Getting to the fundamentals of eating disorders.
Professor Janet [email protected]
Conflict of Interest
• Pharma- Nil
• Books-Several books for patients/carers and professionals.
• NICE guideline committee
• World federation of biological psychiatry guidelines.
Talk Map
• What are eating disorders?
• The history
• The prevalence of eating disorders
• The clinical features.
• Treatment
Spectrum of EDs
Increasing tendency to fatness
Gull 1873Lasegue 1873 Russell 1979
Volkow 2007
Purgi
ng D
isord
er
Stunkard
Orphan Disorders
• What are they?
• Physical or psychological?
• Body image or eating?
• Neurotic or psychotic?
• Developmental or Environmental ?
Cases presenting to primary care in UK (Micali et al 2012)
EDNOS BED most common diagnosis
Epidemiology: Lifetime prevalence)(Hudson et al 2007, Jacobi et al 2004, Preti et al 2009,
Field 2011)
All F M
AN 0.6% 0.9% 0.3%
BN 1% 1.5% 0.5%
BED 3% 3.5% 2.0%
EDNOS
(PD)
15% 10% 5%
Clinical Features
Anorexia NervosaAnorexia Nervosa• Illness defined 1860
• Teenage onset
• Avoid eating
• Excess exercise
• High mortality (up to 20%) & disability
I had a voice in my head that criticised me. It told me I was
dreadful and did not deserve food. It became harder to ignore the voice.
Bulimia nervosa• 1979: Defined by Russell • Core Behaviours: Binge
>1000cal out of control• Compensatory
Behaviours eg Vomit, laxatives, exercise, drugs
• Teenage onset
I used to go to the kitchen and eat as much as I could as quickly as possible to fill the hole I felt inside. I felt horrid
afterwards and would make myself sick
Binge Eating Disorder: History
Recurrent distressing Recurrent distressing bingesbinges
• No food restrictionNo food restriction• No compensatory No compensatory
behavioursbehaviours• ObesityObesityPrevalence: 1-3%Prevalence: 1-3%• Men & women affected Men & women affected
equallyequallyPeak age onset: 13-15 and Peak age onset: 13-15 and
early 20s early 20s
I spent all my time thinking of food. I would wake in the night and want to
eat
What is the Health and Psychosocial Burden?
What is the Health and Psychosocial Burden?
• ↑ Morbidity (Johnson et 2002, Striegel Moore et al 2003,Patton et al 2008).
• Education: interruptions and lower level for AN. (Byford et al 2007).
• Vocational: 21% on state benefits (Hjern et al 2006).
• Social networks small (Tiller et al 1997).• Communication Skills impaired (Takahasi
et al 2006).
The evolution of eating disorders
Anorexia Nervosa Bulimia Nervosa
Bulimia nervosa Drug & alcohol abuse, social anxiety
Binge eating disorder Obesity
Lewinsohn et al 2000, Brukner et 2010, Field et al 2011, Tozzi et al 2005, Milos et al 2005
The Brain Causes
Self regulation systemSelf regulation systemEmbeds eating into social context & Embeds eating into social context & individual valuesindividual values
Hedonic centreReward from food (limbic system
Homeostatic centreHomeostatic centreRegulates input and output of Regulates input and output of energy supplyenergy supply
LearningMemories of food
reward & metabolic consequences
Consequences of malnutrition on the brain
The effect of Nutritional Problems The effect of Nutritional Problems on the brainon the brain
Brain needs 500kcal/day.
Brain needs 7 X caloric intake of muscle
Brain function can be damaged by irregular pattern eating as well as amount.
Consequences of fast/feast/ vomiting on the brain
Animals models of binge eating
• Breeding (impulsive)• Early adversity• A period of under nutrition.• Divert food stomach • Intermittent availability of
highly palatable food• Stress. (Rada et al 2005, Lewis et al 2005,
Avena et al 2005, Corwin 2006, Corwin & Hajnal 2005, Boggiano et al 2005; Avena & Hoebel 2003, Avena & Hoebel 2007, Boggiano et al 2007, Jahng 2011).
