1 One Size Does Not Fit All: An Overview of Eating Disorders Kristin Grasso, Psy.D. Clinical Psychologist and College Liaison.

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One Size Does Not Fit One Size Does Not Fit All: An Overview of All: An Overview of

Eating DisordersEating Disorders

Kristin Grasso, Psy.D.Kristin Grasso, Psy.D.Clinical Psychologist and College LiaisonClinical Psychologist and College Liaison

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Spectrum of Eating Spectrum of Eating DisordersDisorders

Diagnosable Disorder

Diagnosable Disorder

DisorderedEating

DisorderedEating

“Normative Discontent”“Normative Discontent”

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Risk FactorsRisk Factors

Female genderFemale gender Ethnicity Ethnicity Weight and Shape factorsWeight and Shape factors Psychiatric historyPsychiatric history Genetic predispositionsGenetic predispositions Participation in activities that Participation in activities that

promote thinnesspromote thinness Certain personality traitsCertain personality traits

What’s the risk of dieting? The more severely girls diet, the more likely

they are to drink frequently and heavily, as well as to use marijuana and other illicit drugs

Adolescent girls who engage in dieting have a 324% greater risk for obesity than those who do not diet (Stice et al., 1999).

95% of all dieters will regain their lost weight in 1-5 years (Grodstein, 1996).

35% of "normal dieters" progress to pathological dieting. Of those, 20-25% progress to partial or full-syndrome eating disorders. (Shisslak & Crago, 1995).

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Anorexia NervosaAnorexia Nervosa

Refusal to maintain minimum body weightRefusal to maintain minimum body weight

Intense fear of gaining weight or becoming Intense fear of gaining weight or becoming fat, even though underweightfat, even though underweight

Disturbance in experience of weight or Disturbance in experience of weight or shape, undue importance of weight or shape, undue importance of weight or shape, or denial of seriousness of problemshape, or denial of seriousness of problem

AmenorrheaAmenorrhea

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Subtypes of ANSubtypes of AN

Restricting Type:Restricting Type: – person does not engage in binge eating person does not engage in binge eating

or purge behavioror purge behavior

Binge Eating/Purging Type:Binge Eating/Purging Type: – person regularly engages in binge person regularly engages in binge

eating or purging (self-induced vomiting eating or purging (self-induced vomiting or misuse of laxatives, diuretics, or or misuse of laxatives, diuretics, or enemas)enemas)

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Bulimia NervosaBulimia Nervosa

Recurrent episodes of binge eatingRecurrent episodes of binge eating– Eating a large amount of food given the Eating a large amount of food given the

context context – An associated sense of loss of controlAn associated sense of loss of control

Recurrent inappropriate Recurrent inappropriate compensatory behaviorcompensatory behavior– E.g., purging, fasting, excessive exerciseE.g., purging, fasting, excessive exercise– Diuretics and laxativesDiuretics and laxatives

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BN cont’dBN cont’d

Binge eating and compensatory Binge eating and compensatory behavior occur at least behavior occur at least twicetwice per per week for week for 3 months3 months

Self-evaluation is unduly influenced by Self-evaluation is unduly influenced by body shape and weightbody shape and weight

Disturbance does not occur exclusively Disturbance does not occur exclusively during episodes of anorexia nervosaduring episodes of anorexia nervosa

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Subtypes of BNSubtypes of BN

Purging Type:Purging Type: – Regularly engages in self-induced vomiting, or Regularly engages in self-induced vomiting, or

the misuse of laxatives, diuretics, or enemasthe misuse of laxatives, diuretics, or enemas

Non-Purging Type:Non-Purging Type:– Regularly engages in other inappropriate Regularly engages in other inappropriate

compensatory behaviors, i.e. fasting or compensatory behaviors, i.e. fasting or excessive exercise,excessive exercise, but has not regularly but has not regularly engaged in the above stated purging behaviorengaged in the above stated purging behavior

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ED-NOSED-NOS

Most commonMost common

Patient has clinically significant Patient has clinically significant disorder, BUT does not meet AN or disorder, BUT does not meet AN or BN criteriaBN criteria

Comparably severe in relation to AN Comparably severe in relation to AN and BNand BN

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Binge Eating DisorderBinge Eating Disorder

Recurrent episodes of binge eatingRecurrent episodes of binge eating Episodes are associated with 3 or Episodes are associated with 3 or

more of the following:more of the following:– Eating more rapidly than normalEating more rapidly than normal– Eating until uncomfortably fullEating until uncomfortably full– Eating large amounts when not hungryEating large amounts when not hungry– Eating alone because of embarrassment about Eating alone because of embarrassment about

how much one is eatinghow much one is eating– Feeling disgusted with self, depressed, or Feeling disgusted with self, depressed, or

guilty after overeatingguilty after overeating

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BED cont’dBED cont’d

Marked distress regarding binge Marked distress regarding binge eatingeating

Binge eating occurs at least Binge eating occurs at least twotwo days days a week for a week for 6 months6 months

Binge eating is not associated with Binge eating is not associated with regular inappropriate compensatory regular inappropriate compensatory behavior, and does not occur behavior, and does not occur exclusively in course of AN or BNexclusively in course of AN or BN

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What’s the difference?What’s the difference?

