ADOLESCENCE & MAJOR EATING DISORDERS by Prof. Hidle Updated Spring 2010.

ADOLESCENCEADOLESCENCE

&&MAJOR EATING DISORDERSMAJOR EATING DISORDERS

by Prof. Hidleby Prof. HidleUpdated Spring 2010Updated Spring 2010

Suggested VideosSuggested Videos

““Dying to be Thin” – Dying to be Thin” – WILL BE SHOWN DURING LAB TIME!WILL BE SHOWN DURING LAB TIME!

““Adolescent” Adolescent”

““The Enigma of Anorexia Nervosa”The Enigma of Anorexia Nervosa”

Adolescence - Adolescence - overviewoverviewInclude children ages 12-18(21) Include children ages 12-18(21) yearsyearsHistory taking should include the History taking should include the adolescent’s parent(s) as well as the adolescent’s parent(s) as well as the teen teen alonealone, as he/she may be , as he/she may be reluctant to discuss certain topics reluctant to discuss certain topics with a parent present.with a parent present.Respect the adolescent’s need for Respect the adolescent’s need for privacy during physical examprivacy during physical exam

Vital SignsVital SignsBPBP: Systolic 100-120; Diastolic 50-70: Systolic 100-120; Diastolic 50-70TempTemp.: 98-98.6 F.: 98-98.6 FPulsePulse: 60-68 BPM, regular: 60-68 BPM, regularRRRR: 16-20, regular: 16-20, regularOf note, c/o fatigue may result from Of note, c/o fatigue may result from inadequate O2 because the heart inadequate O2 because the heart continues to grow slowly until 17-18 years continues to grow slowly until 17-18 years of age.of age.Hct higher in males due to increased Hct higher in males due to increased growth.growth.

GrowthGrowth: Physical Exam: Physical ExamAdolescence is the Adolescence is the 22ndnd major period of major period of acceleration in growth. acceleration in growth.

Females begin a growth spurt 2 years Females begin a growth spurt 2 years earlier than males.earlier than males.

Females grow 2.5-5” and gain 8-10 IbsFemales grow 2.5-5” and gain 8-10 Ibs

Males grow 3-6” and gain 12-14 IbsMales grow 3-6” and gain 12-14 Ibs

Significant growth in skeletal size, muscle Significant growth in skeletal size, muscle mass, adipose tissue, and skin.mass, adipose tissue, and skin.

CharacteristicsCharacteristicsPoor posture and decreased coordinationPoor posture and decreased coordinationMales tend to be more clumsy than Males tend to be more clumsy than femalesfemalesSleep requirement: 8-9 hours/night Sleep requirement: 8-9 hours/night (females require extra rest prior to (females require extra rest prior to menstruation)menstruation)Skin is supple, firm, with an increase in Skin is supple, firm, with an increase in size and activity of sebacceous glands, size and activity of sebacceous glands, and fully developed eccrine sweat glandsand fully developed eccrine sweat glandsBoth males and females are prone to acneBoth males and females are prone to acne

Sweat glands are more active in males Sweat glands are more active in males than females than females Secondary sex characteristics begin to Secondary sex characteristics begin to develop develop By adolescence, individuals usually have By adolescence, individuals usually have formed their sexual identityformed their sexual identityFemaleFemale: average age of menarche is 12-13 : average age of menarche is 12-13 years years Male maturation is exhibited by voice Male maturation is exhibited by voice changes, appearance of increased body changes, appearance of increased body hair, and broadened shouldershair, and broadened shoulders

Psychosocial considerationsPsychosocial considerationsMood swings are commonMood swings are commonPeers – great importance!Peers – great importance!Striving for independence, but still need Striving for independence, but still need for security of parental love and for security of parental love and restrictions.restrictions.Developing relationships with peers help Developing relationships with peers help reinforce parental values.reinforce parental values.When hospitalized, teens often feel loss of When hospitalized, teens often feel loss of independence and identity. Also fear of independence and identity. Also fear of body image changes, rejection, and loss of body image changes, rejection, and loss of emotional control.emotional control.

