WANT TO KNOW MORE ABOUT:
EATING DISORDERS
Dr Saeideh Saeidi and Ellie Campbell
Yorkshire Centre for Eating Disorders
2 February 2016
[email protected]
[email protected]
AIMS OF THE SESSION

Classifications of eating disorders

Risk factors

Screening

Overview of treatment of eating
disorders
ANOREXIA NERVOSA
Extreme weight loss – BMI less than
18.5.
 Intense fear of weight gain or becoming
fat.
 Self-evaluation is excessively influenced
by body shape and weight.

Body Image
SYMPTOMS OF ANOREXIA
Physical signs
Behavioural signs
Severe weight loss
Periods stopping
Wanting to be left alone
Psychological signs
Wearing big baggy clothes
Dizziness
Intense fear of gaining weight
Stomach pains
Depressed
Constipation
Feeling emotional
Excessive exercising
Lying about eating meals
Denying there is a problem
Poor circulation &
feeling cold
Obsession with dieting
Difficulty sleeping
Mood swings
Distorted perception of body weight
and size
Thinking about food all the time
Feeling guilty after eating
Difficulty concentrating
Wanting to have control
BULIMIA NERVOSA




Bulimia is when a person goes through cycles of
bingeing and purging.
Bingeing is eating a lot of food in a short amount
of time. Purging is when they try to get rid of the
food by vomiting, using laxatives, or excessive
exercise.
The person may be normal weight or overweight.
Self-evaluation is excessively influenced by body
shape and weight.
SYMPTOMS OF BULIMIA
Behavioural signs
Physical signs
Sore throat / swollen glands
Stomach pains
Mouth infections
Irregular periods
Dry or poor skin
Difficulty sleeping
Sensitive or damaged teeth
Psychological signs
Feeling ashamed,
depressed and guilty
Feeling out of control
Mood Swings
Feeling guilty after eating
Eating large quantities of
food
Being sick after eating
Being secretive
Abusing laxatives
BINGE EATING DISORDER




•
Binge eaters feel out of control.
They binge on food – eat a lot of food in a short
amount of time.
Binge eater’s weight may constantly change, and they
may only eat in private.
Eat large amounts of food when not feeling physically
hungry.
Feel disgusted with oneself, depressed, or very guilty
after overeating.
SYMPTOMS OF BINGE EATING DISORDER
Physical signs
Psychological signs
Feeling depressed and
out of control
Weight gain
Behavioural signs
Eating large quantities
of food
Eating inappropriate
food
Being secretive
Mood swings
Feeling guilty after eating
SAMPLE OF A BINGE
Classification of binge eating/overeating
Large
Not large
(DSM-IV definition) but viewed by individual as
excessive
Loss of
control
No loss of
control
Source – Binge eating , Fairburn and
Wilson
Objective
binge eating
Subjective
binge eating
Objective
overeating
Subjective
overeating
GENERAL PSYCHOPATHOLOGY & STARVATION
SYNDROME

Minnesota experiment
(Keys)

Depression

Anxiety, social phobia

Suicidal ideation

OCD symptoms
DEVELOPMENT AND OUTCOME

Can affect people of all ages

Typically develop in late teens to mid twenties

More prevalence among female – 10% of people with eating
disorders are men

On average, ½ of those that seek treatment for AN might
recover completely
 mortality rate is around 1 in 20 for AN

For BN, around 50% of those who receive treatment are likely
to be symptom free 10 years on
 20% will still have the full form of the disorder
 30% have chronic symptoms that do not meet the full BN
criteria or have a pattern of relapse
PREVALENCE IN THE UK GENERAL
POPULATION
Source:
McManus, S., Meltzer, H., Brugha, T., Bebbington, P., & Jenkins, R. (2007). Adult psychiatric morbidity in England, 2007 Results of a household
survey. London: The NHS information Centre for health and social care.
PREDISPOSING/RISK FACTORS

Psychological and psychiatric
Anxiety
 Depression
 Borderline personality disorder has been
implicated in development of BN but data
seem to be inconsistent.
 Certain traits such as low self-esteem and
perfectionism. There is little systematic
research evidence to support their
presence prior to the onset of disorder.


Adverse events
Stressful life events e.g. sexual abuse, bullying
PREDISPOSING/RISK FACTORS

Physical


Premorbid obesity has been documented in BN
(18% to 40%)
Diabetes Mellitus (research can not support
this view)
PREDISPOSING/RISK FACTORS

Family


Social and cultural factors


Family history of affective disorder,
alcoholism and obesity- evidence indicates
that these factors may be specific risk
factors for BN but few studies have
investigated if the rates are higher than
those among the relatives of subjects with
other psychiatric disorders.
Cultural standards regarding body shape.
Dieting
PRECIPITATING FACTORS
Developmental factors
puberty, leaving home, beginning a new
relationship-particularly with the opposite
sex
Negative events
death of a close relative, illness, and
adverse comments on appearance
MAINTAINING FACTORS
Preoccupation with body weight and
shape
 Dieting
 Avoidance
 Low self esteem, perfectionism
 Interpersonal difficulties
 Mood intolerance

