psyc-123: The Psychology, Biology and Politics of Food
Lecture 13 - Eating Disorders and Obesity (Guest Lecture by B. Timothy Walsh) [October 20, 2008]
Chapter 1. General Housekeeping; Introduction to Dr. B. Timothy Walsh [00:00:00]
Professor Kelly Brownell: All right welcome everybody, good morning. I hope you've all recovered from the trauma of taking the mid-term by now. The teaching fellows are in the midst of trauma incurred from having to grade all the mid-terms — but they're doing a good job at that, so we'll try to get those back to you as soon as possible.
I'm delighted, we have a very special guest here today, Dr. Timothy Walsh. I'll do a formal introduction of him in just a moment, but before do that I wanted to give you a little information on deadlines for requirements in the class. There are two — besides the final exam, which is on the last day of class we have two things. One is the OpEd that's due November 17th, and then the final project that's due November 19th. I'm going to give you a little information on the final project today, and then on Wednesday talk a little bit more about the OpEd, and as you know, there's a lot of information on how to do these on the website already.
We have these two deadlines. You might wonder why in the world they're so close together and there are different reasons that you might propose that this is the case. Let me see if there's a reasonable explanation for it. First, we're going to stop the requirements of the concept sheets before these projects are due so that'll you give some breathing space to do these.
Second, is the OpEd is not a terribly complicated project. It only needs to about 650 words and is about the length of a concept sheet. Now, we'd like it to be more finely crafted than that, and as I said, we'll give you criteria for those on Wednesday. We really want to make sure we get good work on these projects. We also would like to see that the work in the class is finished by the end of the term, so you won't have to worry about projects for this class or a final exam during the exam period.
Here are a few things to remember for the final project. First and I'll show you the places on the website where you can get information. There's a lot of information about how to do these projects on the website. We're very flexible in what people submit for the final project. It could be a research proposal, that is a plan for study; I it doesn't have to be a study but a plan for how a study might be done; I it could be anything ranging from photography to painting, to film, to whatever kind of medium you want to use to communicate some important message in the food policy arena and we give examples of those on the website.
Anything that you do that's different that you think may need to get approved by us, to make sure we like the idea before you start it, please get in touch with us. I'll explain how to do that in a minute. If you do something that's not traditional, like a research proposal, which is perfectly fine, like let's just say you do a painting or some photography collection, or something like that, there need to be some text that accompanies it to explain why you did that, and how that might have an impact. We're going to be grading these on creativity, on thoroughness, and on links to the class, and the criteria you'll see you just a minute.
If you go to the course website, there are two places to look for information on how to do the project. There's information under requirements and under projects — so that gives you plenty of information — and among the things you'll see are how to get in touch with Ali Crum, one of the teaching fellows, so if you feel you need feedback on your idea or if you'd like to make the sure idea is an acceptable one for the class, then please contact Ali and her email address is listed here, and as I said, these are the grading criteria that we'll use for the final project. If you have any questions about these, you're welcome to ask me.
I'm delighted today to introduce the first guest lecturer. We have several more later in the semester, but the first guest lecturer of the year, B. Timothy Walsh, M.D. Dr. Walsh is one of the leading experts in the world on eating disorders. In fact, if I had a loved one with an eating disorder, Tim would be the first one I would call.
He received his medical training from Harvard, after an undergraduate degree at Princeton, he's been at Columbia University many years where he is now the William & Joy Ruane — did I pronounce that right? — William & Joy Ruane Professor of Pediatric Psychopharmacology in the Department of Psychology at The College of Physicians and Surgeons at Columbia University. He is a Vice-Chair of Academic Affairs and Faculty Development for the Department of Psychiatry at Columbia University and has served some time as Chair of The Department of Psychiatry at Columbia University. He's worked in the eating disorders area for many years, and runs a clinic at Columbia on the eating disorders research unit at Columbia University at The New York State Psychiatric Institute — which as I mentioned, is one of the most impressive treatment facilities for eating disorders in the world.
He has received many honors and awards over his career, as you might imagine. He's served as an example as a President of The Academy of Eating Disorders, is involved in a number of societies, and is associate editor of the main Eating Disorders journal in the field. He is published extensively in books and articles all over the place — he'll talk about some of this work today — but as I said, is one of the most trusted figures in the eating disorders field.
As a sign of that, he chairs the working group of The American Psychiatric Association that establishes diagnostic criteria for eating disorders. Some of you may have heard if you're connected with psychology at all, about the DSM, The Diagnostic and Statistical Manual of The American Psychiatric Association, which really says here are the criteria for eating disorders; here are the features that people have to have to be diagnosed; here are some of the treatments that follow from those. A very important series of things follow from those criteria. Who gets the diagnosis and who doesn't? What diagnosis people get? Whether the insurance companies cover treatment and a lot of things rest on what that particular committee decides, and Tim Walsh is the chair of that committee.
As I said one of the most trusted and revered figures in the field, I'm delighted that Tim Walsh could join us today to talk about the work he's done on eating disorders. Let's please welcome B. Timothy Walsh.
Chapter 2. Overview on Today's Lecture on Eating Disorders [00:06:24]
Dr. Timothy Walsh: After this kind of introduction you primarily just want to sit down or, thank you very much and leave, it's all downhill from here for me. It's fun to be here; it's the kind of invitation that I really couldn't refuse, both because Kelly is a good and old friend and colleague, and the kick of coming up here to New Haven and talk to a bunch of Yalies. I mean that's — I couldn't miss that opportunity.
I don't usually talk to undergraduates. I do give a talk every year to the first or second year class of med students at Columbia, and the talk I'm going to give you guys is an adaptation of that talk. It's a little bit more medicalized maybe than is right up your alley but I think it'll cover the territory. The point behind the talk is similar for you folks as for the med students.
I'm aiming to give you an understanding of what the eating disorders are but I'm sure you've heard about them: anorexia nervosa, bulimia, bulimia nervosa, maybe binge eating disorder. I want you to know a bit more about them, some more facts, some information, what they are, what the complications are and what — something of what we know about their treatment, a few snippets about how we can treat these folks.
