WEBVTT 00:01.390 --> 00:02.950 Prof: All right welcome everybody, good morning. 00:02.950 --> 00:07.290 I hope you've all recovered from the trauma of taking the 00:07.293 --> 00:08.693 mid-term by now. 00:08.690 --> 00:12.310 The teaching fellows are in the midst of trauma incurred from 00:12.312 --> 00:15.512 having to grade all the mid-terms--but they're doing a 00:15.511 --> 00:18.051 good job at that, so we'll try to get those back 00:18.050 --> 00:19.180 to you as soon as possible. 00:19.180 --> 00:21.730 I'm delighted, we have a very special guest 00:21.727 --> 00:23.787 here today, Dr. Timothy Walsh. 00:23.790 --> 00:26.880 I'll do a formal introduction of him in just a moment, 00:26.880 --> 00:30.980 but before do that I wanted to give you a little information on 00:30.975 --> 00:33.745 deadlines for requirements in the class. 00:33.750 --> 00:37.730 There are two--besides the final exam, which is on the last 00:37.734 --> 00:40.074 day of class we have two things. 00:40.070 --> 00:42.580 One is the OpEd that's due November 17^(th), 00:42.583 --> 00:45.743 and then the final project that's due November 19th. 00:45.740 --> 00:48.740 I'm going to give you a little information on the final project 00:48.735 --> 00:50.875 today, and then on Wednesday talk a 00:50.877 --> 00:53.517 little bit more about the OpEd, and as you know, 00:53.515 --> 00:55.895 there's a lot of information on how to do these on the website 00:55.900 --> 00:56.330 already. 00:56.330 --> 00:58.310 We have these two deadlines. 00:58.310 --> 01:01.470 You might wonder why in the world they're so close together 01:01.472 --> 01:04.912 and there are different reasons that you might propose that this 01:04.906 --> 01:05.776 is the case. 01:05.780 --> 01:09.190 Let me see if there's a reasonable explanation for it. 01:09.188 --> 01:12.378 First, we're going to stop the requirements of the concept 01:12.376 --> 01:15.726 sheets before these projects are due so that'll you give some 01:15.730 --> 01:17.520 breathing space to do these. 01:17.519 --> 01:21.209 Second, is the OpEd is not a terribly complicated project. 01:21.209 --> 01:25.249 It only needs to about 650 words and is about the length of 01:25.247 --> 01:26.497 a concept sheet. 01:26.500 --> 01:29.410 Now, we'd like it to be more finely crafted than that, 01:29.408 --> 01:31.658 and as I said, we'll give you criteria for 01:31.656 --> 01:32.916 those on Wednesday. 01:32.920 --> 01:38.000 We really want to make sure we get good work on these projects. 01:38.000 --> 01:40.310 We also would like to see that the work in the class is 01:40.305 --> 01:43.275 finished by the end of the term, so you won't have to worry 01:43.275 --> 01:46.675 about projects for this class or a final exam during the exam 01:46.682 --> 01:47.252 period. 01:47.250 --> 01:50.070 Here are a few things to remember for the final project. 01:50.069 --> 01:53.459 First and I'll show you the places on the website where you 01:53.462 --> 01:54.752 can get information. 01:54.750 --> 01:57.330 There's a lot of information about how to do these projects 01:57.331 --> 01:58.091 on the website. 01:58.090 --> 02:01.880 We're very flexible in what people submit for the final 02:01.878 --> 02:02.578 project. 02:02.578 --> 02:06.038 It could be a research proposal, that is a plan for 02:06.036 --> 02:08.106 study; I it doesn't have to be a study 02:08.110 --> 02:10.170 but a plan for how a study might be done; 02:10.169 --> 02:14.469 I it could be anything ranging from photography to painting, 02:14.468 --> 02:18.108 to film, to whatever kind of medium you want to use to 02:18.107 --> 02:22.087 communicate some important message in the food policy arena 02:22.086 --> 02:25.446 and we give examples of those on the website. 02:25.449 --> 02:29.379 Anything that you do that's different that you think may 02:29.383 --> 02:32.623 need to get approved by us, to make sure we like the idea 02:32.622 --> 02:34.512 before you start it, please get in touch with us. 02:34.508 --> 02:37.548 I'll explain how to do that in a minute. 02:37.550 --> 02:41.540 If you do something that's not traditional, 02:41.538 --> 02:43.738 like a research proposal, which is perfectly fine, 02:43.740 --> 02:48.190 like let's just say you do a painting or some photography 02:48.187 --> 02:50.467 collection, or something like that, 02:50.473 --> 02:53.543 there need to be some text that accompanies it to explain why 02:53.536 --> 02:55.526 you did that, and how that might have an 02:55.526 --> 02:56.136 impact. 02:56.139 --> 02:58.779 We're going to be grading these on creativity, 02:58.783 --> 03:01.253 on thoroughness, and on links to the class, 03:01.252 --> 03:04.192 and the criteria you'll see you just a minute. 03:04.188 --> 03:07.548 If you go to the course website, there are two places to 03:07.554 --> 03:10.494 look for information on how to do the project. 03:10.490 --> 03:13.110 There's information under requirements and under 03:13.109 --> 03:16.399 projects--so that gives you plenty of information--and among 03:16.396 --> 03:20.016 the things you'll see are how to get in touch with Ali Crum, 03:20.020 --> 03:22.660 one of the teaching fellows, so if you feel you need 03:22.657 --> 03:25.707 feedback on your idea or if you'd like to make the sure idea 03:25.710 --> 03:27.780 is an acceptable one for the class, 03:27.780 --> 03:32.010 then please contact Ali and her email address is listed here, 03:32.008 --> 03:34.998 and as I said, these are the grading criteria 03:35.004 --> 03:37.664 that we'll use for the final project. 