Eating disorders are a group of illnesses exhibiting a progressive course of distorted thinking and behaviors. They are characterized by loss of control over one’s relationship with food and eating. These illnesses have developmental, biological, familial, and socio-cultural roots. Recovery is about achieving balance and healthy nurturance in one’s life.

1. Overview of
Eating Disorders
Alexis Polles, MD

3. Kirstie Alley

4. Mary Kate Olson

5. Princess Dianna

6. Outline
• Eating Disorder
Definitions
• Our Philosophy
• Medical/Psychiatric Issues
– Co-morbidity
• Diagnostic Instruments
• Treatment Goals

7. DSM-IV-TR Descriptions of
Eating Disorders
• The Eating Disorders are characterized by
severe disturbances in eating behavior.
• Three Diagnostic Categories = Form
– Anorexia Nervosa
Restricting Type or Binge Eating/Purging Type
– Bulimia Nervosa
Purging Type or Non-Purging Type
– Eating Disorder NOS
Binge Eating or Compulsive Overeating, etc.
• Function is attempt at self-regulation.

8. Disturbance in Self-Regulation
• The use of food in one’s body to solve
psychological conflicts

9. Our Philosophy from the
Psychiatric Medical Perspective
• Eating disorders are a group of illnesses
exhibiting a progressive course of distorted
thinking and behaviors. They are
characterized by loss of control over one’s
relationship with food and eating. These
illnesses have developmental, biological,
familial, and socio-cultural roots. Recovery
is about achieving balance and healthy
nurturance in one’s life.
Alexis Polles, M.D.

10. Nutritional/Exercise Perspective
• An integrated approach combining spirituality,
psychotherapy, pharmacology, nutrition and
exercise are all necessary to ensure recovery from
an eating disorder. Size and food issues are only
the bandages that cover the underlying wounds of
low self-esteem, trauma, poor communication, and
the need for control. These issues need to be
addressed in order for real healing to occur.
Ralph Carson, Ph.D., RD

11. Trauma and Victimization
• Bulimic link
• Sexual assault is not causal, but is a non-
specific risk factor

12. Brewerton Reviews
(AACAP, 1997/Natl Women’s Study)
• 1. Is CSA associated with BN? Yes
• 2. Is CSA > in BN than AN? Yes
• 3. Is CSA a specific risk factor? No
• 4. Is CSA associated with severe BN? No

13. National Women’s Study
• Random telephone survey of the general
– population of women
• Victimization included
– completed rape, molestation, attempted assault
– aggravated assault
• 54% with BN experienced at least one
• 31% without BN experienced at least one

14. PTSD in the NWS
• 37% of those with BN had PTSD at some
point
• 12% of those in the general pop. had PTSD
at some point
• 22% in BED
• Purging may prevent healing and resolution
• Rape without PTSD, 2% had BN
• Rape with PTSD, 10.4% had BN

15. Functions of the ED in
Victimization
• Regulation of emotional states or
interpersonal conflicts (numbing)
• Avoidance/escape
• Analgesia, self-punishment, self-blame
• Repetition compulsion
• Addictive cycle

16. Therapy Perspective
• Multidisciplinary team approach with a deep
spiritual emphasis allows clients to connect to
their internal conflicts of fear, control and
perfectionism. With the support of a dedicated,
competent staff, clients are able to develop hope
for change and transition into recovery, where
they find healthy connections to their bodies, and
spiritual connections to the disowned self. This
allows for healing in all their relationships.
Mary Bellofatto,
MA, LMHC, CEDS, CP, PAT

17. STAGES OF ADDICTION
USE
Loss of Control and Choice
EARLY
MIDDLE
LATE
NON-ADDICTION
Control and Choice
Occasional relief eating or fasting
Onset of memory fuzziness
Feelings of guilt
Initial avoidance of family and friends
Decrease ability to stop
Inability to determine feelings of fullness
Grandiose and Passive/Aggressive Behaviors
Urgency for food and compensatory behaviors
Geographical escapes
Loss of other interest
Change in tolerance
Work and money problems
Severe relational issues
Physical deterioration
Spiritual deterioration
Severe impairment in thinking
Indefinable fears
Nearly constant obsession/compulsion

18. Adult Feeling Disease Phases
I. Learns Mood Swing
II. Seeks Mood Swing
III. Harmful Dependence
IV. Using Eating Disorder Behavior to Feel Normal
Adolescent Feeling Disease Phases
I. Learns Mood Swing
II. Seeks Mood Swing
III. Harmfully Involved
IV. Harmfully Dependent
“I’m ugly and fat
and don’t fit in”.

