Objectives: This self study module will provide an overview of the history, comorbidity, causes, screening, and treatment of eating disorders.

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1 Objectives: This self study module will provide an overview of the history, comorbidity, causes, screening, and treatment of eating disorders. Historical Perspective Numerous women in the medieval period between the 12 th and 15 th centuries had a condition almost identical to anorexia nervosa. They were fasting to obtain the religious and moral perfection considered desirable in that time (Gordon, 1998). In the period from the 17 th to the 19 th century, fasting girls caused much public controversy. There was conflict between the emerging scientific movement and religious authorities about their credibility. Some church officials and entrepreneurs were even charging admission to watch them fast (Gordon, 1998). The religious ideal of perfection was becoming secular. Gull and Lasegue provided the first medical descriptions of anorexia nervosa in the 1870s and numerous papers were written until the first decade of the 20 th century (Gordon, 1998). The medical interest in eating disorders then went into decline until the 1940 s- although there are newspaper reports about epidemics of self starvation among women in the 1920s due to the popularity of Flapper Girls (Gordon, 1998). Eating disorders are now in the media quite frequently and are often perceived as being wide spread. In reality, the rates of occurrence are between 1 to 3% (Brandsma, 2007). Despite public awareness of eating disorders, they remain some of the least understood of mental illnesses. Eating disorders (ED) are defined as any severe, prolonged disturbance in eating behaviours (Brandsma, 2007, p. 156). The DSM-IV-TR identifies 3 categories: anorexia nervosa, bulimia nervosa, and eating disorder NOS, or not otherwise specified (APA, 2000). Until the mid-1980 s, bulimia nervosa had been considered a syndrome within anorexia nervosa. However the disorder was recognized in people with normal weight, which led to differentiation between the two disorders. Both anorexia nervosa (AN) and bulimia nervosa (BN) involve a distorted perception of body shape and weight with an intense fear of becoming fat. People with anorexia nervosa resist maintaining even a minimally normal body weight. Both involve two kinds of weight loss strategies: The restricting type (weight loss through excessive dieting or exercise) or the binge eating/purging type (weight loss through vomiting, laxatives, diuretics, or enemas) (APA, 2002). Both disorders have serious health consequences: AN can lead to heart and kidney problems and osteoporosis, for example. 20% of sufferers eventually die from the disorder (Brandsma, 2007). Binge Eating Disorder (BED), a variant of the Eating Disorders NOS category, involves a significant loss of control resulting in consumption of large amounts of food with no attempt at weight regulation and no distortion of body image. The incidence in the general population is considered to be about 2 to 3% (APA, 2000; Brandsma, 2007). It is estimated that about 8% of obese people suffer from BED (Brandsma, 2007). It is important to note that most obese people do not have a binge eating disorder. Despite the image of eating disorders as being exclusive to young females, males and older women are affected (Brandsma, 2007; Crisp et al, 2006). BED is more common in males Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 1

