Comorbidity of Eating Disorders with Suicidality and Treatment - PowerPoint PPT Presentation

Comorbidity of Eating Disorders with Suicidality and Treatment Resistant Depression Fernando Fernández -Aranda Professor University Barcelona, Head of Eating Disorders Unit Head of Group CIBEROBN University Hospital of Bellvitge, Barcelona, SPAIN e-mail: ffernandez@bellvitgehospital.cat

Summary- Part 1 • Clinical and Diagnostic Issues in ED. • Comorbidity of Affective Disorders in ED. • Relationship between Affective Disorders and ED: Some shared etiopathological factors. • Suicidality and NSSI in ED • Case Reports

Eating Disorders Unit at the HUB Psychiatry

New ED referrals to HUB > 7.500 ED > 7.500 ED

State of the Art - Diagnosis DSM 5 criteria • Anorexia Nervosa (subtypes AN-R, AN-BP): Extreme weight loss-control. Intense fear gaining weight even though significant low weight. Disturbance weight/shape. Diet/ Purging/Binge eating behaviours. • Bulimia Nervosa: Binge eating episodes, inappropriate compensatory behaviours (self-induced vomiting, laxatives, diuretics or excessive excercise). Overvalued shape/weight. Once a week for three months • Binge Eating Disorders: Binge eating episodes, without compensatory behaviours. Once a week for three months • Other Specified Feeding or ED (OSFED) All criteria are met for either AN or BN (except for current weight is in the normal range or binge eating/compensatory behaviours occur less than one a week for less than 3 months); Sub-threshold disorder (At-AN; At-BN-low BED; Purging Dis.; NES). • Others: PICA, Rumination Disorder; Avoidant/Restrictive Food Intake Disorder (ARFID), UFED 5

EATING DISORDERS Etiopathological/ Risk Factors involved General factors Adolescence/peers influence Eating styles female Living Western Society Individual-specific factors Brain Family Premorbid Genetic/biological vulnerabilities experiences/characteristics Adverse parenting / Dieting Neuronal pathways Traumatic experiences Eating disorder of any type Reward system Depression Teasing /stress Emotional regulation Obesity Perfectionism 5 Substance misuse Impulsivity

Risk factors Explored in Obesity and related Eating Disorders Cross-sectionally and longitudinally Psychopathology Obesity Personality traits Gender/ Age Life-events and trauma Biolog. fact Activity/Sleeping Non-shared Cognitive styles environmental Genetic Biological Neuropsychological Therapy vulnerabilities Disorders Studied Emotional regulation Eating Disorders Food addiction Shared Obesity environmental Smell/Taste Gambling Disorder Beh. Addictions Social Family eating ICD expectations patterns Family styles

Co-morbidity in Eating Disorders Affectiv Anxiety e 64-71% 20-83% ICD ED 9- Person 18% ality 27-77% Substanc e Use 7-69%

Affective Disorders in ED • Clinical studies of women with ED suggest that 20 – 80% of individuals report at least one episode of lifetime major depression • Retrospective reports indicate that both patterns of onset occur depression before ED and vice versa. • Population-based data also support substantial comorbidity between ED and major depression. • Although depressed mood can improve with refeeding, in the case of AN, several medium- and long-term outcome studies suggest that depression commonly persists after recovery from ED • In addition, significantly elevated r elative risks for mood disorders have been reported in relatives of probands with ED

Eating Disorders and Depression: Reciprocal Interaction ED Depression Previous Consequent Primary Secondary 0 10 30 40 20 50 Age

Affective Disorders in ED 6,899 women from the Swedish Twin study Factors account for 38% (95% CI: 8%, 53%) of the liability to AN, 44% (95% CI: 24%, 50%) of the liability to MDD, and 58% (95% CI: 8%, 78%) of the liability to SA. Unique environmental factors account for most of the remaining liability. The genetic correlations suggest some sharing of genetic risk factors: r a =. 48 for AN with MDD, r a =. 49 for AN with SA, and r a =. 77 for MDD with SA

Affective Disorders in ED N= 153 BD 19% lifetime ED (BN>AN> EDNOS) 30.4% currently MDD Depressed BD + lifetiem ED > SA (58.6 vs. 28,5%), more rapid ciclying and earlier age BD onset

Affective Disorders in ED Fernandez-Arandaa et al . Australian and New Zealand Journal of Psychiatry 2007; 41:24 ฀ 31

Affective Disorders in ED Fernandez-Arandaa et al . Australian and New Zealand Journal of Psychiatry 2007; 41:24 ฀ 31

Affective Disorders in ED Fernandez-Arandaa et al . Australian and New Zealand Journal of Psychiatry 2007; 41:24 ฀ 31

Suicidal Attempts in BN 32 24 16 30 26 19 8 0 BN-P BN-OSFED Forcano et al., European Psychiatry 24 (2009) 91-97

Suicidal Attempts in AN 32,5 26 19,5 13 25 6,5 9 0 RAN BPAN Forcano et al., Compreh Psychiatry 52 (2011) 352-358

Suicidal Attempts in ED Female twins (N= 1,002 ) from the Australian Twin Registry (aged 28 – 40 years) • In Anorexia nervosa (AN) 1 out of 5 deaths can be attributed to suicide. • Suicide is elevated for all eating disorder diagnoses, including bulimia nervosa (BN), binge eating disorder (BED) and purging disorder (PD). • The standardized mortality ratios (SMR) for suicide in AN and BN have recently been reported as high as 31.0 and 7.5, respectively, per 100,000 Wade et al..Int J Eat Disord 2015; 48:684 – 691)

Non-Suicidal Self-injury (NSSI) in Eating Disorders N=1649 ( NSSI 20.6% ) 20.9% ED females 17.2% ED males 17.3% AN 23.5% BN 20.4% BED Islam et al.: Eur. Eat. Disorders Rev. 23 (2015) 553 – 560 19.7% EDNOS

Suicidal Attempts in BN Gomez-Exposito et al., 2016: Front. Psychol. 7:1244.

Suicidal Attempts in BN Gomez-Exposito et al., 2016: Front. Psychol. 7:1244.

Depression and Outcome

Conclusions for this first part • Clinical studies of women with ED suggest that 20 – 80% of individuals report at least one episode of lifetime major depression • 8-30 % report Suicidal Attempts and 20.7 % NSSI • Both patterns of onset occur depression before ED and viceversa (34.5% of ED patients presented with MDD onset prior to ED onset). 43.6% of the MDD onsets occurred within 1 year of each other and 67% within a 3 year window. • Depression is associated with higher psychopathology and more severe eating symptomatology. • SA and NSSI are associated with more emotional dysregulation and impulsivity. • Although depressed mood can improve with refeeding, several medium- and long-term outcome studies suggest that depression commonly persists after recovery from AN and is predictor of poorer outcome in BED

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