Eating Disorders
in Adolescence
American Society for Adolescent Psychiatry
March 29, 2014
Steven Crawford, M.D.
Center for Eating Disorders at Sheppard Pratt
S
Eating Disorders
and Co-morbidity
S Depression
S Anxiety
S Substance Use Disorders
S Personality Disorders
S Safety
Co-morbidity: Depression
S
30-50%; 70% lifetime prevalence
S
Affects motivation, psychological
accessibility
S
Starvation status produces similar
affective, cognitive and somatic
symptoms
S
Antidepressants do not work as well
S
Psychological treatments do not
work as well
Co-morbidity: Anxiety
S Anorexia Nervosa:
S 60%
S More obsessional; harm-avoidant
S Bulimia Nervosa:
S 57%
S More outgoing but significant stress in
socializing
S Eating disorder symptoms in both groups tend to bind anxiety.
Anxiety tends to get worse with symptom reduction
Co-morbidity:
Substance Use Disorders
S AN: 27%; BN: 55%; BED: 23%
S Substance abuse develops at various stages of illness
S Amplifies impulsivity and mood instability
S Increases nutritional, hepatic, GI, cardiac and
neurological consequences
Co-morbidity:
Personality Disorders
S Deficits in sense of self commonly seen
in narcissistic and borderline disorders
S Difficulties with regulation of self-
esteem and affect
S Problems with separation and
autonomy
S
Anorexia: obsessive compulsive,
avoidant, dependent
S Bulimia: borderline, narcissistic
Other Than Co-morbidity,
Why Screen?
S Prevalence
S Morbidity and Mortality
S Outcomes
Prevalence
S In the United States:
•
10 million women and 10 million men suffer from clinically
significant ED at some time in their life
•
Rate of development of new cases of ED increasing since 1950
•
Rise in incidence of anorexia in young women (age 15-19) each
decade since 1930 (0.9% of population)
•
Incidence of bulimia in women (age 10-39) tripled from 1988-1993
(1.5% of population)
Morbidity and Mortality
S Serious health consequences including heart failure and other
severe cardiac conditions, kidney failure, osteoporosis and
gastrointestinal disorders.
S Binge eating (the most common eating disorder) is associated with
obesity, heart disease, gall bladder disease and diabetes.
S According to the NIMH, 1 in 10 women with anorexia nervosa
dies of starvation, cardiac arrest, or some other medical
complication. The risk of death among teenage girls with anorexia
is 11 times greater than in disease-free adolescents.
Outcome
S Significant functional
impairment
S High rates of suicide
S Earlier intervention
improves the prognosis
A Few Guiding Principles
S Individuals with eating disorders come in all sizes and
shapes.
S Weight is not a good proxy for eating or exercise practices.
High weight patients may not be getting enough nutrition
and normal weight patients may be engaging in unhealthy
practices to maintain a weight lower than one within their
own genetic range.
S Athletes may be engaging in very unhealthy disordered
eating and eating disorder behaviors
A Few Guiding Principles
S Weight loss is not always a sign of health. An individual
could be developing a serious medical problem or could be
engaging in life threatening behavior in the pursuit of weight
loss
S It needs to be taken seriously when parents raise concerns.
A single consultation about a child’s eating behavior or
weight/shape concerns is a strong predictor of the presence
or development of an ED
How to Screen
S S
S
Do you make yourself Sick because you feel uncomfortably
full?
S C
S
Do you worry you have lost Control over how much you eat?
S O
S
Have you recently lost more than One stone (6.35 kg) in a
three-month period?
S F
S
Do you believe yourself to be Fat when others say you are too
thin?
S F
S
Would you say Food dominates your life?
Additional Screening Questions
S Many people have concerns about food. Please tell me
about your eating habits. Do you worry about your eating or
do you think that others do?
S Some people have concerns about their weight. Please tell
me how you feel about your body and weight?
S Some people have trouble with eating to the point of
discomfort or until they are uncomfortable. Please tell me if
this has been a problem for you
Screening Questions for Parents
S Does your child make negative remarks about his or her body?
S Have you noticed any changes in food related habits? If so,
what?
S Are you concerned about your child’s weight, eating or
exercise habits?
S Does your child eat regular meals with the family?
S Does your child have an increased interest in food-related
activities, but with decreased intake of food?
Frequency of Screening
S A national representative of 10,123 adolescents between
ages 13 to 18 screened for eating disorders
S A majority, 88%, of those that screened positive for eating
disorders had some contact with service providers, mental
health specialty care, school services, or general medical
services
S Only a minority, as low as 2%, talked to a professional about
their eating/weight problems
How
Common
Is It?
• By age 6, girls especially
express body image or
weight concerns
• 40-60% elementary
school girls (ages 6-12)
are concerned about
their weight or becoming
too fat
• Up to 60% female teens
diet regularly
• Over 50% teens
exercise in order to
improve shape or lose
weight
• Approximately 45%
female teens smoke
cigarettes to control
weight
When Does It Become
Disordered Eating?
