Olivia L. Shuttleworth, LICSW, BCD

1

• Olivia L.
  Shuttleworth, LICSW, BCD
• Assistant Professor
• West Virginia University
• oshuttleworth_at_hsc.wvu.edu

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• WHERES THE BEEF?

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Eating Disorders an Overview
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Objectives of the Presentation

• History of Eating Disorders
• Participants will be able to identify the
  different types of eating disorders.
• The DSM IV criteria for each of the eating
  disorders.
• Is the elderly population at risk for eating
  disorders?
• Current treatment for eating disorders.

5
History of Eating Disorders

• Saints fasted and Romans purged.
• Kaplan and Garfield (1984) reported on references
  to Bulimia like symptoms in the Talmud, this
  dating the existence of the disorder back over
  5,000 years.
• The earliest English-language report of Anorexia
  nervosa is that of Richard Mortons (1694)
  reporting on cases of Anorexia nervosa in a young
  man and young woman.

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Prevalence

• Bulimia Nervosa 3 to 8 Women to Men 10 to 1
  ratio
• Women Age Range 15 to 40 (excluding elderly
  population)
• Anorexia Nervosa 1 to 2 Adolescents
• Binge Eating Disorders 3 to 8 Male Athletes
• ED in the Elderly 3 to 1 Women to Men

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Diagnostic Statistic Manual Eating Disorders

• Anorexia Nervosa
• Greek word meaning loss of appetite misnomer.
• Refusal to maintain body weight at or above a
  minimally normal weight for age and height (e.g.,
  weight loss leading to maintenance of body weight
  less than 85 of that expected or failure to make
  expected weight gain during a period of growth,
  leading to body weight less than 85 of that
  expected.
• Intense fear of gaining weight or becoming fat,
  even though underweight.
• Disturbance in the way in which ones body weight
  or shape is experienced, undue influence of body
  weight or shape on self-evaluation, or denial of
  the seriousness of the current body weight.
• (How this relates to the elderly population)
• In postmenarchal females, amenorrhea, i.e., the
  absence of at least three consecutive menstrual
  cycles. (A woman is considered to have
  amenorrhea if her periods occur only following
  hormone, e.g., estrogen, administration.)

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Bulimia Nervosa

• A. Recurrent episodes of binge eating. An
  episode of binge eating is characterized by both
  of the following
• Eating in a discrete period of time (e.g., within
  any two hour period), an amount of food that is
  definitely larger than most people would eat
  during a similar period of time and under similar
  circumstances.
• A sense of lack of control over eating during the
  episode (e.g., a feeling that one cannot stop
  eating or control what or how much one is
  eating).
• B. Recurrent inappropriate compensatory behavior
  in order to prevent weight gain, such as
  self-induced vomiting, misuse of laxatives,
  diuretics, enemas, or other medications fasting,
  or excessive exercise.
• C. The binge eating and inappropriate
  compensatory behaviors occur, on average, at
  least twice a week for three months.
• D. Self-evaluation is unduly influenced by body
  shape and weight.
• E. The disturbance does not occur exclusively
  during episodes of Anorexia nervosa.
• Type Purging Type vs. Non-purging Type
  (exercise and fasting to compensate).

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Risk Factors

• Biological
• Parent/Family
• Anorexia Nervosa Overprotective Family
• Bulimia Nervosa Chaotic Family
• Mothers Attitudes
• Fathers Comments
• Mothers Behavior in Relation to Feeding
• Mothers Eating Disorder
• Society/Culture
• Media
• Fashion Industry
• View of Women
• Toys and Images
• Thin..Success and Power
• Peer Pressure, Eating and Weight
• Psychological/Development

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Assessment of Eating Disorders

• Detecting Eating Disorders in Patients
• Patients present for unrelated illness
• History includes a psychological assessment,
  weight history, change in weight (highest to
  lowest) and patients satisfaction with his/her
  weight
• Note Bulimic women can have a 10 lb. weight
  gain in a 2-3 week period
• Assessment May Be the Key in Detecting Eating
  Disorders in Ones Patients. Primary care
  physicians need to ask the right questions in
  identifying a patient with an eating disorder.
• The anorexia patient is consistently below ideal
  weight for height.
• Do a 24 hour diet recall.
• Include in your questions, Is this person always
  dieting?
• Anorexics may not give accurate information.
• Look for Rigid Rules (never eating sweets) and
  eating rituals (how food is consumed and types)
• Explore what constitutes a binge and if there is
  a feeling of loss of control.
• Ask questions about body image 80 of women
  think they are too fat and need to lose weight.
• Exercise Patterns to stay healthy or a part of
  the bingeing behavior
• Relationships and developmental task (Do they
  date?)

