STOP YOUTH SUICIDE CONFERENCE EATING DISORDERS IN ADOLESCENCE

Transcription

1 STOP YOUTH SUICIDE CONFERENCE EATING DISORDERS IN ADOLESCENCE Mandakini Sadhir, MD Assistant Professor Division of Adolescent Medicine Department of Pediatrics UK healthcare

2 I HAVE NO FINANCIAL DISCLOSURE

3 Learning Objectives At the end of the presentation, participants should be able to : Know about different types of eating disorders Identify symptoms and complications Utilize treatment modalities

4 Eating disorder 3 rd most common cause of chronic condition in adolescents Typically F > M ( 9:1), Common in Caucasian females Recent increase in prevalence in males, minorities and children < 12 years Clinical report Identification and management of Eating Disorders in Children and Adolescence, Rosen, D Copyright 2010 by the American Academy of Pediatrics

5 Morbidity and Mortality Anorexia nervosa #1 Fatal Psychiatric Disorder. Mortality is 6 times higher than normal in adult women Majority of deaths result from medical complication of starvation Suicide is second common cause. Bulimia Nervosa Mortality rate is lower than AN Suicidal ideation and suicidal attempt more common Associated with major depressive, anxiety, obsessive compulsive disorders, substance use disorders Rome, E. Eating disorder in children and adolescents. Current Problems in Pediatric and Adolescent Health Care Volume 42, Issue 2, February 2012, Pages 28 44

6 Multiple Risk Factors Psychological Perfectionism Anxiety Depression Difficulties regulating emotion Obsessive-compulsive behaviors Rigid thinking style Source NEDA

7 Sociocultural Factors Cultural pressures that glorify thinness or muscularity and place value on obtaining the perfect body Size and weight prejudice Emphasis on dieting Sports: Athletes, Gymnasts,

8 Adolescent s Dilemma

9 Biological Risk factors Having a first degree relative with an eating disorder Family history of depression, anxiety, and/or addiction Personal history of depression, anxiety, and/or addiction Presence of food allergies that contribute to picky or restrictive eating (e.g. celiac disease) Presence of Type 1 Diabetes Source NEDA

10 TYPES OF EATING DISORDERS

11 Eating Disorders Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other specified feeding or Eating disorder Avoidant/Restrictive Food Intake disorder Un-specified Eating disorders

12 Anorexia Nervosa Refusal to maintain a body weight expected for height and age; failure to gain weight during a period of growth with body expected for height and age. Intense fear of gaining weight or becoming fat. A disturbance in the way one's body weight or shape is experienced; denial of the seriousness of low body weight; an undue influence of body weight or shape on selfevaluation. Source DSM V

13 Anorexia nervosa Restricting type: Not engaged in recurrent episodes of binge eating or purging behavior. Weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., selfinduced vomiting or the misuse of laxatives, diuretics, or enemas). Severity Mild: BMI 17 kg/m2 Moderate: BMI kg/m2 Severe: BMI kg/m2 Extreme: BMI < 15 kg/m2 Source DSM V

14 Bulimia nervosa Eating an amount of food in a discrete period of time (2 h) that is definitely larger than most people would eat; Recurrent inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxative, diuretics, enemas, or other medications; fasting; or excessive exercise Binge eating and inappropriate compensatory behaviors occur, on average, twice weekly for the previous 3 months Unduly influenced by body shape and weight Source DSM V

15 Binge Eating Disorder A. Recurrent episodes of binge eating. B. Associated with three (or more) of the following: 1.Eating much more rapidly than normal. 2.Eating until feeling uncomfortably full. 3.Eating large amounts of food when not feeling physically hungry. 4.Eating alone because of feeling embarrassed by how much one is eating. 5.Feeling disgusted with oneself, depressed, or very guilty afterward. C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. Source DSM V

16 Other specified eating disorder Atypical anorexia nervosa (Met all criteria except weight is within or above normal range) Bulimia nervosa (of low frequency and/or limited duration): Binge-eating disorder (of low frequency and/or limited duration): Purging disorder: Recurrent purging behavior in the absence of binge eating. Night eating syndrome: Recurrent episodes of night eating such as eating after awakening from sleep or after the evening meal. There is awareness and recall of the eating. Causes significant distress and/or impairment in functioning. Not associated with other eating disorder, medical condition, medication. Not related to changes in the individual s sleep-wake cycle or by local social norms. Source DSM V