S Nutritional adequacy of diet
S Impact of feeding/eating disturbance on weight, growth,
and physical development
S Impact of feeding/eating disturbance on social and
emotional development/function
S Impact of feeding/eating disturbance on interaction with
caregiver on family function
Eating Disorders: DSM-5
S Anorexia Nervosa
S Bulimia Nervosa
S Binge-Eating Disorder
S ARFID
S Pica
S Rumination Disorder
Anorexia Nervosa
S Restriction of energy intake relative to requirements, leading
to a significantly low body weight in the context of age, sex,
developmental trajectory, and physical health.
S Intense fear of weight gain or persistent behavior that
interferes with weight gain
S Body Image Disturbance with undue influence of body
weight/shape on self-evaluation
Emotional and
Behavioral Signs of
Anorexia Nervosa
•
•
•
•
•
Refusal to eat
Denial of hunger
Excessive exercise
Eating only a few certain
"safe" foods, usually those
low in fat and calories
Adopting rigid meal or
eating rituals, such as
cutting food into tiny
pieces or spitting food out
after chewing
Physical Signs of
Anorexia Nervosa
S Emaciation
S Brittle nails
S Hyperactivity
S Hair loss on scalp
S Bradycardia
S Lanugo hair
S Hypotension
S Brittle hair
S Dry skin
S Edema
S Yellow skin, especially
S Cyanotic and cold hands
palms
and feet
Growth Chart
Bulimia Nervosa
S Recurrent episodes of binge eating
S Recurrent inappropriate compensatory behavior designed to
prevent weight gain
S Binge-Purge episodes occur once per week for 3 months
S Self-evaluation is unduly influenced by body shape and
weight
S No evidence of Anorexia Nervosa
Behavioral Signs
S Frequent use of bathroom after
meals
S Unexplained disappearance of
food from kitchen
S Ongoing observed consumption
of large quantities of food
without associated weight gain
S Evidence of emesis on toilet
Physical Signs of
Bulimia Nervosa
S
Calluses on the back of the hand
S
Salivary gland hypertrophy
S
Erosion of dental enamel
S
Mouth ulcers
S
Periodontal disease
S
Hematemesis
S
Dental caries
S
Edema
S
Petechiae
S
Abdominal bloating
S
Perioral irritation
Binge Eating Disorder
S Recurrent episodes of binge eating
S Binges are associated with 3 or more of the following:
S Eating rapidly
S Eating until uncomfortably full
S Eating large amounts when not hungry
S Eating alone due to embarrassed with how much one eats
S Feeling disgust, guilt or depressed after overeating
S Marked distress during binge eating
S Binge episodes occur once per week for three months
S Binge is not associated with recurrent use of inappropriate
compensatory behavior
Binge Eating Disorder
Epidemiology
S Lifetime prevalence rate in women of 3.5%
S Lifetime prevalence rate in men of 2.0%
S Prevalence is as high as 30% in individuals seeking bariatric
surgery
ARFID
S
Apparent lack of interest in eating or food, avoidance based on sensory
characteristics of food; concern about aversive consequences of eating and this
concern results in significant weight loss or failure to achieve expected weight
gain or faltering growth in children; significant nutritional deficiency; marked
interference with psychosocial functioning
S
The disturbance is not explained by lack of available food or by a culturally
sanctioned practice.
S
No body image disturbance.
S
No concurrent medical condition or mental disorder responsible for eating
disturbance.
Classification
Other Specified Feeding
or Eating Disorder
Anorexia
Nervosa
Binge-Eating
Disorder
O
Bulimia
Nervosa
Unspecified Feeding
or Eating Disorder
Etiologic Factors
S Psychological
S Personality
S Sociocultural
S Genetic
S Family
S Biologic
Psychological
S Separation-Individuation
S Retreat from puberty/Avoidance of maturational challenges
S Phobic avoidance disorder
S Issues of control
S Low self-esteem
Sociocultural
S Kids watch up to 5 hrs of TV/day
S Up to 6-7 hours of total media
exposure (TV, Internet, etc) daily
S Body image is significantly more
negative after viewing thin media
images
S Facebook and social media
Family
S No longer believed to be an “anorexogenic” or a
“psychosomatic” family
S There are believed to be family dynamics that develop in
presence of eating disorder that serve as maintenance
mechanisms
S Correlation with a parenting style marked by high concern
Personality
Traits
S Perfectionism
S Harm-avoidant
Genetic
S Eating disorders run in families
S Twin concordance studies is greater for monozygotic
compared to dizygotic twins
S Anorexia nervosa: 31-76%
S Bulimia nervosa: 28-83%
S Molecular genetic studies point to the serotonin 2A receptor
gene
Biologic
S 1950: Starvation Study, Keys et al
36 young healthy, psychologically stable men
were restricted to 50% of their normal intake
leading to 25% weight loss.