I want to give you a feel for this, for these disorders. You clearly will know people, you may already know people who struggle with these problems, and I'd like to give you a sense of what it is like to struggle with these problems. I'm going to spend a bit of time trying to take you inside an eating disorder and have a feeling for how difficult it can be. Then I will mention a little about the little we know about etiology, something about treatment, the treatment part is more just to illustrate how you can apply scientific methods to establish facts about treatment. How do we know that something works? — and just illustrate with a few examples of that. That's what — that's my plan.
The things I'm going to be talking about, the entities that I'm going to talk about are listed here. There are really only two that are formally defined, the top two, anorexia nervosa and bulimia nervosa. Binge eating disorder I will talk about briefly towards the end; that's basically binge eating without the purging. Obesity, a few more words on that later, but at least right now, obesity is not a psychiatric disorder, it's not a psychiatric illness. It's a medical condition, excess body fat; and that's not a psychiatric problem, it's a physiological, physical diagnosis.
Let me get started, and the way this thing is organized is I'm going to give you sort of a cross-sectional view of anorexia nervosa, then a cross-sectional view of bulimia, and then talk a little bit about etiology, where it comes from and then talk a little bit about treatment and finally talk a little bit about binge eating disorder.
Chapter 3. Cross-Section of Anorexia Nervosa [00:10:04]
Anorexia nervosa. One of the remarkable things about anorexia nervosa — you still hear me? — is it's been around a long time. We tend to think of it and understandably in terms of the current cultural emphasis on being thin and fit, especially for women in our society; but there's lots of reasons to think its been around much longer than the current cultural emphasis.
Way back in the fourteenth century some of the Italian saints, if they were to be dropped into our midst today, might get a diagnosis of anorexia nervosa. People have written a book — a book has been written about whether some of these folks might be viewed as having a wholly anorexia. They — like St. Catherine of Siena, what we know about her is a little suggestive of the eating disturbances we see today in our clinics. In 1689, Richard Morton, on a book called, A Treatise on Consumptions, consumption came to mean tuberculosis but way back in 1689 it probably covered a whole host of infectious diseases and all kinds of wasting conditions. He described an eighteen year-old girl with what he called nervous consumption and she sure sounds like she had anorexia nervosa.
He didn't have the benefit of the DSM criteria nor did Sir William Gall and Charles Leseque, an Englishman and a Frenchman; but these folks over a century ago described in the medical literature cases — like a half a dozen cases each — of young women who clearly had what we call anorexia nervosa. It was Sir William Gall's name that stuck and that's what we still call it.
A tangent: Anorexia, it's a bad name, it really is literally not quite right. Anorexia is the technical term described for loss of appetite. So when you get the flu and you feel crummy, you don't want eat that's — you have anorexia. The problem with the term for this illness is that these guys, most of them really haven't lost their appetites. They're kind of suppressing food intake but if — there is a lot of indications that they still have some appetite. They don't lose the drive to eat. Anyway, the name has been around for a century, it stuck, and even though it's a little bit off it's not bad, and it's well recognized, so that's the name of this condition.
The diagnosis of this condition is typically not hard. It is characterized by this relentless pursuit of thinness; a drive to be thin that sort of knows no bounds, and will brook no contradiction. Accompanied by an intense fear of gaining weight or becoming fat, and that's despite the fact that these folks by definition are significantly underweight, and often dramatically, as they lose weight they become more afraid of becoming fat. The skinnier they become, the more terrified they are of gaining weight. It's a real paradox, but very powerful. That's the core of it — always has been the core of it — and it's as I said, you don't mix it up with too many other things.
Now, Kelly mentioned the good old DSM. The DSM that's the Diagnostic and Statistical Manual of The American Psychiatric Association and it's got it in a name and a number for every psychiatric diagnosis. When you go to the doctor and you see insurance forms, there's a space for diagnostic code. So if you go in with strep throat there is a code for strep throat. Well DSM has the codes and the names for all the psychiatric disorders and it's — as Kelly said, I've been involved somewhat frighteningly in the construction of these things, and the fear is people take this stuff much more seriously than they probably should. I mean that's another whole-a whole course on the politics and meaning of diagnostic codes.
Anyway, these are the official current DSM criteria for anorexia nervosa and they-I'm not going to spend a long time going through these but what they try to capture, in somewhat more formal language, are those three things that I had on the previous slide: a refusal to maintain body weight at or above minimally normal weight for age and height — so they're underweight by definition; accompanied by an intense fear of gaining weight or becoming fat even though they're skinny; criterion (c) is the most awkward, at least in terms of language, the short hand is distortion of body image.
What often happens — I mean this is a lot of multi-syllable words there — what often happens is things like, somebody despite weighing 80 pounds will say, oh my thighs still touch sometimes, I'm just not right, this isn't as it should be. Or they'll find a skin fold even at 80 pounds they can find a fold of skin and say this is not — this isn't the way it should be, this isn't right, so they'll focus on a part of their bodies and say this isn't right, I need to keep losing weight or I can't stand to gain any. Women with anorexia nervosa don't have regular menstrual cycles. Those are the core criteria, the official criteria, but what they don't do very well is give you a sense of what this disorder is like.
What I'm going to do is spend a few minutes reading from a letter that I got, to date myself over thirty years ago when I was a psychiatric research fellow or resident I think, at Montefiore Hospital in the Bronx just learning psychiatry and was just getting introduced by people like this one to anorexia nervosa. What this woman does is — she was-she had heard of a research project that we were doing, and wrote a letter of introduction to describe what was troubling her in hopes that we might be able to provide some assistance. In doing so, she really wrote one of the best descriptions from the inside of what it's like to have anorexia nervosa followed by the development of bulimia. Permit me to read for a few minutes from her letter. "Several years ago in college I started using laxatives to lose weight. I started with a few and increased the number as they became ineffective. After two years I was taking 250 to 300 Ex-Lax pills at one time with a glass of water, twenty at a gulp. I'd lose as much as ten pounds in a 24-hour period, mostly water and some food, dehydrated so I couldn't stand, could barely talk. I ended up in the university infirmary several times with a diagnosis of food poisoning or flu. Bland diets, medications and I was released in a day or two.