17 Avoidant and restrictive food intake disorder(arfid) Eating or feeding disturbance associated with one or more of the following: 1. Significant weight loss (or failure to gain weight or faltering growth in children); 2. Significant nutritional deficiency; 3. Dependence on enteral feeding; 4. Marked interference with psychosocial functioning. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. No body image concerns. Not attributable to a concurrent medical condition or mental health disorder. Source DSM V

18 What are the symptoms?

19 Frequently checking weight Eating tiny portions or refusing to eat Avoiding eating with others Hoarding and hiding food Eating in secret Disappearing after eating often to the bathroom Unusual food rituals (cutting food into small pieces, chewing each bite an unusually large number of times, eating very slowly) Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism) Little concern over extreme weight loss Source- NEDA

20 Obsessive interest in cooking shows on television and collecting recipes Cooking elaborate meals for others, but refusing to eat them themselves Consumption of only safe or healthy foods Withdrawing from social activities Steals or hoards food in strange places Drinks excessive amounts of water Uses excessive amounts of mouthwash, mints, and gum Hiding weight loss by wearing bulky clothes Excessive exercising even when ill or injured, or for the sole purpose of burning calories Source- NEDA

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22 Physical Signs Changes in weight Stomach issues- constipation or reflux etc. Period irregularities Missing periods Dizziness, lightheadedness Fainting spells Feeling cold all the time Sleep problems Cuts and calluses across the top of finger joints

23 Physical exam Acrocyanosis Hair loss Lanugo Eroded Tooth Enamel Russell s Signs

24 Physical exam Bulimia nervosa 1. Normal/overwei ght 2. Irregular HR 3. Erosion of dental enamel 4. Parotid enlargement 5. Russell s sign 6. Peripheral edema 7. Psych: Impulsive Anorexia nervosa 1. Emaciated 2. Bradycardia 3. Hypotension 4. Orthostasis 5. Dry, yellowish skin 6. Acro-cyanosis 7. Peripheral edema 8. Psych: Inhibited Source- Neinstein Adolescent Health

25 MEDICAL COMPLICATIONS

26 Sudden Death is common due to cardiac complications- Low Heart, irregular heart beat Decrease in brain volume, cognitive deficits, seizures, myopathy, peripheral neuropathy Anemia is common, May have low white count, low platelets leading to bleeding complication Casiero et al. Cardiovascular complications of eating disorders card in review 2006; 14:

27 Other complications Delayed gastric emptying and decreased intestinal motility>>bloating and Constipation Elevated Liver enzymes, Hypercholesterolemia. Laxative abuse: Rectal prolapse Vomiting: GE reflux, esophagitis, Mallory-Weiss tears. Source- AAP 2010

28 Bone health Osteopenia and Osteoporosis is common and a severe complication. Affects both males and females Increased risk for stress fractures. High risk in younger patients-1/3 of peak bone density occurs in adolescence. Low Bone mineral density and risk of fracture may persist in adulthood even after recovery. Endocrine effects of anorexia nervosa. Miller KK. Endocrinology and Metabolism Clinics North Am Sep;42(3): doi: /j.ecl

29 Anorexia and Bone health Nutrition is key! Weight gain and resumption of menses help to increase BMD Oral estrogen and progestin have no significant effect In one study, transdermal estrogen seem to be helpful Supplement with Ca and Vitamin D Endocrine manifestations of eating disorders, Warren, MP J Clin Endocrinol Metab Feb;96(2): doi: /jc

30 Anorexia and Periods Loss of periods after regular periods established is common Cessation of menses affects bone mineral density Resumption of menses: May occur 3-6 months after weight restoration Continued weight gain may be needed if no menses Percentage of body fat associated with resumption of menses No role of OCP unless needed for contraception Treatment Goal Weight in Adolescents with Anorexia Nervosa: Use of BMI Percentiles Golden,N et al International Journal of Eating Disorders 41: Percentage Body Fat by Dual-Energy X-Ray Absorptiometry Is Associated With Menstrual Recovery in Adolescents With Anorexia Nervosa, Pitts, S etal Journal of Adolescent health 2014 Mar 5. pii: S X(14) doi: *NCHS # CDC