NutritionNutritionFemales 11-14 years of age need Females 11-14 years of age need approximately 2200 Kcal/day; 15-18 approximately 2200 Kcal/day; 15-18 years of age, 2100 Kcal/dayyears of age, 2100 Kcal/dayMales 11-14 years of age need Males 11-14 years of age need approximately 2700 Kcal/day; 15-18 approximately 2700 Kcal/day; 15-18 years of age, 2800 Kcal/day.years of age, 2800 Kcal/day.ProteinProtein: 45-56 Grams/day (15% of : 45-56 Grams/day (15% of total Kcal) in both males and females total Kcal) in both males and females to support muscle growthto support muscle growth

IncreasedIncreased need for iron and calcium need for iron and calcium (1200 mgs/day) – especially needed (1200 mgs/day) – especially needed for bone growth for bone growth

All of the adult 32 teeth have erupted All of the adult 32 teeth have erupted by late adolescenceby late adolescence

Fluid requirement = ~2000 cc/dayFluid requirement = ~2000 cc/day

Adolescence tends to snack and skip Adolescence tends to snack and skip meals = unhealthy eating habitsmeals = unhealthy eating habits

SafetySafetyCauses of death in this age-Causes of death in this age-group:group:

1) MVA 1) MVA (motor vehicle accidents)(motor vehicle accidents)

2) Homicide2) Homicide

3) Suicide3) Suicide

EATING DISORDERSEATING DISORDERSAnorexia NervosaAnorexia Nervosa

Bulimia NervosaBulimia Nervosa

Binge Eating DisorderBinge Eating Disorder

Anorexia NervosaAnorexia Nervosa

People who People who intentionally starve intentionally starve themselvesthemselves

Usually begins in young people Usually begins in young people around the time of pubertyaround the time of puberty

Extreme weight loss (>15% Extreme weight loss (>15% below the person’s normal body below the person’s normal body weight)weight)

May look emaciated, but are May look emaciated, but are convinced they are overweight (“convinced they are overweight (“the the mirror liesmirror lies”)”)

May require hospitalization to May require hospitalization to prevent starvationprevent starvation

Food and weight becomes obsessionsFood and weight becomes obsessions

Compulsiveness may involve strange Compulsiveness may involve strange eating rituals or refusal to eat in front eating rituals or refusal to eat in front of othersof others

For example, the person may collect For example, the person may collect recipes and prepare feasts for family recipes and prepare feasts for family and friends, but not partake in the and friends, but not partake in the meals themselvesmeals themselves

May adhere to strict exercise May adhere to strict exercise routines routines

Loss of menstrual periods is commonLoss of menstrual periods is common

Men with anorexia often become Men with anorexia often become impotentimpotent

Medical Complications - AnorexiaMedical Complications - Anorexia

Starvation can damage vital organs Starvation can damage vital organs such as the heart and brainsuch as the heart and brain

To protect itself, the body shifts into To protect itself, the body shifts into ““slow gearslow gear”:”:

1) Monthly menstrual periods stop1) Monthly menstrual periods stop

2) RR, HR and BP drop2) RR, HR and BP drop

3) Thyroid function slows3) Thyroid function slows

Nails and hair become brittle, the Nails and hair become brittle, the skin dries, yellows, and becomes skin dries, yellows, and becomes covered with soft hair (lanugo)covered with soft hair (lanugo)

Excessive thirst and frequent Excessive thirst and frequent urination may occur (s/s UTI)urination may occur (s/s UTI)

Dehydration contributes to Dehydration contributes to constipationconstipation

Reduced body fat leads to lowered Reduced body fat leads to lowered body temperature and the ability to body temperature and the ability to withstand coldwithstand cold

Mild anemia, swollen joints, reduced Mild anemia, swollen joints, reduced muscle mass, and light-headedness muscle mass, and light-headedness may occurmay occur

If anorexia becomes severe, the If anorexia becomes severe, the client may lose calcium from the client may lose calcium from the bones, making them brittle and bones, making them brittle and prone to breakageprone to breakage

Dysrhythmia and Dysrhythmia and heart failureheart failure

In severe situations, the brain In severe situations, the brain shrinks, causing personality changes. shrinks, causing personality changes. However, this can be reversed when However, this can be reversed when normal weight is reestablished normal weight is reestablished

In National Institute of Mental Health In National Institute of Mental Health (NIMH) supported research, scientists (NIMH) supported research, scientists have found that many patients with have found that many patients with anorexia also suffer from other anorexia also suffer from other psychiatric illnesses. psychiatric illnesses.

