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The University of Michigan Depression Center Colloquium Series

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Title: Nervosa: Epidemiology Author: David S Rosen Last modified by: University of Michigan Created Date: 5/3/1998 6:51:11 PM Document presentation format – PowerPoint PPT presentation

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Title: The University of Michigan Depression Center Colloquium Series


1
The University of Michigan Depression Center
Colloquium Series
  • The Colloquium Series is made possible by an
    educational grant from GlaxoSmithKline.

2
U-M Depression Center ColloquiumEating
Disorders and DepressionClinical Context
  • David S. Rosen, M.D., M.P.H
  • University of Michigan Medical School
  • Ann Arbor, Michigan, USA

3
Spectrum of Eating Disorders
Risk Factors
Healthy Eater
Typical Dieter
Pathological Dieter
ED-NOS
ED
Protective Factors
4
Prevalence of Eating Disorders

5
Anorexia Nervosa DSM-IV Diagnosis
  • Weight loss (or refusal to gain weight) below
    normal for age and height
  • Fear of fat, even though underweight
  • Body image distortion or overconcern about
    weight or shape even though underweight
  • Amenorrhea (abnormal fxn of H-P-G axis)

6
Anorexia Nervosa Presentation
  • Nutritional deficiency and wasting
  • Delusion of being fat
  • Obsession to be thinner
  • Denial
  • High rates of medical complications
  • High rates of psychiatric co-morbidity

7
Anorexia Nervosa Epidemiology
  • Point prevalence lt 1
  • Lifetime prevalence 0.6-4.0
  • Increasing prevalence in past 30 years
  • Females gtgt males
  • Typically presents in adolescence
  • Increasing presentation among atypical patients
    (e.g., males, children, people of color,
    immigrants, low SES)
  • Partial syndromes are common

8
Bulimia Nervosa DSM-IV Diagnosis
  • Binge eating lack of control over binges
  • Abnormal compensatory behavior to manage weight
  • Overconcern with body weight or shape
  • Symptoms at least 2x/week for 3 mo

9
Bulimia Nervosa Presentation
  • Recurrent, secretive binge eating
  • Awareness that eating is abnormal
  • Fear of loss of control over eating
  • Short-term relief from compensatory behaviors
  • Depression, shame, guilt
  • Low, normal, or high weight
  • High rates of medical complications
  • High rates of psychiatric co-morbidity

10
Bulimia Nervosa Epidemiology
  • Point prevalence 0.4-3.0
  • Lifetime prevalence 1-6
  • Increasing prevalence in past 10 years
  • Females gtgtgt males
  • Occurs primarily in older adolescents and young
    adults
  • Partial syndromes are common

11
Spectrum of Eating Disorders
Risk Factors
Healthy Eater
Typical Dieter
Pathological Dieter
ED-NOS
ED
Protective Factors
12
Eating Disorders Etiology
  • Multifactorial Etiology
  • Biologic risk factors
  • Individual/psychological risk factors
  • Familial risk factors
  • Sociocultural risk factors

13
Etiology Biologic Risk Factors
  • EDs aggregate within families with distinct and
    significant genetic effects
  • Genetic (and environmental) influences vary
    across adolescence and may be variably expressed
    at different stages of development
  • Consistent association of EDs with alteration in
    Serotonin function

14
Etiology Biologic Risk Factors
  • Native animal models of AN exist among swine,
    sheep, and goats Genetically determined
    physiological response to excessive leanness
    oversensitivity to stress
  • Animal models of binge eating have been developed
    in rats Restriction/re-feeding cycles response
    to stress exposure to highly palatable food.
  • Binge eating appears to be motivated by reward
    rather than metabolic need

15
Etiology Heritable Risk
  • AN 11x more likely in female relatives of AN
    proband vs. relatives of controls
  • BN 4-5x more likely in female relatives of BN
    proband vs. relatives of controls
  • 15 lifetime risk of ED in female relatives of
    AN or BN proband vs. 4 lifetime risk in
    relatives of controls

Strober et al. Am J Psychiatry 2000 157393
16
Etiology Individual Characteristics
  • Perfectionism
  • Over-achieving
  • Obsessional thinking
  • Low self-esteem
  • Depression
  • ? History of sexual abuse

17
Etiology Sociocultural Pressure
  • Societys focus on attractiveness
  • Prevailing cultural stereotypes
  • Thin is beautiful
  • Unhealthy media representationsof women
  • Emergence of pro-Ana and pro-mia influences

