Tag Archives: cognitive behavioral therapy

Practical strategies for the diagnosis and management of binge eating disorder

Binge eating disorder (BED), now included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 is defined as follows:

  • Recurrent and persistent episodes of binge eating
  • Binge eating episodes that are associated with three (or more) of the following:
    • Eating much more rapidly than normal
    • Eating until feeling uncomfortably full
    • Eating large amounts of food when not feeling physically hungry
    • Eating alone because of being embarrassed by how much one is eating
    • Feeling disgusted with oneself, depressed, or very guilty after overeating
  • Marked distress regarding binge eating
  • Absence of regular compensatory behaviors (such as purging)

Particularly common among females (See Cases 1, 2, and 3) and associated with obesity, BED poses physical, psychological, and social challenges that decrease health-
related quality of life (HRQOL) and increase disease burden.

Etiology

The etiology of BED is multifactorial and complex. Although associated with hedonic hunger, BED is linked less to pleasure and more to an attempt to suppress negative feelings through bingeing without purging.2 Motivation to binge likely also arises from homeostatic hunger.

Risk factors

Risk factors for BED include genetics, female gender, Caucasian ethnicity, weight concern, negative body image, childhood problems, low self-esteem and self-efficacy, low family cohesion, psychiatric morbidity, and stressful events.3,4 In addition, a community-based case–control study demonstrated that patients with BED, versus controls, were significantly more likely to report sexual abuse and repeated severe physical abuse. The typical overweight person with BED is overly concerned with body shape and weight. BED is most likely to occur in young women of high socioeconomic status in industrialized countries, but it is not limited to this population (See Cases 1, 2, and 3).

Binge-eating disorder in children and adolescents

In children and adolescents, early identification and treatment of BED is vital (See Case 1). Loss of control over eating is associated with modifiable lifestyle factors. Often considered temporary, BED is actually a long-term chronic condition often associated with co-morbid obesity. Childhood factors that increase risk for BED include obesity, self-criticism, poor self-esteem, body dissatisfaction, and emotional abuse.5 In female adolescents and young adult women, BED is associated with pre-existing depressive symptoms and an increased risk for developing mood disorders.6

Specific goals of treatment for children and adolescents include treatment of underlying depression or anxiety, improvement of self-esteem, normalization of eating patterns, promotion of physical activity, and implementation of family therapy to address family dysfunction and engage family members in supporting the patient’s recovery. BED treatment outcomes can be optimized through early detection and referral to eating disorder specialists; incorporating a multidisciplinary treatment team to address the physical, psychological, nutritional, and spiritual aspects of BED; and combining cognitive behavioral therapy (CBT), a self-help program, and, when appropriate, pharmacotherapy.

Co-morbid psychiatric disorders

Co-morbid anxiety, mood, and disruptive behavior disorders are common in patients with BED, as are obsessive-compulsive disorder, post-traumatic stress disorder, and substance abuse. Co-morbid obesity increases psychopathology, emotional eating, concerns about weight and body shape,7 and perhaps a desire for bari­atric surgery.8 Obesity and BED are common in patients with bipolar disorder. In patients with personality disorders, alexithy­mia (a personality construct characterized by the subclinical inability to identify and describe emotions in the self) correlates more highly with BED than with other eating disorders.9

A case–control study showed that patients with BED, compared with controls, reported a significantly greater number of adverse life events during the year prior to symptom onset, suggesting that the accumulation of stressful events can trigger the disorder.10 Even after weight loss and CBT, patients with BED experienced higher morning basal cortisol levels than did a control group without BED.

Effects of disordered eating patterns on reproductive health

Disordered adolescent eating patterns affect one’s development, with implications for reproductive function. Behaviors associated with risk-taking and self-harm frequently co-exist with eating disorders and increase risks for unplanned pregnancy and sexually transmitted infections. Obesity is strongly associated with conditions that adversely affect reproductive function.

In anovulatory overweight or obese women, sustained gradual weight loss will regulate menstrual cycles and increase the chance of spontaneous ovulation and conception.11Lifestyle modification has been shown to improve reproductive function.

Effects of binge eating disorder on pregnancy

Pre-pregnancy and pregnancy dietary patterns of women with BED may influence pregnancy outcomes. Many obstetricians do not query patients about weight control or disordered eating during pregnancy, and many patients do not seek treatment. Studies evaluating maternal and fetal outcomes in women with eating disorders are limited.

Women with BED during pregnancy are considered high risk. BED treatment during pregnancy is important for long-term management and reduction of harmful behaviors such as smoking; in fact, treatment during pregnancy is particularly likely to produce long-lasting results.

Pregnant patients with BED need frequent prenatal visits to discuss problems related to both nutrition and BED. Healthcare providers (HCPs) should do the following:

• Empower women to discuss weight and body-image concerns during pregnancy;
• Educate patients that uneven weight gain patterns may occur in pregnancy;
• Inform patients that controlling BED during pregnancy reduces the risk for a large-for-gestational-age newborn;
• Provide or refer for dietary support and meal planning;
• Assess and/or refer for management of psychiatric co-morbidities;
• Provide a routine postpartum visit at 1-2 weeks to monitor for relapse or exacerbation of BED; and
• Provide nutritional and dietary counseling for breastfeeding mothers and for the first 6-12 months postpartum.12

Co-morbid physical disorders

Binge eating disorder is associated with multiple physical co-morbidities, with decreased HRQOL and physical and psychosocial functioning.13 A large majority of individuals with BED receive medical treatment for co-morbidities, particularly obesity-related conditions such as type 2 diabetes mellitus (DM). Weight loss in patients with type 2 DM and BED who control their eating habits is similar to that in persons who have never experienced BED. BED may precede bariatric surgery and/or re-emerge post-surgery.