While the majority have While the majority have co-occurring co-occurring clinical depressionclinical depression, others suffer from , others suffer from anxiety, personality, or substance abuse anxiety, personality, or substance abuse disorders, and many are at risk for suicidedisorders, and many are at risk for suicideObsessive-compulsive disordersObsessive-compulsive disorders (OCD), an (OCD), an illness characterized by repetitive illness characterized by repetitive thoughts and behaviors, can also thoughts and behaviors, can also accompany anorexiaaccompany anorexiaIndividuals with anorexia are typically Individuals with anorexia are typically compliant in personalitycompliant in personality but may have but may have sudden outbursts of hostility/anger or sudden outbursts of hostility/anger or become socially withdrawnbecome socially withdrawn

Bulimia NervosaBulimia NervosaConsume large amounts of foodConsume large amounts of foodRid their bodies of the excess calories by Rid their bodies of the excess calories by vomiting, abusing laxatives or diuretics, vomiting, abusing laxatives or diuretics, taking enemas, or exercising obsessivelytaking enemas, or exercising obsessivelyA combination of all of the above may be A combination of all of the above may be used = used = purgingpurgingDue to the “Due to the “binge and purgebinge and purge” cycle, the ” cycle, the individual usually maintains a normal or individual usually maintains a normal or slightly above normal body weightslightly above normal body weight

Due to their often Due to their often normal body weightnormal body weight, a , a person with bulimia may successfully hide person with bulimia may successfully hide their problem from family, friends and their problem from family, friends and medical personnel for years.medical personnel for years.

Binging/purging can range from once or Binging/purging can range from once or twice a week to several times a daytwice a week to several times a day

Dieting heavily between episodes of Dieting heavily between episodes of binging/purging is commonbinging/purging is common

Eventually, ~Eventually, ~50% of those with anorexia 50% of those with anorexia will develop bulimiawill develop bulimia

Bulimia typically begins during Bulimia typically begins during adolescence (as with anorexia)adolescence (as with anorexia)

Most common in women but also found in Most common in women but also found in menmen

Person is ashamed of their strange habits Person is ashamed of their strange habits and may delay seeking medical help until and may delay seeking medical help until their 30s-40stheir 30s-40s

By that time, their eating behavior is By that time, their eating behavior is deeply ingrained and more difficult to deeply ingrained and more difficult to changechange

Medical Complications - Medical Complications - BulimiaBulimiaBody can be severely damaged, even with Body can be severely damaged, even with a “normal” body weighta “normal” body weightVomitingVomiting: acid in the vomit wears down : acid in the vomit wears down the outer layer of the teeth and can cause the outer layer of the teeth and can cause scarring on the backs of hands when scarring on the backs of hands when fingers are pushed down the throat to fingers are pushed down the throat to induce vomitinginduce vomitingEsophagus becomes inflamed Esophagus becomes inflamed Lymphadenopathy: Glands near the Lymphadenopathy: Glands near the cheeks become swollencheeks become swollen

BingingBinging: In severe cases, the : In severe cases, the stomach can rupturestomach can rupture

PurgingPurging: May lead to heart failure : May lead to heart failure due to loss of vital minerals (i.e. due to loss of vital minerals (i.e. potassium)potassium)

Irregular menstrual periodsIrregular menstrual periods

Decreased interest in sexDecreased interest in sex

Some individuals with bulimia struggle Some individuals with bulimia struggle with addictions; drug abuse, alcohol with addictions; drug abuse, alcohol abuse, and/or compulsive stealingabuse, and/or compulsive stealing

May suffer from clinical depression, May suffer from clinical depression, anxiety, OCD, and other psychiatric illnessanxiety, OCD, and other psychiatric illness

