to stop bingeing/purging.
• Pts physical symptoms warrant greater
  supervision (fainting, dehydration, heart
  palpitations)
• Pt is resisting current level of care

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Specific LOC Considerations

• OP high motivation, gt85 IBW
• IOP moderate motivation, gt80IBW
• PHP gt75
• RTC clinical issues
• IP lt75 IBW, psych co morbid severe (SI)
• UCSD Intensive Family Therapy program
• Legal controversy

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Outcome Data for EDs

• Data mixed results due to design of studies
• AN 10 yr 50 rec, 20-30 improved but still
  symptomatic, 10-20 chronic, up to 10 mortality
• BN 10yr 50-70 rec, 30 some improvement, 20
  chronic

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Outcomes for EDS

• Some studies show ave of 7 years to rec
• Less than 1 year of treatment has poorer
  prognosis
• Chronicity, OCPD, purging in AN associated with
  worse outcome