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Physiological Symptoms and Medical Complications

• From Starvation and Weight Loss
• Abdominal Pain
• Acrocyanosis amenorrhea or irregular periods
• Anemia, leucompenia, thrombocytopenis
• Arrhythmias
• Brittle nails
• Bradycarydia
• Cold intolerance
• Constipation
• Decreased LH, FSH, estrogen
• Edema
• Elevated liver enzymes
• Emaciation
• Fatigue
• Hair thinning or loss
• Hypotension
• Hypothemia
• Insomnia
• Osteoporosis

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From Purging

• Arrhythmias
• Chest pain or burning
• Dental enamel erosion
• Electrolyte imbalance (particularly hypokalemia)
• Elevated liver enzymes
• Esophageal tears
• Esophagitis
• Hermatemisis
• Ipecac cardiomyopathy

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Treatment for Anorexia Nervosa

• Family involvement is very important.
• Medication may be warranted if co-morbid symptoms
  are present
• Depression and/or Obsessive Compulsive Disorder
• Inpatient may be necessary for the individual
  with severe emaciation.
• Ideal would be an eating disorder unit/program.
• Behavior Modifications to establish normal eating
  patterns.
• Patient may need a caloric intake 3,000 4,000
  calories daily.
• Exercise may be reduced or restricted.
• Patient may be monitored for input/output and may
  require a lock door order to monitor purging
  behavior.
• Goal To increase patient weight to 5-10
  recommended weight.
• Outpatient, Individual, and Family Therapy

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Treatment for Bulimia Nervosa

• May require inpatient treatment depending on
  medical problems or psychiatric disturbance,
  i.e., suicide.
• Outpatient, Individual, Group, and Family
  Therapy. Food diaries kept by the individual and
  Cognitive Behavior Therapy.

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More In-Depth Look at Treatment

• Gender Based Diagnoses and Treatment of Males
• The males may present with a different
  presentation than females. Males may not present
  with a drive for thinness but a better body image
  and improving strength. Screening instruments
  may be used to look at male body image attitudes
  and the drive to exercise.
• Mental Health/Primary care professionals should
  include questions about diet, eating, and
  exercise behaviors as a standard part of their
  intake protocol, rather than limiting them for
  times when they suspect a client suffers from an
  eating disorder.
• Questions that should be assessed for men
  include the use of steroids (men use steroids
  to improve appearance, muscularity, and body
  image disturbance) daily smoking, alcohol use,
  and pain medication are correlates for binge
  eating among men.
• The Eating Disorder Inventory and the Eating
  Disorder Attitudes Test, which measure disordered
  eating attitudes and behaviors are typically used
  for females but do not assess muscularity body
  image concerns . (The Psychology of Men and
  Muscularity McCreary 2007)
• The Eating Disorder Inventory is still valid for
  men but some have added items to existing
  subscales (Oates-Johnson and DeCourville, 1999)
  EDI to assess not only desire to lose weight,
  which is what the original measure assessed, but
  also mens desire to gain weight and muscle mass.

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Other Key Points in Male Gender Based Therapy

• Males and Eating Disorders Gender-Based
  Therapy for Eating Disorder Recovery (Teri
  Greenberg Stefanie and Eva Schoen 2008)
• Begin therapy by assessing mens ideas about
  therapy and preconceived notions about what
  therapy can and cannot accomplish.
• Explore the clients masculine identity and
  validate his socialization experiences, including
  per influences or significant events related to
  disordered eating.
• The mental health professional can inform the
  client about realistic body images, proper
  nutrition and the dangers of steroids and can
  challenge disturbed body image while examining
  media images.
• Explore what purpose the eating disorder serves
  cope with stress, identifying and expressing
  feelings, including sexual feelings associated
  with disordered eating.
• Assess family interactions, communication styles
  and family roles, males may adopt a patient role
  within the family.

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Cognitive Behavior Therapy for Eating Disorders
(CBT-E)

• CBT-E
• Is a transdiagnostic approach to be used with a
  full range of eating disorders.
• For including Bulimia and eating disorders NOS
  which comprises the majority of eating disorders
  in out patient settings.
• Is recommended for patients/clients with a BMI
  between 15 and 40
• Differs from regular CBT by not referring to CBT
  concepts such as automatic thoughts, core
  beliefs, and schemas, but instead emphases is
  placed on helping patients change the ways they
  behave and then analyzing the results. Essential
  to the treatment is that patients learn to
  de-center from their eating problem.
• The origin of the problem is not addressed, nor
  is every clinical feature of the eating disorder.
• The amount of change which occurs in the first
  few weeks of treatment is said to be a strong
  predictor of eventual outcome.