2 and in women of middle age and older (Brandsma, 2007). Some studies suggest that eating disorders in general are occurring more frequently in women over 40 (Brandsma, 2007). Whether this is an emerging trend or simply an area that has been overlooked in the past is unclear. Until recently, eating disorders were regarded as a disease of affluent, white women in Western society. However research indicates that eating disorders occur in men and women of diverse cultural and socio-economic background (Cummins, Simmons & Zane, 2005). Comorbid Psychiatric Illness Eating disorders have high rates of comorbidity with anxiety disorders (Kaye et al, 2004). The estimates vary from about 25% up to 75% in some studies (Swinbourne et al, 2007). In the majority of cases, the anxiety disorders were present in childhood before the eating disorder appeared (Kaye et al, 2004; Cumella et al, 2007). There is a particularly high comorbidity of eating disorders with Obsessive-Compulsive Disorder (OCD): up to 43% of patients with BN have OCD and up to 62% of AN patients (Cumella et al, 2007). Most often, OCD precedes the eating disorder (Cumella et al, 2007). Those who have OCD are more likely to develop an eating disorder at a younger age (Swinbourne & Touyz, 2007). OCD may be a risk factor, or may share some common neurobiological or genetic origins with eating disorders (Cumella et al, 2007; Swinbourne & Touyz, 2007). Some studies have shown that not all the OCD themes of those with eating disorders have to do with food: There are also themes of cleanliness, perfectionism and rigidity present. Some suggest that this indicates an underlying personality trait that may play a role in the development and persistence of eating disorders (Swinbourne & Touyz, 2007). Researchers have looked at the presence of Axis II features in eating disorders. There are indications that higher rates of Obsessive Compulsive Personality Disorder exist in those with eating disorders, especially those with AN of a restricting type (Swinbourne & Touyz, 2007). Estimates of comorbid personality disorders involving borderline and avoidant types range from 42% to 75% (APA, 2000). Those with ED who do not meet the criteria for an axis II diagnosis nonetheless tend to display anxiety, perfectionism, dichotomous thinking, and rigidity (Kaye et al, 2004). There is evidence that the restrictive versus binging/purging variations in ED correlate with the comorbid patterns. Bulimic variants show a high correlation with alcohol and chemical dependencies, cluster B personality disorders and seasonal affective disorder (Steiger, 2004). Roughly one third of binge pattern sufferers also exhibit reckless and self-destructive behaviour. Restrictive types, on the other hand, may be more prone to OCD. Disorder involving binging/purging may involve impulse control issues, whereas restrictive types tend to involve compulsive over-control (Steiger, 2004). The results are not conclusive however. Approximately one third of those who display the binge/purge pattern are nonetheless compulsive, perfectionist and harm avoiding (Steiger, 2004). Sexual abuse has been reported in 20-50% of people with eating disorders- higher than the general population (APA, 2000). One study by Faravelli et al (2004) found that women who had been sexually assaulted were more likely to report an eating disorder than woman who had not. Eating disorders are considered one of the psychiatric results of sexual assault, along with mood disorders, PTSD, and substance abuse disorders (Swinbourne & Touyz, 2007). Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 2

3 Causes of Eating Disorders Until recently, the psychiatric views of anorexia nervosa were dominated by psychoanalytic claims that it was driven by a fear of sexuality and unresolved conflict with parents (Brandsma, 2007). Some clinicians have characterized families of eating-disordered patients as enmeshed, over controlling and invalidating, but there is insufficient research to support this perspective (Brandsma, 2007). Gorrell (2001) reported that at any given time 90% of women in our culture admit to body image dissatisfaction, 75% describe themselves as preoccupied with weight, and 50% are on a diet. Despite the pervasive preoccupation with weight in our culture, less than 3% of women will develop an eating disorder- which strongly suggests that there is a genetic transmission of vulnerability (Lilenfield & Kaye, 1998). Research in genetics and brain mechanisms has now changed the common view that eating disorders may be due only to family, cultural, or developmental problems. Patients with anorexia tend to have premorbid traits of perfectionism, inhibition and anxiety, which have genetic links (Strober et al, 2006). There is also evidence that eating disorders tend to aggregate in families (Strober et al, 2006), especially so in male patients (Crisp et al, 2006). First degree relatives of binge pattern ED sufferers have propensity to substance abuse, panic disorders, impulse control difficulties (Steiger, 2004). Those who suffer from restrictive type pathology are more likely to have relatives with obsessive-compulsive traits (Steiger, 2004). Serotonin pathways are suspect in the persistence of eating disordered behaviour, as well as the markedly higher rates of the disorder in females. Anorexia tends to be a more persistent disease in women than in men. It is hypothesized that women may have greater sensitivity to the effect that chronic dieting has on serotonin levels, or that hormonal effects on serotonin pathways may increase vulnerability (Strober et al, 2006). Serotonin has been linked to worry and anxiety as well as the regulation of satiety after meals. It is possible that dysregulation in this pathway is in some way connected to the illness (Strober, 2006). 5-HT (brain serotonin), is linked to eating behaviour. In both animal and human studies, increases lead to reduced eating behaviour and reductions in serotonin activity instigate compulsive binge eating (Steiger, 2004). It is unclear how serotonin is involved in eating disorders. Investigations are complicated by the fact that serotonin levels are affected by stringent dieting, as is mood and behaviour. More research is required to sort out the precise role serotonin may play (Steiger, 2004). Severe life events or difficulties are often found in the history of those with eating disorders (Treasure, 1998; Swinbourne & Touyz, 2007). Serotonin and the hypothalamicpituitary axis are involved in controlling this stress. Damage may occur with prolonged and severe exposure to stressors and this has been well documented in studies of post traumatic stress syndrome. In animal studies, lesions on specific parts of the hypothalamus can cause voracious overeating (Beumont, 1998). Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 3