Screening and diagnosis

Assessment for eating disorders, including BED, should be part of a routine health evaluation. HCPs can use an assessment tool or pose a simple screening question in a matter-of-fact, nonjudgmental, empathetic manner to facilitate open conversation: Do you have thoughts, feelings, or behaviors regarding eating, weight, or body image that occupy most of your time or that make you feel out of control? (See Cases 1, 2, and 3.) The SCOFF Questionnaire can be useful. Practical strategies for screening and diagnosis implemented by the authors include the following:
• Use an eating disorder screening question at routine visits as patients age from childhood through the older adult years;
• Engage patients in a conversation about possible BED;
• Maintain accurate chronological weight records;
• Be familiar with DSM-5 diagnostic criteria;
• Obtain a 24-hour written food intake and feelings journal for
7 consecutive days (including weekends) and review the journals with patients;
• Assess for underlying depression or anxiety; initiate medication if indicated;
• Use physical, nutritional, and psychological findings to incentivize patients to engage in treatment;
• Avoid references to calories, weight, and dieting that may exacerbate feelings of shame or excessive focus on food;
• Advocate an approach for treatment of BED and obesity that does not center on the need for dieting but, instead, emphasizes the importance of specialized psychological, medical, and nutritional care;
• Be familiar with eating disorder specialists in your geographic area and be able to implement the referral process; and
• Confirm that patients follow through with BED treatment.

Binge-eating disorder subtypes may manifest in difficult-to-treat food addictions, which are common in patients with co-existing histories of addictive personality or substance abuse disorder. A marker of substance dependence includes consumption of high-fat/high-sugar foods.14 A food addiction symptom count (using criteria similar to those for substance abuse disorder in the DSM-5) should be obtained for these patients.15 Emotions associated with binge eating may be experienced differently by individuals from specific ethnic, racial, and cultural groups.

Treatment

The American Psychiatric Association has established levels of care guidelines for patients with eating disorders, who can be difficult to treat. Many patients with BED experience shame, embarrassment, self-disgust, depression, and guilt as a result of their eating disorder. They tend to eat secretly or alone and may hide binge foods. Patients may deny that they have an eating disorder and may be reluctant to discuss BED with their HCP. Many patients who use binge eating to deal with difficult life situations are reluctant to eliminate this behavior and do not fully commit to a treatment program. Others welcome interventions that may improve HRQOL.

Nonpharmacologic approaches
Cognitive behavioral therapy, considered a first-line therapy for BED, and interpersonal psychotherapy are effective in patients with BED (See Cases 1, 2, and 3). Other nondrug approaches usually entail a combination of a lifetime nutritional plan, assertiveness training, improved stress management, and moderate exercise to increase lean muscle mass.

Pharmacotherapy
No agent is FDA-approved for the treatment of BED. An application for an indication for lisdexamfetamine dimesylate as a treatment for BED likely will be filed soon with the FDA. Multiple pharmacologic agents have demonstrated benefits at varying dosages in trials conducted between 2005 and 2010.

Antidepressants
Antidepressants address common mood-related co-morbidities. Of note, many patients with BED consume tryptophan-containing carbohydrates that synthesize serotonin. When these patients’ serotonin levels are low, cravings commence. Antidepressants that inhibit reuptake of serotonin can help decrease compulsive/binge eating. In many patients with co-morbid depression (or if CBT is unavailable), selective serotonin reuptake inhibitors (SSRIs) can decrease bingeing (and purging) by 50%, although some patients may not respond to treatment or may relapse with SSRI dis­continua­tion.16 Bupropion has beneficial effects on weight and does not have SSRI side effects. Bupropion dosages of 300-450 mg/day have been shown to be effective.17Psychostimulants
Agents used to treat attention defi­cit hyper­activity disorder (ADHD) affect dopamine/norepinephrine systems associated with both the etiology of BED and eating behavior/reward behavior. An epide­miologic relationship between BED and ADHD has been noted in adolescents18 and adults.19 An association has also been reported between bulimia nervosa (BN) and ADHD; a small study of patients with co-morbid BN and ADHD showed the efficacy of psycho­stim­­ulant medication. An ongoing study is comparing methyl­phen­i­date with CBT in the treat­ment of BED.20Pharmacotherapy during pregnancy
Few studies have evaluated the use of psychotropic agents during pregnancy other than a large cohort evaluation of SSRIs. Additional data may guide decision making regarding the use of agents such as bupropion, methylphenidate, memantine, naltrexone, sodium oxybate, topiramate, and zonisamide in pregnant women.

Conclusion

Binge-eating disorder is a complex, multifactorial condition that requires a comprehensive and integrated course of treatment. Nurse practitioners and other advanced practice HCPs caring for women are positioned to play important roles in patient assessment and management.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013.

2. Witt AA, Lowe MR. Hedonic hunger and binge eating among women with eating disorders. Int J Eating Disord. 2014;47(3):273-280.

3. Jacobi C, Hayward C, de Zwaan M, et al. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull. 2004;130(1):19-65.

4. Jacobi C, Paul T, de Zwaan M, et al. Specificity of self-concept disturbances in eating disorders. Int J Eat Disord. 2004;35(2):204-210.

5. Dunkley DM, Mashib RM, Grilo CM. Childhood maltreatment, depressive symptoms, and body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. Int J Eat Disord. 2010;43(3):274-281.

6. Skinner HH, Haines J, Austin SB, Field AE. A prospective study of overeating, binge eating and depressive symptoms among adolescent and young adult women. J Adolesc Health. 2012;50(5):478-483.

7. Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review on physical therapy interventions for patients with binge eating disorder. Disabil Rehabil. 2013;35
(26):2191-2196.

8. Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric morbidity in obese women with and without binge eating. Int J Eat Disord. 2002; 32(1):72-78.

9. Wheeler K, Gruner P, Boulton M. Exploring alexithymia, depression and binge eating in self-reported eating disorders in women. Perspect Psych Care. 2005;41(3):114-123.