AN trumps BNAN trumps BN

Presentation of AN vs. BNPresentation of AN vs. BN

The dieting factorThe dieting factor

Binge Eating Disorder and obesityBinge Eating Disorder and obesity

“Drunkorexia” and other terms to be aware of…

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PrevalencePrevalence

Anorexia: .5-1%Anorexia: .5-1%

Bulimia: 1-3%Bulimia: 1-3%

Binge Eating Disorder: .7-4%Binge Eating Disorder: .7-4%

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Etiology Etiology

The etiology of eating disorders is The etiology of eating disorders is multi-factorialmulti-factorial, with importance of , with importance of specific factors varying with each specific factors varying with each individualindividual

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Men and Eating DisordersMen and Eating Disorders

10% of eating disordered 10% of eating disordered individuals are maleindividuals are male

There is a greater stigma There is a greater stigma for males than femalesfor males than females

Eating disorder behavior Eating disorder behavior can present differently can present differently in malesin males

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Beyond Food…Beyond Food…

Eating disorders appear to be all about food…Eating disorders appear to be all about food…they are not.they are not.

Simply eating more/less will not make things Simply eating more/less will not make things better and often, when someone begins to eat, better and often, when someone begins to eat, things get harderthings get harder

Issues related to control, coping with emotions, Issues related to control, coping with emotions, self-esteem, guilt and shame, etc will become self-esteem, guilt and shame, etc will become MORE intense as someone stabilizesMORE intense as someone stabilizes

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Common Comorbid Common Comorbid DisordersDisorders

Major Depressive Disorder or DysthymiaMajor Depressive Disorder or Dysthymia– 50-75%50-75%

Anxiety DisordersAnxiety Disorders– 64%64%

Sexual AbuseSexual Abuse– 20-50%20-50%

Obsessive-Compulsive DisorderObsessive-Compulsive Disorder– 25% (AN); 41% overall25% (AN); 41% overall

Substance AbuseSubstance Abuse– 12-18% (AN); 30-37% (BN)12-18% (AN); 30-37% (BN)

Bipolar DisorderBipolar Disorder– 4-13%4-13%

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Health ConsequencesHealth Consequences AnorexiaAnorexia

– Abnormally slow heart rate & blood pressureAbnormally slow heart rate & blood pressure– Reduction of bone densityReduction of bone density– Muscle loss, weaknessMuscle loss, weakness– Severe dehydrationSevere dehydration– Anemia, LeukopeniaAnemia, Leukopenia– Reproductive consequencesReproductive consequences– 5-20% mortality rate5-20% mortality rate

PHYSICAL SIGNS: lanugo, headaches, feeling cold, PHYSICAL SIGNS: lanugo, headaches, feeling cold, tingling in extremities, feeling faint, dry skin, hair losstingling in extremities, feeling faint, dry skin, hair loss

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Health ConsequencesHealth Consequences

BulimiaBulimia– Electrolyte ImbalancesElectrolyte Imbalances– Esophageal tearsEsophageal tears– UlcersUlcers– Salivary gland enlargementSalivary gland enlargement– Dental DiseaseDental Disease

PHYSICAL SIGNS: headaches, fatigue, tingling in PHYSICAL SIGNS: headaches, fatigue, tingling in extremities, feeling faint, sore throat and swollen extremities, feeling faint, sore throat and swollen glands, Russell’s sign, dental problemsglands, Russell’s sign, dental problems

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Health ConsequencesHealth Consequences

BEDBED– High blood pressureHigh blood pressure– High cholesterol levelsHigh cholesterol levels– Heart disease as a result of elevated Heart disease as a result of elevated

triglyceride levelstriglyceride levels– Secondary diabetesSecondary diabetes– Gallbladder diseaseGallbladder disease

PHYSICAL SIGNS: temperature irregularities, joint PHYSICAL SIGNS: temperature irregularities, joint pain, decreased endurance and fatiguepain, decreased endurance and fatigue