I wouldn't eat for days and then would eat something and overcome by guilt at eating and by hunger would eat, and eat, and eat. A girl on my dorm floor told me that she occasionally forced herself to vomit so she wouldn't gain weight. I did this every once in a while, and discovered that I could consume large amounts of food, vomit, and still lose weight. I lost nearly 50 pounds over a few months to 90 pounds. My hair started coming out in handfuls and my teeth were loose. I never felt lovelier and more confident about my appearance. Physically streamlined, liberated, close to the bone. I was flat everywhere except my stomach when I'd binged, when I'd be full blown and distended, so I was bent over with each rib and back vertebrae outlined. After vomiting my stomach is once more flat and empty.
The more weight I lost the more I was afraid of getting fat. I was afraid to drink water for days at a time because it would add pounds on the scale and make me miserable — yet I drank or drink easily a half a gallon of milk and other liquids at once when binging. I exercised for hours each day to tone my figure from the weight fluctuations, and joined the university track team. I wore track shoes all the time and ran to classes and around town, stick legs and arms pumping. I went to track practice daily after being sick, until I was forced to quit. A single lap would make me dizzy, cramping my stomach and legs.
At some point during my last semester before dropping out, I came across an article on anorexia nervosa. Its application frightened me. My own personal obsession with food and body weight was shared with other people. I hadn't menstruated in two years, so I forced myself to eat and digest healthy food. I hated it.
I studied nutrition and gradually forced myself to accept a new attitude towards food, as vitalizing, something needed for life. I gained weight fighting panic and in a rigid controlled way I've maintained myself nutritionally ever since at about 110 pounds at 5 foot six. I know what I need to survive and I eat it, a balanced diet with the fewest possible calories, mostly vegetables, fruit, fish, fowl, whole grain products.
In five years I haven't eaten anything like pizza, pastas or pork, sweets or anything fattening, fried or rich without being very sick. Once I allowed myself an ice cream cone but I'm usually sick if I deviate by as much as one bite.
It was difficult for me to face people at school and I dropped courses each semester, collecting incompletes, but finishing well in the few classes I stayed with. The absurdity of my reclusiveness was evident even to me during my last semester, when I signed up for correspondence courses while living only two blocks from the correspondence university building on campus. I felt I'd be able to face people when I lost just a few more pounds.
Fat. I can't stand it. This feeling is stronger and more desperate than any horror or what I'm doing to myself. If I gain a few pounds, I hate to leave the house and let people see me, yet I'm sad to see how I've pushed aside the friends, activities, and state of energized health that once rounded my life.
For all this hiding, it'll surprise you to know that I am by profession a model. Last year when I was more in control of my eating and vomiting, I enjoyed working in front of a camera and was doing well. Lately I've been sick too much and feel out of shape and physically unself-confident for the discipline involved.
The more I threw up when I was in college the longer it took, and the harder it became. I needed to use different instruments to induce vomiting. Now I double two electrical cords and shove them several feet down into my throat. This is preceded by six to ten doses of Epicat which is the stuff you can get in drugstores over the counter to induce vomiting in kids who have had something they shouldn't have eaten. My knees are calloused from the time spent kneeling sick. The eating, vomiting process takes usually two to three hours, sometimes as long as eight. I dread the gagging and the pain, and sometimes my throat is very sore and I procrastinate using the Epicat and the cords.
After emptying my stomach completely, I wash thoroughly. In a little while I'll hydrate myself with a bottle of diet soda and take a handful of 40 milligram Lasix. Lasix is a powerful fluid pill, water pill by prescription only, for which she has numerous prescriptions. Sometimes I am faint and very cold. I splash cool water on my face, smooth my hair, but my hands are shaking some. I'll take some aspirin if my hands hurt sharply, so I can sleep later. My lips and fingers are blue and cold and I see in the mirror that blood vessels are broken, leaving red spots over my eyes, but they always fade in a day or two.
There's a certain relief when it's over that the food is gone and I'm not horribly fat from it. I cry often for some rest, some calm, but it's foolish for me to cry for someone, for someone to help me when it's only me who is hiding and hurting myself."
That remains thirty years later, one of the most compelling descriptions of what these illnesses are like, starting with anorexia nervosa and developing into what we now call bulimia nervosa. It illustrates that this woman, though tortured by her obsession and by her behavior, is clearly smart, clearly articulate, and her thinking is otherwise pretty clear. She's not crazy, she's not psychotic, and it also illustrates the peculiar ambivalence she feels. She understands what's smart and sensible, tries to do it, but struggles mightily.
A couple other things: one, the history she gives of vomiting getting harder and harder as she did it, is unusual. Most folks who start to induce vomiting find it gets easier and easier, so that's unusual. The other thing that's worth noting is the last I heard from her was as long time ago. She did come, she was part of the research study, went back to the Midwest where she was from — and the last I heard from her was an announcement of her wedding. As far as I know, she made a very full recovery from these disorders which illustrates that despite the severity of these kind of behavioral problems and the physical problems associated with them, people can get all the way better from these eating disorders. They are not life sentences and she — her history, as far as I know, illustrated that.
Back to more technical things. One of the things that you discover taking care of people of anorexia nervosa is there's a lot you've got to worry about, and they worry about, and their families worry about that is — than is part of the official diagnostic criteria. There's a lot of stuff that's going on that gets in people's way.
This slide summarizes some of the behavioral things that go wrong and some of the physical things that go wrong. Not always but quite often.