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The Core of CBT-E

• The core of CBT-E is to address the six main
  mechanisms which serve to maintain most eating
  disorders
• The over evaluation of shape and weight
• The over evaluation of control over eating
• Dietary restraint
• Dietary restrictions
• Being underweight
• Event or mood triggered change in eating
• If a patient is underweight this is the top
  priority of treatment
• Cognitive Behavior Therapy and Eating Disorders
  (Christopher G. Fairburn 2008)

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Eating Disorders in the Elderly

• Older Americans are being diagnosed with the
  eating disorder Anorexia nervosa. Although
  statistics are not available, therapists and
  rehabilitation centers that specialize in eating
  disorders report that every year they are
  ministering to more middle aged and older
  patients.
• Thin Gray Line (Michelle Time Lodge, 2006)

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Age Related Anorexia and the Epidimiology of
Eating Problems in Older Adults, with a Focus on
Italy International Psychogeriatrics (March
2003)
Age Related Anorexia and the Epidimiology of
Eating Problems in Older Adults

• An unintentional reduced energy intake causing
  weight loss may be caused by social or
  physiological factors. Poverty, loneliness, and
  social isolation are the predominant social
  factors that contribute to decreased food intake
  in older adults. Depression is a common problem
  in this population that can cause loss of
  appetite. The reduction of food intake may be
  due to the reduced drive to eat (hunger)
  resulting from a lower need state, or it arises
  because of more rapidly acting or more potent
  inhibitory (satiety) signals. Physical factors
  such as poor dentition and ill-fitting dentures
  or age-associated changes in taste and smell may
  influence food choice and limit the type and
  quantity of food eaten by older adults. Older
  adults are also major users of prescription
  drugs, a number of which can cause malabsorption
  of nutrients, gastrointestinal symptoms, and loss
  of appetite. Although age-related reduction in
  energy intake is largely a physiologic effect of
  healthy aging, it may predispose older adults to
  the harmful anorectic effects of psychological,
  social, and physical problems.

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Death from Anorexia Nervosa Age Span and Sex
Differences (P.L. Hewitt, S. Coren and G.D. Steel
2000)

• Although there is little written on differences
  in clinical presentation for elderly vs. young
  individuals with Anorexia nervosa, there are
  suggestions that the clinical picture is very
  similar, with the exception, of course, that
  amenorrhea may be due to menopause in women. For
  example, Cosford and Arnold (1992) reviewed
  several cases of Anorexia nervosa in elderly
  patients and found that the elderly patients
  showed similar psychopathology to that of typical
  younger individuals with Anorexia nervosa, which
  is consistent with other work on subclinical
  anorexia nervosa in elderly men (Miller, et al.,
  1991).

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Death from Anorexia Nervosa (contd)

• Moreover, they also found that about half had
  initial onset of the disorder early on whereas
  the other half had a late onset after age 50.
• Numerous reports indicate that elderly
  individuals with Anorexia nervosa come to the
  attention of clinicians following significant
  stressful events. The elderly can experience
  significant stressors, such as loss of a loved
  one, retirement, changes in living situations
  thus these environmental events may play a role
  in exacerbating or initiating an episode of
  Anorexia nervosa in elderly individuals.

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• The hypothesis by Hewitt, Coren and Steel
  suggests that there are two forms of Anorexia
  nervosa.
• The first they call, Classic Anorexia,
  characterized by early onset prior to age 45 and
  the latter form of the disorder which should be
  called Presbyanorexia.
• Overall their study provides descriptive and
  demographic data based on death certificates that
  more women die from Anorexia nervosa than do men,
  although the ratio of women to men changes among
  older individuals. This study suggests there are
  two fatal forms of the disorder one that impacts
  mainly younger women, and a second form that
  comes later in life.

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Body Image, Body Dissatisfaction, and Eating
Attitudes in Midlife and Elderly Women (Diane M.
Lewis and Fary M. Cachelin CSU, LA, CA USA 2001)

• Cohort differences in body image, drive for
  thinness, and eating attitudes in middle-aged and
  elderly women were examined. Participants were
  125 women between the ages of 50 and 65
  (middle-aged group), and 125 women 66 years and
  older (elderly group). Instruments used were
  figure ratings (Stunkard, Sorensen,
  Schulsinger, 1983), and scales of the Eating
  Disorder Inventory (EDI Garner, Olmstead,
  Polivy, 1983). Items were developed to assess
  fear of aging. The middle aged group, as
  compared to the elderly group, had more drive for
  thinness, disinhibited eating, and interoceptive
  confusion. The elderly group reported body size
  preferences and levels of body dissatisfaction
  that were similar to the younger women. There
  was a positive relationship between fear of aging
  and disordered eating. Sociocultural standards
  of body image and pressures toward thinness
  affect different generations of older women in
  similar ways.