10. Pike KM, Wilfley D, Hilbert A, et al. Antecedent life events of binge-eating disorder. Psychiatry Res. 2006;142(1):19-29.

11. Pandey S, Pandey S, Maheshware A, Bhattacharya S. The impact of female obesity on the outcome of fertility treatment. J Hum Reprod Sci. 2010;3(2):62-67.

12. Harris AA. Practical advice for caring for women with eating disorders during the perinatal period. J Midwifery Womens Health. 2010;55 (6):579-586.

13. Rieger E, Wilfley DE, Stein RI, et al. Comparison of quality of life in obese individuals with and without binge eating disorders. Int J Eat Disord. 2005;37(3):234-240.

14. Cooper R. Could your patient have an eating disorder? Nurs Womens Health. 2013;17(4):317-324.

15. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale food addiction scale. Appetite. 2009;52(2):430-436.

16. Mehler PS, Anderson AE. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore, MD: John Hopkins University Press; 2010.

17. Stahl SM, Pradko JF, Haight BR, et al. A review of the neuropharmacology of bupropion, a dual norepinephrine and dopamine reuptake inhibitor. Prim Care Companion J Clin Psychiatry. 2004;6(4):159-166.

18. Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.

19. Hudson J, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.

20. Quilty LC, Kaplan A. Center for Addiction and Mental Health, Toronto, Ontario, Canada. Methylpheni­date versus cognitive behavior therapy in overweight or obese adult females. ClinicalTrials.gov. 2014.

Dying to be thin: Recognizing and treating anorexia in adolescents

Ubiquitous images of waiflike models and other females in the media prompt many adolescent girls in the United States to curb their caloric intake and lose weight, even to a perilously low level. The authors provide up-to-date information regarding identification, assessment, and management of anorexia in adolescent girls so that nurse practitioners can intervene before this illness threatens these patients’ lives.

For most girls and women in the United States, images of extremely thin models and other females in the media do not greatly influence their own body image or their eating or exercise habits. For other girls and women, however, the focus on thinness becomes distorted, obsessive, and extreme, and contributes to the development of an eating disorder that can have catastrophic consequences.1 The reasons for this body image disturbance are likely related to a combination of psychological, environmental, and biologic factors; adolescent females seem to be among the most vulnerable. When adolescent girls, as opposed to women, develop an eating disorder, they present with greater emotional distress, functional impairment, and suicide risk; a dangerously lower body mass index (BMI); and an increased need for mental health assessment and treatment.2 Females with eating disorders, versus those with other psychiatric disorders, are more likely to attempt suicide and to undergo inpatient treatment.2,3

According to a recent cross-sectional survey, about 3% of girls aged 13-18 years have some form of eating disorder: 0.3% have anorexia, 0.9% have bulimia, and 1.6% have a binge eating disorder.4 In this study, although most teens with an eating disorder reported seeking some form of treatment, only a minority received treatment specifically for their eating or weight problems. To increase the likelihood that adolescent girls with anorexia, the most common eating disorder, receive the help they need from nurse practitioners (NPs) who see them for primary care, the authors provide background information about anorexia and then discuss its signs and symptoms (S/S), screening, diagnosis, and treatment.

Background information

Anorexia nervosa, an eating disorder characterized by immoderate food restriction, inappropriate eating habits or rituals, obsession with having a thin figure, and an irrational fear of weight gain, as well as a distorted body-image, tends to develop during adolescence, with peaks in onset at ages 14 and 18.5 Fear of gaining weight is the driving force behind anorexia; afflicted individuals refuse to sustain a minimally normal weight.6 To achieve their goal of losing weight, these individuals restrict their food intake and may exercise excessively. Some of them may use laxatives, diuretics, and enemas to accelerate weight loss.

Individuals with anorexia view themselves as fat despite being thin or even emaciated. They judge their self-worth by their weight, and they tend to have a greatly distorted body-image and cognitive thought process.6 Driven by perfectionism, even after receiving therapy, these girls find that they can never quite achieve their “ideal” weight.5

Signs and symptoms

The most obvious sign of anorexia is extreme thinness or emacia­tion.7 Other S/S related to body weight and body-image include a relentless pursuit of thinness, an unwillingness to maintain a normal or healthy weight, an intense fear of gaining weight, a distorted body-image, low self-esteem, and a denial of the danger of low body weight. Over time, anorexia takes a toll on the body; common physical manifestations of anorexia include dry skin, brittle hair and nails, lanugo (fine downy hair) all over the body, decreased blood pressure and heart rate, cold extremities, severe constipation, and mild anemia.5-8

Anorexia can have severe adverse effects on many body systems as well. It is associated with a reduction in bone density,1 which may lead to an increased risk for fractures. Some young patients with anorexia fail to reach their full adult growth potential. Anorexia can cause muscle weakness and wasting, and damage to the structure and function of the heart.7 In addition, anorexia can lead to cerebral atrophy and delayed neurocognitive development. When anorexia is untreated or inadequately treated, patients can die, usually of medical complications (e.g., arrhythmia, multi-organ failure) or from suicide.9

View: Eating disorders

Screening

One commonly used tool is the SCOFF screen,10 which asks patients with suspected eating disorders these questions:

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you recently lost Over 15 pounds in a three-month
    period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

A “yes” answer to two or more of these questions indicates that an eating disorder may be present. The Eating Disorder Examination, an interview of the patient by the healthcare provider (HCP),11 and the self-reported Eating Disorders Examination-Questionnaire12 are both considered valid screens for eating disorders and for determining specific features of a person’s condition (e.g., vomiting, laxative use).

