Michelle

1
Michelle

• 19 yo single E3 medical technician
• CC nausea fatigue
• Second visit in 3 months
• Nausea sporadic throughout day
• Falls asleep quickly, but sleep is restless

2
Michelle

• PMH Unremarkable
• FH Father with alcohol dependence
• SH
• Relationship recently ended
• New supervisor
• 4-6 beers on weekend outings
• VS T37C, HR 72, BP 118/74, BMI 27

3
What would prompt you to ask her about her eating
or dietary habits?
4
Michelle

• PMH Unremarkable
• FH Father with alcohol dependence
• SH Relationship recently ended new supervisor
  ETOH use
• VS T37C, HR 72, BP 118/74, BMI 27
• Dietary History
• 3-4 times/wk eats 4-5 slices of pizza and bag of
  chips

5
What might you ask to explore the possibility of
an eating disorder?
6
What aspects of the care of eating disorders are
appropriately managed by a family physician?
7
Practical Approaches to Identifying and
TreatingEating Disorders

• Pamela M. Williams MD
• Jeffrey Goodie PhD
• Uniformed Services University

8
Overview

• By the close of this session, you should have
  increased confidence in
• Listing and applying the diagnostic criteria for
  eating disorders
• Utilizing a screening tool to identify eating
  disorders in at risk populations
• Prescribing evidenced-based, individualized
  treatment programs

9
Epidemiology

• Lifetime prevalence
• Anorexia nervosa 1
• Bulimia nervosa 1-2
• Binge-eating disorder 2.6
• 5-10 of the obese population
• Women vs. men
• Anorexia and bulimia nervosa
• 10x more common in women
• Binge eating disorder
• 33 of those diagnosed are men

• Median age onset
• Anorexia bulimia 18-21 years old

10
Eating Disorder in Primary Care

• Anorexia
• 4.2-8.1 per 100,000 (UK-Netherlands)
• Bulimia Nervosa
• 11.4 per 100,000 (Netherlands)

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Eating Disorders in the Military
Mean Rate of ED Dx per Year

• Diagnosed eating disorders1
• DMED database 1998-2006
• Disordered eating
• pre post deployment2
• Millennium Cohort Study
• (N 46,219)
• 8 questions on PHQ
• Combat exposed women 1.78x more likely to
  develop ED

Incidence of self-reported disordered eating
1Antczak, Brininger. Eating Disorders, 2008
16363-77 2Jacobson et al. Am J Epidemiol.
2009169415-27
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13
Diagnosis?

• 1-2 times per week Michelle will eat 4-5 slices
  of pizza (a small pizza) with an entire bag of
  chips.
• She is 5 6 weighs 110 lbs
• Believes that she needs to lose 5 lbs

Other Questions?
14
The first time a threw up, I had been hating my
body, hating my body, and hating my body-for
yearsI stopped watching TV, put down my bag of
Fritos and just sort of, in this drugged stupor,
walked downstairs, pulled back my braids and
throw up.You start setting goals for yourself,
I want to get down to 100, I want to get down to
90, I want to get down to 80, and it just gets
lower and lower. I remember seeing the scale,
and it said 63 and I want, 50!
-Marya Perfect Illusions Eating Disorders and
the Family
15
Anorexia Nervosa (AN)

• Weight below minimally normal for age/height
• Intense fear of gaining weight
• Disturbance in how weight/body shape is
  experienced
• Undue influence of body weight on
  self-evaluation, or
• Denial of seriousness of current weight
• Amenorrhea in postmenarcheal females
• Specific types
• Restricting Type No binge eating or purging
  behaviors
• Binge Eating/Purging Type

16
Diagnosis?

• 2-3 times per week Michelle will eat 4-5 slices
  of pizza (a small pizza) with an entire bag of
  chips, and a pint of ice cream.
• Will not eat the following day
• She is 5 6 weighs 125 lbs
• Believes that she needs to lose 5 lbs

Other Questions?
17
It was a way for me to feel numb. Like I could
take everything in, all of the days stress, all
of the feelings I felt-and just get rid of them
all at once by just throwing up. You just start
eating and throwing up again. I dont do it on
purpose. Its just something that happens, that
my brain does.
-Suni Perfect Illusions Eating Disorders and
the Family
18
Bulimia Nervosa (BN)

