Eating Disorders - Johns Hopkins Hospital Presentation PDF

Allisyn Pletch, RN, MSN, PMHCNS-BC Clinical Nurse Specialist Johns Hopkins Hospital Eating Disorders Program 9/25/23 Throughout this talk, I will be showing some pictures and talking about some issues and behaviors topics that may be difficult for some in the audience. Please be sure to care for y...

Allisyn Pletch, RN, MSN, PMHCNS-BC Clinical Nurse Specialist Johns Hopkins Hospital Eating Disorders Program 9/25/23 Throughout this talk, I will be showing some pictures and talking about some issues and behaviors topics that may be difficult for some in the audience. Please be sure to care for yourself. For continuity, I will be primarily using she/her pronouns when talking about individuals with eating disorders except when discussing specific patient stories. 9/25/23 Outline • Review key points of diagnostic criteria of Anorexia Nervosa, Bulimia Nervosa, OSFED, and ARFID • Review physical, psychiatric, and psychosocial comorbidities and consequences of eating disorders. • Discuss maladaptive behaviors and nursing interventions. • Outline goals of treatment and preferred modalities of treatment. 9/25/23 Eating Disorders • Anorexia Nervosa • Bulimia Nervosa • ARFID (Avoidant/Restrictive Food Intake Disorder) • OSFED (other specified feeding or eating disorder – previously EDNOS) • BED - Binge Eating Disorder 9/25/23 Cardinal features of eating disorders Cognitive disturbance Overvalued idea = “morbid fear of fatness” Disordered Behaviors Disturbance in eating habits = restricting, binge eating, vomiting, laxative, diuretic or diet pill abuse, excessive exercise Anorexia Nervosa • Key points in diagnosis: • Intake inadequate for body requirements • Fear of gaining weight OR persistent behavior to avoid gaining weight • Disturbance in how body is experienced – overvaluation of body weight/shape. • APA (2013) 9/25/23 SPECIFY SUBTYPE • RESTRICTING • Weight loss is achieved and maintained primarily through caloric restriction and/or exercise • No episodes of bingeing • BINGE/PURGE • During last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviors. • **weight separates this from Bulimia** or purging • APA (2013) 9/25/23 Not a new disease Sir William Gull • “Every step had to be fought. She was most loquacious and obstinate, anxious to overdo herself bodily and mentally” (Sir William Gull, 1873) • In 1874 anorexia nervosa was introduced as a clinical diagnosis by two different physicians, Sir Richard Morton • Sir Richard Morton (1694)first English language description in Treatise of Consumptions. Described an 18 year old girl “Mr. Duke’s Daughter of St. Mary Axe” as “…like a skeleton clad only in skin” with “total suppression of monthly courses and coldness of body”. “…from which time her appetite began to abate and her digestion to be bad, her flesh also began to be flaccid and loose”. (Morton, 1694) Charles Lasègue of France. 9/25/23 Bulimia Nervosa • KEY POINTS • Binge eating • compensatory behaviors in order to prevent weight gain • Self evaluation is overly influenced by body shape and weight. • Binge eating and compensatory behaviors occur, on average, once a week for 3 months • These behaviors do not occur during episodes of Anorexia Nervosa (APA- 2013) 9/25/23 What is a binge?? Eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances a sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating) Often done in secret and terminated only by abdominal pain, physical exhaustion, lack of other binge food, social interruption or compensatory behavior Followed by intense feelings of shame, guilt, and self hatred. Types of food eaten vary according to ritual, accessibility, and ease of vomiting Actual caloric count varies from 100-10,000 calories. (APA, 2013; Keel 2017) 9/25/23 Oral Effects of Bulimia (webmd.com, 2009) Parotid enlargement Russell’s sign 9/25/23 Avoidant or Restrictive Food Intake Disorder (ARFID) • KEY POINTS • Persistent pattern of characterized by: • • • • Fears about negative consequences of eating (e.g., vomiting, choking, perceived allergic reaction). LIMITED FOOD INTAKE related to types of food or overall quantity The pattern of disordered eating is also accompanied by at least one of the following: • • • • • • Lack of interest in food or poor appetite. Significant weight loss or failure to gain weight/grow as expected. Nutritional deficiency (e.g., anemia). Dependence on nutritional supplements or tube feeding. Impairment in psychosocial functioning. not due to cultural practice or lack of available resources does not occur during a course of Anorexia or Bulimia and is not