31 Female Athlete Triad

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33 Treatment

34 Management Includes:- I. Medical and Nutritional Intervention II. Psychological Intervention III. Pharmacologic Intervention Treatment settings : Inpatient, partial hospitalization residential or outpatient NEDA

35 Levels of Care 1) Inpatient Hospitalization - Medical Stabilization - Psychiatric Stabilization Suicidality

36 Criteria for In-Patient Management (One or More) 1. Severe malnutrition (weight 75% average body weight for age, sex, and height) 2. Dehydration 3. Electrolyte disturbances (hypokalemia, hyponatremia, hypophosphatemia) 4. Cardiac dysrhythmia 5. Physiological instability Severe bradycardia (heart rate 50 beats/minute daytime; <45 beats/minute at night) Hypotension ( 80/50 mm Hg) Hypothermia (body temperature 96 F) Orthostatic changes in pulse ( 20 beats per minute) or blood pressure (10 mm Hg) 6. Arrested growth and development 7. Failure of outpatient treatment 8. Acute food refusal 9. Uncontrollable binging and purging 10. Acute medical complications of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.) 11. Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis) 12. Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive compulsive disorder, severe family dysfunction) Golden, N.H. et al. (2003). Eating disorders in adolescents: Position paper of the Society for Adolescent Medicine. J Adolesc Health, 33(6):

37 Partial Hospitalization Full day out patient care Medically stable, and not a threat to themselves or others Some motivation; cooperative; patient preoccupied with intrusive, repetitive thoughts >3 hours/day Needs some structure to gain weight. Others able to provide at least limited support and structure Partial hospitalization programs last between 3 and 12 hours per day, depending on the patient s needs. Source - NEDA

38 Residential Treatment Medically stable ( intravenous fluids, nasogastric tube feedings, or multiple daily tests are not needed) Poor-to-fair motivation Preoccupied with intrusive repetitive thoughts 4 6 hours a day Patient cooperative with highly structured treatment Needs supervision at all meals Source - NEDA

39 Outpatient Treatment Less intense Involves seeing a medical provider, nutritionist and therapist on regular and frequent basis Source - NEDA

40 NUTRITIONAL REHABILITATION

41 Energy Requirements Calorie requirements determined by Gender: M>K, Body composition, Adolescent s size, Level of Activity Female : 11-18yo 2200cal/day Male: 11-14yo cal/day 15-18yo cal/day Source

42 Psychotherapy Family based therapy : Maud slay Method Evidence based and effective in teens 3 phases : a) Weight restoration: Assist Parents in re-feeding b) Returning control over eating to the adolescent c) Establishing healthy adolescent identity NEDA

43 Psychotherapy Cognitive Behavioral therapy ( CBT) It aims to modify distorted beliefs and attitudes about the meaning of weight, shape and appearance, which are correlated to the development and maintenance of the eating disorder. NEDA

44 Other types of Psychotherapy Interpersonal therapy- focuses on interpersonal difficulties rather than behavioral aspects of disordered eating. Dialectical Behavioral therapy( DBT)-Treatment focuses on developing skills to replace maladaptive eating disorder behaviors. NEDA

45 Medication Limited role for treatment of Anorexia Used for treating co existing conditions such as anxiety, depression May help with purging behaviors in Bulimia

46 Good prognosis Short illness duration (< 3 yrs) Early onset (<14 yrs) No associated comorbid psychological diagnoses No binging and purging Insight present Supportive family Poor prognosis Longer duration of illness Lower minimal weight Diagnosis at later age Comorbid mental illness Binging and purging Low self-esteem

47 Take home points Eating disorder is a common chronic condition in adolescence High mortality due to sudden death and suicide Recognize symptoms and intervene early Treatment requires multidisciplinary approach Nutrition and weight gain reverses most medical complications Intensive treatment early on may be necessary

48 Questions? THANK YOU