Diagnosis

New diagnostic criteria

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5) states that anorexia, which primarily affects adolescent girls and young women, is characterized by distorted body image and excessive dieting that leads to severe weight loss, with a pathologic fear of becoming fat.9 The DSM-5 lists three diagnostic criteria for anorexia:

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

The new diagnostic criteria have several minor but important changes from previous editions. Criterion A focuses on behaviors such as restricting caloric intake, and no longer includes the word refusal in terms of weight maintenance because that implies intention on the part of the patient and can be difficult to assess.13 In the DSM-5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.14 The DSM-IV-TR Criterion D15 requiring amenorrhea, or the absence of at least three menstrual cycles, has been deleted from the DSM-5. This criterion cannot be applied to males, pre-menarchal females, females taking oral contraceptives, or postmenopausal females. In some cases, individuals exhibit all other S/S of anorexia but still report some menstrual activity.

Diagnostic tests

Early detection of anorexia is important. As patients approach the 5-year mark of living with the illness, recovery becomes increasingly less likely.16 NPs should ask all female patients about their self-perception, self-image, and overall satisfaction with their body appearance. Height, weight, and BMI should be monitored at every visit. Additional testing is considered on a case-by-case basis. Laboratory tests such as complete blood count, electrolytes, liver function tests, serum albumin, urinalysis, and thyroid-stimulating hormone level are considered as part of the initial workup.17

Poor nutrition and extremely low caloric intake take a toll on the body not only in terms of appearance but also in terms of overall function. The hypovolemia that occurs in relation to anorexia can result in an atrophic heart and decreased cardiac output. An electrocardiogram and perhaps an echocardiogram should be included as part of the standard workup because of the high likelihood that arrhythmias will occur; arrhythmia is the most common cause of death in patients with anorexia. Prolonged QTc interval, bradycardia, heart block, and hypovolemia are just a few of the likely end points related to the atro­phic heart and the electrolyte imbalances.18Differential diagnosis

Many other diagnoses can contribute to, coexist with, or be solely responsible for extreme weight loss. When working up a patient with a suspected eating disorder, NPs must consider other diagnoses such as HIV/AIDS, major depression, anxiety disorder, post-traumatic stress disorder, sexual abuse, substance abuse, brain tumor, inflammatory bowel disease, malabsorption syndrome, lupus, cancer, and esophageal motility disorders.

Because isolated cases of anorexia—without other co-morbid conditions—are rare, NPs should screen patients with anorexia for depression, anxiety, and other mental health disorders. Monitoring for suicidal ideation and ascertaining a patient’s risk for suicide are vitally important.

Treatment

Nurse practitioners are key members of the healthcare team that formulates a comprehensive treatment plan for patients with anorexia. Despite treatment offered, relapse risk remains high. Thirty percent to 50% of treated individuals relapse after an inpatient stay, especially during the first 2 years post-discharge.8Pharmacotherapy

No drugs have been approved by the FDA for treatment of anorexia nervosa, and no research supports the use of medications to cure the disorder.6 However, once patients reach their maintenance weight, selective serotonin reuptake inhibitors may help reduce obsessive-compulsive behaviors.6 Several randomized controlled trials are currently assessing the possible benefit of olanzapine, aripiprazole, and quetiapine.19 The results of these studies are not yet available. Many patients in whom atypical antipsychotics are indicated will not take these medications because of their association with weight gain.6Non-pharmacologic approaches

Cognitive behavioral therapy (CBT) is the gold standard for treating patients with anorexia.20 CBT assists patients, who view their body with unrealistic scrutiny and resist gaining any weight, in changing their unhealthy body-image. A recent Cochrane review evaluated the efficacy of family-based therapy (FBT), also known as the Maudsley Approach, in treating anorexia.21 In this intensive outpatient treatment approach, parents play a major role in (1) helping restore their adolescent child’s weight to a normal level for her age and height, (2) returning control over eating to the child, and (3) encouraging normal adolescent development through an in-depth discussion of these crucial developmental issues as they pertain to their child.21 The review showed that FBT was slightly superior to usual care (i.e. patient-based care) in treating adolescents with anorexia. In a more recent comparative trial, FBT, with its focus on facilitation of weight gain, was as effective as systemic family therapy, which addresses general family processes, and could be delivered at lower cost.22Hospitalization

Because of the life-threatening effect of starvation on the body, many patients with anorexia require hospitalization.3 If a patient is experiencing an extreme electrolyte imbalance or weighs below 75% of ideal body weight, the treatment is immediate inpatient unit treatment with medical stabilization. Because of the urgent need to reintroduce food in patients with anorexia, a rare but potentially fatal condition called refeeding syndrome may occur. This syndrome, attributed to a metabolic alteration in serum electrolytes, sodium retention, and vitamin deficiencies, taxes the patient’s system by overburdening the body with fluids too quickly.6Treatment at a psychiatric facility

Many patients with anorexia are admitted to an inpatient psychiatric facility in a crisis state. A comprehensive assessment is necessary, and symptoms such as suicidal ideation must be managed immediately. Some inpatient psychiatric facilities such as the Remuda Ranch at the Meadows, in Wickenburg, Arizona,23 specialize in the treatment of eating disorders in females. At this facility, treatment duration is flexible; some patients stay 1-2 weeks, whereas others with more severe illness may remain in treatment for 30 days or longer. Each patient has an individualized treatment plan implemented by a team of HCPs that includes a psychiatric and primary care provider, a registered dietician, a licensed master’s or doctoral-level therapist, a psychologist, and registered nurses. Along with treating the patient’s eating disorder, the team treats coexisting problems such as depression, anxiety, substance abuse, and trauma.

