ࡱ> !` gbjbj\\ 4>>  \\\8 QpuD$'h uu k\""" """X fd M \(QF %hV%Pffj% 8͚:"C͚͚͚d͚͚͚Q C8M$A 8M  Eating Disorders and Alcoholism (Slide 1) Laurie McCormick, M.D. University of Iowa Carver College of Medicine, Department of Psychiatry Spring 2009 I. Introduction A. Eating disorders are common, but hard to identify (Slide 2) 1. Prevalence of all eating disorders are !; ~5% of US population 1,2 a. 3% US @& & ~ 1% B&have an eating disorder (anorexia or bulimia nervosa) b. Binge eating occurs equally in B& & @& ~ 5% 3 2. 80% of US @& are dissatisfied w/ body  50% of these are of normal weight 4 3. 45% @& & 25% B& & are on a diet on any given day in US 4. 35% of  normal dieters in US ! pathological dieting; ~ 25% of those ! to EDs 5 (Slide 3) 5. In the EAT-II longitudinal study of ~ 5,000 Junior/Senior HS students 6 a. ~ 65% of teenage @&; 35% of teenage B& used unhealthy weight control measures (e.g. skip meals/food substitutes/fast/smoke) b. ~20% of teenage @&; 10% of teenage B& used very unhealthy weight control measures (e.g. vomit/diet pills/laxatives/diuretics) 6. Shame/secretiveness prevents identification 7,8 B. Alcohol use disorders (AUDs) are also common (Slide 4) 1. U.S. adults: a. ~90% lifetime alcohol use 9 b. ~50% used alcohol in past year c. 60% of HS seniors have already been drunk 2.  Hazardous drinkers ! (>5 drinks/day) ~ 25% past year 10,11 a. Not abuse or dependence b. B& e" 5 drinks/day or e" 15 drinks/wk c. @& e" 4 drinks/day & e" 8 drinks/wk d. Risk for alcohol-related problems (!blood pressure, cancer risk) 3. Alcohol abuse prevalence 12 a. 18% lifetime: B& > @& (~2:1) b. 5% 12-month prevalence c. <10% will progress to dependence 4. Alcohol dependence prevalence 12 a. 13% lifetime: B& > @& (~2:1) b. 4% 12-month prevalence c. 50% will develop clinically relevant symptoms of withdrawal (e.g. hand tremor/hallucinations/nausea/vomiting/seizures/insomnia) d. Only seek treatment C. Mortality & Morbidity of EDs & AUDs (Slide 5) 1. EDs - ! mortality rate of any psychiatric ds a. 18X ! in mortality rate, ! lifespan by a decade 13 b. 12% will die (> from suicide) 14 2. ED  all bodily systems begin to shut down (osteoporosis, amenorrhea, muscle wasting) 3. AUDs - ! 3-4X early death 15 a. Health related (e.g. stroke, cancer, heart ds), !risk for @& w/ mild-moderate drinking b. Accidents c. Suicide *This lecture reviews (Slide 6) 1. Definitions of EDs & AUDs 2. Relationships between EDs & AUDs 3. Screening & identification of EDs & AUDs 4. Assessment & management of EDs & AUDs II. Definitions of EDs & AUDs A. What are EDs? Youtube video from eating disorder awareness week (Slide 7) 1.DSM-IV definition of AN(WAFE mnemonic) (Slide 8) a. Weight Refusal to maintain weight at 85% of expected b. Amenorrhea (only in @& of child-bearing age) c. Fear of gaining weight d. Self-Evaluation is influenced by weight/shape e. Sub-types: i. Restricting  (e.g. ! intake, skipping meals) ii. Binge-eating/purging  (e.g. ! food intake w/ compensatory restricting, vomiting, &/or laxative use) iii. 50% of AN cross-over from restricting to binge-purge type (over 7 years) 2. DSM-IV definition of BN (BICEN mnemonic) (slide 9) a. Binge eating episodes recurrent b. Inappropriate compensatory behavior recurrent c. Compensatory behavior 2X/week for 3 months d. Self-Evaluation due to body weight/shape e. Not occurring exclusively during AN f. Sub-types: i. Purging (e.g. vomiting, laxatives, diuretics) ii. Non-purging (restricting food intake, over exercising) g. Cross-over rates 16,17 i. 50% of BN overweight from overeating rarely crosses over to AN ii. 30% of AN cross over to BN 3. Eating disorder Not Otherwise Specified (ED-NOS) (slide 10) a. AN or