prevalence of body image fears
80% of 4th graders are afraid of being fat
50% kids in middle school believe they are overweight and are on diets
1/2 teen girls and 1/3 teen boys use unhealthy methods to control weight
50% ED clients >30yo, 13% of W >50yo have sx of ED
DSM IV categories re ED
Anorexia Nervosa, Bulimia Nervosa, EDNOS
(DSM V includes BED, Other specified Feeding or ED (OSFED) & unspecified feeding or eating disorder
DSM IV criteria for Anorexia Nervosa
a. refusal to maintain BW @ or above minimally appropriate (ie to B, and took out D re amenorrhea
issue with DSM IV criteria for AN
what about M? they don’t have periods.
Also, <85% may not occur till later in dz.. hard to get insurance coverage with this criterion
DSM IV criteria Bulimia Nervosa
A. Recurrent binge episodes char by BOTH
- eating in short time, large amt
- sense of lack of control
B. Recurrent compensatory behavior to prevent wt gain
- self induced vomiting
- laxative/diuretic, enemas or other meds
- Fasting
- Excessive exercise
C. Binges and compensatory acts average at least 2x/wk for 3 mth
D. Self eval unduly influence by body shape and weight
E. Disturbance does not occur exclusively during episodes of AN
two types: purging, nonpurging
*DSM V changes to ONCE a wk
what did BED used to be classified under in DSM IV
EDNOS
DSM IV criteria EDNOS
disorders of eating that do not meet criteria for AN or Bulimia nervosa
- subclinical AN, BN
- refusal to maintain wt w/o AN or BN
- night eating
- orthorexia
- diabulimia
- BED
*now this is OSFED
what are some less common feeding and eating disorders
PICA - eating non nutritive substances ie chalk
Rumination d/o: regurgitating food, re swallowing or spitting
Avoidant/restrictive food intake disorder: refusing to eat but no body image disturbance
Co-morbid dx wth Ed include
Anxiety: OCD, GAD, SAD, panic
Depression: MDD, Bipolar, Dysthymia
Addiction: drugs, lcohol, pills, gambling, shopping
ADHD: inattentive, hyperactive/impulse
PTSD: flashbacks, nightmares, avoid triggers
Personality disorder: BORDERLINE* Narcissictic (axis II)
what should we remember to assess for in ED pt?
distorted body image and desire to lose weight
Mental health disorders a/w ED
MDD, bipolar, OCD, ADHD, Somatization, Substance abuse
Physical health d/o a/w ED
hyperthyroidism, malignancy, IBD, immunodeficiency, malabsorption, chronic infections, Addison’s dz, DM
Epidemiology ED
average onset age 14-19
80% F
affects all races, ethnicities, income levels
Prevalence of ED
F:
anorexia 0.9%, Bulimia 1.5%, BED 3.5%
M
AN 0.3%, Bulimia 0.5%, BED 2%
genetic vs environment and ED
40% genetics
60% environment
Genetics/biology contributing to ED
Predisposition for mental illness
- anxiety/ocd, depression, addiction, adhd
Emotional dysregulation
Personality traits: perfectionistic, people pleaser, emotionally sensitive, strong willed, impulsive
Body shape/size: body size larger than avg, distribution of fat, thyroid function
Adolescence and puberty: hormonal changes, higher risk tolerance
Environment contributors..
Family relationships
Trauma/abuse (physical, psych/emotional, sexual, neglect)
Parental modeling (eating, body image, exercise)
Peer relationships, bullying
Appearance-focused culture
Body focused sports
what is the function of ED
NOT about food/vanity
“creative coping mechanisms”
- numb emotions, manage anxiety, feel in control, feel successful at something, safely express emotions, hurt self
how to ID ED
they may address it.. trying to gain/lose wt, seeking meds, needing medical clearance for sport/school/work
or they may not
THus… observable s/sx
consistent wt fluctuations, sig under/overwt, swollen parotid glands, scar tissue on fingers, cold hands/feet, persistent cough/sore throat, tooth enamel damage, esophageal damage or inflame, dry or brittle hair/nails/skin, lanugo on face arms, baggy clothing, vague answers when asked about what they eat
Med complications
amenorrhea, dehydration, electrolyte, irreg heart beat, hypoTN, osteopenia, infertility, sore throat/cough, GERD, bloating, constipation, diarrhea, dizzy/faint, unexplained stomach pain, DM
what questions to ask
- think about food/body a lot
- feel in control of relationship w/ food
- changed diet?
- doing anything to control weight?
- how freq/long do you exercise
- how do you feel about your body
How to respond…
- create warm, safe environment for them to open up
- don’t comment on appearance
- probe and ask questions
- provide education about medical/physical consequences of their behaviors WITHOUT SHAMING THEM
- thank them for being brave enough to tell you the truth
- provide referrals
tx ED
SSRI: Prozac, Zoloft, LEXAPRO, celexa
*Prozac only approved med for ED (specifically bulimia)
SNRI: pristiq, Cymbalta, Effexor
atypical antipsychotics
- abilify, Risperdal, Seroquel
- help tx OCD, unstable mood, sleep problems, borderline PD, impulsivity, cutting
- CI: possible wt gain
BZ: Xanax, Klonopin
-may help before meals with anxiety
CI: habit forming, numb emotions
ADHD: decrease urge to use substances
- CI: decreased appetite, wt loss
anticonvulsants: topomax, lamictal
CI: underwt, purging