Nurse practitioner role

Because NPs may be the first HCPs to come into contact with an adolescent with anorexia, they must be able to recognize the S/S of an eating disorder, screen for and diagnose the disorder, and treat or refer the patient to prevent further harm. Treatment may entail prescribing medications, which, although not curative, can lessen S/S. Pharmacotherapy for patients with eating disorders targets three domains: (1) remission of presenting S/S during acute treatment, (2) prevention of relapse in the post-acute phase, and (3) diversion of recurrences over the lifetime course.24 The treatment plan will also likely include CBT to enhance the patient’s self-image. If the NP is not well versed in providing CBT, a referral to a mental health specialist is advisable. FBT is also a reasonable therapeutic approach. In all cases, education of family members regarding anorexia and its treatment is vital. The Box lists useful resources for NPs and their patients.

Those NPs who are treating patients with anorexia should initially see these patients weekly to monitor their weight and to check their laboratory values. Frequency of weight monitoring and lab testing will decrease over time as patients demonstrate the ability to maintain a maximum tolerable weight. Reactions of patients with anorexia to requests to step on a scale range from reluctance to resistance to outright refusal. Refusal to be weighed is a patient’s right, and should be viewed as a protective mechanism in which the patient is avoiding a perceived negative stimulus, as opposed to a demonstration of defiance. In some instances, obtaining an accurate weight and completing certain tests are essential to rule out complications such as heart failure. Although most life-threatening sequelae that occur in the acute phase of anorexia subside in the post-acute phase, ongoing monitoring can help ensure that liver and kidney function have stabilized, that electrolyte and vitamin deficiencies have corrected, and that BMI remains at an acceptable level.

Nurse practitioners caring for patients with anorexia are members of a team of HCPs, which
usually includes a dietician, a counseling psychologist, and a psychia­trist. Some patients engage in only limited treatment with their NP, and periodically engage in more intensive treatment with a mental health specialist when their illness becomes more severe. Understanding that the treatment phase is often characterized by remissions and exacerbations helps NPs know what to expect. At the very least, NPs will play an integral part in keeping patients engaged in the treatment process. Supporting patients from their entry into treatment and through recovery can help them endure the extensive rehabilitative process and ultimately save their lives.

Erik Southard is the Director of the DNP Program, Department of Advanced Practice Nursing; Renee N. Bauer is Director of 2nd Degree Track, Department of Baccalaureate Nursing; and Andreas M. Kummerow is Director RN to BS Track, Department of Baccalaureate Nursing Completion, all at Indiana State University in Terre Haute. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.

Useful Resources

References

1. Hudson LD, Court AJ. What pediatricians should know about eating disorders in children and young people. J Paediatr Child Health. 2012;48(10):869-875.

2. Stice E, Marti CN, Rohde P. Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnosis in an 8-year prospective community study of young women. Abnorm Psychol. 2013;122(2):445-457.

3. Dooley-Hash S, Banker JD, Walton MA, et al. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. Int J Eat Disord. 2012;45(7):883-890.

4. Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.

5. Fursland A, Byrne S, Watson H, et al. Enhanced cognitive behavior therapy: a single treatment for all eating disorders. J Couns Dev. 2012; 90(3):319-329.

6. Halter MJ. Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 7th ed. St. Louis, MO: Saunders; 2014.

7. National Institute of Mental Health. What Are Eating Disorders? www.nimh.nih.gov/health/topics/
eating-disorders/index.shtml

8. Berends T, van Meijel B, van Eldburg A. The Anorexia Relapse Prevention Guidelines in practice: a case report. Perspect Psychiatr Care. 2012;48(3):149-155.

9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders: Fifth Edition. Washington, DC: American Psychiatric Publishing; 2014.

10. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire, a new screening tool for eating disorders. West J Med. 2000;172(3):164-165.

11. Fairburn CG, Cooper Z, O’Connor M. Eating disorder examination. In: Fairburn CG. Cognitive Behavior Therapy and Eating Disorders. New York, NY; Guilford Press; 2008. http://rcpsych.ac.uk/pdf/EDE_16.0.pdf

12. Fairburn CG, Beglin S. Eating disorder examination-questionnaire. Appendix in: Fairburn CG. Cognitive Behavior Therapy and Eating Disorders. New York, NY: Guilford Press; 2008. https://www.rcpsych.ac.uk/
pdf/EDE-Q.pdf

13. Mannix M. DSM-5 updates for eating disorders: implications for diagnosis and clinical practice. Brown Univ
Child Adolesc Behav Letter. 2012;28(12):3.

14. American Psychiatric Association. Highlights of Changes from DSM-IV-TR to DSM-5. 2013. www.
dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders: Fourth Edition-Text Revision. Washington, DC: American Psychiatric Publishing; 2000.

16. Ben-Tovim D. Clinical eating disorders: outcome, prevention and treatment of eating disorders. Curr Opin
Psychiatry. 2003;16(1):65-69.

17. Richardson B. Pediatric Primary Care, Practice Guidelines for Nurses. 2nd ed. Burlington, MA: Jones & Bartlett; 2013.

18. Casiero D, Frishman WH. Cardiovascular complications of eating disorders. Cardiol Rev. 2006;14(5):
227-231.

19. Watson HJ, Bulik CM. Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychol Med. 2013;43(12): 2477-2500.

20. Watson, HJ, Allen K, Fursland A, et al. Does enhanced cognitive behaviour therapy for eating disorders improve quality of life? Eur Eat Disord Rev. 2012;20(5):393-399.

21. Fisher C, Hetrick S, Rushford N, Family therapy for anorexia nervosa. Cochrane Database Syst Rev. 2010;
14(4):CD004780.

22. Agras SW, Lock J, Brandt H, et al. Comparison of 2 family therapies for adolescent anorexia nervosa. JAMA Psychiatry. 2014;71(11):1279-1286.

23. Remuda Ranch website. From the /Desk of the CEO. https://www
.remudaranch.com/alumni-link-newsletter-articles/248-from-the-desk-of-the-ceo

24. Kruger S, Kennedy SH. Psychopharmacotherapy of anorexia nervosa, bulimia nervosa and binge-eating disorder. J Psychiatry Neuro­sci. 2000;25(5):497-508.