BN with partial criteria i. AN w/o amenorrhea or at normal body weight ii. BN with compensatory behavior (e.g. running, purging) < 2X week iii. Purging disorder without binges 18 or chewing food & then spitting out b. Partial criteria AN and BN have @&:B& ratio of 2:1 19 c. Binge eating disorder (BED) 20 i. Recurrent episodes of binge eating (i.e. eating a lot in < 2 hrs) ii. A sense of lacking control over eating iii. Binges are associated with 3 or > of the following - Eating much more rapidly than normal - Eating until feeling uncomfortably full - Eating a large amount of food when not feeling physically hungry - Eating alone/embarrassed by how much one is eating - Feeling disgusted with self, depressed or very guilty after overeating iv. Marked distress regarding binges v. Binge eating occurs e" 2X/week x 6 mo s vi. Binges  not w/ compensatory behaviors (fasting/purging/exercise) vii. Does not occur during the course of AN or BN 4.Alcohol abuse/definitions (slide 11) a.DSM-IV alcohol abuse i. Repeated problems in same 12 months w/ e" 1 of: ii. Inability to fulfill role obligations iii. Use in physically hazardous situations iv. Legal problems v. Social or interpersonal problems vi. Never met criteria for dependence b.DSM-IV alcohol dependence i. Repeated problems over same 12 months w/ e" 3 of: ii. Tolerance: ! use for same effect; ! effect with same amount used iii. Withdrawal syndrome or ! alc use to ! anxiety/ insomnia/tremors iv. Use larger/longer than intended v. Desire or unsuccessful efforts to cut down vi. ! time spent in alcohol-related activities vii. Give up important activities viii. Continued use despite persistent problems *This lecture reviews (Slide 12) 1. Definitions of EDs & AUDs 2. Relationships between EDs & AUDs 3. Screening & identification of EDs & AUDs 4. Assessment & management of EDs & AUDs III. Relationships of ED & AUD A. EDs & AUDs can co-occur (slide 13) 1. A meta-analysis 41 studies of @& (1985-2006) = ! risk of AUD w/ BN, but not AUD & AN 21 a. Only 4 studies showed a negative association b. Disordered eating behaviors may be more strongly associated w/ alcohol related problems rather than use 22 c. Cross over from BN to AUD or vice-versa may ! occur over time 23 i. 1/2  ED occurs before AUD ii. 1/3  AUD occurs before ED iii. 10% had onset of both AUD & ED  same year 2. Comorbidy increases severity? a. No, but AUD severity, not BN severity  predict poorer outcome 23 b. AUD severity in AN ! !! risk of death 14 c. Screen for AUDs in AN! B. ED + AUD Comorbidity (slide14) 1. Anxiety disorders = ! risk factor for developing an ED &/or AUD a. 2/3 of EDs have anxiety ds  before onset of ED 24 b. Anxiety also almost always precedes onset of AUD not after 25 2. Some similar psychological characteristics in women with BN & AUD a. ( novelty seeking (thrill seeking/pleasure new experiences) predispose to BN & AUD 26,27 b. ( novelty seeking & ( affect from rewards in BN + AUD, compared to BN w/o AUD 26 b. Novelty seeking mediates risk of AUD in alcohol dependent families 27 3. Binge eating in ED & heavy drinking in AUD - similar psychological functions 28,29 a. Women with AUD & ED binge for emotional relief or reward 28 i. Heavy drinking  related to needing ( reward +/- ! intense emotions 29 ii. Binge eating  ! intense emotions +/- ! urge/temptations to drink C. Sociocultural explanations for EDs (slide 15) 1. Example: dual-pathway model of overeating in BN 30,31 a. Pressure to be thin & thin-ideal internalization can lead to body dissatisfaction b. Body dissatisfaction leads to dieting & negative affect, which leads to bulimic sxs & over-exercising c. Neuroticism predispositions further drive