18
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19
Malnutrition
  • Decreased metabolic rate
  • Inability to maintain body temperature
  • Decrease in brain mass (? Reversible)
  • Cognitive changes
  • Affective symptoms
  • Medical sequelae of malnutrition are the leading
    cause of death in anorexia nervosa

20
Medical Complications of EDs
  • Cardiovascular complications
  • Gastrointestinal complications
  • Fluid/electrolyte complications
  • Skeletal complications
  • Renal complications
  • Endocrine, hormonal,and reproductive
    complications
  • Skin and dental complications
  • Re-feeding syndrome

21
Psychiatric Co-morbidity
  • Affective disorders, suicidality
  • Anxiety disorders
  • Obsessional behavior, OCD
  • Substance abuse
  • Suicide is the leading cause of deathin bulimia
    nervosa

22
Anxiety Disorders and EDs
  • Methodologically rigorous controlled study of 271
    women with AN and BN
  • Lifetime co-morbidity with at least one anxiety
    d/o 70 (significantly gt controls)
  • Most anxiety disorders persist after recovery
  • In approximately half of co-morbid cases, the
    anxiety disorder precedes the ED

Godart NT et al. Psychiatr Res 2003 117245
23
Depression and EDs
  • Longitudinal, community-based, Children in the
    Community study
  • Depressive disorders are independent risk factors
    for the development of EDs (OR8.45) and ED Sx.
  • Depressive disorders during early adolescence are
    associated with development of later EDs
  • EDs during adolescence associated with
    significantly increased risk of depressive
    (OR4.32) and anxiety disorders (OR4.13) during
    early adulthood.

Johnson JG et al. J Consulting and Clin Psychol
2002 51119Johnson JG et al. Arch Gen
Psychiatry 2002 59545
24
AN State-of-the-Art Treatment
  • Few RCTs and little evidence.
  • Interdisciplinary treatment is considered to be
    the standard of care
  • Early nutritional rehabilitation is essential
  • CBT is the most useful psychotherapy
  • In adolescents, evidence strongly supports
    family-oriented treatment
  • Limited role for pharmacotherapy

25
BN State-of-the-Art Treatment
  • Self-help strategies are of limited value
  • BN-focused CBT is the most effective treatment
    but short-term outcomes are still poor (lt 50)
  • Pharmacotherapy (SSRIs, Topiramate) is a useful
    adjunct to CBT but is less effective as
    monotherapy or when combined with self-help
  • Early response to treatment is a useful predictor
    of both short- and long-term outcomes

26
Prognosis
  • Inadequate data inadequate follow-up
  • Variable definitions of recovery and cure
  • Long-term outcomes are better than previously
    assumed
  • Significant ongoing risk of psychiatric illness
  • Relapse prevention is important!
  • Mortality is still significant

27
Outcome of AN by Age at Onset and Duration of
Follow-up
Both younger age at onset, and longer duration
of follow-up are associated with better outcomes.
Adol Onset
All Ages
Steinhausen HC. Am J Psychiatr 2002 1591284
28
Prognosis
  • At long-term follow-up, most adolescent patients
    with ED (70) have fully recovered and gt80 have
    normal eating, weight, and menses. However, they
    will have spent more than 1/3 of their lives in
    treatment!
  • At long-term follow-up, approximately 10 of
    patients will have persistent AN, 20 will have
    BN, and 5 will have died.

Steinhausen H-C et al. Eur Child Adolesc Psych
2003 1291-98
29
Outcome of Adolescent-Onset ED in a Longitudinal
Cohort of Girls
  • 982 adolescent girls from a school-based
    Australian cohort 14-15 y/o at entry
  • Seven waves over six years
  • Point prevalence of ED 2.4 at age 15-18
  • Point prevalence of ED 3 at age 20
  • Prevalence of ED 8.8 across entire study
  • Only 11 of teens with ED still had ED at
    follow-up
  • However, nearly half had persistent depression
    and/or anxiety at follow-up

Patton GC et al. Eur Child and Adol Psychiatr.
2003 12 (Suppl 1)I25
30
Summary
  • Eating disorders are common, even though AN and
    BN are uncommon
  • Biology and genetics are fundamental to the
    etiology of eating disorders
  • Medical complications of eating disorders may
    affect every organ system and can be serious or
    fatal.
  • Significant psychiatric co-morbidity

31
Summary
  • Early treatment of adolescent ED may be
    associated with a better prognosis
  • With excellent treatment, it is reasonable to
    expect a good prognosis (but be prepared to work
    at it for a very long time).
  • More effective treatments for ED are urgently
    needed and may be informed by a better
    understanding of their biology
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