Practical strategies for the diagnosis and management of binge eating disorder

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By Amy McKeever, PhD, CRNP, WHNP-BC and Laura J. Clauss, APRN, NP-C, CEDS, F-IADEP

Faculty

Amy McKeever, PhD, CRNP, WHNP-BC
Assistant Professor, College of Nursing, Villanova University, Villanova, Pennsylvania
Laura J. Clauss, APRN, NP-C, CEDS, F-IAEDP
President, CEO, and Medical Director, The Center for Eating Disorders Management, Inc., Bedford, New Hampshire

Intended audience
Nurse practitioners (NPs) and other advanced practice healthcare providers (HCPs) who care for women.

Continuing education (CE) approval period
Now through February 29, 2016

Estimated time to complete this activity
1 hour

Program description/identification of need
Gap 1: In 2013, binge eating disorder (BED) was designated as a formal diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. BED is underdiagnosed and undertreated. NPs in women’s health are the primary HCP and contact for many women, and are positioned to identify patients with BED and provide treatment and/or referral.
Gap 2: Many HCPs, including NPs, who care for women are insufficiently educated about the etiology of BED and its association with genetic and environmental factors, as well as its prevalence in women with obesity.
Gap 3: Various pharmacologic agents have been studied with regard to their efficacy in patients with BED, many of whom have co-morbidities. HCPs need information about the usefulness of currently available and investigational agents to treat both BED and common co-morbidities.

Gaps in practice
Gap 1: NPs in women’s health, as well as other HCPs who specialize in the care of women, are well positioned to screen for and diagnose BED. This activity will better enable them to do so.
Gap 2: A multifaceted approach to treatment for BED is required. HCPs need information about appropriate treatment options, and need to know which members of the health-management team are best positioned to offer these options.
Gap 3: Many patients with BED have co-morbidities associated with obesity. Identification of pharmacologic agents that will improve symptoms of both BED and co-morbid conditions can help optimize patient outcomes.

Educational objectives
At the conclusion of this activity, participants should be better able to:
• Discuss current diagnostic criteria for BED.
• Apply effective patient–HCP communication strategies regarding BED and its effects, including those related to fertility and future pregnancy.
• Evaluate nonpharmacologic and pharmacologic approaches to BED treatment.
• Monitor patient progress, adjust treatment plans, and make referrals as appropriate.

Credit designation statement
This Activity (No. J-15-02) has been evaluated and approved by the Continuing Education Approval Program of the National Association of Nurse Practitioners in Women’s Health (NPWH) for 1.0 contact hour of CE credit, including 0.5 contact hours of pharmacology content. Each participant should claim only those contact hours that he/she actually spent in the educational activity.

Accreditor disclosure of conflicts of interest policy
NPWH policy requires all faculty to disclose any affiliation or relationship with a commercial interest that may cause a potential, real, or apparent conflict of interest with the content of a CE program. NPWH does not imply that the affiliation or relationship will affect the content of the CE program. Disclosure provides participants with information that may be important to their evaluation of an activity. Conflicts of interest were resolved according to NPWH policy prior to development of content. The faculty report that they have nothing to disclose.

Disclosure of unlabeled use
NPWH policy requires authors to disclose to participants when presenting information about unlabeled use of a commercial product or device or an investigational use of a drug or device not yet approved for any use. This monograph contains a discussion of unapproved uses for these drugs: topiramate, zonisamide, naltrexone, methylphenidate, and lisdexamfetamine dimesylate.

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The authors discuss the etiology of binge eating disorder (BED), as well as techniques for screening and diagnosis and recommended treatments. They also describe common mental and physical co-morbidities in patients with BED and the disorder’s potential effects on reproductive health and pregnancy. Three relevant case studies—of a teenage girl, a woman in the middle of her reproductive years, and a woman nearing menopause—illustrate how healthcare providers can evaluate and manage patients with BED.

Key words: binge eating disorder, disordered eating, co-morbidities, cognitive behavioral therapy, pharmacotherapy

Binge eating disorder (BED), now included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),1 is defined as follows:

  • Recurrent and persistent episodes of binge eating
  • Binge eating episodes that are associated with three (or more) of the following:
    • Eating much more rapidly than normal
    • Eating until feeling uncomfortably full
    • Eating large amounts of food when not feeling physically hungry
    • Eating alone because of being embarrassed by how much one is eating
    • Feeling disgusted with oneself, depressed, or very guilty after overeating
  • Marked distress regarding binge eating
  • Absence of regular compensatory behaviors (such as purging)

Particularly common among females (See Cases 1, 2, and 3) and associated with obesity, BED poses physical, psychological, and social challenges that decrease health-
related quality of life (HRQOL) and increase disease burden.

Etiology

The etiology of BED is multifactorial and complex. Although associated with hedonic hunger, BED is linked less to pleasure and more to an attempt to suppress negative feelings through bingeing without purging.2 Motivation to binge likely also arises from homeostatic hunger.

Risk factors

Risk factors for BED include genetics, female gender, Caucasian ethnicity, weight concern, negative body image, childhood problems, low self-esteem and self-efficacy, low family cohesion, psychiatric morbidity, and stressful events.3,4 In addition, a community-based case–control study demonstrated that patients with BED, versus controls, were significantly more likely to report sexual abuse and repeated severe physical abuse. The typical overweight person with BED is overly concerned with body shape and weight. BED is most likely to occur in young women of high socioeconomic status in industrialized countries, but it is not limited to this population (See Cases 1, 2, and 3).