4 Screening and Assessment Eating disorders are to be suspected when a person has excessive dieting; intense exercise; terror of weight gain; use of laxatives, diuretics, and/or purging; obsessions with food, calories, and recipes; depression and mood changes; frequent weighing; guilt or shame about eating; and social withdrawal. Of course, people with eating disorders may be very secretive about these practices. Freund et al (1993) found that two simple questions may help screen clients during a general nursing assessment: Are you satisfied with your eating patterns? and Do you ever eat in secret? If the client might have an eating disorder, further questions should obtain the following information (Stuart & Laraia, 1998): 1) Actual and desired weight 2) Onset and pattern of menstruation 3) Food restrictions and fasting patterns 4) Frequency and extent of binging and vomiting 5) Use of laxatives, diuretics, diet pills, etc. 6) Body image disturbances 7) Food preferences and peculiarities 8) Exercise patterns SCOFF Screening Tool (Morgan, 1999) Do you make yourself sick because you feel uncomfortably full? Do you worry that you have lost Control over how much you eat? Have you recently lost more than 6Kg. in a 3 month period? Do you believe yourself to be fat when others say you are too thin? Would you say that food dominates your life? One point for every 'yes'. A score of 2 or more indicates a likely case of anorexia or bulimia. Eating disorders can be life threatening and assessment of physical status is essential. Those who are 40% below or 100% above their ideal weight are most likely to have life threatening problems- but vomiting, diuretics, and laxatives can create a serious risk at any weight. Eating disorders have the highest rates of death of all psychiatric disorders. Various studies indicate that about 20% of those with anorexia will die within 20 years of the onset from both suicide and physical illness -- and 76% will achieve full recovery (APA, 2000). Almost every part of the body is impaired but the immediate risks may include the following (Stuart & Laraia, 1998): 1) Electrolyte imbalance: Hypokalemia and hypochloremic metabolic acidosis (due to purging). Dehydration, edema, hypomagnesemia, and hyperamylasemia. 2) Cardiovascular problems: arrhythmias, hypotension, and bradycardia due to starvation. Obesity can cause hypertension and cardiac complications. 3) Gastrointestinal complications: esophagitis and parotitis due to vomiting. Delayed gastric emptying due to starvation. 4) Other: Anemia due to starvation. Diabetes mellitus due to obesity. Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 4

5 Treatment Goals of Treatment in the University of Alberta Hospital Eating Disorder Program The initial goals for treating eating disorders should include: - making sure that the person's health is not in immediate danger (if it is, this needs to be taken care of first) - restoring and maintaining a healthy body weight - developing healthy eating patterns - normalizing the amount and type of food eaten Longer term treatment goals may include: - the development of stress management skills - strengthening coping skills - putting assertiveness skills into practice - learning ways to resolve conflict - addressing family and interpersonal relationship issues - resolving issues around abuse and trauma - enhancing body-image and self-esteem - developing a strong, resilient "self. Hhttp:// Antidepressant medication is found to be helpful in some cases, but there are safety concerns in those who are severely malnourished, as the risk of seizures is increased (APA, 2006). SSRI treatment has been shown to be effective for bulimia, especially in those with comorbid depression and anxiety (APA, 2006). According to the Cochrane Collaboration, Cognitive Behavioural Therapy (CBT) is considered first line treatment. Evidence is limited as studies are few and involve small numbers (Bacaltchuk et al 2008). CBT combined with psychodynamic and interpersonal therapy also show good results (APA, 2006). In adolescents, family involvement, support and treatment are considered essential. In older patients, individual circumstances should be considered (APA, 2006). Conclusion Eating Disorders are a very disabling and potentially lethal mental health disorder. The condition is not cured by will power or caused by fashion magazines. Our attitudes can help those who are suffering this illness or make their suffering worse. On the following pages are 16 points for staff and families to consider when in a helping role. One of the key points is to remember that people are much more than their diagnosis- stand up against the illness, not the person. Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 5