20. Anorexia Nervosa
• A progressive and potentially fatal illness with
the highest mortality rate of any psychiatric
illness characterized by:
– Refusal to maintain body weight (BMI less than
17.5 or 85% IBW)
– Intense fear of weight gain or becoming fat
– Judges self harshly by weight or shape
– In postmenarcheal females, amenorrhea (3 cycles)

22. Anorexia Nervosa
• Associated Descriptive Features:
– Plays with food or has rituals with food
– Guilt or shame about eating
– Difficulty eating in public
– Sensitivity to cold temperatures
– Depression and irritability
– Socially withdrawn
– Perfectionism
– Overly controlled social and emotional life

23. Anorexia Nervosa
• Associated Medical Issues:
– Laboratory
– Cold intolerance
– Constipation
– Abdominal pain
– Lethargy
– Increased energy
– Low blood pressure
– Dry Skin/Yellow Skin (hypercarotenemia)
– Edema
– Dental erosions
– Scars on the back of hands
– Osteoporosis
– Decreased estrogen

24. Anorexia Nervosa
• Other Features:
– More prevalent in industrial societies
– Rarely begins before puberty
– Onset between 14 and 18
– Rarely starts after age 40
– Significant number of those with restricting type
develop binge eating
– Long term mortality is over 10% and death usually
due to starvation, suicide or electrolytes
– There is a familial pattern
– Significantly higher concordance rates for
monozygotic vs dizygotic twins

25. Human StarvationHuman Starvation
• Sleep disturbance
• Weakness
• GI disturbance
• Decreased BMR
• Decreased libido
• Decreased energy
• Decreased
concentration
•Poor judgment
•Apathy
•Depressed mood
•Anxiety
•Irritability
•Anger
•Psychosis
•Social withdrawal
•Disturbed attitude
toward food

26. 2001 NEDA Stats on Men
• 25% American men are on diets
• 41% Men dissatisfied with their weight
• 70% College-age men dissatisfied w/body image
• 32% College males dieting past 6 months
• 50% High-school freshmen dieting past 6 months
• 28% Boys / 40% Adolescent males trying to gain weight
• 1 Million boys and men have eating disorders

27. Bulimia Nervosa
• Is a potentially devastating disease which is
characterized by:
– Recurrent episodes of binge eating
• Eating in a discrete period of time an amount of food which is
definitely larger than what most people would eat.
• Sense of lack of control over eating
– Recurrent compensatory behaviors to prevent weight gain
• Laxative, diuretics, enemas, fasting, exercise, other drugs
– Behavior occurs on average twice a week for 3 months
– Self-evaluation unduly influenced by body shape and
weight
– Types
• Purging type = vomiting, diuretics, enemas
• Non-purging type = fasting, exercise

28. Bulimia Nervosa
• Associated Descriptive Features:
– Typically within the normal weight range
– Likely to be overweight prior to onset
– Increased frequency depressive symptoms and low
self-esteem
– Increased frequency anxiety symptoms
– Binge eating frequently begins during an episode of
dieting
– Periods of remission longer than 1 year have better
long term outcome
– Familial pattern with bulimia, mood disorders,
substance abuse and possibly obesity

29. Bulimia Nervosa
• Associated Medical Issues:
– Laboratory (Frequent low potassium)
– Dental erosions
– Parotid gland enlargement
– Scars on back of hand
– Menstrual irregularities
– Fatal problems can include esophageal tears,
gastric rupture, and cardiac arrhythmias
– Rectal prolapse

30. Eating Disorder NOS
– AN with regular menses
– AN with normal weight
– BN that occurs less than twice a week
for less than 3 months
– Chewing and spitting out but not
swallowing food
– Binge ED

31. Binge Eating Disorder
• Recurrent episodes of binge eating
• Binges have at least 3
– Eating more rapidly than normal
– Eating until uncomfortably full
– Eating large amounts when not physically hungry
– Eating alone due to embarrassment
– Feeling disgusted, depressed or very guilty after overeating
• Marked distress regarding binge eating
• Occurs 2 days a week for 6 months
• No regular use of compensatory behaviors

32. Binge Eating Disorder
• Associated Descriptive Features:
– May be triggered by depression and anxiety
– May feel numb or spaced out during a binge
– Grazing with no planned meal times
– Many have been on multiple diets
– Usually overweight

33. Prevalence of Overweight and Obesity
in U.S. Women: BMI >25 Ages >20*
50.7% All women
49.2% White
65.85% Black
47.4% White, non-Hispanic
66.0% Black, non-Hispanic
65.9% Mexican American
* NIH Guidelines, September 1998, pg 69S – from NHANES III data 1988-94
Low-income or low-educated US women more likely to
be obese than those with higher socioeconomic status.
Low-income or low-educated US women more likely to
be obese than those with higher socioeconomic status.
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

34. Women and Weight Gain:
Risks and Consequences
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

35. Obesity in Women:
Consequences for Children
In addition to:
• Low family income
• Lower cognitive stimulation
• High fat/calorie intake
• Avid T.V. watching
• Maternal obesity: best predictor of
childhood obesity
1. USDA, Nutrition Insights, May 1999
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