Self regulation systemSelf regulation systemEmbeds eating into social context & Embeds eating into social context & individual valuesindividual values
Hedonic centreReward from food (limbic system
Homeostatic centreHomeostatic centreRegulates input and output of Regulates input and output of energy supplyenergy supply
Restriction from cognitive control
Damaged by starvation
Over sensitive reward centre ↑
binging Starvation ↑ rewardFast/feast ↑ reward
Brain areas implicated in eating disorder symptomsSecondary problems
Consequences on other people
The interpersonal perpetuating cycle
Distressing EDSymptoms
And Behaviours
Carers concernedAnd anxious at ED
symptoms
Carers respond:Expressed emotion
AccommodateEnable
•(Zabala et al, Eur Eat Rev 2009)
Kyriacou et a 2008Sepulveda et al 2009
• Amy’s line manager phoned you saying that she was worried that Amy had anorexia nervosa. Amy comes to see you reluctantly saying that nothing is wrong.
Opening Moves
• Normalise ambivalence about attendance. Who is the prime mover, peers, self, line manager?
• Elicit concerns: physical, psychological, spiritual, family, social, education/career, forensic.
• Elicit readiness to change.• Assess medical risk.• Ethical responsibility: Discuss issues of
confidentiality. If high risk need to involve others, professionals.
Is it Anorexia Nervosa?
• Usually the history from self or informants is clear.
• Atypical cases ie with no overt concern about eating, shape & weight do occur
• Differential Diagnosis: examine over time (can they gain weight?), ESR, C reactive protein, platelets, TFT , albumin are useful screening tests
Physical SignsPhysical Signs
Parotid or submandibular gland enlargement
Eroded teeth "Russell's sign" callus on back of hand
Cold blue hands, nose and feet
Lanugo hair
WWW.eatingresearch.com-health professionals
What is the Risk?The Brief Medical Risk Assessment
www.eatingresearch.com
• Skeletal power to examine for myopathy which is a good marker of severity.
• Blood pressure and HR to measure cardiac function and circulation. The fall in BP between sitting & standing & dizziness is a measure of dehydration.
• Core temperature- level of metabolism. • Blood markers of organ failure: liver,
marrow, kidney.
Danger Signs
Difficulty arising from squat/sit up
Tetany
LFT’s
Na K
Fits, Coma
Glucose
Arrythmias, SyncopePR<40bpmBP<80mmHgPostural drop>20mmHg
Rapid Rate Weight loss
Hb WCC platelets
Petechial rashUlcer
Treatment
Systematic reviews: AN
Outpatient
psychotherapy
Specific >non specific
Hay et al 2008
Family therapy Probable effect Fisher et al 2010
Antidepressants Little effect Claudino et al 2006
Antipsychotics In progress Claudino et al
Systematic reviews: BN
Outpatient
psychotherapy
CBT large Hay et al 2003
Self help Small effect Perkins 2006
Antidepressants TCA, SSRI, Large effect
Bacaltchuk 2003,
Aiger, Treasure WFBP 2011
Antidepressants & therapy
Large effects Bacaltchuk 2001
Systematic reviews: BED
Outpatient
psychotherapy CBT, IPT< DBT
Moderate binge
Nil-small weight
Vocks 2009
Self help Small effect Vocks 2009
Orlistat, topiramate Moderate binge
Moderate weight
Vocks 2009
Antidepressants
SNRI> SSRI
Moderate binge
Nil-small weight
Vocks 2009
Aiger, Treasure WFBP 2011
Perkins, S Cochrane Systematic Reviews 2006 Issue 3
New Tools for Eating Disorder Treatment
Books Web base Mobile Games
More effective if used with guidance
Guided Self Help (GSH)
• BN: GSH= CBT (Thiels et al 1998) , GSH > CBT for sustained benefit (Mitchell et al 2011).
• BN adolescents. GSH>FT (Schmidt et al 2007).
• BED: GSH> BWL (Grilo et al 2005) GSH>IPT post Px & 2 y (Wilson et al 2010).
• BN EDNOS: GSH>TAU (Streigel Moore et al 2010), GSH> wait list (Traviss et al 2010).
• AN : GSH> TAU: pre admission (Fichter et al 2008) post admission (Fichter et al 2011)
Outcome
The Long Term Outcome of Anorexia Nervosa (Stoving et al 2011)
20-25% Persistent illness
Median recovery 7 years
N=351, Male %%
The outcome of Bulimia Nervosa (Stoving et al 2010)
40% Chronic Illness
Median Recovery 12 years
N=361, Male 1%
Conclusion
• Eating disorders are increasing and they have a persistent course.
• Genetic, environmental and developmental factors contribute to causes.
• Eating disorders have profound effects on brain, body and social network.
• Biological, psychological and social process maintain the disorders.
• Early intervention before secondary effects become entrenched is essential to avoid harmful costs.
• A collaborative approach with individual and family is essential.