MEDIA INFLUENCE
Changing face and figure of beauty:
 1950s

MEDIA INFLUENCE
Changing face and figure of beauty:
 1960s

MEDIA INFLUENCE
Changing face and figure of beauty:
 1990s – Heroin Chic

MEDIA INFLUENCE – FASHION DEATHS



Luisel Ramos, 22, died shortly after stepping off a runway during a fashion
show in Montevideo.
Her sister, Eliana Ramos, died soon after.
While no medical report was immediately released after Eliana's death,
Judge Roberto Timbal says that she died of a heart attack.
MEDIA INFLUENCE – NOT JUST WOMEN
MEDIA INFLUENCE – NOT JUST WOMEN

Jeremy Gillitzer battled anorexia and bulimia for
most of his adult life. Through a regime of
chronic starvation, self-induced vomiting and
relentless exercise, he whittled his body down
to practically nothing. When he died in 2010 at
the age of 38, he weighed 66 pounds.
MEDIA INFLUENCE – THE AIRBRUSH
MEDIA INFLUENCE – THE AIRBRUSH
THE SCOFF (BMJ 1999, BMJ 2004)
S – do you make yourself SICK because you feel
uncomfortably full?
 C – do you worry you have lost CONTROL over how
much you eat?
 O – Have you recently lost more than ONE stone in
a 3 month period?
 F – do you believe yourself to be FAT when others
say you are too thin?
 F – would you say that FOOD dominates your life?

TREATMENT OF EATING DISORDERS

Foundation of treatment
Adequate nutrition
 Stopping purging behaviours
 Reducing excessive exercise
 Individual /group therapy
 Family interventions
 Medication
 Education

TREATMENT OF AN
Aims
 Restoring the person to a healthy weight
 Treating the psychological issues related to
ED
 Reducing/eliminating behaviours or thoughts
that lead to insufficient eating – eg dietary
rules
 Relapse prevention
TREATMENT OF AN

CBT or other comparable modality eg IPT, CAT,
DBT.


No difference between modality
Medication
No evidence for SSRI for AN symptoms.
 SSRI beneficial for treatment of comorbid anxiety and
depression


Nutritional counselling
TREATMENT OF BN
Aims
 To reduce or eliminate binge eating and
compensatory behaviours
 Treating psychological issues related to ED
 Reducing or eliminating maintaining factors
 Relapse prevention
TREATMENT OF BN




Self help/guided self help programme
(30%)
CBT-BN (1:1) is the most effective.
Evidence for other modalities eg IPT, DBT
Nutritional counselling
TREATMENT OF BN

Medication
Fluoxetine or other SSRI for BN symptoms.
Fluoxetine 60mg day – higher dose is needed to
tx BN
 SSRI for comorbid symptoms
 Medication is not as acceptable or well
tolerated as psychological treatments
 BN patients have increased risk of self harm –
risk of overdose need to be considered

TREATMENT OF BED
Group or individual CBT-BED for binge
eating and comorbid symptoms
 Behavioural weight management
 Nutritional counselling
 Medication

 SSRI
for comorbid depression and anxiety
STEPPED CARE APPROACH TO EATING DISORDERS
Step 1
Mild to moderate eating problems
Primary care level – GP practice or
Primary care mental health service
Step2
Moderate to severe eating problems
Secondary level – community mental health teams, psychology services
Step 3
Severe eating problems
Tertiary level – Yorkshire Centre for Eating Disorders
WHY ARE CHILDREN DIFFERENT?

Children are still growing! BMI is more reliable for
adults and adolescents who have stopped
growing



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Serial heights and weights are more useful.
Diagnostic criteria do not readily fit children and
adolescents
Average weight gain during puberty is 14 kg for
girls and 15 kg for boys
Risk of permanent growth impairment and
osteoporosis if puberty is delayed.
EATING DISORDERS IN UNDER 18’S
40% of girls (25% of boys) begin dieting in
adolescence
 Six to 12 per cent of adolescents choose to
become vegetarian, giving them increased
independence from family eating patterns
 Third commonest chronic illness of
adolescence

BULIMIA NERVOSA
Typical onset is >16- rare in children
 Easier to conceal
 Environmental limitations- children may have
less resources to access food to binge, less
opportunity to binge-purge at school etc.

VITAL WHEN REFERRING
 Current
height and weight
 Physical investigations e.g. blood tests, ECG
 Rate of weight loss
 Current mood and behaviours
IMPORTANT WHEN REFERRING
 Skipping
meals
 Restricting meals
 Binge eating
 Self induced/spontaneous vomiting
 Laxatives
 Diuretics
 Excessive exercise
 Substance misuse
REFERRAL CRITERIA

GP refers to CAMHS community service
(3x teams – west, east and south)
 East and West have dedicated ED service, South has
staff with a special interest
 Can offer maximum of weekly appointments

If more input required, referred to CAMHS
Outreach service – Can offer daily
appointments
 If no change – referred to CAMHS inpatient unit

YCED SERVICES

Inpatient
 19
beds
 2 male beds
 Multidisciplinary team
 Programmes - Intensive Care, Recovery, Risk Reduction, Stepped-Approach,
Symptom Interruption
YCED community treatment service
 Outpatient

YCED

See hand-out for referral criteria
QUESTIONS