Rogers treats children, adolescents and adults with:
• Anxiety disorders
• Eating disorders
• Mood disorders
• Substance use disorders
800-767-4411 rogershospital.org

Brad E.R. Smith, M.D.
Medical Director
Eating Disorder Services
Rogers Memorial Hospital

• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Other Specified Feeding or Eating Disorder
– Atypical anorexia nervosa, bulimia with low frequency, binge eating with low frequency, purging disorder, night eating disorder
• Unspecified Feeding or Eating Disorder

• Combination of longstanding behavioral, emotional, psychological, interpersonal, biological and social factors.
• Natural size and shape largely determined by genetics, so fighting that can lead to unhealthy practices.
• 20 million women and 10 million men suffer from clinically significant eating disorder at some time in their life.
• Highest mortality rate of any psychiatric disorder

• Restriction of energy intake relative to requirements, leading to significantly low body weight
• Intense fear of gaining weight or becoming fat, even though underweight
• Disturbed way in which body weight or shape is experienced, undue influence of weight on selfevaluation, or denial of seriousness of low weight

• Restricting type: no binge eating or purging behavior
(purge is vomiting or misuse of laxatives, diuretics, enemas) in past 3 months
• Binge-eating/purging type: regularly engaged in binge-eating or purging behavior in past 3 months

• Mild: BMI less than or equal to 17
• Moderate: BMI between 16 and 16.99
• Severe: BMI between 15 and 15.99
• Extreme: BMI less than 15

• Prevalence: 0.4% of late adolescent to early adult females meet full criteria. Subthreshold rates higher.
Limited data in male populations.
• Age of Onset: mean is 17 y.o., possibly bimodal at 14 and 18 y.o.
• Mortality: 5% per decade

• Often begins after stressful life event (transition to college)
• Recovery after single episode, fluctuating course of recovery and relapse, chronic deterioration over years
• Increased risk among first degree biological relatives with Anorexia Nervosa and mood disorders
• Increased risk in occupations/avocations that encourage thinness: modeling, elite athletes, dancing

• Whole Body: low weight, dehydration, hypothermia, cachexia, weakness, fatigue
• Cardiovascular: palpitations, lightheadedness, dizziness, weakness, SOB, chest pain, cold extremities, bradycardia, orthostatic, weak pulse
• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, neuropathy
• Endocrine: fatigue, cold intolerance, diuresis, hypothermia

• GI: vomit, pain, bloating, constipation, distension with meals, parotid swelling, dental caries, diarrhea
• GU: changes in urinary volume
• Hematology: fatigue, cold intolerance, bruising
• Immune: low white blood cells, reduced febrile response to infections
• Integument: changes in hair, hair loss, dry/brittle hair, yellow skin, lanugo, acne

• Muscular: weakness, aches, cramps, muscle wasting
• Pulmonary: reduced aerobic capacity, wasting of respiratory muscles
• Reproductive: arrested development of sex characteristics and psychosexual maturation, loss of libido, loss of menses, regression of sex characteristics, fertility problems, pregnancy complications
• Skeletal: bone pain, short stature and arrested skeletal growth, osteopenia, osteoporosis

• Recurrent binge eating episodes
– Eating large amount in period of time compared to normal
– Sense of lack of control during episode
• Recurrent compensatory behavior to prevent weight gain (vomiting, laxatives, diuretics, enemas, meds, fasting, overexercise)
• Once per week for three months
• Self-evaluation unduly influenced shape, weight
• Not exclusively during anorexia

• Mild: 1-3 episodes of compensatory behaviors per week
• Moderate: 4-7 episodes of compensatory behaviors per week
• Severe: 8-13 episodes of compensatory behaviors per week
• Extreme: 14 or more episodes of compensatory behaviors per week

• Prevalence: 1-1.5% in adolescent and young adult females, 0.1-0.3% in males. Subthreshold symptoms higher.
• Age of Onset: late adolescence or early adulthood
• Mortality: 2% per decade

• Often begins during or after dieting
• Chronic or intermittent
• Increased risk if Bulimia Nervosa, a mood disorder, or substance abuse in relatives
• Cross-over to Anorexia Nervosa: 10-15%

• Cardiovascular: weakness, palpitations, arrhythmias
• CNS: apathy, poor concentration, cognitive impairment, anxious, depressed, irritable, seizures, peripheral neuropathy
• GI: heartburn, reflux, blood in vomit, pain, constipation, bloating, gastric or esophageal rupture, perforation, enlarged salivary glands, esophageal erosions, pancreatitis, colonic dysmotility
• Integument: scarring on dorsum of hand (Russell’s sign), petechia, conjunctival hemorrhages after vomit

• Metabolic: weight fluctuations, muscle cramping, pitting edema
• Muscular: weakness, myopathy (worst in ipecac users)
• Oropharyngeal: dental decay, pain in pharynx, swollen cheeks and neck, dental caries
• Reproductive: fertility problems, spotty menstrual periods
• Skeletal: bone pain, arrested skeletal growth, osteopenia or osteoporosis