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Body Image, Body Dissatisfaction, and Eating
Attitudes in Midlife and Elderly Women (contd)

• The elderly population in the US has been
  increasing steadily, and it is expected that in
  the next millenium, the growth of this segment of
  the population will exceed that of all other age
  groups. The majority of the elderly population
  are, and will continue to be, women (U.S. Bureau
  of the Census, 1966). The changes associated
  with the aging of the body most likely have an
  effect upon body image (Krueger, 1989). Yet,
  until recently, research on body image and eating
  disorders has focused almost exclusively on
  younger, adolescent and college-aged populations.
• The clinical picture of eating disorders in the
  elderly is similar to that seen in adolescents
  (Hsu and Aimmer, 1988), and there appears to be
  considerable continuity between midlife-and
  adolescent-onset Anorexia nervosa (Dally, 1984).
  It has been suggested that the psychological and
  physical changes associated with aging and
  menopause may parallel the changes associated
  with puberty and menarche, producing eating and
  weight related concerns that are similar in the
  different age groups of women (Gupta, 1990)
  (Kellett, Trimble, and Thorley, 1976).

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Never Too Old For Eating Disorders or Body
Dissatisfaction A Community Study of Elderly
Retired Women in Innsbruck, Austria(Barbara
Mangweth-Matzek, PhD, Claudia Ines Rupp, PhD,
Armand Hausmann, MD, Karin Assmayr, MA, Edith
Mariacher, MA, Georg Kemmler, PhD, Alexandra
Whitworth, MD, and Wilfried Biebl, MD 2006)

• A randomly selected nonclinical sample of 1,000
  women, aged 60-70 years, was contacted for our
  questionnaire survey covering current eating
  behavior, weight history, weight control, body
  attitude, and disordered eating (DSM-IV).
• The 475 (48) women included in our analyses had
  a mean BMI of 25.1 but desired a mean BMI of
  23.3. More than 80 controlled their weight and
  over 60 stated body dissatisfaction.
• Although EDs and body dissatisfaction are typical
  for young women, they do occur in female elderly
  and therefore should be included in the
  differential diagnosis of elderly presenting with
  weight loss, weight phobia, and/or vomiting.

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• It has been established that eating disorders
  may be present in those of older age, despite the
  fact that diagnostic criteria of DSM-IV and
  ICD-10 are ambiguous on this aspect. (1.2). What
  is less established is whether these
  presentations represent a continuation of a
  lifelong illness or whether eating disorders can
  present for the first time in older age.
  (Samantha Scholtz, MRCPsych, Laura S. Hill, MSc,
  MRCPsych, Hugbert Lacy, MD, Mphil, FRCPsych
  2009)
• This study was to determine whether eating
  disorders can present for the first time in older
  people.

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• This is a descriptive study of patients above
  the age of 50 years who have presented to a
  national eating disorder center within the last
  10 years.
• Thirty-two patients were identified data were
  available for 26 of these patients and 11 agreed
  for further interview and questionnaire
  completion. There were no cases where the eating
  disorder had its onset late in life. Of the 11
  interviewed, six participants retained a
  diagnosis of Anorexia nervosa, four had EDNOS and
  only one was recovered. Co-morbid depression was
  universal in those still suffering with an eating
  disorder diagnosis, and their level of social
  functioning was impaired.

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• Anorexia nervosa is a chronic and enduring
  mental illness that, although rare, can be found
  in older people.
• In our sample, we found no evidence of
  late-onset disorders all describe cases that
  were lifelong.

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Two Case Studies on Eating Disorders and the
ElderlySevere Eating Disorder Initially
Diagnosed in a 72-Year Old Man(Susan G.
Maneijias Parke, MD, Joel Yager, MD, and William
Apfeldorf, MD, PhD 2008)