attributable to other medical condition. • No significant body image distortion or fear of weight gain APA (2013) 9/25/23 How to identify ARFID: The 3 “types” THE PICKY EATER • Limited Range of preferred foods – • • • • • becomes narrower over time. Avoids whole food groups Food preferences based on brand, temperature, color, texture and taste REFUSAL to try new foods May gag in response to eating/trying non preferred foods Persists longer than 2 years and unresolved by late childhood FOOD FEARS • Avoids specific foods or food groups • Fearful something BAD will happen after eating avoided foods • Stomach pain/ nausea • • Vomiting • Choking • Allergic reaction Eating habits changed AFTER traumatic event/incident • Frequent complaints of headaches, stomachaches, nausea • Weight loss • 239932609 tternock Poor Appetite • Denies feeling hunger • Early satiety • Comfortable and routinely skips meals/ goes long periods of time without eating No “drive” to eat Not excited or interested in food Hides/throws away food May complain of stomach pain, nausea, etc May lack insight into poor eating habits • • • • • Other specified feeding or eating disorders (OSFED) • DSM-4 known as EDNOS • Person exhibits the symptoms of Anorexia Nervosa, Bulimia Nervosa or Binge Eating Disorder but will not meet the full criteria for diagnosis of these • includes atypical anorexia nervosa (anorexia without the low weight), • bulimia or BED with lower frequency of behaviors or limited duration • purging disorder • night eating syndrome. • APA (2013) 9/25/23 Binge Eating Disorder • • • • Characterized by repeated episodes of binge eating Binges occur, on average, 1x per week for 3 months NO compensatory behaviors occur Binges are associated with • Eating more rapidly than normal • Eating until feeling uncomfortably full • Eating large amounts when not physically hungry • Eating in secret d/t embarrassment over how much or what one is eating • Feelings of guilt, disgust or shame following eating 9/25/23 Eating disorders: the numbers • Eating disorders affects people of every age, race, gender, gender identity, sexual orientation, SES, and religion. These factors can, in fact, sometimes be a barrier to recognition and care. • Approximately 30 million Americans (and 70 million individuals globally) live with an eating disorder. (National Association of Anorexia Nervosa and Associated Disorders) • 0.9% women and 0.3% men AN • 1.5% women and 0.5% men BN • 3.5% women and 2% men BED • Global eating disorder prevalence increased from 3.4% to 7.8% between 2000 and 2018. (The American Journal of Clinical Nutrition, 2019) • Over 10,000 deaths each year are the direct result of eating disorders (Edcare 2023) 9/25/23 Eating Disorders in Men • Estimated to be up to 20% of individuals with eating disorders. • Diagnostic criteria, etiology and treatment is similar between men and women there are different risk factors, clinical presentations, comorbidity and consequences. • Men > women have been obese prior to onset • Men > women start dieting/behaviors as result of teasing rather than social comparison • Men > women may want to develop a more muscular physique rather than thin ideal 9/25/23 Functional issues resulting from eating disorders • Interpersonal conflict and isolation • Occupational and educational limitations • Stunting or delay of social development and performance. 9/25/23 Eating Disorders and other Psychiatric Illnesses • Affective disorders (especially depression) occurs in 50-80% of patients with both Anorexia and Bulimia Nervosa. • Anxiety disorders (especially OCD and social phobias) occur in 30-65% of patients with both Anorexia and Bulimia Nervosa. • Personality disorders occurs in 20-50% of patients with both disorders. Substance Use Disorder and Eating Disorders • Up to 50% of individuals with ED misuse alcohol or illicit drugs as compared to 9% in general population. • Up to 35% of individuals who misuse alcohol or illicit drugs have an ED as compared to 3% in general population. Most commonly misused substances are alcohol, marijuana, nicotine, caffeine, amphetamines, heroin and cocaine. • Substance Use Disorder occurs in 12-21% of patients with Anorexia and in up to 55% of patients with Bulimia. Contributing Factors Genetic Predisposition/ Personality - • • • Leanness (AN) • • Novelty seeking (BN) • • Impulsivity (BN) Perfectionism (AN) Neuroticism (AN) Conflict avoidant (AN) Emotional Instability (BN) Life Stressors, Illness Puberty • • 1st degree relatives are 11x more likely to develop AN; and 5-9x in BN; Heritability in twin studies : AN and BN 28-58% DIETING Individual genetic vulnerability helps to explain, despite the pervasiveness of dieting less than 3% develop AN/BN 9/25/23 genetics loads the gun and environment and society pull the trigger” (Bulik, 2008 ) …… 6/2018 Maladaptive Behaviors • Restricting • Bingeing • Purging • Excessive Exercise 9/25/23 Restricting 9/25/23 Bingeing 9/25/23 Purging .,.,......... ...