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Dealing with Eating Disorders in Family Medicine
Collaborative Mental Health Care Network April 17, 2004
Colleen Flynn, MD, FRCPC
Teaching Objectives
• Present a conceptual model of ED as it applies to diagnostic criteria and treatment approach
• Discuss “setpoint theory” and its therapeutic application in the treatment of ED
• Discuss an approach to caring for adults with ED in family medicine
Learning Objectives
• Increase recognition of ED symptoms via a conceptual model
• Understand role of dieting in the perpetuation of ED
• Develop a stepped approach to the management of adults with ED
Conceptualizing Eating Disorders Russell, G. Bulimia Nervosa: An ominous variant of anorexia nervosa. Psychol Med 1979:9;429-48
Psychopathology / Cognitive Distortion
Behavioural Disturbance Compensatory Consequence
Anorexia Nervosa (DSM IV)
•Intense fear of gaining weight even though underweight.
•Refusal to maintain weight at minimally normal level for age & height (85% expected)
•Amenorrhea in postmenarcheal females.
Restricting Type and Binge-Eating/Purging Type
•Disturbance in way one’s body size is experienced or undue
influence on self-evaluation or denial of seriousness of current low weight.
Bulimia Nervosa (DSM IV)
•Self-evaluation is unduly influenced by body shape and weight.
•Recurrent episodes of binge
eating. 1.Eating in a discrete time period an amount larger than most.
2. A sense of lack of control
inappropriate compensatory behaviour in order to prevent weight gain.
Purging Type and Nonpurging Type
•Recurrent
•Frequency: 2 / week
Eating Disorder, NOS (DSMIV)
• Partial syndrome Anorexia Nervosa• Partial syndrome Bulimia Nervosa• Binge Eating Disorder• Chews and Spits• Night Binge Eating
Screening Questions
• Are you unhappy with your body weight?• Are you dieting? • Have you lost weight?• Do you experience binge eating?• Do you purge after eating?• Do you feel your exercise is out of control?Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John
Hopkins, 1999.
Prevalence• AN: 0.5 - 1% Woodside, DB. A review of Anorexia Nervosa and Bulimia
Nervosa. Curr Probl Pediatr; 1995;25:67-89.
• BN: 1.1% full syndrome2.3% partial syndrome
Garfinkel, Lin, Goering, Spegg, Goldbloom, Kennedy, Kaplan, Woodside. Bulimia Nervosa in a Canadian community sample. Amer J Psych; 1995;152:1052-8.
• BED: 25% of medically obese patients Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John Hopkins, 1999.
Comorbid Psychiatric Illness(50-70%)
• Mood Disorders• Panic Disorder• Generalized Anxiety Disorder• Obsessive Compulsive Disorder• Post Traumatic Stress Disorder• Alcohol / Drug Abuse• Personality Disorders
Mehler & Andersen, A Guide to Medical Care and Complicatons: Eating Disorders, John Hopkins, 1999.
Regulation of Body Weight
• Dieting
• Setpoint theory
• Evidence of Setpoint theory and the effects of starvation on behaviour.
Implications of Dieting forEating Disorders
• In N. America 80% girls, 10% boys on diets by age 13 Mellin, Irving, Scully. Prevalance of disordered eating in
girls. J Amer Dietetic Ass 1992:92;851-3.• Dieters - 3.3 times more likely to binge eat
and 5.7 times more likely to vomitJones, Bennett, Olmsted, Lawson, Rodin. Disordered eating attitudes and behaviours in teenaged girls: a school-based study. CMAJ Sept 4, 2001; 165(5):547-52.
• Dieting schoolgirls at one year showed 20% had progressed to an ED as opposed to 3% ofnondieters Patton, Johnson-Sabine, Wood, Mann, Wakeling. Abnormal eating attitudes in London schoolgirls. Psychol Med 1990:20;383-94.
Heritability Estimates of Various Conditions
• Breast Cancer 45%• Coronary Artery Disease 49%• Epilepsy 50%• Alcoholism 57%• Hypertension 57%• Schizophrenia 68%• Height 80%• Weight 81%Stunkard et al. A twin study of Obesity. JAMA 1986:256;51-4.
Setpoint Theory
• The body is biologically programmed to weigh a certain amount
• The body defends a certain weight that is unique to each individual
• A number of factors determine what one’s natural weight will be
The Keys Study: Keys et al (1950), The biology of human starvation.
Minneapolis,University of Minnesota Press
• Scientists wanted to establish the best way to refeed people who had starved in Europe as a result of WWII
• 100 men volunteered, 40 with exceptional physical & psychological health selected
• 24-week period of dietary restriction with goal to lose 25% of body weight
Keys StudyFindings Before Semi-Starvation
• Subjects were pleasant, well-adjusted, active
• Were not weight & shape preoccupied
Keys StudyFindings During Experiment
• Decreased BMR, lowered body temperature• bradycardia, hypotension• Lethargy• Impaired concentration & judgment• Reduced libido
Keys StudyFindings During Experiment
• Withdrawn, depressed• Irritability, mood swings• Nail biting• Preoccupied with food• Increased use of salt, spices, coffee, tea,
chewing gum, cigarettes
Keys StudyDuring the Refeeding Phase
• Increase in hunger immediately following a large meal
• Consumption of enormous quantities of food without feeling satisfied
• Subjects did not skyrocket into obesity
graph
Significance of the Keys Study
• Challenges the popular notion that body weight is easily altered if one has enough “willpower”
• Demonstrates that the body has a strong biological drive to defend its target weight or setpoint.