body dissatisfaction & visa-versa as well as negative affect, which then drives depression and low self-esteem D. Common mechanisms: food & alcohol = reward & motivation (slide 16) 1. Similar dopamine/opiates dysregulation of reward motivation/pleasure in ED & AUD? 32,33 2. Dopamine release in brain s mesolimbic system  regulates reward from food/drugs/alcohol 34 a. Wobbly D2 dopamine receptor (DRD2)  A1 allele - !DA binding w/ alc in AUDs 35,36 b. Example: Wobbly DRD2 A1 allele - !DA binding w/ food in BED/BN/obesity 37,38 3. Opioid dysregulation affects food & alcohol intake in ED & AUD 39,22 a. Low/moderate alcohol ( beta-endorphin in mesolimbic system 39 b. Strong opiate receptor mu (G allele of A118G) ( opiate binding w/ food in BED 40 c. Opioid receptor kappa 1 (OPRK1) long allele ( opiate binding w/ alcohol in AUD 41 d. Opiate antagonists may help interrupt reinforcing effects of food 42 & alcohol 43 E. Genetic & environmental risk factors (slide 17) 1. Genetics explain 50% of AUD & 70% of ED risks 43,44 a. Primarily based on twin studies, adoption and family studies b. Multiple genes contribute to ( & ! risks (e.g. asthma & DM polygenetic + environmental risks) 2. Sociocultural factors contributing to EDs 45 (Slide 19) a.  Thin ideal +  pressures to be thin ! body disatisfaciton ! dietary restraint + negative affect ! exercise and/or binge/purge cycles b. Neuroticism & low self-esteem may be major mediators *This lecture reviews (Slide 18) 1. Definitions of EDs & AUDs 2. Relationships between EDs & AUDs 3. Screening & identification of EDs & AUDs 4. Assessment & management of EDs & AUDs IV. How to screen & identify patients A. Inquire about disordered eating, self-evaluation based on weight 1. Patient Health Questionnaire (PHQ) modified PRIME-MD 46 (slide 19) a. Patient administered with 15 sections for various psychiatric disorders i. Sections 6,7, 8 have 9 questions (yes/no) to abnormal eating patterns ii. Do you often feel you cant control what/how much you eat? iii. Do you ever vomit? iv. Sections 9,10 have 7 questions (yes/no) to detect alcohol related problems v. Do you drink alcohol? Did your doctor of suggest you should stop? b. Overall accuracy 85%; sensitivity to detect 75%; specificity for the illness 90% 2. Eating Disorder Examination Questionnaire (EDE-Q) - abnormal eat & wt concerns (slide 20) a. Patient administered 28 items (6-point scale) i. Have you tried to limit the food you eat to influence your shape/weight? ii. In the past month, have many times did you feel lost control over eating? b. Sensitivity 80%, specificity 80% 47 B. Inquire about hazardous drinking & alcohol-related problems 1. Alcohol Use Disorders Identification Test (AUDIT) (slide 21) a.10-item questionnaire (5-point scale) reviewing drinking patterns & problems 48 b.Score of > 8 = positive test for hazardous drinking / ! risk of alcohol dx c.Sensitivity to detect: 50-90%;specificity for disease: 80% 2. AUDIT-C (3-question version of the full 10-item AUDIT) a. First 3 questions of the AUDIT  provides a faster screening for AUD 49 i. How often do you have a drink of alcohol? ii. How many drinks of alcohol drinks on one occasion? iii. Do you ever have 6 or more on a given day? b.Positive score for identifying hazardous drinking ! B& > 4; Women > 3 c.Nearly as sensitive/specific as full AUDIT C. ED complaints & findings (slide 22) 1. Abnormalities found in ED a. Complaints: i. Constipation (irritable bowel syndrome), ii. Gastroesophageal reflux disease, iii. Dental cavities, iv. Menstrual irregularity b. Physical findings: i. Emaciated appearance if anorexic ii. Dental erosions if bulimic, iii. Enlarged salivary/parotid glands