• Recurrent episodes of binge eating (gt 2x wk, gt 3
  m)
• Eat more food than normal in a discrete period
  of time
• Lack of control over eating during the episode
• Recurrent inappropriate compensatory behaviors
• Self-eval overly influenced by shape and/or
  weight
• Types Purging or non-purging
• Note not occurring during an episodes of AN

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Eating Disorder NOS

• Patient does not meet criteria for other
  disorder
• Criteria for Anorexia are met EXCEPT
• Individual has regularly menses and/or
• Current weight is in the normal range
• Criteria for Bulimia are met EXCEPT
• Less than twice a week or less than 3 months
• Inappropriate compensatory behavior, but normal
  body weight and small amount of food
• Repeatedly chewing spitting out large amounts
  of food

20
Diagnosis?

• 2-3 times per week Michelle will eat 4-5 slices
  of pizza (a small pizza) with an entire bag of
  chips, and a pint of ice cream.
• She is 5 6 weighs 125 lbs
• Believes that she needs to lose 5 lbs

Other Questions?
21
I would eat everything I could find in one
sittingwhole pizzas, dozens of cookies,
sandwiches, chips and ice cream. I would guzzle
soda from liter bottles. Worst of all, I would
do this all day non stop until I was physically
ill. I would actually feel hung over the next
day. The eating seemed to help me forget the
pain of losing my dad. My weight really began to
climb. As my weight increased, feelings of shame
and embarrassment returned.
-from Friendly Mirrors and Contented Closets
22
Binge Eating Disorder (BED)

• Recurrent episodes of binge eating
• Eat more food than normal in a discrete period
  of time
• Lack of control over eating during the episode
• Three (or more) of the following
• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling
  hungry
• Eating alone, embarrassed by how much one is
  eating
• Feeling disgusted, depressed, very guilty after
  eating
• Marked distress with binge eating
• Occurs at least 2x week for 6 months
• NO inappropriate compensatory behaviors

Research criteria
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24
Risk Factors?
25
Risk Factors

• Activity/occupation stressing
• Thinness
• Physical fitness
• Family history of
• Eating disorders
• Substance abuse
• Mood disorders

• Premorbid obesity
• Severe life stressors
• Perfectionism
• Body dissatisfaction
• Low self-esteem

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Screening

• I have an eating disorder ? 1 complaint
• Options
• Screen all female adolescents/young adults
• Symptom based screening
• Fatigue, dizziness, low energy
• Amenorrhea, weight loss
• GI distress
• Polyuria, polydipsia
• Insomnia

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SCOFF Questions

• Do you make yourself Sick (induce vomiting)
  because you feel uncomfortably full?
• Do you worry that you have lost Control over how
  much you eat?
• Have you recently lost more than One stone (14 lb
  6.4 kg) in a three-month period?
• Do you think you are too Fat, even though others
  say you are too thin?
• Would you say that Food dominates your life?

• Scoring
• One point for every Yes answer
• Score 2 likely case of anorexia or bulimia
• Sensitivity 100 Specificity 87.5

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Common Assessment Measures

• Eating Attitudes Test (EAT)
• Eating Disorder Inventory (EDI)
• Bulimia Test-Revised
• Bulimia Investigatory Test Edinburgh (BITE)

29
Other Questions to Consider

• How many diets have you been on in the past year?
• Do you think you should be dieting?
• Are you dissatisfied with your body size?
• How does your weight affect how you think about
  yourself?
• Sometimes people think about how they are eating
  all day to the point that it is difficult to
  concentrate on anything else. Does that happen
  to you?

30
Evaluation

• Physical exams and/or lab results not diagnostic
• Obtain accurate weight (discrete)

31
Potential Physical Findings
32
Treatment
33
Interdisciplinary Team

• Physician
• Behavioral Health Provider
• Dietician
• Family

34
Motivating Patients to Change

• Therapeutic relationship
• Getting permission
• Can we discuss your eating habits?
• Assessing motivation
• What do you like about the way you eat?
• What do you dislike?
• What are benefits/downsides of changing?
• How important is it for you to change?
• How confident are you that you can change?