Behaviorally and psychologically people, with anorexia nervosa are obsessed with food. There are good foods, there are bad foods: if I eat a good food I'm a better person, if I eat a bad food I'm a worse person, so moral values. They often develop, typically develop strange eating patterns: certainly diets that avoid calories, but also strange concoctions, strange flavors. On our inpatient unit down at Columbia, we really have to basically prohibit artificial sweeteners like Sweet N' Low because these folks really, really want to get their hands on these artificial sweeteners. They add vast quantities of — some of them add vast quantities of artificial sweeteners to things like salad and lettuce.
Some of them will binge eat. The kind of binge eating that that letter illustrated, is a characteristic of maybe half of patients with anorexia nervosa, who sometime their illness whether underweight will start to binge eat. Some of them will abuse laxatives and fluid pills like she did. Compulsive behavior is commonly observed. A lot of the compulsive behavior is around food and exercise and things like that, but sometimes it starts to get into other areas, rituals with clothes and makeup, and how the room is organized.
People with anorexia nervosa, if they talk about their mood, which can be hard for them, are depressed. Again, that letter kind of illustrates it. There's this unhappiness that pervades much of their life. They become socially isolated typically, so a kid who's been an outgoing sixth grader and in ninth grade develops anorexia nervosa and becomes more of a bookworm, and someone who's running track long distance. Increased physical activity is a common feature, at some point, of many people who develop anorexia nervosa.
The right side of the slide are physical problems, and this is again more for the med student types, but just to illustrate, almost every system in the body gets something wrong with it in anorexia nervosa, if you look hard enough. This means body temperature is down, heart rate is down, blood pressure is down, lanugo is this interesting soft hair that some folks regrow — I'll show you a picture in a minute — it's normal in infancy, but in some people it reappears in anorexia nervosa. Edema, fluid retention and ankle swelling happens sometimes, blood counts are down, liver function tests can be abnormal, the reproductive axis — actually it's interesting. It's a brain based shut down of the reproductive axis.
The way, believe it or not, and you guys may already know this which I probably didn't know until I finished medical school, the way the reproductive hormones are controlled is from the brain. The brain puts out a hormone which hits the pituitary gland right below the brain, which secretes things like glutenizing hormone and follicle stimulating hormone, and it's these things that have the ovaries make estrogen.
What happens in anorexia nervosa is the brain stops making this key release hormone so there's top-down amenorrhea, and this is profound. I mean this is why these folks don't menstruate. Thyroid's a little messed up. Cholesterol can be high for reasons I've never understood. If you look at brain mass with things like MRI imaging it appears to be down, and bone density starts to go down. So a lot goes haywire, and this stuff can be serious medically.
Now one of the things that's worth knowing, among the things worth knowing from this is — and it probably wouldn't surprise you is the stuff on the right side of the slide, all these physical things are seen in any form of malnutrition. This is what happens to humans when they're starved, these sort of complications.
What problem isn't as obvious is that statement is also true of the stuff on the left side of the slide. Human starvation creates a lot of psychological and behavioral change and the best documentation for this is a remarkable study done during World War II in the late — mid to late 40s, mid-1940s, published a few years later called The Minnesota Study.
You've heard about this apparently, what it documents is the remarkable changes that occur with starvation and there is a paper that — maybe you can add to next year's class, there's a paper coming out — that came out of it called Induction of Experimental Neurosis in Man by Starvation. They describe in these men a whole bunch of physical changes, behavior and psychological changes, including some really irrational strange behavior that these guys developed because of starvation.
One of the things that implies is that therefore a lot of what people with anorexia nervosa are struggling with, are the psychological and behavioral effects of starvation. It isn't just sort of a part of the illness, this is an affect of the illness. So to get these folks better we got to fix the starvation. In other words, it doesn't make sense that we can fix the problems of starvation without — by doing anything else but fixing the starvation. We can't give them a pill; we can't give them a psychotherapy that will make all that go away, if they're still starving. Reversing the starvation, the principle is, becomes part of the treatment, it's not the end result of successful treatment, it's part of the treatment.
Here are a few illustrations. This is a picture of a patient on our unit some years ago, you can figure — you can detect how skinny she is by the hollow of her cheeks and how prominent her jawbone is, but these are the soft body hard called lanugos, it's on her cheek, it's on the back of her neck, and it appears in some folks, not all, during anorexia nervosa. This is bone density, so what this shows is by groups of kids by year of age, twelve to seventeen. This bone mineral density in the spine, so just a little beam — a reading to convey a little beam of how much calcium there is basically in the spine.
The open circles on the top are normal kids, and you can see as you would expect — these are all girls — as adolescence precedes bone density increases. It's during adolescence and early adulthood that peak bone density is achieved. It's probably true for all of you. This is it! From here on it's downhill, like for many other parts, you've probably hit peak about now, and including bone density, let's hope you hit a high level because it's downhill from here. The next series are girls who've had anorexia nervosa but less then a year and their bones are still normal. The closed circles are bones from girls, bone density among girls who have had anorexic nervosa for more then a year, and you can see even in these youngsters there's a significant change.
Now most of this isn't symptomatic in these youngsters, but the worry is, if there really is a window of opportunity to hit your — what nature intended for your peak bone density to be, and you miss it because you've got anorexia nervosa, it's possible you won't be able to play catch up. So that's one worry about permanent physical effects of anorexia nervosa. But everything else, all that other stuff that was on the right side of that slide, if you fix the starvation it gets fixed like the reproductive system it wakes up again, it goes back to normal, there's no reason we have to suspect that there's any permanent damage to anything except maybe bones from having anorexia nervosa. So a complete recovery physically and psychologically is entirely possible. It does happen; it happens a lot fortunately.
Who gets this thing? I'm sure you already know this; it's mostly women, mostly girls but not all. Men, boys get the real item. Everything's parallel, they don't make much testosterone like the girls don't make much estrogen, but they get the real live illness. It tends to begin in adolescence, mid-adolescence, and start right around the time of puberty or even a little before, certainly fresh onset in the twenties, but rare after that. Still does tend to come from the middle-upper classes, though not exclusively. You certainly see people from poor families who present with anorexia nervosa. I assume because of the link to economic state, tends still to be Caucasian in this country, but again, not exclusively, all racial and ethic groups can get this.