36. Childhood Predictors of
Adult Obesity
Strong associations found:
– Parental fatness:
• Whether due to genes or lifestyle is unknown1
– Birth weight:
• Increased fatness with higher birth weight1
– Timing and rate of maturation:
• Early menarche (before 11 yrs) in girls doubled chances
of being overweight
• Highest prevalence in early-maturing black girls2
1. Parsons TJ, et al, Int J Obesity (1999) 23, Supp 8, S1-107
2. Adair LS, Gordon-Larsen P. Am J Pub Hlth April 2001, Vol 91, No 4;642-644
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

37. Benefits of
Modest (5 – 10%) Weight Loss
• Lowers TC, triglycerides, LDL, BP and left
ventricular mass
 Blood glucose in type II diabetics
• Improves HDL cholesterol, lower back pain,
reflux, lower extremity arthralgias, obstructive
sleep apnea
• Often can decrease medications for obesity-
related conditions
NHLBI Guidelines, June 1998
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

38. Recommended Dietary Intake
Reduces Disease Risk
• Study of 42,254 women assigned a “score” based on #
servings from the dietary guidelines
• Of those who followed the guidelines:
30% less likely to die of any cause
40% less likely to die of cancer (colon,
breast, endometrial, and gallbladder)
33% less likely to die of heart disease
42% less likely to die of stroke
Kant et al, JAMA 2000
Source; Caroline M. Apovian, MD and Center for Nutritional Research Charitable Trust

39. Risk Factors for Men
• Childhood obesity
• Family history
• Psychiatric co-morbidity
• Alcohol and substance abuse
• Gender dysphoria and sexual orientation
(Gay and Bi-sexual males over represented)
• Weight related sports
(Gymnast, runners, body-builders, rowers,
wrestlers, jockeys, dancers and swimmers)

40. Psychiatric Co-morbidity
• Commonly occurring Axis I co-morbidity:
– Major Depression
– Anxiety Disorders
• OCD, Social Phobia, PTSD
– Substance Abuse/Dependence except in restricting AN
– Somatoform Disorders
• Body Dysmorphic Disorder
• Axis II
– BN and Cluster B (Borderline)
– AN and Cluster C (Avoidant, OCPD)

41. Assessment Tools
• General physical exam (include labs)
• Nutritional consultation
• BMI/% body fat
• Interview
• Written instruments

42. BMI
• Body Mass Index Score
–Less than 19 % Underweight
–19%-25% Desirable Range
–25%-30% Overweight
–30% + Obese
BMI = (
Weight in Pounds
(Height in inches) x (Height in inches)
) x 703

43. Approximately 13%
Kate Moss
Approximately 15%
Courtney Cox
Approximately 18.5%

44. Meg Ryan
Approximately 19.5%
Lower Healthy
Tony Braxton
Approximately 25%
Upper Healthy
Jennifer Lopez
Approximately 28%
Overweight

45. Jennifer Lopez
Approximately 28%
Overweight
Ricki Lake
Approximately 30%
Borderline Obese
Camyrn Manhiem
Approximately 39%
Obese

46. Assessment Instruments
• EDI III– Self Report
• Questionnaire on Eating and Weight—Revised
• DSM

47. Review of Information on Healthy Eating
• For those of you who watch what you eat... Here's the final
word on nutrition and health. It's a relief to know the truth
after all those conflicting medical studies:
• 1. The Japanese eat very little fat and suffer fewer heart
attacks than the British or Americans.
• 2. The Mexicans eat a lot of fat and suffer fewer heart
attacks than the British or Americans.
• 3. The Japanese drink very little red wine and suffer fewer
heart attacks than the British or Americans.
• 4. The Italians drink excessive amounts of red wine and
suffer fewer heart attacks than the British or Americans.
• 5. The Germans drink a lot of beer and eat lots of sausages
and fats and suffer fewer heart attacks than the British or
Americans.

48. Goals of Treatment
• Restoring healthy eating patterns.
• Restoring healthy body weight.
• Identifying and treating underlying emotional issues.
• Developing coping strategies for dealing with day-to-day stressors.

49. General Treatment PrinciplesGeneral Treatment Principles
• Diagnostic evaluation
• Relative chronology
• Potential functional links
• Treat concurrently
• Normalize brain function
-Re-feed
-Psychotherapy
-Maintenance

51. General Treatment Principles
• Normalizing brain function
– Nutritional rehabilitation
– Abstinence from substance abuse/dependence
• Acute withdrawal

52. Intensive TherapyIntensive Therapy
• CBT
• DBT
• IPT
• Family Therapy
• Psychodynamic/experiential
• 12 step recovery models
• Psychopharmacology
• Trauma based