Effects of Starvation:
Emotional and Social Changes
S Physical
S Emotional
S Social
S Cognitive
S Attitudes and Behaviors
toward Food
Multidetermined Nature of
Eating Disorders
Eating Disorders Treatment
S Only one-third of people with AN in the community receive
mental health care
S Only 6% of people with BN receive mental health care
S 80% of individuals with severe eating disorders do not
receive intensity or duration of care warranted by their
symptoms
Eating Disorder Treatment
S Due to ambivalence regarding recovery, outside
support/decision making may be necessary regardless of
age
S Engage families and decrease sense of guilt/blame
Eating Disorder Treatment
S Symptom Management
S Medical Management
S Therapy
Symptom Management
S Nutritional Rehabilitation: normalize eating pattern with
weight gain of 0.2kg/day
S Nutritional Stabilization: normalize eating pattern with
decreased focus on weight
S Increased tolerance of sensation of fullness
S Increased tolerance of body image dissatisfaction
S Always assess for psychiatric risk, including suicidal ideation
Medical Management
S Collaboration between psychiatrist, non-physicians and
primary care physicians
S Regular consistent weigh-ins
S Ongoing laboratory/vital signs monitoring
S Annual bone densities
S Regular dental exams
Therapy
S Cognitive-Behavioral Therapy
S Interpersonal Psychotherapy
S Dialectical Behavioral Therapy
S Family Therapy
Indication for Hospitalization
S Severe malnutrition (wt less than or equal to 75% IBW)
S Dehydration
S Electrolyte disturbances
S Cardiac dysrhythmias
Indication for Hospitalization
S Physiologic instability
S Bradycardia (heart rate < 50)
S Hypotension ( BP < 80/50)
S Hypothermia (body temperature < 96)
S Orthostatic changes in pulse or blood pressure
S Acute complications of purging
S hemetemesis
Indication for Hospitalization
S Acute psychiatric emergencies
S Suicidal ideation
S psychosis
S Co-morbidity interfering with treatment of eating disorder
S Depression
S Obsessive-compulsive disorder
S Severe family dysfunction
Family Based Treatment
S Highly focused, staged treatment
S Emphasis on behavioral recovery rather than insight and
understanding
S This approach might indirectly improve family functioning
S Supports gradual increased independence from therapy
Principles of
Family Based Treatment
S Agnostic view of cause of illness
S Initial focus on symptoms
S Parents are responsible for weight restoration
S Non-authoritarian therapeutic stance
S Separation of child and illness (Externalization)
Collaborative Care Model
S
Janet Treasure et al
Janet Treasure PhD, FRCP, FRCPsych
Series of workshops
designed to educate carers
on the key skills that
clinicians have in treating
eating disorders so that
there is more continuity in
care between the treatment
setting and at home.
Collaborative Care Model
S Address universal needs of carers:
S Connection with other carers
S Support
S Skills training
Collaborative Care Skills
S Motivational Interviewing
S Trans-theoretical model of change
S Self-Care
S Behavior Analysis
Pharmacotherapy:
Anorexia Nervosa
S SSRI’s
S Not for treatment of Anorexia Nervosa
S Primarily beneficial in the treatment of co-morbid diagnoses
Pharmacotherapy:
Anorexia Nervosa
S Olanzapine
S 3 open label trial
S Benefit in weight gain and cognition as well as improved body
image
S Quetiapine
S 2 open trials
S Improved results in psychopathology testing, not significant for
weight gain
S Risperdone/Aripriprazole
S Positive case reports
Treating the Adolescent
With Bulimia Nervosa
S CBT is most studied
S Effectiveness well established in BN
S Preliminary studies suggest effectiveness in AN
S Focus is on changing eating behaviors and attitudes that
maintain eating disorder
S IPT and DBT have been demonstrated to be effective
Pharmacotherapy:
Bulimia Nervosa
S Fluoxetine
S Considered the gold standard of pharmacotherapy for BN
S Dosing at 60mg significantly more effective than 20mg
S Anxiolytics
S May be beneficial in affect modulation
S Potential for behavioral disinhibition and worsening of binge-
purge cycle
Conclusions
S AN and BN are serious mental illnesses with significant medical
and psychiatric morbidity and mortality, regardless of the
individual’s weight
S Full resolution of symptoms is an essential goal of treatment.
This includes:
S Nutritional rehabilitation
S Weight restoration and stabilization
S Resumption of menses (where appropriate)
S Cessation of binge eating and/or purging behaviors
Conclusions
S Family treatment should be recommended for virtually all
adolescents with AN
S CBT or IPT should be recommended for virtually all
patients with BN
S Medications should be used as an adjunct, but there are no
clearly efficacious agents for AN
S SSRI’s, higher doses, can be effective for BN
Conclusions
S Treatment of co-morbid conditions and medical
complications is essential
S Early recognition and timely intervention, based on a
developmentally appropriate, evidence based bio-psychosocial multidisciplinary approach, should be the standard of
care in every community