The folks who develop anorexia nervosa: are they sick? Do they look strange or peculiar prior to illness onset? Probably not much as best we know, it's very hard to know for sure, but probably not much. Maybe a little obsessional, a little more rule-bound than their peers, but not a lot. Typically, there are exceptions, but these are typically not kids who stand out as being troubled kids prior to this illness. It remains relatively uncommon despite what we hear about it and read about it in the press. It remains a relatively uncommon illness, fortunately.
As I said, what happens to folks who develop this? Full recovery; a major chunk of the people get better period; psychologically, physically they get better and live happily ever after. On the other hand, people continue to die of anorexia nervosa and the best estimate — and I'll show you the data in a second — the best estimate is 5% of people who develop anorexia nervosa and — people who have serious anorexia nervosa so they go to a medical center; 5% of them die per decade of being followed.
If you just try to see what happened to them, five or ten years later 5% die per decade and that's mostly starvation, they just drop dead at a low body weight or suicide. The rest of the folks, a third to a half something like that, are alive but continue to have symptoms of some sort, including bulimia like the young woman whose letter I read from. She recovered from anorexia nervosa but then developed bulimia — which I hope, and think she eventually got over. It's very rare for anybody who's had anorexia nervosa to ever become obese which is interesting.
These are the mortality — this is the backup data for that 5% per decade and also one of the reasons I put it in here is to illustrate to you how people in the medical field get data. It's still not a very sophisticated study but it's useful.
What this fellow did, Pat Sullivan way back in 1995, he collected — he just looked up forty-two studies in the literature that had presented information on how long on average they had followed the group of patients, of individuals, and what fraction of the people had died. Each dot is a study.
So this one way out here, I think is a study from Sweden, it was actually published many years ago where they managed to follow most of the patients for thirty-five years, and at that point almost 25% of that group had died. This straight line — now there's a lot of scatter but this straight line is the best approximation of these data and leads to roughly every decade you get about 5% of the folks die so that's that data.
Now you think 1995, that was a long time ago, we're clearly doing better now. Well, the red dot is a study from Germany I think two years ago, and it remains a worry. That doesn't-it's very hard, there are all kinds of differences between these studies. I mean age of the patients, how they were picked up, all kinds of reasons to-for them not to be comparable. But we certainly don't have any strong reason to believe that the outcome of anorexia nervosa, I mean serious anorexia nervosa is dramatically better now then it was 25 years ago, I'm sad to tell you.
Chapter 4. Cross-Section of Bulimia Nervosa [00:37:52]
Okay, so that's cross-section of anorexia nervosa. Another — this is a quick cross-section of bulimia nervosa. Again, like anorexia nervosa, the core features are really straightforward. Its recurring episodes of binge eating, and recurring inappropriate compensatory behaviors to compensate for the binge eating, that's it. Again, in this case, as long as people will tell you, are willing to describe what they're doing, it's a simple diagnosis to make. But if they're not willing to tell you what they're doing, you can probably never be sure, despite a lot of circumstantial evidence that may make you think that they have it.
Here again, is the DSM-IV criteria which just to articulate that in somewhat more formal terms, recurring episodes of binge eating, recurring and inappropriate compensatory behavior to prevent weight gain, the DSM-IV somewhat arbitrarily, but to keep a lot of people who probably don't have a mental disorder from getting this label potentially said, we're not going to give this label, the label should not be given to folks unless they are binge eating and doing inappropriate things to compensate at least twice a week for three months. There's a frequency cut, it has to be a recurrent, persistent behavioral problem. These people worry more then their peers about their shape and weight.
Criterion (e) says this isn't just anorexia nervosa. This may be — one of these fine points — what it means is if somebody's got anorexia nervosa and they're underweight and they meet the criteria for that illness, but they're also binging and vomiting, they only have one eating disorder, they have anorexia nervosa with binge eating and vomiting. They don't have anorexia — they don't have two eating disorders, they don't have anorexia nervosa and bulimia nervosa. So this — what this does in the formal system is the trump. It means anorexia nervosa trumps bulimia nervosa so that's what — that somewhat confusing thing does.
Now let me see what I've got next. Back to good old DSM. So Dr. Walsh, what is a binge? Now the committee that I — I chaired this committee the last time this was done, that was about twenty years ago, so I have not been asked to get it right this time. I clearly have — I had to repeat the course. Anyway, this is maybe a part of the reason, a committee of wise people — I think they were wise, this is the wisest I could find — labored hard to come up with a definition of what's a binge. Eating in a discrete period of time like less then two hours an amount of food that's definitely larger then most people would eat in a similar period of time under similar circumstances, accompanied by a sense of lack of control.
Now it's all right but its still — it's subjective. I mean it means that the clinician tries to get a history from the patient and makes a judgment about whether that amount of food that the patient said that they were currently eating is really more then somebody would appear to eat in that time. But just — and you see people who come to the clinic complaining of I didn't want to eat the cookie, I ate the cookie, I couldn't stand myself so I induced vomiting. Well a cookie's not — that's not — is that a binge?
It's hard to draw the line, but just to make the point that many people with bulimia, in fact, really have a behavioral disturbance.
I'll read to you a list of what one of our patients wrote down she consumed during the course of one binge between 4:30 and 6:00 one afternoon, and that was five butterfly pastries, three barbequed chickens, three-quarters of a small jar of mayonnaise, a quarter of a loaf of Italian sliced bread, a quarter of a pound of margarine, a regular sized jar of peanut butter, a half a gallon of milk, twelve ounces of Sugar Crisp, a box of chocolate chip cookies, a liter of Diet Sprite and two cans of cake icing; and that was thrown up by the end of that period, and a similar binge was repeated at 10:00.
