1. Eating Disorders & Alcoholism Laurie McCormick, MD Assistant Professor, Psychiatry University of Iowa © AMSP

2. 2/31 Eating Disorders - Common but Difficult to Identify 5% of US population has an ED ~ 1% AN ♀>> ♂ ~ 3% BN ♀>♂ ~ 1% BED ♀=♂ 80% of US ♀ - dissatisfied with body 50% ♀ / 25% ♂ - on a diet any given day © AMSP

3. 3/31 Disordered Eating Continuum 1/3 of dieters → pathological dieting; 1/4 of pathological dieters → EDs 2/3 ♀ + 1/3 ♂ teens - unhealthy wt control 1/5 ♀ + 1/10 ♂ – very unhealthy wt control Shame/secretiveness ≠ identification © AMSP

4. 4/31 Alcohol Use Disorders Are Common © AMSP %/yr (Lifetime) Hazardous25 Abuse 5 (15) Dependence 5 (10)

5. 5/31 Mortality/Morbidity of EDs & AUDs © AMSP EDs - ↑ mortality rate of all psychiatric ds AN - most deadly psychiatric illness BN - electrolyte disturbance AUDs - 3-4X ↑ in early death Health related (stroke, cancer, heart ds) Accidents Suicide

6. 6/31 This Lecture Reviews Definitions Relationships Screening & identification Treatment & management © AMSP

7. What are Eating Disorders? © AMSP 7/31 http://www.youtube.com/watch?v=QSqtVDIwnHo

8. 8/31 Anorexia Nervosa (AN) Weight - refusal to keep weight ~ 85% expected Amenorrhea Fear of gaining weight Evaluation of self - influenced by weight/shape * 30% cross over to BN over time © AMSP

9. 9/31 Bulimia Nervosa (BN) Binge eating – recurrently Inappropriate compensation Compensation - 2X/wk x 3 mo’s Evaluation of self - influenced by body image Not occurring during AN * Rarely cross-over to AN © AMSP

10. 10/31 Eating Disorder – NOS (ED-NOS) Sub-threshold AN or BN Binge eating disorder (BED) Eating large amounts of food in <2hrs Distress from lack of control while eating Eating when not hungry Guilt from overeating No compensatory behaviors Occurs ≥ 2X/wk x 3 mo’s © AMSP

11. 11/31 Alcohol Abuse / Dependence © AMSP Dependence 12-months of  3: - Tolerance - Withdrawal -  use - ↓ ability to quit -  time using alcohol - ↓ social activities - Continued use Abuse 12-months of  1: - ↓ obligations - Hazardous situations - Legal problems - Interpersonal problems - Not alcohol dependence

12. 12/31 This Lecture Reviews Definitions √ Relationships Screening & identification Treatment & management © AMSP

13. 13/31 Can EDs + AUDs Co-Occur? 2X ↑ risk of AUD w/ BN, not AN (only in ♀) Alcohol related problems > alcohol use ♀ BN & risk of AUD 50% - ED before AUD 40% - AUD before ED 10% onset of AUD & ED at the same time © AMSP

14. 14/31 ED + AUD Comorbidity Anxiety → ↑ risk AUDs & EDs ↑ risk of BN + AUD in ♀= impulsivity, novelty seeking, immature defenses Comorbid AUD + ED = worse outcome? Only in AN © AMSP

15. Sociocultural Model for EDs Pressure to be thin Thin-ideal internalization Body dissatisfaction Dieting (restraint) Negative affect Exercise Binge/purge Low self-esteem Neuroticism © AMSP 15/31 Depression

16. 16/31 Food Addiction = Motivation & Reward © AMSP ↓ Dopamine - DRD2 A1 allele ↑ Opiate - Mu G allele - Kappa 1 long allele Ventral

17. 17/31 Genetic & Environmental Risk Factors Genetic +/- Environment +/- © AMSP

18. 18/31 This Lecture Reviews Definitions √ Relationships √ Screening & identification Treatment & management © AMSP

19. 19/31 Patient Health Questionnaire (PHQ) 16 sets of questions Sections 6-8: (9 questions) - ED Sections 9-10: (7 questions) - AUD “Feel you can’t control what or how much you eat?” “Do you ever vomit?” Overall accuracy - 85% Sensitivity to detect - 75% Specificity for the illness - 90% © AMSP

20. 20/31 Eating Disorder Examination (EDE-Q) 28 item questionnaire (6-pt scale) “Trying to limit food to influence shape/weight?” “In the past month, lose control over eating?” Sensitivity - 80% Specificity - 80% © AMSP

21. 21/31 AUDIT – Alcoholism Screening 10-item questionnaire (5-pt scale) 1. How often do you have a drink of alcohol? 2. How many drinks of alcohol in one occasion? 3. Do you ever have 6 or more on a given day? Score of > 8/50 = hazardous drinking Sensitivity to detect: ~ 80% Specificity for disease: 80% © AMSP

22. 22/31 ED Complaints & Findings Physical findings: Emaciated appearance Enlarged salivary/parotid glands Complaints: Constipation Gastroesophageal reflux disease Dental caries/broken teeth Menstrual irregularity © AMSP

23. 23/31 Laboratory Findings - EDs ↓ potassium ↑ amylase ↑ ALT/AST ↓ white blood count ↓ bone density © AMSP

24. 24/31 This Lecture Reviews Definitions √ Relationships √ Screening & identification √ Treatment & management © AMSP

25. 25/31 Stages of Treatment © AMSP Identification Intervention - brief intervention - motivational interviewing Inpatient - detoxification - weight stabilization - break binge/purge cycle Day treatment/outpatient - rehabilitation - psychopharmacology - cognitive behavioral tx Outpatient - relapse prevention

26. 26/31 Initial Intervention Directive brief interventions Motivational interviewing Feed back on risks Responsibility for change Advice Menu of treatment options Empathetic interaction Self-efficacy enhancement © AMSP

27. 27/31 Meds for ED - Limited Efficacy © AMSP Fluoxetine (Prozac) Topiramate (Topamax) Cognitive Behavioral Therapy ↓ purge √√ ↓ binge √√√ ↓ weight √√ ↑ abstinence (>12 mos) √

28. 28/31 Meds for AUDs - Limited Efficacy © AMSP NaltrexoneAcamprosateTopiramate ↓ urges√√√ ↓ drinks√√√ ↓ relapse√√√ ↑ abstinence (>12 mos) √√√

29. 29/31 Meds for Combined ED + AUD Naltraxone Inconsistent findings Acamprosate ↓ cravings for food & alcohol in AUD Topiramate ↓ heavy drinking days by 50% in AUD ↓ weight in BED by 7lbs - 21 wks ↓ weight by 5kg in 16 wks © AMSP

30. 30/31 Psychotherapeutic Interventions Family therapy for AN in adolescents Cognitive behavioral therapy (CBT) Improves outcome in EDs Improves outcome in AUDs Group therapy/support groups © AMSP

31. 31/31 Summary Definitions √ Relationships √ Screening & identification √ Treatment & management √ © AMSP