6 The following is advice from the UAH Eating Disorder Program for family and staff dealing with someone suffering from an Eating Disorder: 1) Be direct and non-punitive, point out the specific things you ve observed that have aroused your concern: You ve lost weight. You seem preoccupied with food and weight. You ve been isolating yourself. You seem tired and sad. You spend so much time exercising. Communicate care, concern, and compassion while emphasizing your belief that something must be done. Focus on the misery, isolation, and disturbance that the symptoms are causing. Avoid expressing wonder or awe about the extreme nature of the symptoms. Make clear your desire for the person s return to health and effective functioning, instead of casting judgment on the symptoms as bad. 2) Be prepared to end the conversation if you are met with anger or a lack of response. Simply restate your concerns as above, and suggest a referral resource. 3) Avoid becoming the savior, therapist, or collaborator of the person with symptoms. In other words, do not promise to keep symptoms a secret, formulate a treatment plan, or adjust around the symptoms. Make note of the fact that eating disorders are very difficult to overcome without professional help which also means that unsuccessful efforts that may have been made are not due to moral failing or a lack of drive to succeed. 4) A common characteristic in someone who seeks treatment for an eating disorder is ambivalence, or a wavering determination to suffer the discomfort necessary to recover. Especially if symptoms are overwhelming or the sufferer is not an adult, your help may be needed in making the decision to seek treatment. Parents may invoke authority over a minor by insisting: You will see a doctor before. In all but the most extreme circumstances, an adult must consent to treatment, but loved ones can still influence the decision by communicating their concern and their understanding of the need for treatment. 5) Do not imply that bulimia nervosa is less serious than anorexia nervosa simply because the person with symptoms may not be underweight. 6) Avoid giving advice about weight or exercise, or oversimplifying the problem by comparing it to an addiction or a desire to appear slim. Listen carefully, and never show disgust for behaviors. 7) Describe your concerns in private, in a non-threatening setting. 8) Remember that this is a person you re dealing with not an anorectic or bulimic. Help the person to avoid identifying herself as an illness, rather than in individual. Stand against the illness but not the person. 9) Be aware that the physiological and psychological effects of an eating disorder (e.g. emotional instability, denial, and self-absorption) may reduce the person s ability to benefit from your efforts and even those of mental health care professionals. This is especially important to keep in mind when weight is very low. 10) Keep in mind that eating disorders can be difficult to detect given the denial, secretiveness, cultural reinforcement, and ambivalence surrounding the symptoms. Remember that you are not responsible for the eating disorder, but as a source of support you can make many contributions to recovery. 11) In recovery, offer to help the person deal with anxiety. The prospect of weight gain creates terror of becoming fat, true fear, not just an exaggerated concern. Be prepared to listen, wipe away tears, provide distraction, and keep up spirits on the difficult road to recovery. Exercise all the patience you can to help the person make it through the night, and remember that bizarre urges and behaviors can be just as frightening to her as they are to you. Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 6

