Clinical correlate # 7 Eating disorders Study questions 1. Refer to the clinical correlate on the biopsychosocial model in Unit
1. How does this model apply to the understanding of eating disorders? To their treatment?
A. A 24-Year-Old Woman With Anorexia Nervosa Katherine A. Halmi, MD, Discussant JAMA. 1998;279:1992-1998.The above article is an excellent review of the tremendous challenges patients with anorexia and their physicians face. The following is a summary of this ‘clinical crossroads’ feature. For access to full-text JAMA, you must use your own library access. Patient presentation Ms. K. reports being the only child of parents who themselves were only children. She states a lot was expected of her. She states “ I was always afraid to tell them what I was thinking or feeling because I didn't want to disappoint them.” Eventually these expectations translated into expectations she had of herself. She tries to keep her weight above a self-determined threshold of 73 pounds. “When I get to 73 lb, that is a justification for me to feed myself, to take care of myself. I can then say, okay, you've got to take care of yourself now, because if you don't you're either going to die, have a heart attack, or go into the hospital.” Only at that low weight does she feel that the space she takes up is justified. She admits that the eating disorder is an important, inseparable part of her identity and that it has the feel of an addiction. Her doctors report that taking care of this patient is very challenging. The patient interviewed 7 different clinicians before deciding on one. The primary care doctor is unwilling to challenge her to much because she’s afraid the patient will just leave. Diagnosis 4 Criteria: 1. Weight less than 85% of normal for weight and height (Ms K is at 64% of lowest acceptable weight) Two subtypes: Bulimia is bingeing and purging, but remaining within 85% of normal weight. Bulimics tend not to develop amennorhea. Physical abnormalities include: Leukocytosis In vomiting patients: Prevalence Bulimia: 1-year prevalence: 0.17% for females age 15 to 29 years attending a primary care health clinic Psychiatric Comorbidities Lifetime prevalence of major depression was present in 68% (10-year follow-up study) Etiology Biological vulnerability: genetics, serotonergic system dysfunction; corticotropin-releasing hormone (CRH) secretion released when dieting is a powerful anorexiant. Low oxytocin and high vasopression levels may also have an influence once dieting gets in gear. Psychological predisposition: escape from aversive developmental issues and distressing life events. Dieting a source of confidence and control Societal influences: images and ideals of thinness Clinical course Most common cause of death: cardiovascular collapse Treatment When to hospitalize: no controlled trials assessing this Possible indicators for hospitalization: Primary care to manage medical problems Nutrition Cognitive behavioral therapy : “The central assumption underlying the cognitive method is that unpleasant feelings and maladaptive behaviors are mediated by dysfunctional (incorrect, inaccurate, rigid, and extreme) beliefs and negative automatic thoughts. In this technique, patients learn to note their thoughts and judgments about food, weight, and body image. Next, they list facts and evidence to support the anorectic thoughts, and then facts and evidence that cast doubt on these thoughts. Finally, patients reach a reasoned conclusion that is used to govern their behaviors related to eating. It is important to explain to patients that they should not expect to "believe" their reasoned conclusion. Patients should learn that this is an appropriate way to think and use it to guide their behavior.” Medications are not very effective Cyprohepatidine: antidepressant effects and promotion of weight gain in restrictive types Antidepressants are usually ineffective unless patient begins to approach normal weight. Depression may be a physiologic function of the anorexic state
B. Victor Fornari M.D. , Ida F. Dancyger Ph.D. Psychosexual development and eating disorders Adolesc Med 14:61-75, 2003 The relationship among eating disorders (EDs), psychosexual and identity development, and physical maturation (puberty) is reviewed. The developmental tasks of adolescence are summarized, and research from both community studies and clinical samples on the association between the development of an ED and putative risk factors that include pubertal development and psychosexual behaviors and attitudes for children and adolescents is reviewed. Specific issues explored include the role of child and adolescent abuse and EDs in males. Overall evidence suggests the following: there are inconsistent findings regarding early pubertal development as a risk factor; there is some support for differences between the ED subtypes in sexual attitudes, behaviors, and experiences; sexual abuse is not a specific risk factor; and gender identity issues may play more of a role for adolescent males than females. However, psychosexual issues are neither sufficient nor necessary for the development of an ED in a young person. It should be considered as only one factor in the multidimensional, multifactorial framework needed to clarify this complex and still poorly understood set of disorders.
Two quotes from the article above are as follows: “Beaumont, George, and Smart concluded that there were significant differences between patients (adolescents and young adults) with restricting anorexia nervosa and those with purging anorexia nervosa.[ 8 ] Sexual experience (as measured by having a steady boyfriend, having had intercourse, and having used oral contraceptives) was lower in those with restricting anorexia nervosa compared to those with purging anorexia nervosa. Garfinkel et al. also compared patients with restricting anorexia nervosa (AN-R) to patients with anorexia nervosa with bingeing/purging behaviors (AN-BP); they also found differences in sexual behaviors and experience.[ 34 ] Specifically, more subjects in the AN-R group reported that they had never had sexual intercourse, whereas more subjects in the AN-BP group reported the use of oral contraceptives and having engaged in oral sex. Careful clinical attention to both current social functioning and a history of childhood trauma enables the treatment team to understand the individual fully and to intervene at the appropriate level. For these adolescents, psychosexual development may be delayed, and maturation may be intermittent or complex.” “Clinically, in our experience, an emaciated immature body configuration may be an adaptation to avoidance of adult intimacy. This may be particularly so in young people with a history of sexual abuse who may find protection from the demands of adolescent social and sexual expectations frightening and overwhelming. On the other hand, other young people's sexual adaptation following a history of sexual abuse may include excessively provocative sexual acting-out behavior.” |