I'm not — I don't think this is typical but what I would want you to understand that people with bulimia who come to clinics to get treatment and who get the diagnosis appropriately have a behavioral disturbance. It's not just I feel like I ate too much and I feel bad about it and I did something funny afterwards; their eating is not normal and we — it's still a problem of where to draw the line for sure and that is a problem. There's no question that there's a behavioral abnormality that's involved in this disorder.
A few bits about the characteristics of folks with this illness. It's a lot like anorexia nervosa, and as I already said, a bunch of people who have had anorexia nervosa end up moving into bulimia when they gain weight, their weight becomes normal, but they keep binging and vomiting. It's mostly women. Weight's normal. Onset's a little bit older then anorexia nervosa. If typically anorexia nervosa is a high school illness this is typically a college illness with a lot of variation.
Binges are large among people who come to clinics. What people binge on — I don't know if you folks hear it, but for awhile you were hearing about carbohydrate craving, and carbohydrate binging — people don't binge on pure carbohydrate that would be — I mean this group probably knows this better then I do, that would orange juice and grapes, and Kool-Aid. They binge on sweet fat foods, the kind of foods mammals like to eat, at least humans like to eat, they're combinations of sweet and fat, so donuts, ice cream, coffee cake; it's that sort of stuff that we all like and that's what people tend to binge on.
Most people who come to clinics with — and meet criteria for bulimia induce vomiting afterwards so that for sure in the most common inappropriate compensatory behavior. About a third take laxatives, excessive amounts of laxatives. Among normal weight people who do this, this is a physical complication, again maybe a more med student oriented, but the most important thing to know is that most people who do this regularly like for five or ten years, have no physical complications. This is impressively tolerated, as long as weight is maintained at a normal range. The body is able to tolerate this sort of stuff, on average, surprisingly well. Now it doesn't mean its good and it doesn't mean there aren't complications, it just means that fortunately they're uncommon.
The things you do occasionally see are menstrual irregularity, problem with teeth, I'll show you that in a second, and large salivary glands like the glands that blow up when you get the mumps right in front of your ears, they get enlarged. People who abuse — anybody who abuses laxatives to induce bowel movements can become dependent on laxatives. Epicat is the stuff that I mentioned that the woman who wrote the letter had taken. If you take too much of that stuff you can make yourself sick from it. Rarely, very rarely fortunately, there are cases reported of people who consume so much during a binge that they'll rupture their stomach and that's got a mortality, that kills people, but fortunately it is extremely rare, knock on wood.
The physical abnormalities I won't detail but they're the kind of — they result from the purging behavior. If you — if for whatever reason you're vomiting a lot, self-induced or otherwise, you start to — your fluid balance and salt balance gets messed up in characteristic ways and that's what happens to these folks; some of them but rare. You run standard lab tests on 100 people with bulimia, you get abnormalities in five, it's not anywhere near as common as you would think.
Uh oh, technical problem. Stuck! This is an example of an enlarged carotid gland, salivary gland, and people can — some people get swollen up. It's probably the stimulation, it's probably the repeated stimulation of the eating and the vomiting that causes some hypertrophy of these glands, growth, and enlargement.
Teeth. This is a young lady who we saw at our clinic and she has a filling in her top right front tooth and that's probably related to the bulimia. What's more striking even then that is the size of her top teeth. Her top front teeth are actually shorter then her bottom front teeth and it turns out that any kind of acid softens dental enamel. Don't suck on too many lemons! So any kind of acid over time will soften dental enamel and eventually it'll get soft enough, it'll start to chip away; and some people with bulimia purge enough by inducing vomiting and wash, particular their front teeth, with stomach acid over and over and over again that they start to lose tooth, they start to lose dental enamel, and that's what happened here. So that's obviously a permanent complication of bulimia, rare but it obviously happens.
This is just — this has some historical interest but I won't bore you with that. This illustrates just how prominent these behaviors can become. This is the back of somebody's hand with bulimia, and what you can see is a callous on the back of her hand, there and there, calluses. She got these by inducing vomiting, by tickling the back of her throat with her fingers, and every time she did that the back of her hand would bump against her front teeth so she got calluses on the back of her hand. It gives you some idea for some of these people just how recurrent and obsessive, if you will, the behaviors can become that you see things like — rarely see things like this.
Chapter 5. Prevalence of Eating Disorders among Women [00:49:21]
I've already told you that the prevalence of anorexia nervosa among women, lifetime prevalence remains pretty low, half a percent, a percent and real live bulimia nervosa, I mean card carrying, DMS-IV bulimia nervosa is one or two percent, so it's more. Certainly bulimia nervosa is more common.
Now, you're probably thinking, wow it's got to be more then that, I know people or I've met people or whatever. What — I think a part of that impression is that these numbers are for full bore syndrome, with all the characteristics, the diagnostic characteristics that I've described.
There are a lot of other people who have eating disorders, there's no question they have real clinically significant easting disorders that have features of anorexia nervosa and bulimia, but aren't full-fledged. If you look at atypical cases or sub-threshold cases, you probably at least double those kinds of numbers, but counts are hard because we don't have good labels for what those things are. Hardcore is relatively uncommon but certainly not unknown variants that are less severe are also significant in number and probably you get up to a 5% kind of number. Is that a question? Should I take a question, doctor?
Professor Kelly Brownell: Well you have about twenty minutes left.
Dr. Timothy Walsh: I got twenty minutes left. I'll take a question.
Dr. Timothy Walsh: That's the problem with taking questions. The question is, so what do you mean by full recovery, doctor? Well that's complicated, and that's why the numbers are fuzzy. You can — it's relatively easy to define physical recovery from anorexia nervosa in terms of weight. You can pull a number. It's relatively easy to say, assuming someone's being truthful, that they've stopped vomiting and are no longer binging, so we got that.