• Recurrent episodes of binge eating
• 3 or more: eat more rapidly, uncomfortably full, large amounts despite no hunger, eating alone due to embarrassment, disgusted with oneself/depressed
• Marked distress
• 1 day/week for 3 months
• No use of compensatory behaviors

• Mild: 1-3 episodes per week
• Moderate: 4-7 episodes per week
• Severe: 8-13 episodes per week
• Extreme: 14 episodes per week

• Prevalence: 1.6% females, 0.8% males
• Age of onset: late adolescence or early adulthood

• Dieting often follows onset of illness
• Remission rates higher than Bulimia or Anorexia
• Cross-over to other eating disorders not as common
• Increased risk for obesity and associated complications

Depression
Anxiety
Alcohol abuse and/or dependence
Posttraumatic stress disorder
70% life time prevalence
63% life time prevalence
40% OCD
Social phobia 20%
Anorexia Nervosa 17%
Bulimia Nervosa 46%
13%

• Anorexia: estimates vary between restricting type vs binge/purge type, lower than BN and BED
• Bulimia Nervosa: 22.9% have alcohol abuse
• Binge Eating Disorder: 57% males and 28% females with lifetime substance abuse
• Associated with higher rates of impulsivity---shoplifting, self-injury, suicidal behaviors, laxative abuse
• Holderness et al, 1994 indicated 50% of ED patients had some form of substance abuse/dependence compared to
9% of general population

What to Look for:
• Any signs of the medical complications listed previously
• Significant weight changes
• Family reports
• Behaviors

• Obsessively counting calories/nutritional content
• Cutting food into small pieces, hiding food, unusual combinations of condiments
• Gum, ice, candy
• Loose clothing
• Bathroom during or after meals
• Long time to eat

• Express concerns in non-judgmental way
• Offer information on illness/complications
• Avoid “triggering” terms – fat, healthy, better
• Ask open-ended questions

• Comprehensive team: therapists, dietitian, primary care physician, psychiatrist
• Outpatient
• Intensive Outpatient
• Partial Hospital Program
• Residential Treatment Center
• Inpatient
– ED Hospital
– Medical/Surgical Hospital

• Nutritional rehabilitation
• Psychotherapy
– Individual, group
– CBT, DBT, IPT, psychodynamic, family
• Medications
– Antidepressants
– Antipsychotics
– Anxiolytics
– Topiramate

• Early intervention has best success
– 70% of adolescents who received treatment had full recovery at 5 yrs
• Adult hospitalized patients 4 yrs later
– 44% good outcomes
– 28% intermediate
– 24% poor
– 5% died

• Community support
• Peer support (12 step programs)
• Transitional living
• Group homes
• Using legal system
• Earlier recognition

• Optimism
• Facing fear
• Moral compass, ethics, and altruism
• Spirituality and religion
• Social support
• Role models
• Training: physical health
• Brain fitness
• Cognitive and emotional flexibility
• Meaning, purpose, growth
• Steven Southwick, M.D. and Dennis Charney, M.D.

• 36 y.o. P.A. ---health care professional
• Started in HS, first admitted in past year---denial, covering up, deceit
• Going through divorce---high impact on family
• Lost job---high impact on work
• Wife wanted another child---testosterone level low
• Restricting primarily----a man restricts
• Started out trying to eat healthy for sports---slippery slope
• 5’11” admit weight 103 (BMI 14.5)---thinks he is overweight

• Mood down---deficiency in protein leads to low neurotransmitter, meds cannot work
• Alcohol use at half pint of hard alcohol---numb self, calorie intake uncommon
• Started binge and purge---idea that starvation leads to binge
• Hypokalemia---supplement electolytes, high risk of arrhythmia
• Liver enzyme elevation---alcohol or ED
• One child age 5---nearly apathetic to being away from
• Edema with refeeding---fluid shifts, cardiac overload
• Pulse 42---cardiac dysfunction

• Mother professor, father engineer---loving, professional parents can have child with ED
• Hiding food, deny even when caught---deceit and denial
• Grabbed excessive equal at AA meeting, presented completely innocent---deceit and denial
• NG tube for weeks, turning off---deceit
• Meals take long time, rituals---OCD high comorbidity
• Insurance MD thinks “must be something else”---severe
ED is its own illness
• Compliance improved with insurance threatening to cut out---sometimes the insurance may help

• 800 mg of quetiapine---distorted thinking unphased
• Able to improve compliance (i.e. when insurance threatening)---behavioral component of this leads to misperceptions
• Went on to RTC, improving---even very complex situations can improve

• Rogers Memorial Hospital: rogershospital.org
• National Eating Disorder Association (NEDA): nationaeatingdisorders.org
• National Association of Anorexia and Associated
Diseases (ANAD): anad.org

Rogers’ Eating Disorder Services are offered at these Wisconsin locations:
• Oconomowoc
• Milwaukee (West Allis)
• Madison
800-767-4411 rogershospital.org