Eating Disorders. Anorexia Nervosa. DSM 5:Eating Disorders. DSM 5: Feeding and Eating Disorders 9/24/2015

Transcription

1 DSM 5: Feeding and Eating Disorders Eating Disorders Marsha D. Marcus, PhD The North American Menopause Society October 3, 2015 Feeding and Eating Disorders are characterized by a persistent disturbance of eating or eating related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. DSM 5:Eating Disorders Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder (BED) Other Specified Feeding or Eating Disorder Unspecified Feeding or Eating Disorder Anorexia Nervosa Anorexia Nervosa is characterized by a persistent restriction of energy intake relative to requirements leading to a significantly low body weight Intense fear of gaining weight or becoming fat, or persistent behavior to avoid weight gain, even though at a markedly low weight Disturbance in the way in which one's body weight or shape is experienced, undue influence of body shape or weight on self evaluation, or persistent lack of recognition of the seriousness of current low body weight 1

2 Bulimia Nervosa Bulimia Nervosa (BN) is characterized by recurrent, persistent episodes of binge eating, which have two critical features: Eating, in a discrete period of time (e.g., within any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances 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) There are recurrent inappropriate compensatory behaviors to prevent weight gain, such as self induced vomiting; misuse of laxatives, diuretics, or other medications, fasting; or excessive exercise Self evaluation is unduly influenced by body shape and weight Binge Eating Disorder Binge eating disorder (BED), like BN, is characterized by recurrent episodes of binge eating, but without regular the compensatory behaviors in BN The binge eating episodes are associated with three (or more) of the following clinical correlates : Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of being embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty after overeating Marked distress regarding binge eating is present Subjective Binge Eating The amount eating in binge episodes is highly variable Many episodes consist of a small or moderate number of calories Subjective binge episodes (SBEs): Eating an amount of food that is perceived by the individual to be large, but is not definitely larger than most others would eat An associated sense of loss of control Eating Disorders Symptomatology Symptoms of eating disorders are common in the general population and also are associated with distress and dysfunction Restrictive dieting Driven exercise Purging behaviors Binge eating Over concern with shape and weight Body dissatisfaction 2

3 Lifetime Prevalence of DSM IV Eating Disorders* Males (%) Females Total (%) (%) Anorexia nervosa Bulimia nervosa Binge eating disorder Sub threshold binge eating disorder Any binge eating *Hudson, Hiripi, Pope, Kessler, 2007 Psychiatric Co morbidity Associated with Any Binge Eating * % Odds Ratio Any anxiety disorder Any mood disorder Any impulse control disorder Any substance use disorder Any disorder *Hudson, Hiripi, Pope, Kessler 2007 BMI Distribution for BN and BED Eating Disorders and Mid Life Women BMI Distribution 12 Month BN (%) 12 Month BED (%) No Disorder (%) < 18.5 (underweight) (normal) (overweight (class I) (Class II) (class III) (total obese) Disordered eating in mid life may represent: Persistent or chronic disorder Recurrence or exacerbation New onset disorder 3

4 Increased Admissions among Mid Life Women Percent of women 40 years or older admitted for inpatient eating disorders treatment by year of admission (Ackard et al., J Psychosomatic Res, 2013) Eating Disorder Diagnoses Vary by Age Group (18 24 years vs. 40+ years)* Disordered Eating in Mid Life The estimated point prevalence for eating disorders in mid life is 4.6%* More than 10% of women older than 50 years endorse symptoms of eating disorders Older and younger women report high levels of body dissatisfaction (40 80%) *Elran Barak et al., J Nervous Mental Dis, *Mangweth Matzek et al., IJED, 2014; 4

5 Reasons for Body Dissatisfaction in Mid Life Biological Menopausal status, Body Mass Index Psychological Negative affect, importance of appearance, aging anxiety Sociocultural Role transition, history of adversity Is the Menopausal Transition a Window of Vulnerability? Investigators examined the relation between menopausal status and eating disorders and associated pathology in 436 community women Peri menopausal women had a markedly higher prevalence of eating disorders than premenopausal women Peri menopausal women also reported higher levels of body image concerns *Mangweth Matzek et al., Int J Eat Disorders, 2013 Disordered Eating as a Function of Menopausal Status Pre MP (N=192) N (%) Peri MP (N=110) Eating Disorders 4 (2)* 10 (9)* 7 (5) AN BN BED Unspecified ED Sub Threshold EDs 7 (4) 7 (6) 7 (5) Binge Eating Purging Ov/Ob Post MP (N=134) Screening Referral Treatment Implications for Clinicians 5

6 Eating Disorder Screen for Primary Care* Are you satisfied with your eating patterns? Do you ever eat in secret? Does your weight affect the way you feel about yourself? Have any members of your family suffered with an eating disorder? Do you currently suffer or have you ever suffered in the past from an eating disorder? Cotton M et al., J Gen Intern Med, 2003 Psychotherapy for Eating Disorders Weight restoration is the cornerstone of treatment of AN Specialty care referral is indicated Psychosocial treatment is effective in treatment of BN and BED Cognitive behavior therapy Interpersonal therapy Dialectical behavior therapy Pharmacotherapy of BN & BED Pharmacotherapy There is no clearly efficacious medication for AN Antidepressant treatment moderately effective in the treatment of BN and BED Strongest evidence for SSRIs FDA Approved treatment BN Fluoxetine (60 mg/day) BED Lisdexamfetamine dimesylate (50 70 mg/day) Dearth of long term outcome data 6

7 Summary Eating disorders and associated symptoms are common in mid life women Query patients about weight related and eating behavior concerns Consider depressive symptoms and other psychiatric co morbidity Discuss referral to mental health provider 7