Where it gets really hard to know is psychological. I mean how much obsession with shape and weight is within normal limits? That — people have various criteria for that and it will — it seems very clear that many people with anorexia, who once had anorexia nervosa, will continue to be at least somewhat more concerned about body, shape, and weight, and eating than their peers. But is that — are they recovered or aren't they recovered? And then you can get into a debate of what constitutes full recovery. That's what you get for asking. That's a good question; I mean I wish I had a good question. The problem isn't the question, the problem is the answer. Anyone else want to pop in with a question? I'm kind of transitioning to a slightly different section I think. All right, let me keep rolling, I'm about on time.
Chapter 6. Theories of Development of Eating Disorders; Obesity [00:52:32]
Why do these things happen? Why do people get anorexia nervosa and bulimia? The answer is: we do not know. I mean let's make this absolutely clear, and let me tell the med students and the psychiatric residents, we do not know why people get eating disorders. Now, it's not that we don't know something, and I'll give you some illustrations of the things we know, but it's far from rigorously predictive, so we go to a sixth grade class and talk to, get blood samples from all the girls and we know okay well these three girls are going to get anorexia nervosa. We are so far from our ability to do that, that it means we really don't know. We can — we know some things but we don't know anywhere like what we should.
The theory that I would suggest to you that helps understand development of disorders, including eating disorders, thinks about things in areas and in different kinds of factors. There are things that increase the chances that someone's going to get an eating disorder. Being female, genes contribute, there's little question about that, environment matters and the kind of culture you're grown up in and the society — the family culture, the school culture, and the society you're in, and particularly our society which emphasizes, especially for women being thin as being some marker of attractiveness. Most people have those, most women in this country have those factors, or many of those factors, but most of them don't get anorexia nervosa or bulimia. Things precipitate the illness.
The things that appear to precipitate these illnesses appear to be stresses of adolescence. But typically the people who develop these illnesses aren't exposed to dramatically stronger stresses. Adolescence is stressful, you got to learn to maneuver all kinds of things, get into college, go to Yale; that's stressful, but they're normal. I mean part of growing up is learning to navigate the stresses of growing up in adolescence. For some people that — some of the stresses for adolescents, of adolescence seem to trigger an eating disorder in a way that I think fundamentally is a bit mysterious.
Then once the thing gets started, it seems to take on a life of its own and a simple example might be for bulimia, folks continually diet, food deprivation tends to make you want more food, so that could lead to binge eating which could lead to more vomiting and dieting, which could set the stage for more binge eating.
There's the sense that once the illness or these illnesses get started there's a vicious cycle that keeps them going and what's — what I think is true is the clinician's job taking care of patients is to interrupt that. I mean it's my job to help people get over the illness. That doesn't mean necessarily figuring out why they got it; only if figuring out why they got it helped. If that isn't going to help me help them get over the illness, it doesn't matter. It's a little extreme but it-the focus has to be, as best we can figure out, what's keeping this thing going.
That's how we tend to think about the development of eating disorders. Multifactorial interactions making some people more vulnerable then others. Stress, illness develops and then persists and takes on a life of its own, that's the picture. A lot of unknowns that I wish we had a better handle on.
To talk about one: culture. So what are the images that we see? I don't know if Kelly goes through any of this sort of stuff elsewhere in the course, anyway, so images of women that are presented to us. Whatever you may or may not think of Sports Illustrated and the swimsuit issue, here's the 1965 cover and the 1999 cover, and again telling you more then I probably should, this is when I was in your seat. I was in where you're sitting back in 1965, so if I picked up and I have no idea whether I saw that or not, this is what I would have seen. I have no recollection, I deny, absolutely deny.
This woman, I would suspect has — she's a normal cover girl, that's (a) normal cover girl. She's got more — there are more indications she has subcutaneous and normal body fat then there are on this lady. She's posed in a certain way and she looks very lean compared to this woman who has obviously normal body fat. You would tend to believe that the images we're seeing are changing have changed.
These are data from a letter to the editor to JAMA, The Journal of the American Medical Association from 2000, showing the BMI, the body mass index, which I assume you are familiar with, the indication of normality of weight in adults. The BMIs of Miss America pageant winners over whatever this is, eighty years, going down, and there's variation of course, but the Miss Americas have gotten skinnier. There is a cultural trend.
Now, precisely what this trend has to do with the development of eating disorders to nail it, to say this is why there's more eating disorders then there used to be is very hard to — in a rigorous scientific way but I — in my heart, I think it's got to be that the emphasis on being thin and being fit and the push on people to diet increases the chances that people are going to get into trouble of one sort or another. Whether it causes more anorexia nervosa or not is unclear, it's hard to think it doesn't cause some trouble.
Now, just a few words about obesity, I mean there is no question that compared to obesity eating disorders are a much less severe public health problem. I mean you — it's easy too — because of the numbers, the fraction of people who are obese in our country are far, far higher and have medical complications associated with that than the folks who have eating disorders.
I mentioned the DSM a bunch of times, for DSM V, and that work is now going on for reconstructing DSM for V; and Nora Volkow who is head of NIDA, The National Institute of Drug Abuse, and Chuck O'Brien who runs the psychiatry department at The University of Pennsylvania, in an editorial in The American Journal of Psychiatry last year, wondered should obesity be included as a brain disorder, i.e., a mental disorder.
I honestly don't think so, I think there are a bunch of reasons — a whole bunch of — Kelly and I could perhaps discuss — I think it's a bad idea on multiple levels, but it's gotten to this point that people are starting to think what are the connections, and that's a very interesting question, is what are the links between obesity and eating disorders? How would we understand those which is a great question but I don't think we're going to get — I don't think obesity is going to make it for DSM-V. Ten minutes, we're going to make it, we're all right ten minutes.