High risk for suicidal behavior due to their High risk for suicidal behavior due to their binge/purge eating combined with the binge/purge eating combined with the psychiatric conditions abovepsychiatric conditions above

Binge Eating DisorderBinge Eating DisorderResembles Bulimia NervosaResembles Bulimia Nervosa

Episodes of uncontrolled eating or bingingEpisodes of uncontrolled eating or binging

However, differs from Bulimia in that the However, differs from Bulimia in that the individual does individual does NOTNOT purge their body of purge their body of excess foodexcess food

A feeling of “loosing control” when eatingA feeling of “loosing control” when eating

Eat large quantities of food and do not Eat large quantities of food and do not stop until they are uncomfortably fullstop until they are uncomfortably full

Difficulty loosing weight and keeping Difficulty loosing weight and keeping it off, more so than do people with it off, more so than do people with other serious weight problemsother serious weight problemsUsually obese with a history of Usually obese with a history of weight fluctuationsweight fluctuationsFound in ~2% of the general Found in ~2% of the general populationpopulationWomen > menWomen > menOccurs in ~30% of people Occurs in ~30% of people participating in medically supervised participating in medically supervised weight control programsweight control programs

Medical Complications – Medical Complications – Binge EatingBinge Eating

Prone to serious medical problems Prone to serious medical problems associated with obesity:associated with obesity:High cholesterolHigh cholesterolHypertensionHypertensionDiabetesDiabetesHigher risk for gallbladder disease, heart Higher risk for gallbladder disease, heart disease, and some types of cancerdisease, and some types of cancerA/T NIMH research, binge eaters have high A/T NIMH research, binge eaters have high rates of co-occurring psychiatric illnesses, rates of co-occurring psychiatric illnesses, especially depressionespecially depression

TreatmentTreatmentAny eating disorderAny eating disorder is most successfully is most successfully treated when diagnosed treated when diagnosed EARLYEARLY!!Unfortunately, many individuals with Unfortunately, many individuals with eating disorders may deny having a eating disorders may deny having a problem even when approached about problem even when approached about suspicious behaviors/symptomssuspicious behaviors/symptomsFor example, individuals with anorexia For example, individuals with anorexia may not receive medical or psychological may not receive medical or psychological attention until they have already become attention until they have already become dangerously thin and malnourisheddangerously thin and malnourished

Eating disorders in Eating disorders in males may be males may be overlookedoverlooked because anorexia and bulimia because anorexia and bulimia are relatively rare in boys and menare relatively rare in boys and men

The importance of treatment early on The importance of treatment early on cannot be emphasized enoughcannot be emphasized enough

The longer abnormal eating behaviors The longer abnormal eating behaviors persist, the more difficult it is to overcome persist, the more difficult it is to overcome the disorder and its effects on the bodythe disorder and its effects on the body

Long-term treatment may be requiredLong-term treatment may be required

Supportive family/friends is importantSupportive family/friends is important

Steps in treatment – Steps in treatment – with suspected eating disorderwith suspected eating disorder

Physical examPhysical exam: to rule out other illnesses: to rule out other illnessesIf an eating disorder is If an eating disorder is diagnoseddiagnosed, , determine whether the patient is determine whether the patient is immediate medical danger and requires immediate medical danger and requires hospitalization or can be treated hospitalization or can be treated outpatientoutpatientHospitalizationHospitalization: if excessive and rapid : if excessive and rapid weight loss took place; serious metabolic weight loss took place; serious metabolic disturbances; clinical depression or risk of disturbances; clinical depression or risk of suicide; severe binge eating and purging, suicide; severe binge eating and purging, or psychosisor psychosis

Complex interaction of emotional and Complex interaction of emotional and physiological problems with most physiological problems with most eating disorders, requiring a eating disorders, requiring a comprehensive treatment plancomprehensive treatment plan.. Treatment team should include:Treatment team should include:

