Eating Disorders Detection and Treatment. Scott Crow, M.D. Professor of Psychiatry University of Minnesota Chief Research Officer The Emily Program

Transcription

1 Eating Disorders Detection and Treatment Scott Crow, M.D. Professor of Psychiatry University of Minnesota Chief Research Officer The Emily Program

2 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1995, 2005 (*BMI 30, or about 30 lbs overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% accessed May 7, 2007

3 Trend in Body Mass Index (BMI) of Miss America Pageant Winners, 1922 to1999 The horizontal line represents the World Health Organization s BMI cutoff point for under nutrition JAMA 2000;283:1569

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5 What Causes Eating Disorders?

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7 Catherine of Gull publishes Russell Siena Dies Anorexia Nervosa names Bulimia CE 2000 CE

8 Genetic Factors in Eating Disorders Family history studies Twin studies Linkage studies Candidate gene studies

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10 TV in Fiji TV Time 1 Time 2 arrives Becker et al, 2002

11 EAT 26 Scores Becker et al, 2002

12 Self-induced Vomiting to Control Weight % Becker et al, 2002

13 How does one reconcile genetic and sociocultural data with epidemiologic data?

14 Causal Model ED Environmental Risk Factors Individual Genetic Risk Factors Resilience

15 How Common are Eating Disorders?

16 Lifetime Community Prevalence of Eating Disorders NCS-R N=9,282 AN = Anorexia Nervosa Hudson et al, Biol. Psychiatry 2007, 61(3):348-=58 BN = Bulimia Nervosa NCSR= National Comorbidity Survey Replication

17 Eating Disorders 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Eating Disorder, Not Otherwise Specified

18 Anorexia Nervosa

19 Anorexia Nervosa Weight < 85% of IBW Body image disturbance Fear of fat (amenorrhea)

20 Anorexia Nervosa Peak age onset Predominantly female Restricting and purging subtypes are encountered High rates of comorbid psychopathology

21 Complications of Starvation Osteoporosis Bradycardia Hypotension Hypoglycemia Hypothermia Hepatitis

22 10 Year Follow up of AN Outcome % 5 0 Recovered Good Intermediate Poor Deceased Eckert et al, Psychol Med 1995;25:

23 Suicide Mortality Rates for Various Psychiatric Conditions % Opiate Abuse Eating Disorders Alcohol Abuse Schizophrenia MDD Bipolar Disorder Harris ED, Barraclough BM. Medicine (Baltimore) 1994;73;

24 Bulimia Nervosa

25 Bulimia Nervosa Recurrent binge eating Recurrent purging Binge eating/purging at least 2x/wk for 3 months. Overevaluation of shape/weight Not AN

26 Purging Vomiting Laxatives Diuretics Diet pills

27 Bulimia Nervosa Peak age onset Prevalence 1 3% Predominantly female 80% are of normal weight High rates of comorbid psychopathology

28 Complications of Purging Electrolyte disturbance Intestinal dysfunction Catastrophic GI trauma (rare) Myopathy, Cardiomyopathy (Ipecac)

29 Long Term Course of BN 11% 0.6% 17.9% Full BN Full AN ED NOS Remission 70.5% EDNOS: Eating Disorders Not Otherwise Specified Keel et al. Arch Gen Psychiatry 1999;56:63-69

30 Fertility in BN 24% Never pregnant At least one pregnancy 74% 2% Unable to conceive Crow SJ, et al. Am J Psychiatry 2002;159:

31 Eating Disorders Not Otherwise Specified

32 Detection of ED Look at high risk: Female Mood, anxiety d/o, CD Teens/20 s Weight change Athletics, dance

33 Detection of ED Open ended works poorly Be prepared to ask repeatedly Be aware of referral options

34 Detection of ED Hypokalemia in young healthy females highly specific, not highly sensitive Weight loss

35 Treatment of Eating Disorders 1. Nutritional rehabilitation 2. Psychotherapy 3. Medications

36 Nutritional Treatment Adequate intake, resumed safely Meal patterning Variety of foods and settings

37 Psychotherapy Cognitive Behavior Therapy (CBT) Family Based Therapy (FBT) Interpersonal Therapy (IPT) Dialectical Behavior Therapy (DBT)

38 Psychotherapy FBT is a key treatment for adolescent AN Multiple therapies effective for BN, BED in adults Psychotherapy for adults with AN is more difficult

39 Medications for AN

40 Medications for BN Most or all antidepressants work Gold standard: Fluoxetine qd Bupropion is contraindicated (Seizures) Duration probably at least that for MDD Overall response lower than psychotherapy

41 Medications for BED Many Antidepressants and Appetite Suppressants work for BE Results for weight loss are variable but this is often a key patient goal Duration unclear

42 Summary ED are common Complications are common Nutrition and psychotherapy are key interventions Medications play a limited supportive role