Eating Disorders eating or eating related behavior that results in - - PDF document

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Eating Disorders

Marsha D. Marcus, PhD The North American Menopause Society October 3, 2015

DSM‐5: Feeding and Eating Disorders

• Feeding and Eating Disorders are

characterized by a persistent disturbance of eating or eating‐related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.

DSM‐5:Eating Disorders

• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)
• Other Specified Feeding or Eating

Disorder

• Unspecified Feeding or Eating

Disorder

Anorexia Nervosa

Anorexia Nervosa is characterized by a persistent restriction of energy intake relative to requirements leading to a significantly low body weight

• Intense fear of gaining weight or becoming fat, or persistent

behavior to avoid weight gain, even though at a markedly low weight

• Disturbance in the way in which one's body weight or shape

is experienced, undue influence of body shape or weight on self‐evaluation, or persistent lack of recognition of the seriousness of current low body weight

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Bulimia Nervosa

Bulimia Nervosa (BN) is characterized by recurrent, persistent episodes of binge eating, which have two critical features:

• Eating, in a discrete period of time (e.g., within any 2‐hour period),

an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances

• A sense of lack of control over eating during the episode (e.g., a

feeling that one cannot stop eating or control what or how much one is eating) There are recurrent inappropriate compensatory behaviors to prevent weight gain, such as self‐induced vomiting; misuse of laxatives, diuretics, or

• ther medications, fasting; or excessive exercise

Self evaluation is unduly influenced by body shape and weight

Binge‐Eating Disorder

Binge eating disorder (BED), like BN, is characterized by recurrent episodes of binge eating, but without regular the compensatory behaviors in BN The binge‐eating episodes are associated with three (or more) of the following clinical correlates :

• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of being embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed, or very guilty after
• vereating

Marked distress regarding binge eating is present

Subjective Binge Eating

• The amount eating in binge episodes is highly

variable

– Many episodes consist of a small or moderate number of calories

• Subjective binge episodes (SBEs):

– Eating an amount of food that is perceived by the individual to be large, but is not definitely larger than most others would eat – An associated sense of loss of control

Eating Disorders Symptomatology

• Symptoms of eating disorders are common in

the general population and also are associated with distress and dysfunction

• Restrictive dieting
• Driven exercise
• Purging behaviors
• Binge eating
• Over‐concern with shape and weight
• Body dissatisfaction

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Lifetime Prevalence of DSM‐IV Eating Disorders*

Males (%) Females (%) Total (%) Anorexia nervosa .3 .9 .6 Bulimia nervosa .5 1.5 1.0 Binge eating disorder 2.0 3.5 2.8 Sub‐threshold binge eating disorder 1.9 .6 1.2 Any binge eating 4.0 4.9 4.5 *Hudson, Hiripi, Pope, Kessler, 2007

Psychiatric Co‐morbidity Associated with “Any Binge Eating”*

% Odds Ratio Any anxiety disorder 59.5 3.7 Any mood disorder 44 3.0 Any impulse control disorder 40.2 2.2 Any substance use disorder 28.7 2.8 Any disorder 76.5 3.7

*Hudson, Hiripi, Pope, Kessler 2007

BMI Distribution for BN and BED

BMI Distribution 12‐Month BN (%) 12‐Month BED (%) No Disorder (%) < 18.5 (underweight) ‐ ‐ 2.0 18.5‐24.9 (normal) 15.3 19.0 36.7 25‐29.9 (overweight 42.2 35.7 36.2 30‐34.9 (class I) 3.5 25.6 15.1 35‐39.9 (Class II) 20.3 3.6 6.2 40+ (class III) 18.7 16.2 3.8 30+ (total obese) 42.4 45.4 25.1

Eating Disorders and Mid‐Life Women

• Disordered eating in mid‐life may represent:

– Persistent or chronic disorder – Recurrence or exacerbation – New onset disorder

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Increased Admissions among Mid‐Life Women

Percent of women 40 years or older admitted for inpatient eating disorders treatment by year of admission (Ackard et al., J Psychosomatic Res, 2013)

Eating Disorder Diagnoses Vary by Age Group (18‐24 years vs. 40+ years)*

*Elran‐Barak et al., J Nervous Mental Dis, 2015.

Disordered Eating in Mid‐Life

• The estimated point prevalence for eating

disorders in mid‐life is 4.6%*

• More than 10% of women older than 50 years

endorse symptoms of eating disorders

• Older and younger women report high levels
• f body dissatisfaction (40‐80%)

*Mangweth‐Matzek et al., IJED, 2014;

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Reasons for Body Dissatisfaction in Mid‐Life

– Biological – Menopausal status, Body Mass Index – Psychological – Negative affect, importance of appearance, aging anxiety – Sociocultural – Role transition, history of adversity

Is the Menopausal Transition a “Window of Vulnerability”?

• Investigators examined the relation between

menopausal status and eating disorders and associated pathology in 436 community women

– Peri‐menopausal women had a markedly higher prevalence of eating disorders than pre‐ menopausal women – Peri‐menopausal women also reported higher levels of body image concerns

*Mangweth‐Matzek et al., Int J Eat Disorders, 2013

Disordered Eating as a Function of Menopausal Status

Pre – MP (N=192) N (%) Peri – MP (N=110) Post – MP (N=134) Eating Disorders 4 (2)* 10 (9)* 7 (5) AN BN 2 2 3 BED 1 4 2 Unspecified ED 1 4 2 Sub‐Threshold EDs 7 (4) 7 (6) 7 (5) Binge Eating 5 5 3 Purging Ov/Ob 2 2 4

Implications for Clinicians

• Screening
• Referral
• Treatment

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Eating Disorder Screen for Primary Care*

• Are you satisfied with your eating patterns?
• Do you ever eat in secret?
• Does your weight affect the way you feel

about yourself?

• Have any members of your family suffered

with an eating disorder?

• Do you currently suffer or have you ever

suffered in the past from an eating disorder?

Cotton M et al., J Gen Intern Med, 2003

Psychotherapy for Eating Disorders

• Weight restoration is the cornerstone of

treatment of AN

– Specialty‐care referral is indicated

• Psychosocial treatment is effective in

treatment of BN and BED

– Cognitive behavior therapy – Interpersonal therapy – Dialectical behavior therapy

Pharmacotherapy of BN & BED

• Pharmacotherapy

– There is no clearly efficacious medication for AN – Antidepressant treatment moderately effective in the treatment of BN and BED

• Strongest evidence for SSRIs
• FDA‐Approved treatment

– BN ‐ Fluoxetine (60 mg/day) – BED ‐ Lisdexamfetamine dimesylate (50‐70 mg/day)

• Dearth of long‐term outcome data

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Summary

• Eating disorders and associated symptoms are

common in mid‐life women

– Query patients about weight‐related and eating behavior concerns – Consider depressive symptoms and other psychiatric co‐morbidity – Discuss referral to mental health provider