Binge-eating disorder in children and adolescents

In children and adolescents, early identification and treatment of BED is vital (See Case 1). Loss of control over eating is associated with modifiable lifestyle factors. Often considered temporary, BED is actually a long-term chronic condition often associated with co-morbid obesity. Childhood factors that increase risk for BED include obesity, self-criticism, poor self-esteem, body dissatisfaction, and emotional abuse.5 In female adolescents and young adult women, BED is associated with pre-existing depressive symptoms and an increased risk for developing mood disorders.6

Specific goals of treatment for children and adolescents include treatment of underlying depression or anxiety, improvement of self-esteem, normalization of eating patterns, promotion of physical activity, and implementation of family therapy to address family dysfunction and engage family members in supporting the patient’s recovery. BED treatment outcomes can be optimized through early detection and referral to eating disorder specialists; incorporating a multidisciplinary treatment team to address the physical, psychological, nutritional, and spiritual aspects of BED; and combining cognitive behavioral therapy (CBT), a self-help program, and, when appropriate, pharmacotherapy.

Co-morbid psychiatric disorders

Co-morbid anxiety, mood, and disruptive behavior disorders are common in patients with BED, as are obsessive-compulsive disorder, post-traumatic stress disorder, and substance abuse. Co-morbid obesity increases psychopathology, emotional eating, concerns about weight and body shape,7 and perhaps a desire for bari­atric surgery.8 Obesity and BED are common in patients with bipolar disorder. In patients with personality disorders, alexithy­mia (a personality construct characterized by the subclinical inability to identify and describe emotions in the self) correlates more highly with BED than with other eating disorders.9

A case–control study showed that patients with BED, compared with controls, reported a significantly greater number of adverse life events during the year prior to symptom onset, suggesting that the accumulation of stressful events can trigger the disorder.10 Even after weight loss and CBT, patients with BED experienced higher morning basal cortisol levels than did a control group without BED.

Effects of disordered eating patterns on reproductive health

Disordered adolescent eating patterns affect one’s development, with implications for reproductive function. Behaviors associated with risk-taking and self-harm frequently co-exist with eating disorders and increase risks for unplanned pregnancy and sexually transmitted infections. Obesity is strongly associated with conditions that adversely affect reproductive function.

In anovulatory overweight or obese women, sustained gradual weight loss will regulate menstrual cycles and increase the chance of spontaneous ovulation and conception.11Lifestyle modification has been shown to improve reproductive function.

Effects of binge eating disorder on pregnancy

Pre-pregnancy and pregnancy dietary patterns of women with BED may influence pregnancy outcomes. Many obstetricians do not query patients about weight control or disordered eating during pregnancy, and many patients do not seek treatment. Studies evaluating maternal and fetal outcomes in women with eating disorders are limited.

Women with BED during pregnancy are considered high risk. BED treatment during pregnancy is important for long-term management and reduction of harmful behaviors such as smoking; in fact, treatment during pregnancy is particularly likely to produce long-lasting results.

Pregnant patients with BED need frequent prenatal visits to discuss problems related to both nutrition and BED. Healthcare providers (HCPs) should do the following:

• Empower women to discuss weight and body-image concerns during pregnancy;
• Educate patients that uneven weight gain patterns may occur in pregnancy;
• Inform patients that controlling BED during pregnancy reduces the risk for a large-for-gestational-age newborn;
• Provide or refer for dietary support and meal planning;
• Assess and/or refer for management of psychiatric co-morbidities;
• Provide a routine postpartum visit at 1-2 weeks to monitor for relapse or exacerbation of BED; and
• Provide nutritional and dietary counseling for breastfeeding mothers and for the first 6-12 months postpartum.12

Co-morbid physical disorders

Binge eating disorder is associated with multiple physical co-morbidities, with decreased HRQOL and physical and psychosocial functioning.13 A large majority of individuals with BED receive medical treatment for co-morbidities, particularly obesity-related conditions such as type 2 diabetes mellitus (DM). Weight loss in patients with type 2 DM and BED who control their eating habits is similar to that in persons who have never experienced BED. BED may precede bariatric surgery and/or re-emerge post-surgery.

Screening and diagnosis

Assessment for eating disorders, including BED, should be part of a routine health evaluation. HCPs can use an assessment tool or pose a simple screening question in a matter-of-fact, nonjudgmental, empathetic manner to facilitate open conversation: Do you have thoughts, feelings, or behaviors regarding eating, weight, or body image that occupy most of your time or that make you feel out of control? (See Cases 1, 2, and 3.) The SCOFF Questionnaire can be useful. Practical strategies for screening and diagnosis implemented by the authors include the following:
• Use an eating disorder screening question at routine visits as patients age from childhood through the older adult years;
• Engage patients in a conversation about possible BED;
• Maintain accurate chronological weight records;
• Be familiar with DSM-5 diagnostic criteria;
• Obtain a 24-hour written food intake and feelings journal for
7 consecutive days (including weekends) and review the journals with patients;
• Assess for underlying depression or anxiety; initiate medication if indicated;
• Use physical, nutritional, and psychological findings to incentivize patients to engage in treatment;
• Avoid references to calories, weight, and dieting that may exacerbate feelings of shame or excessive focus on food;
• Advocate an approach for treatment of BED and obesity that does not center on the need for dieting but, instead, emphasizes the importance of specialized psychological, medical, and nutritional care;
• Be familiar with eating disorder specialists in your geographic area and be able to implement the referral process; and
• Confirm that patients follow through with BED treatment.

Binge-eating disorder subtypes may manifest in difficult-to-treat food addictions, which are common in patients with co-existing histories of addictive personality or substance abuse disorder. A marker of substance dependence includes consumption of high-fat/high-sugar foods.14 A food addiction symptom count (using criteria similar to those for substance abuse disorder in the DSM-5) should be obtained for these patients.15 Emotions associated with binge eating may be experienced differently by individuals from specific ethnic, racial, and cultural groups.