• Mr. T., a 72-year old Caucasian, divorced,
  retired, male engineer was brought to our
  psychiatric emergency services by police due to
  concern of grave passive neglect when he failed
  to follow-up from post-surgical treatment of a
  significant basal cell carcinoma. Mr. Ts
  daughter had involved Adult Protective Services
  when her father began to show progressive
  difficulty managing finances, shopping and
  keeping appointments. His apartment was found to
  be filthy and without electricity, phone service,
  or food. Upon presentation, Mr. T. was
  cachectic, disheveled, and maladorous, with a
  nonhealing, unattended facial lesion. He denied
  current alcohol or substance abuse. He denied
  depressed, irritable, or elevated mood, overt
  psychotic symptoms or suicidal or homicidal
  ideation, and asked to be left alone. He was
  admitted to the geriatric-psychiatry ward for
  further assessment, safety, and stabilization.
• Past history revealed long-standing food
  preoccupations and restrictive eating habits. We
  learned that decades earlier Mr. T. had published
  an alternative health book on nutrition and
  that the over-zealous rigidity with which he
  followed his unusual diet apparently contributed
  to his divorce years ago. According to his
  ex-wife, he ordinarily drank sufficient supply.
  Initially, he had felt that only grains,
  vegetables, and fruits were needed to survive,
  but over the years he further restricted his diet
  almost entirely to fruit.

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• Mr. T was presumptively diagnosed with EDNOS and
  Dementia secondary to nutritional deficiency
  (cyanocobalamin). During his hospital stay, he
  strongly denied feeling overweight or worrying
  about weight but would power walk every day and
  acknowledged, on the eating disorder
  questionnaire (EDQ), (20) that he did so to
  control weight. He revealed no overt signs of a
  distorted body image and, notably, ate well
  throughout his stay. Although he emphasized that
  he believed he required very little protein and
  no fat at all and requested a vegetarian diet, he
  was noted to hoard food and even order bacon,
  which he would hide, and later vehemently deny
  that he had ever asked for, or would ever eat
  bacon. Eventually Mr. T admitted to a history of
  bulimia years ago, although on the EDQ he
  stated that the first/only time he had
  self-induced vomiting was at age 68. On repeated
  mental status examinations, Mr. T. was easily
  irritated and frustrated around issues of food
  and of not being able to return home.

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• Conclusion
• True clinical Anorexia in elderly males
  usually results from the Anorexia of aging, i.e.,
  with loss of appetite occurring with the
  dwindles. (21) Although Mr. T did suffer from
  some of the risk factors associated with Anorexia
  of aging (living alone, dire financial situation,
  decreased cognitive ability), he did not appear
  to have actually lost interest in eating or his
  appetite. He was preoccupied with food and, in
  fact, seemed to enjoy eating. However, he
  consistently and strictly maintained clearly
  erroneous beliefs about nutrition that led him to
  severely limit the variety and quantity of his
  food intake. Although he seemed not to harbor a
  strongly distorted body image, he steadfastly
  denied the serious medical risks imposed by his
  presenting low body weight and BMI, poor wound
  healing, and dangerously low cyanocobalamin
  status. Though he denied fearing weight gain, he
  initially exercised daily for long periods of
  time, and at least once admitted this was to
  control weight. According to criteria in the
  text revised 4th edition of the DSM, (22) Mr.
  Ts symptoms were most consistent with AN (though
  he laced the distorted weight perception a
  criterion that has been called into question with
  the emerging conceptualizations of atypical AN
  typologies (23,24), probably of the binge
  eating/purging type, notably with a past history
  of Bulimia, but currently with exercise as a
  form of compensatory behavior.

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Anorexia Nervosa in the Elderly a
Multidisciplinary Diagnosis(Kodwo A. Pobee and
Lawrence R. LaPalip 1996)

• This case study describes an 82-year old female
  sheltered care resident with features of Anorexia
  nervosa and presents a literature review of
  Anorexia in the elderly. The woman was admitted
  to a sheltered care retirement home with
  complaints of lack of appetite and weight loss.
  On presentation she weighed 85 pounds (75 of her
  ideal body weight) and ate only one third to a
  quarter of her meals. Although she denied having
  a history of Anorexia nervosa, induced vomiting,
  or any concern about her figure or weight,
  nursing staff reported various gastrointestinal
  complaints like gagging, vomiting, and episodes
  of diarrhea, and found a collection of laxatives.
  Possible etiologies for the patients poor
  appetite and weight loss were discussed at
  several multidisciplinary care conferences
  attended by a dietitian, social worker,
  pharmacist, geropsychiatrist, nurses, and
  geriatricians. The final diagnosis of Anorexia
  nervosa evolved after considering the information
  contributed by all team members. The diagnostic
  features of three forms of Anorexia are
  described classical or adolescent Anorexia
  nervosa, tardive Anorexia (Anorexia nervosa when
  it appears for the first time in the elderly and
  not a condition persisting from adolescence), and
  idiopathic Anorexia of the elderly (differing
  from tardive Anorexia mainly in that loss of
  appetite appears early, and there is no fear of
  obesity and no body image disturbance).

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THE END