-.. .. , =~· ···-- 9/25/23 Excessive Exercise 9/25/23 Body image disturbance 9/25/23 Treatment Principles Ego Syntonic behaviors, feelings and values that are in harmony with one’s own self image Behavior Ego Dystonic-behaviors, feelings and values that are in conflict with one’s own self image Ambivalence Thoughts Feelings 9/25/23 Levels of Care Outpatient IOP Partial Hospitalization(PHP) Residential Inpatient Hospitalization 9/25/23 Treatment Modalities • Cognitive Behavioral Therapy (CBT) • Dialectical Behavioral Therapy (DBT) has been shown to have benefit in treating Anorexia, Bulimia and BED (Black & Andreasen, 2014) • Identifies and challenges irrational thinking patterns and emotional dysregulation which is associated with unhealthy behaviors. • Family Based Treatment (FBT) or Maudsley Approach – 9/25/23 Medical Interventions – Pharmacologic and other • Re-feeding is the biggest risk during treatment of anorexia. • Continuous Dextrose infusion; post prandial finger sticks, daily CMP, mag and phos • Constipation • Calcium channel agents, psyllium, polyethylene glycol • Hypoglycemia • Orthostasis/tachycardia • IV fluids, salt tablets • Gastric bypass/diabetic protocols How can nurses help to stop Maladaptive Behaviors • • • • • • Identify behaviors in non judgmental way Reinforce structure and consistency Prevent patients from engaging in behaviors Identifying the trigger for behavior. Identifying adaptive coping strategies. Exposure and response prevention. • Reviewing emotions and feelings that arise from NOT engaging in behaviors. • Reviewing emotions and feeling that arise from WHEN they engage in behaviors. 9/25/23 What do I ask??? • Can you tell me what you ate in the last 24 hours? • How often do you weigh yourself? Have you lost/gained weight in • • • • last month? Have you ever made yourself vomit when you were full? Have you ever used laxatives, diuretics, diet pills, or other weight loss supplements? How often do you exercise? What is a usual routine? Have you ever eaten more than usual? When was that and what was happening? How often do you think about food, weight and shape? 9/25/23 Key Points to remember…… • The behavior becomes driven and conditioned • The problem is in what the patient “does” • Dieting becomes a consuming passion to the exclusion of other activities. • The behaviors becomes rewarding and self-sustaining and fuel fear of fatness. • The more weight the patient loses, the “fatter” he/she feels. • Anorexia has highest mortality rate of all psychiatric disorders – this is due to medical complications and suicide 9/25/23 References • • Keel, PK (2017) Eating Disorder and Obesity (3rd edition). New York; Guilford Press • Bankoff SM, Richards LK, Bartlett B, Wolf EJ, Mitchell KS. Examining weight and eating behavior by sexual orientation in a sample of male veterans. Compr Psychiatry. 2016;68:134–9. https://doi.org/10.1016/j.comppsych.2016.03.007. • Bell K, Rieger E, Hirsch JK. Eating disorder symptoms and proneness in gay men, lesbian women, and transgender and gender non-conforming adults: comparative levels and a proposed mediational model. Front Psychol. 2019;9(2692). https://doi.org/10.3389/fpsyg.2018.02692. • Fast facts on eating disorders: (2016) retrieved from : www. https://www.aedweb.org/index.php/education/eating-disorder-information/eatingdisorder-information-14#12 • Bulik, CM; Kleinman, SC & Yilmaz, Z (2016) 29 (6) 383-386 Current Opinion in Psychiatry Genetic epidemiology of eating disorders • Parker, L.L., Harriger, J.A. Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature. J Eat Disord 8, 51 (2020). https://doi.org/10.1186/s40337-020-00327-y • Thornton, LM; Mazzeo, SM & Bulik, CM (2011) Current topics in Behavioral Neuroscience (6) 141-156. The Heritability of Eating Disorders: Methods and Current Findings • • Attia, E (2017) Eating Disorder and Obesity (3rd edition). New York; Guilford Press • LaGrange, D (2015). Treatment Manual for Anorexia Nervosa American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Washington, DC : American Psychiatric Publishing. Fairburn, CG (2008) Cognitive Behavior Therapy and eating Disorders. New York; Guilford Press Second Edition: A Family-Based Approach: New York: Guilford Press 9/25/23 Questions? Comments? • [email protected] 9/25/23