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

5

• 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.

• 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).

• 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

• Others:

PICA, Rumination Disorder; Avoidant/Restrictive Food Intake Disorder (ARFID), UFED

5

General factors Individual-specific factors

Living Western Society Adolescence/peers influence female Eating styles Family Adverse parenting / Dieting Eating disorder of any type Depression Obesity Substance misuse Brain Genetic/biological vulnerabilities Neuronal pathways Reward system Emotional regulation Premorbid experiences/characteristics Traumatic experiences Teasing /stress Perfectionism Impulsivity

EATING DISORDERS Etiopathological/ Risk Factors involved

Activity/Sleeping Personality traits Cognitive styles

Biological

Shared environmental

Non-shared environmental

Life-events and trauma Neuropsychological vulnerabilities Family eating patterns Family styles Psychopathology Gender/ Age

• Biolog. fact

Obesity Social expectations Genetic

Risk factors Explored in Obesity and related Eating Disorders

Therapy

Emotional regulation Food addiction Smell/Taste

Cross-sectionally and longitudinally

Disorders Studied Eating Disorders Obesity Gambling Disorder

• Beh. Addictions

ICD

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

Co-morbidity in Eating Disorders

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 relative risks for mood disorders have been reported in relatives of probands with

ED

10

Eating Disorders and Depression: Reciprocal Interaction

20 30 40

Previous Consequent Primary Secondary

Age

Depression ED

50

Affective Disorders in ED

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: ra=.48 for AN with MDD, ra=.49 for AN with SA, and ra=.77 for MDD with SA 6,899 women from the Swedish Twin study

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

• f Psychiatry 2007; 41:24฀ 31

Affective Disorders in ED

Fernandez-Arandaa et al . Australian and New Zealand Journal

• f Psychiatry 2007; 41:24฀ 31

Affective Disorders in ED

Fernandez-Arandaa et al . Australian and New Zealand Journal

• f Psychiatry 2007; 41:24฀ 31

Suicidal Attempts in BN

Forcano et al., European Psychiatry 24 (2009) 91-97 26 19 30

8 16 24 32

BN-P BN-OSFED

Suicidal Attempts in AN

Forcano et al., Compreh Psychiatry 52 (2011) 352-358 9 25

6,5 13 19,5 26 32,5

RAN BPAN

Suicidal Attempts in ED

Female twins (N= 1,002) from the Australian Twin Registry (aged 28–40 years)

Wade et al..Int J Eat Disord 2015; 48:684–691)

• 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

Non-Suicidal Self-injury (NSSI) in Eating Disorders

Islam et al.: Eur. Eat. Disorders Rev. 23 (2015) 553–560

N=1649 (NSSI 20.6%) 20.9% ED females 17.2% ED males 17.3% AN 23.5% BN 20.4% BED 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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