InternistInternist

NutritionistNutritionist

Individual psychotherapistIndividual psychotherapist

Psycho-pharmacologist Psycho-pharmacologist

Psychological aspectPsychological aspectSome form of Some form of psychotherapypsychotherapy is usually is usually neededneededA psychiatrist, psychologist or other A psychiatrist, psychologist or other mental health professional meets with the mental health professional meets with the patient individually and provides ongoing patient individually and provides ongoing emotional supportemotional supportThe goal is for the patient to understand The goal is for the patient to understand and cope with the illnessand cope with the illnessGroup therapyGroup therapy has been especially has been especially effective for individuals with bulimiaeffective for individuals with bulimia

The effectiveness of The effectiveness of combiningcombining psychotherapy psychotherapy and medications has been research by NIMHand medications has been research by NIMHResearchers found that both Researchers found that both intensive group intensive group therapy and antidepressant medicationstherapy and antidepressant medications benefitting patients suffering from bulimiabenefitting patients suffering from bulimiaThe combination treatment was particularly The combination treatment was particularly effective in preventing relapse once medications effective in preventing relapse once medications were discontinuedwere discontinuedFor patient with For patient with binge eating disorder, cognitive-binge eating disorder, cognitive-behavioral therapy and antidepressantbehavioral therapy and antidepressant medications may also be usefulmedications may also be usefulFor For anorexiaanorexia, antidepressant medications may be , antidepressant medications may be effective when combined with other forms of effective when combined with other forms of treatmenttreatment

Team EffortTeam EffortMental health professionals need to Mental health professionals need to combine treatment with those of other combine treatment with those of other health professionals in order to obtain the health professionals in order to obtain the best treatment.best treatment.

MD/NPMD/NP – treat any medical complications – treat any medical complications

NutritionistNutritionist – advise on diet and eating – advise on diet and eating regimenregimen

Psychologist/psychiatrist Psychologist/psychiatrist – treat the – treat the mental/emotional aspectmental/emotional aspect

The challenge of treating eating disorders The challenge of treating eating disorders is made more difficult by the metabolic is made more difficult by the metabolic changes changes To maintain stable weightTo maintain stable weight, individuals with , individuals with anorexia may actually have to consume anorexia may actually have to consume more calories than some of similar weight more calories than some of similar weight and age without an eating disorderand age without an eating disorderIn contrast, a person with bulimia may In contrast, a person with bulimia may gain excess weight if they consume the gain excess weight if they consume the number of calories required to maintain number of calories required to maintain normal weight in others of similar size and normal weight in others of similar size and ageage

Support Groups and InformationSupport Groups and Information

Group therapyGroup therapy: Part of therapy which : Part of therapy which has shown to be very successfulhas shown to be very successful

InternetInternet: Even informational sources : Even informational sources and connecting with others through and connecting with others through the web regarding the web regarding eating disorderseating disorders

Common Symptoms of Eating Common Symptoms of Eating DisordersDisorders

Common S/S of Eating Disorders *Anorexia *Bulimia Binge EatingCommon S/S of Eating Disorders *Anorexia *Bulimia Binge EatingExcessive weight loss in relatively short periodExcessive weight loss in relatively short period X X Continuation of dieting although bone-thinContinuation of dieting although bone-thin X XDissatisfaction with appearance; belief that Dissatisfaction with appearance; belief that body is fat, even though severely underweight X body is fat, even though severely underweight X Loss of monthly menstrual periodsLoss of monthly menstrual periods X X X XUnusual interest in food and development of Unusual interest in food and development of strange eating ritualsstrange eating rituals X X X X Eating in secretEating in secret X X X X X XObsession with exerciseObsession with exercise X X X XSerious depressionSerious depression X X X X X XBinging; consumption of large amounts of foodBinging; consumption of large amounts of food X X X XVomiting or use of drugs to stimulate vomiting, Vomiting or use of drugs to stimulate vomiting, bowel movements, and urinationbowel movements, and urination X XBinging but no noticeable weight gainBinging but no noticeable weight gain X XDisappearance into bathroom for long periods Disappearance into bathroom for long periods of time to induce vomitingof time to induce vomiting X XAbuse of drugs or alcoholAbuse of drugs or alcohol X X X X

** Some individuals suffer from anorexia and bulimia and have symptoms of both** Some individuals suffer from anorexia and bulimia and have symptoms of both

THE END!THE END!