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Treatment: AnorexiaTreatment: Anorexia

Psychopharmacoloy:Psychopharmacoloy: interventions typically recommended after interventions typically recommended after

weight restorationweight restoration Medication can begin earlier with focus on Medication can begin earlier with focus on

maintaining weight and normalizing eatingmaintaining weight and normalizing eating

PsychologicalPsychological Insufficient evidence regarding Insufficient evidence regarding

psychological interventionspsychological interventions CBT, IPT, Family TherapyCBT, IPT, Family Therapy

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Treatment: BulimiaTreatment: Bulimia

PsychopharmacologyPsychopharmacology reduce frequency of disturbed eating reduce frequency of disturbed eating

behaviors.behaviors. FDA approved medication for BN: fluoxetine FDA approved medication for BN: fluoxetine

(Prozac) (Prozac) Bupropion (Wellbutrin) has been associated Bupropion (Wellbutrin) has been associated

with seizures in purging bulimic patients and with seizures in purging bulimic patients and its use is its use is not recommendednot recommended. .

PsychologicalPsychological First line is CBTFirst line is CBT IPT and DBTIPT and DBT

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General Treatment IssuesGeneral Treatment Issues

Require multidisciplinary approachRequire multidisciplinary approach Nutritional counseling and medication must Nutritional counseling and medication must

not be sole treatmentnot be sole treatment

Psychotherapy will generally require Psychotherapy will generally require at least 1 year and most likely longerat least 1 year and most likely longer

Specialist in Eating Disorders Specialist in Eating Disorders preferred over general practitionerpreferred over general practitioner

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Levels of CareLevels of Care

InpatientInpatient

Partial HospitalizationPartial Hospitalization

Intensive OutpatientIntensive Outpatient

Outpatient Outpatient

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Indicators for HospitalizationIndicators for Hospitalization

In general:In general:– individual is below estimated healthy individual is below estimated healthy

weight weight – Rapid, persistent decline in oral intake or Rapid, persistent decline in oral intake or

weight and/or or uncontrollable purgingweight and/or or uncontrollable purging– weight at which physical instability is likely weight at which physical instability is likely

to occur to occur – Serious medical abnormalities Serious medical abnormalities – Comorbid psychiatric issues that warrant Comorbid psychiatric issues that warrant

increased supportincreased support

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PrognosisPrognosis AnorexiaAnorexia

– 50% recover50% recover– 33% improve somewhat33% improve somewhat– 20% remain chronically ill20% remain chronically ill

****mortality is 6x peers without anorexia mortality is 6x peers without anorexia and is the highest of any psychiatric and is the highest of any psychiatric illness!!illness!!

BulimiaBulimia– 50% recover50% recover– 18-30% improve somewhat18-30% improve somewhat– 20% continue to meet full criteria20% continue to meet full criteria

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ReferencesReferences Deshmukh, R. & Franco, K. (2003). Deshmukh, R. & Franco, K. (2003). Eating DisordersEating Disorders. Retrieved December . Retrieved December

9, 2006, 9, 2006, http://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eatihttp://www.clevelandclinicmeded.com/diseasemanagement/psychiatry/eating/eating.htmng/eating.htm

Grodstein, F., Levine, R., Spencer, T., Colditz, G.A., Stampfer, M. J. (1996). Three-year follow-up of participants in a commercial weight loss program: can you keep it off? Archives of Internal Medicine. 156 (12), 1302.

National Eating Disorders Association's Information website: www.NationalEatingDisorders.org

Practice Guideline for the Treatment of Patients with Eating Disorders (3Practice Guideline for the Treatment of Patients with Eating Disorders (3rdrd Edition) Edition) http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=EatingDisorders3ePG_04-28-06file=EatingDisorders3ePG_04-28-06

Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3), 209-219.

Stice, E., Cameron, R., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight reduction efforts prospectively predict growth in relative weight and onset of obesity among female adolescents. Journal of Consulting and Clinical Psychology, 67, 967-974.

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For More Information:For More Information:

http://www.nationaleatingdisorders.org– NEDA Educator ToolkitNEDA Educator Toolkit

http://www.eatingdisorders.org– The Center for Eating Disorders at The Center for Eating Disorders at

Sheppard PrattSheppard Pratt http://www.something-fishy.org Handbook of Treatment for Eating Handbook of Treatment for Eating

Disorders: 2Disorders: 2ndnd Edition by David Garner Edition by David Garner Ph.D. and Paul E. Garfinkel, M.D.Ph.D. and Paul E. Garfinkel, M.D.