Chapter 7. Binge Eating; Treating Eating Disorders [01:00:29]
Binge eating disorder, recurrent binge eating, no compensatory behavior, feeling bad about it, so binge eating no purging. Interesting, these guys and girls are older, these tend to be middle age people, more males, maybe a little bit more female, but a lot more males have this then anorexia or bulimia. Most are overweight or obese and most have mood and anxiety disturbance. Now — that was it, that's all I'm going to say about binge eating disorder other then it's status in DSM-IV. In DSM-IV it's in the back of the book, it's a maybe it should be a disorder category, in DSM-V it's up for grabs and that's — it is a hot topic and we could talk a while about that.
A few words about treatment. One of the reasons labels are important, should be important, is they tell you about what treatments might work. For eating disorders, I believe, that the labels, imperfect though they are for anorexia and bulimia, tell you about different things. I think it supports some validity of the DSM system for eating disorders.
These are treatments for — let's talk anorexia nervosa first. These are treatments proposed for anorexia nervosa. On the left physical treatments, on the right psychological treatments, a great history of mental health treatment; hormones, lobotomy, shock treatment, Thorazine, insulin, Prozac is at the bottom, and all kinds of psychotherapies, meaning two things. One: people — this illness can be very difficult to treat, people will throw at it anything that's in their tool bag in trying to help people get better.
Two: the only way you know something's going to work in general, is you got to do a control trial, you got to, got to, got to apply scientific methods to know whether any of this stuff works or is worthless. You need data, good data; it's very hard to come by. What we know is people have to gain weight, I mean from the rationale I gave you a while back, believe it or not it's hard to gain weight. I mean that's an unbelievable statement but for these people it's hard to gain weight. To gain — you scholars and Dr. Brownell will agree with these calculations, but a human pound is worth about 4,000 kilocalories thermodynamically. If you want to lose a pound you've got to create a caloric deficit of about 4,000 kilocalories. To gain a pound it's the opposite — you got to create an excess of intake over expenditure of around 3,500/4,000 calories.
We get people who are 30 pounds underweight. We want them to gain two or three pounds a week, that's an excess beyond what's needed for maintenance which is more like 2,000 calories a day, they've got to take in an extra 8,000 to 12,000 calories per week, so an extra 1,000 or 2,000 calories per day, day in and day out, that's very hard. It's very hard for any us believe it or not, very hard for people with these eating disorders.
We can do it. We can do it in structured treatment programs with just having them eat and you rarely — parenteral role means IV or NG — not parental, parenteral; parenteral methods mean you don't usually have to put an IV in, people can be talked into eating. We don't have a silver bullet for psychotherapy; one of the things that's really interesting is the development of this Maudsley Method of family treatment for young non-chronic patients with anorexia nervosa. It puts the parents in charge of their treatment. You got a sick kid, you really got to get this kid eating again, we're to help you, but it's your responsibility. It's wild but it works apparently. We need more data but the early returns are very encouraging. No pills work, I mean we got — I'm a psychiatrist, we got pills for almost every human ailment. I mean we're good. For anorexia nervosa we got nothing, it's really a stunner.
For example, this is a study that we did in our unit, people who are hospitalized with anorexia nervosa, seven weeks — this is the weight just in pounds, gaining weight we can help people gain weight on Prozac and placebo, didn't help didn't hurt, made no difference. Even more remarkably perhaps Prozac — this is the Prozac group and the placebo group, and a measure of depression — this is a self rating form for mood — there's no difference and mood gets better in both groups but it doesn't get more better on Prozac then placebo, it doesn't seem to work. It's a real disappointment and a real problem, but this is data. One of the reasons to show this to you is you can get data to evaluate utility of interventions and you need data, otherwise you're just making stuff up.
For bulimia it's a different picture. One of the remarkable things is that for bulimia the data are different. We have a good — for example we have a good form of psychotherapy called cognitive behavioral therapy and medications clearly work. Just to illustrate I mean I could — we could go on for a while, but just to illustrate some of these kind of data, these are the drug data, these are each — so each trial — each set of bars is one trial in which people were randomized. These are typically outpatients randomized to active drug in dark blue and placebo in light blue, followed for eight weeks and what I'm measuring here is percent reduction in binge frequency, where obviously — I mean for 100% reduction on binge frequency we want it to go away.
We'll take statistically significant differences between drug and placebo as the indicator of utility and it almost always works. Different drugs, each — these are by and large different drug per trial but drugs work, they help people reduce binge frequency. This is a Prozac trial, 60 milligrams of Prozac compared to placebo clearly reduced binge frequency. Prozac's the only pill for any eating disorder. Prozac for bulimia, FDA has given a stamp of approval. It's interesting, you can get data, you can learn things from the data but treatment and you can hopefully improve folk's treatment.
Binge eating disorder is more — is interesting and more complicated. For binge eating disorder we want people to stop binging, we'd like their obesity to get better, we'd like them to lose weight and we'd like them to feel better psychologically so you're kind of aiming at three targets. There's more words here, I should have made this simpler; but the bottom line is, what's confusing about binge eating disorder is anything you give people makes them stop binging. I mean it's easy relatively to have them stop binging, but there doesn't appear to be anything like a tight link between stopping binging and losing weight which is puzzling. I don't — I think we're a bit in a muddle about what exactly to know about how to treat binge eating disorder but it's — this is a moving target. I mean this is something people are working hard these days.
Okay, to sum up, anorexia nervosa: a disorder recognized for centuries, still poorly understood, and sometimes, not always but sometimes still difficult to treat. Bulimia nervosa: more recently recognized, first clearly identified as a syndrome in 1979. Useful treatments rapidly developed, psychotherapies, medication, interesting.
Binge eating disorder: a lot of questions I think still exist. We still really don't know for sure that it's a real disorder, so that's my sense of the state of the field as of October 20th.
Finally, I wanted to say thank you to Dr. Brownell for inviting me to do this, it is a kick to come to Yale and be with you folks.
I wanted to before I closed finally, I wanted full disclosure. You may have noticed — I got a lot of blue, I got the blue shirt, I got the blue background on the slides, there's a lot of orange that's been prominently displayed, so I cannot leave you without one final recommendation for beating Yale, my true colors. Thank you. I'm happy to take questions.
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