35
Function of Eating Disorders?

• Stress management
• Structure
• Worth Thin
• Source of control
• Physiological consequences

36
Anorexia
Bulimia
Binge Eating
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Anorexia

• Behavioral Therapy C
• Nutritional rehabilitation
• Weight gain 0.5-1kg/week
• Modify beliefs about food, weight, and control
• Improve self-concept
• Medications C
• Should not be sole treatment modality

38
Bulimia Behavioral Interventions

• Behavioral Therapy A
• Cognitive behavioral therapy (CBT)
• Interpersonal therapy (IPT)
• Self-help B

• Cognitive behavioral therapy
• Typical treatment course 15-20, 50 min
  appointments
• Developing relationship
• Self monitoring
• Eliminating forbidden foods
• Delaying binges and purges
• Changing thinking about food, weight, shape
• Problem solving
• Relapse prevention

39
Bulimia Behavioral Interventions

• Behavioral Therapy A
• Cognitive behavioral therapy (CBT)
• Interpersonal therapy (IPT)
• Self-help B

• Interpersonal therapy
• Typical treatment course 15-20, 50 min
  appointments
• Focus on modifying interpersonal relationships
  and functioning
• Less emphasis on specific eating behaviors and
  thoughts

40
Bulimia Pharmacotherapy

• Medications B
• SSRIs (typically high dose)
• Tricyclic antidepressants
• Trazodone
• Monoamine oxidase inhibitors
• Note Bupropion (contraindicated)

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Binge Eating Disorder

• Behavioral Therapy A
• Cognitive behavioral therapy
• Interpersonal therapy
• Guided self-help B
• Self-monitoring
• Educate (eating, weight)
• Develop eating schedule
• Reduce strict dieting
• Develop stress management alternatives
• Relapse prevention

42
Binge Eating Disorder

• Medications B
• SSRIs (high dose)
• Tricyclic antidepressants
• Antiepileptics
• Appetite suppressants

43
Level of Care Determination
Comorbid disorders
Medical status
Suicidality
Ability to control compulsions
Weight
Motivation
Geography
Purging behavior
Environmental Stress
Structure needed to eat/gain weight
Practice guideline for the treatment of patients
with eating disorders, third edition. APA 2006.
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Prognosis

• Anorexia nervosa
• 47 recover, 33.5 improve
• Bulimia nervosa
• 70 fully recover
• Binge eating disorder
• 40-87 fully recover

Sullivan et al. Am J Psychiatry. 1998 155(7)
939-46. Keel et al. Arch Gen Psychiatry. 1999 56
(1) 63-69. Berkman et al. Int J Eat Disord.
2007 40 (4) 293-309.
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Is there a role for prevention?

• Prevention programs can reduce risk factors and
  future onset of eating disorders
• More successful programs
• Target high risk individuals, 15 years and older
• Delivered by trained professional
• Focus on body acceptance and reduce thin-ideal
  internalization
• Evidence-based programs
• The Body Project

Stice, Shaw, Marti. Annu Rev Clin Psych. 2007
3207-231
46
Take Home Points

• Family physicians are at the forefront of
  identifying patients with eating disorders and
  motivating them to engage in treatment.
• Eating disorders serve a critical function for an
  affected patient.
• Most patients, particularly those with bulimia
  and binge eating disorder, can be effectively
  treated in the outpatient setting under the care
  of an interdisciplinary team.

47
Questions?
48
Recommended Resources

• Fairburn CG. Overcoming Binge Eating. New York,
  NY Guilford Press 1995.
• Pritts SD, Susman J. Diagnosis of eating
  disorders in primary care. Am Fam Physician.
  200367(2)297-304.
• Williams PW, Goodie JG, Motsinger CD. Treatment
  of eating disorders. Am Fam Physician.
  200877(2)187-195, 196-197.
• Yager J, Devlin MJ, Halmi KA, et al. Practice
  guideline for the treatment of patients with
  eating disorders, third edition. American
  Psychiatric Association 2006.
• www.something-fishy.org
• http//www.nationaleatingdisorders.org/