if bulimic c. Laboratory findings: (Slide 23) i. ! amylase (>123 u/L), ii. ! alanine & aspartate aminotransferance (ALT = >67u/L / AST = >65u/L), iii. ! potassium (hypokalemia = <3.5mEq/L), iv. ! white blood count (<4.3 x 103mm3), v. ! bone density (osteopenia = < 1.5-2.0 SD /osteoporosis = < 2.0SD) *This lecture reviews (Slide 24) 1. Definitions of EDs & AUDs 2. Relationships between EDs & AUDs 3. Screening & identification of EDs & AUDs 4. Assessment & management of EDs & AUDs V. Management of patients with eating disorders & alcoholism (slide 25) A. Comorbidity of these disorders occur so which disorder to treat first & what setting? 1. Inpatient hospitalization for ED - severe malnutrition; cannot normalize food intake a. Specialized units - nutritional rehabilitation/regular meals/abstinence from binge/purge b. Psychotropic interventions & treat psychiatric & medical comorbidities c. Psychotherapeutic approaches d. More details later about approaches for each disorder 2. Inpatient hospitalization for AUD 1st if risk for serious withdrawal symptoms a. Nutritional rehabilitation/alcohol withdrawal with benzodiazepines b. Referrals made for outpatient treatment 3. Partial hospitalization programs a. Both AUD & ED treatment  separate programs, lasting 2-4 wks on average b. Day programs for ED treatment for AN & BN i. 40% remission at 1-yr follow-up (f/u) 50 ii. ! BN symptoms after inpatient vs. day treatment, same result @ 3mo f/u 51 c. Day programs for AUD  may ! abstinence & more cost-effective 52 i. Day treatment vs. outpatient 62% vs. 39% for self-selected group ii. Mid-level severity/self-selected had ! abstinence & was more cost-effective iii. 20-30% of highly motivated people with AUD can attain remission w/o tx 53,54 4. Long-term outpatient programs a. Long-term psychotherapy for ED may be indicated - multiple relapses are common 55 b. Long-term alcoholic anonymous (AA) group therapy - ! outcome 56 c. Outcome is good for both disorders i. 50% complete, 70% partial remission for EDs - 1 yr after tx 57 ii. 50-60% abstain or improve functioning for AUD - 1 yr after tx 58 iii. No simple way to match different treatments for specific patients B. Initial interventions (slide 26) 1. Directive brief interventions may ! compliance & improve outcome 59-61 a. Explain risks for developing an AUD or ED b. Educate about dangers of continued heavy drinking and/or unhealthy eating or weight control methods c. Provide examples of benefits of change 2. Brief motivational interviewing may ! compliance & is also cost-effective 62-65 a. Feed back on risks b. Responsibility for change c. Advice d. Menu of treatment options e. Empathetic interaction f. Self-efficacy enhancement C. Psychotropic medication interventions for ED & AUD Limited efficacy of psychotropic medications for ED 66 (slide 27) a. 3 randomized controlled trials (RCTs) of fluoxetine (Prozac) at 60mg qD 67 i. Blocks serotonin reuptake ii. 50% ! binge frequency in BN in the short-term (8-16 wks) iii. No long-term difference in remission rates (1 yr or longer) iv. Side-effects include emotional blunting, possible agitation, insomnia b. 2 RCTs of fluoxetine 60mg qD w/ or w/o cognitive behavioral therapy (CBT) 68,69 i. Remission @16wks = 12% w/ CBT vs 20% CBT + med or placebo 68 ii. Remission @16wks = 25% w/ CBT + med vs 15% w/ med only 69 c. Fluoxetine no better than placebo for BED 70 d. RCT of Toparimate (Topamax) 25-400mg qD: i. ! binge episodes from 5 to 3 /day  for both BN & BED 71 ii. Weight loss of ~ 5 pounds over 10 weeks, compared to 0 for placebo 2. Limited efficacy of psychotropic medications for AUD (slide 28) a. FDA treatments: disulfiram (Antabuse), naltrexone (Revia), acamprosate (Campral) 72 i. Most evidence of efficacy for naltrexone 50-100mg qD: - Blocks opiate receptors - 25% ! rate of heavy drinking 73 - Response may be better for those with a family history of AUD 74 - Safest side-effect profile (drowsiness/drug interactions/liver fxn) ii. Acamprosate  ! time to relapse (36% abstinent vs 23% placebo @ 6mo) 75 - Blocks glutamate/GABA - Can cause GI upset & diarrhea iii. Combined naltrexone 50mg qD & acamprosate 666mg TID - synergistic 76 iv. Disulfiram 250mg qd  ! abstinence & ! relapse in 12 wk trial 77 - Causes an aversive response if alcohol is consumed during its use - Limited evidence of efficacy - Potentially dangerous side effects: liver disease, depression, psychosis b. Non-FDA treatment: Topiramate (Topamax) 300mg/d ! > 50%! heavy drinking dys 78 i. Blocks glutamate transmission ii. ! abstinence from 35 to 60 days iii. ! daily drinks from 6 to 4 iv. ! measures of liver problems (!GGT by >50%) c. Naltrexone, acamprosate & topiramate  ! alcohol intake if abstinence isn t possible 3. Possible overlapping efficacy for EDs & AUDs (slide 29) a. No good evidence for naltrexone for EDs b. An open label trial of acamprosate for BED & alcohol dependence  4wks 79 i. ! cravings for food in AUD ii. No weight gain c. RCTs of Topiramate for BED & AUDs 80 i. ! heavy drinking days by 50% in AUD ii. ! weight in BED by 7lbs in 21 wks iii ! binge episodes a week from 3.5 to 2.5 & ! weight by 5kg in 16 wks 81 D. Psychotherapeutic interventions for EDs & AUDs (slide 30) 1. Efficacy of psychotherapeutic approaches in ED a. Most evidence for family therapy in adolescents 82 i. Corrects dysfunctional/enmeshed boundaries between parents & children ii. Therapist supports adolescent indivuation & ! guilt/criticism from parents b. Efficacy of cognitive behavioral therapy (CBT) for BN & BED 83 i. CBT = systematic approach to !dysfunctional thoughts/behavior ii. Guided self-hdlp or group options iii. 60% abstinent & ! purging by 80% vs treatment as usual - 16 wks 84 2. Efficacy of psychotherapeutic approaches in AUD a. A variety of psychosocial & psychotherapeutic approaches may ! outcome 85 b. Alcoholics anonymous (AA) support groups may ! time to relapse 86 i.  12 step approach examples: - One cannot control addiction - Recognize a greater power can give strength - Turn life over to that power - Make a list of those harmed & make amends with them ii. AA should be used in conjunction with psychotherapeutic approaches VI. Summary (slide 31) A. Definitions of ED & AUD are important to know, can occur together & are common B. Significant relationships between ED & AUD - points to overlapping etiology & possible tx C. Screening & identification are important under recognized & under treated D. 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h^h`gd/кѺҺ#$NPRwx123ɱɜxɜ[Cɜ*1hhB*CJOJQJ^JaJmHphsH/h.Dh/B*CJOJQJ^JaJphwh)8j?h.Dh/B*CJOJQJU^JaJph#h/B*CJOJQJ^JaJph#hB*CJOJQJ^JaJph)h.Dh/B*CJOJQJ^JaJph/h.Dh/B*CJOJQJ^JaJphwh=2jh.Dh/B*CJOJQJU^JaJph8j=h.Dh/B*CJOJQJU^JaJphCEGȾbi&(*MN̗̂p^Gp^Gp^p^̂-h.Dh/0JB*CJOJQJ^JaJph#h/B*CJOJQJ^JaJph#hB*CJOJQJ^JaJph)h.Dh/B*CJOJQJ^JaJph/h.Dh/B*CJOJQJ^JaJphwh=8j^Ah.Dh/B*CJOJQJU^JaJph2jh.Dh/B*CJOJQJU^JaJph1hh/B*CJOJQJ^JaJmHphsHbcdmGHIdefudɴɴyɴ\ɴɴyɴ8jDh.Dh/B*CJOJQJU^JaJph#h/B*CJOJQJ^JaJph#hB*CJOJQJ^JaJph-h.Dh/0JB*CJOJQJ^JaJph)h.Dh/B*CJOJQJ^JaJph2jh.Dh/B*CJOJQJU^JaJph8jCh.Dh/B*CJOJQJU^JaJphdefDE^_`oeɴɴywɴZɴɴyɴ8jGh.Dh/B*CJOJQJU^JaJphU#h/B*CJOJQJ^JaJph#hB*CJOJQJ^JaJph-h.Dh/0JB*CJOJQJ^JaJph)h.Dh/B*CJOJQJ^JaJph2jh.Dh/B*CJOJQJU^JaJph8jMFh.Dh/B*CJOJQJU^JaJphor TF, Higgins-Biddle JC, Dauser D, Burleson JA, Zarkin GA, Bray J.  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