Treatment

The American Psychiatric Association has established levels of care guidelines for patients with eating disorders, who can be difficult to treat. Many patients with BED experience shame, embarrassment, self-disgust, depression, and guilt as a result of their eating disorder. They tend to eat secretly or alone and may hide binge foods. Patients may deny that they have an eating disorder and may be reluctant to discuss BED with their HCP. Many patients who use binge eating to deal with difficult life situations are reluctant to eliminate this behavior and do not fully commit to a treatment program. Others welcome interventions that may improve HRQOL.

Nonpharmacologic approaches
Cognitive behavioral therapy, considered a first-line therapy for BED, and interpersonal psychotherapy are effective in patients with BED (See Cases 1, 2, and 3). Other nondrug approaches usually entail a combination of a lifetime nutritional plan, assertiveness training, improved stress management, and moderate exercise to increase lean muscle mass.

Pharmacotherapy
No agent is FDA-approved for the treatment of BED. An application for an indication for lisdexamfetamine dimesylate as a treatment for BED likely will be filed soon with the FDA. Multiple pharmacologic agents have demonstrated benefits at varying dosages in trials conducted between 2005 and 2010.

Antidepressants
Antidepressants address common mood-related co-morbidities. Of note, many patients with BED consume tryptophan-containing carbohydrates that synthesize serotonin. When these patients’ serotonin levels are low, cravings commence. Antidepressants that inhibit reuptake of serotonin can help decrease compulsive/binge eating. In many patients with co-morbid depression (or if CBT is unavailable), selective serotonin reuptake inhibitors (SSRIs) can decrease bingeing (and purging) by 50%, although some patients may not respond to treatment or may relapse with SSRI dis­continua­tion.16 Bupropion has beneficial effects on weight and does not have SSRI side effects. Bupropion dosages of 300-450 mg/day have been shown to be effective.17Psychostimulants
Agents used to treat attention defi­cit hyper­activity disorder (ADHD) affect dopamine/norepinephrine systems associated with both the etiology of BED and eating behavior/reward behavior. An epide­miologic relationship between BED and ADHD has been noted in adolescents18 and adults.19 An association has also been reported between bulimia nervosa (BN) and ADHD; a small study of patients with co-morbid BN and ADHD showed the efficacy of psycho­stim­­ulant medication. An ongoing study is comparing methyl­phen­i­date with CBT in the treat­ment of BED.20Pharmacotherapy during pregnancy
Few studies have evaluated the use of psychotropic agents during pregnancy other than a large cohort evaluation of SSRIs. Additional data may guide decision making regarding the use of agents such as bupropion, methylphenidate, memantine, naltrexone, sodium oxybate, topiramate, and zonisamide in pregnant women.

Conclusion

Binge-eating disorder is a complex, multifactorial condition that requires a comprehensive and integrated course of treatment. Nurse practitioners and other advanced practice HCPs caring for women are positioned to play important roles in patient assessment and management.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013.

2. Witt AA, Lowe MR. Hedonic hunger and binge eating among women with eating disorders. Int J Eating Disord. 2014;47(3):273-280.

3. Jacobi C, Hayward C, de Zwaan M, et al. Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy. Psychol Bull. 2004;130(1):19-65.

4. Jacobi C, Paul T, de Zwaan M, et al. Specificity of self-concept disturbances in eating disorders. Int J Eat Disord. 2004;35(2):204-210.

5. Dunkley DM, Mashib RM, Grilo CM. Childhood maltreatment, depressive symptoms, and body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. Int J Eat Disord. 2010;43(3):274-281.

6. Skinner HH, Haines J, Austin SB, Field AE. A prospective study of overeating, binge eating and depressive symptoms among adolescent and young adult women. J Adolesc Health. 2012;50(5):478-483.

7. Vancampfort D, Vanderlinden J, De Hert M, et al. A systematic review on physical therapy interventions for patients with binge eating disorder. Disabil Rehabil. 2013;35
(26):2191-2196.

8. Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric morbidity in obese women with and without binge eating. Int J Eat Disord. 2002; 32(1):72-78.

9. Wheeler K, Gruner P, Boulton M. Exploring alexithymia, depression and binge eating in self-reported eating disorders in women. Perspect Psych Care. 2005;41(3):114-123.

10. Pike KM, Wilfley D, Hilbert A, et al. Antecedent life events of binge-eating disorder. Psychiatry Res. 2006;142(1):19-29.

11. Pandey S, Pandey S, Maheshware A, Bhattacharya S. The impact of female obesity on the outcome of fertility treatment. J Hum Reprod Sci. 2010;3(2):62-67.

12. Harris AA. Practical advice for caring for women with eating disorders during the perinatal period. J Midwifery Womens Health. 2010;55 (6):579-586.

13. Rieger E, Wilfley DE, Stein RI, et al. Comparison of quality of life in obese individuals with and without binge eating disorders. Int J Eat Disord. 2005;37(3):234-240.

14. Cooper R. Could your patient have an eating disorder? Nurs Womens Health. 2013;17(4):317-324.

15. Gearhardt AN, Corbin WR, Brownell KD. Preliminary validation of the Yale food addiction scale. Appetite. 2009;52(2):430-436.

16. Mehler PS, Anderson AE. Eating Disorders: A Guide to Medical Care and Complications. 2nd ed. Baltimore, MD: John Hopkins University Press; 2010.

17. Stahl SM, Pradko JF, Haight BR, et al. A review of the neuropharmacology of bupropion, a dual norepinephrine and dopamine reuptake inhibitor. Prim Care Companion J Clin Psychiatry. 2004;6(4):159-166.

18. Swanson SA, Crow SJ, Le Grange D, et al. Prevalence and correlates of eating disorders in adolescents: results from the national comorbidity survey replication adolescent supplement. Arch Gen Psychiatry. 2011;68(7):714-723.

19. Hudson J, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358.

20. Quilty LC, Kaplan A. Center for Addiction and Mental Health, Toronto, Ontario, Canada. Methylpheni­date versus cognitive behavior therapy in overweight or obese adult females. ClinicalTrials.gov. 2014.