7 12) Keep in mind that eating disorders can be difficult to detect given the denial, secretiveness, cultural reinforcement, and ambivalence surrounding the symptoms. Remember that you are not responsible for the eating disorder, but as a source of support you can make many contributions to recovery. 13) In recovery, offer to help the person deal with anxiety. The prospect of weight gain creates terror of becoming fat, true fear, not just an exaggerated concern. Be prepared to listen, wipe away tears, provide distraction, and keep up spirits on the difficult road to recovery. Exercise all the patience you can to help the person make it through the night, and remember that bizarre urges and behaviors can be just as frightening to her as they are to you. References 14) Learn what you can do in your area to get help quickly in the event of a physical emergency (fainting, vomiting blood, emaciation and weakness, muscle spasms, Conclusion self-mutilation, suicide attempt). Do not hesitate to take control of Eating such a situation. disorders are a life threatening, biologically rooted, medical illness. Although the media may sometimes give the impression that eating disorders are new fad, they have a long, 15) Be tragic, sensitive and to often charged hidden situations history. such It has events only been involving the food, last or decade comments that on research her weight and and clinical appearance. experience When has in doubt, led to the effective best course treatment of action and is usually understanding. to say or do For nothing most people, unless you recovery are specifically is a asked to help. Remember that even positive comments on appearance will likely be interpreted in terms of lengthy process involving specialized intervention by a multidisciplinary team. fatness or thinness. 16) Last, but not least, treat yourself kindly. This will show the sufferer the importance of self-kindness and not setting impossible targets. Role modeling is the most fundamental effort you can make, and should not be discounted just because it may come easily to you. References From: Hhttp:// DSM-IV-TR Criteria for Anorexia 1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). 2. Intense fear of gaining weight or becoming fat, even though underweight. 3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight. 4. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) (APA, 2000) DSM-IV-TR Criteria for Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. (APA, 2000) Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 7

8 DSM-IV-TR Eating Disorder Not Otherwise Specified This category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include: 1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses. 2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range. 3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for duration of less than 3 months. 4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa. (APA, 2000) Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 8

9 References American Psychiatric Association (2006). Practice guidelines for the treatment of patients with eating disorders. American Journal of Psychiatry, 163 (7), American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders: Text Revision. Washington, DC: APA Bacaltchuk, J, Hay, P, Trefiglio, R. (2008). Antidepressants versus psychological treatments and their combination for bulimia nervosa (review). The Cochrane Collaboration, 2. Brandsma, L. (2007). Eating disorders across the life span. Journal of Women and Aging, 19(1/2), Cumella, E, Kally, Z, & Wall, A. (2007). Treatment responses of inpatient eating disorder women with and without co-occurring OCD. Eating Disorders, 15, Cummins, L, Simmons, A, Zane, N (2005). Eating disorders in Asian populations: A critique of current approaches to the study of culture, ethnicity and eating disorders. American Journal of Orthopsychiatry, 75(4), Faravelli, C, Giugni, A, Salvatori, S, & Ricca, V. (2004). Psychopathology after rape. American Journal of Psychiatry, 161, Gordon, R. (1998) Concepts of eating disorders: A historical reflection, In Neurobiology in the Treatment of Eating Disorders. Eds. Hoek, H., Treasure, J. & Katzman, M., Chichester, UK: Wiley & Sons. Gorrell, C. (2001) Finding fault: Magazines may be abetting-though not aiding-an epidemic of eating disorders. Psychology Today, September/October. Kaye, W, Bulik, C, Thornton, L, Barbarich, N, Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), Lilenfield, L. & Kaye, W. (1998) Genetic studies of anorexia and bulimia nervosa. Neurobiology in the Treatment of Eating Disorders. Eds. Hoek, H., Treasure, J. & Katzman, M., Chichester, UK: Wiley & Sons. Marcus, M. (2002). Effective management of adolescents with anorexia and bulimia. Journal of Psychosocial Nursing, (40)2, Morgan, J., Reid, F. & Lacey, J. (1999) The Scoff questionnaire: Assessment of a new screening tool for eating disorders. British Journal of Medicine, 319, Steiger, H. (2004). Eating disorders and the serotonin connection: state, trait and developmental effects. Review of Psychiatric Neuroscience, 29 (1), Strober, M, Freeman, R, Lampert, C, Diamond, J, Teplinsky, C, DeAntonio, M. (2006). Are there gender differences in core symptoms, temperament, and short-term prospective outcome in Anorexia Nervosa? International Journal of Eating Disorders, 39 (7), Swinbourne, J, & Touyz, S. (2007). The co-morbidity of eating disorders and anxiety disorders: A review. European Eating Disorders Review,15, Treasure, J. (1998) Neurobiology introduction, In Neurobiology in the Treatment of Eating Disorders. Eds. Hoek, H., Treasure, J. & Katzman, M., Chichester, UK: Wiley & Sons. Original, 2002, Revised, 2008: Information and Evaluation Services Daniel.scott@albertahealthservices.ca 9