• The body is not simply “reprogrammed” at a lower setpoint once weight loss has been achieved
Keys StudyImplications for Eating Disorders
• Many symptoms are a result of starvation
• Symptoms are not restricted to food & weight but extend to virtually all areas of psychological & social functioning
A Stepped Approach to Treating Eating Disorders
Psychopathology / Cognitive Distortion
Behavioural Disturbance Compensatory Consequence
A Stepped Approach to Treating Eating Disorders
• Therapeutic mileau
• Recognizing the stage of treatment– Living safely with the illness
– Working toward symptom interruption
– Relapse prevention
Therapeutic Mileau
• Empathic, non-judgemental, non-blaming
• Be aware of personal preference / bias / prejudice and avoid enactment
• Support treatment philosophy of setpoint theory and weight regulation
Stage 1:Living Safely with the Illness
• Safety
• Living with illness
Safety(Goal = keep them alive)
• Monitoring for the physical complications of semi-starvation, purging and refeeding
• High risk: - severe or rapid weight loss-increased frequency of symptoms
• Emaciated patients may be young but their bodies can be as frail as some 90 year olds
• Responding to psychological crisis
Living with the Illness
• Nonspecific supportive psychotherapy• Understanding egosyntonic aspects• Enhancing egodystonic aspects• Expanding activities and social connections• Education around ED and consequences• Negotiating small changes in symptoms• Pharmacotherapy
Stage 2: Working toward Symptom Interuption
• Education• Nutritional rehabilitation
– Non-dieting approach• Motivational enhancement techniques• ED specific CBT / IPT / family therapy • Behavioural therapy to address symptoms• Pharmacotherapy
Education
• Illness and diagnosis• Physical and psychological complications• Precipitating and perpetuating factors• Setpoint theory and weight regulation• Role of starvation in the binge / purge cycle• Normalized eating• Coping strategies
The Non-Dieting Approachand Structured Eating
• 3 meals & 1-3 snacks daily• Daily caloric intake: about 2000 calories• Food = Medicine, needs regular dosing• Eat by the clock• Plan ahead to avoid undereating / overeating• No forbidden / phobic / “bad” foods• All foods can fit
Cognitive Behaviour Techniques
• Self-monitoring of symptoms including time of day, type of meal, intake, urges, symptoms
• Examine symptoms by exploring connections between the situation, feelings and automatic thoughts
• Develop behavioural strategies
Behavioural Strategies
• Self soothing activities• Coping phrases• Delay• Distraction• Problem solving• Limit setting
Stage 3: Relapse Prevention
• Examining “slip ups”
• Reinforcing learned strategies
• Addressing underlying psychopathology
Pharmacotherapy
• SSRI anti-depressants:– Prozac– Paxil– Zoloft– Celexa
• Uses:– binge urges– co-morbid mood and anxiety illnesses
Anti-depressants & Anorexia Nervosa
• Do not work in underweight, emaciated individuals
• Some evidence of usefulness in weight-restored individuals to prevent relapse
Anti-depressants & BulimiaNervosa Fluoxetine Bulimia Nervosa Collaborative Study Group. Fluoxetine in the treatment of Bulimia Nervosa. Arch. Gen. Psych. 1992:49;139-47.
• 60% reduction in symptoms of bingeing and purging
• High doses often needed• Effective as an adjunct to other treatments• Effect not related to treatment of depression• After response, continue for at least one
year
Pharmacotherapy: Anxiolytics
• Benzodiazepines or low dose antipsychotics
• May be helpful for short term use (eg. treating anxiety before meals)
• Antipsychotics may help weight restoration in AN by decreasing eating disordered thoughts
Pharmacotherapy: GI
• Prokinetic agent to help with symptoms of bloating, reflux and abdominal pain after eating (eg. domperidone)
• Constipation: avoid stimulant laxatives (including sennakot)– Bulk agents: psyllium fiber– Osmotic agents: lactulose, GoLYTELY, Peglyte
Outcome• AN: Mortality - 5% at 5-8 years, 20% at 20 years
Full Recovery - 32 - 71% over 20 yearsChronicity - 20% over 20 years
• BN: Mortality: 5% over 2-5 yearsRecovery: 20 - 25% continuously well
20 - 25% continuously illWoodside , DB. A review of Anorexia Nervosa and Bulimia Nervosa.
Curr Probl Pediatr; 1995;25:67-89
• BED: significantly better outcome than BNStriegel-Moore, Wilson, Wilfley, Elder, Brownell. Binge-eating in an obese community sample. Int J Eat Disord; 1998;23:27-38
Suggested Resources
• Eating disorders: a guide to medical care and complications. P. Mehler & A. Andersen.
• Turning Points: A psychoeducational program for overcoming and eating disorder. R. Davis & W. Phillips. Distributed through NEDIC.
• The overcoming bulimia workbook. R. McCabe, T. McFarlane & M. Olmsted.
• Overcoming binge eating. C. Fairburn.• Gurze eating disorders resource catalogue.
www.bulimia.com (800)-756-7533.
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