03:37.660 --> 03:41.090 If you have any questions about these, you're welcome to ask me. 03:41.090 --> 03:44.260 I'm delighted today to introduce the first guest 03:44.258 --> 03:44.998 lecturer. 03:45.000 --> 03:47.470 We have several more later in the semester, 03:47.466 --> 03:50.866 but the first guest lecturer of the year, B. Timothy Walsh, 03:50.872 --> 03:51.462 M.D. 03:51.460 --> 03:54.700 Dr. Walsh is one of the leading experts in the world on 03:54.699 --> 03:55.959 eating disorders. 03:55.960 --> 03:58.530 In fact, if I had a loved one with an eating disorder, 03:58.531 --> 04:00.571 Tim would be the first one I would call. 04:00.568 --> 04:04.188 He received his medical training from Harvard, 04:04.188 --> 04:06.548 after an undergraduate degree at Princeton, 04:06.550 --> 04:09.570 he's been at Columbia University many years where he 04:09.569 --> 04:12.829 is now the William & Joy Ruane--did I pronounce that 04:12.826 --> 04:15.366 right?--William & Joy Ruane Professor of 04:15.372 --> 04:19.042 Pediatric Psychopharmacology in the Department of Psychology at 04:19.043 --> 04:23.193 The College of Physicians and Surgeons at Columbia University. 04:23.189 --> 04:27.069 He is a Vice-Chair of Academic Affairs and Faculty Development 04:27.067 --> 04:31.007 for the Department of Psychiatry at Columbia University and has 04:31.007 --> 04:34.757 served some time as Chair of The Department of Psychiatry at 04:34.757 --> 04:36.407 Columbia University. 04:36.410 --> 04:41.460 He's worked in the eating disorders area for many years, 04:41.459 --> 04:45.239 and runs a clinic at Columbia on the eating disorders research 04:45.242 --> 04:48.962 unit at Columbia University at The New York State Psychiatric 04:48.964 --> 04:53.164 Institute--which as I mentioned, is one of the most impressive 04:53.163 --> 04:56.843 treatment facilities for eating disorders in the world. 04:56.839 --> 04:59.929 He has received many honors and awards over his career, 04:59.932 --> 05:01.252 as you might imagine. 05:01.250 --> 05:04.710 He's served as an example as a President of The Academy of 05:04.706 --> 05:07.456 Eating Disorders, is involved in a number of 05:07.459 --> 05:09.989 societies, and is associate editor of the 05:09.990 --> 05:12.660 main Eating Disorders journal in the field. 05:12.660 --> 05:16.070 He is published extensively in books and articles all over the 05:16.069 --> 05:19.759 place--he'll talk about some of this work today--but as I said, 05:19.759 --> 05:22.409 is one of the most trusted figures in the eating disorders 05:22.408 --> 05:22.778 field. 05:22.778 --> 05:26.168 As a sign of that, he chairs the working group of 05:26.165 --> 05:29.825 The American Psychiatric Association that establishes 05:29.834 --> 05:33.014 diagnostic criteria for eating disorders. 05:33.009 --> 05:36.169 S some of you may have heard if you're connected with psychology 05:36.168 --> 05:37.628 at all, about the DSM, 05:37.632 --> 05:40.572 The Diagnostic and Statistical Manual of The American 05:40.574 --> 05:43.864 Psychiatric Association, which really says here are the 05:43.858 --> 05:47.568 criteria for eating disorders; here are the features that 05:47.569 --> 05:50.029 people have to have to be diagnosed; 05:50.029 --> 05:53.009 here are some of the treatments that follow from those. 05:53.009 --> 05:56.219 A very important series of things follow from those 05:56.223 --> 05:56.933 criteria. 05:56.930 --> 05:59.560 Who gets the diagnosis and who doesn't? 05:59.560 --> 06:01.250 What diagnosis people get? 06:01.250 --> 06:04.620 Whether the insurance companies cover treatment and a lot of 06:04.617 --> 06:07.867 things rest on what that particular committee decides, 06:07.870 --> 06:10.890 and Tim Walsh is the chair of that committee. 06:10.889 --> 06:14.109 As I said one of the most trusted and revered figures in 06:14.108 --> 06:16.368 the field, I'm delighted that Tim Walsh 06:16.374 --> 06:19.274 could join us today to talk about the work he's done on 06:19.274 --> 06:20.354 eating disorders. 06:20.350 --> 06:24.390 Let's please welcome B.***Timothy Walsh. 06:24.389 --> 06:26.489 It is a great pleasure to be here honestly. 06:26.490 --> 06:30.190 After this kind of introduction you primarily just want to sit 06:30.194 --> 06:33.904 down or, thank you very much and leave, it's all downhill from 06:33.898 --> 06:34.868 here for me. 06:34.870 --> 06:42.120 It's fun to be here; it's the kind of invitation 06:42.122 --> 06:47.762 that I really couldn't refuse, both because Kelly is a good 06:47.757 --> 06:52.607 and old friend and colleague, and the kick of coming up here 06:52.613 --> 06:55.733 to New Haven and talk to a bunch of Yalies. 06:55.730 --> 06:58.450 I mean that's--I couldn't miss that opportunity. 06:58.449 --> 07:04.179 I don't usually talk to undergraduates. 07:04.180 --> 07:09.630 I do give a talk every year to the first or second year class 07:09.625 --> 07:14.565 of med students at Columbia, and the talk I'm going to give 07:14.574 --> 07:17.424 you guys is an adaptation of that talk. 07:17.420 --> 07:20.800 It's a little bit more medicalized maybe than is right 07:20.798 --> 07:24.238 up your alley but I think it'll cover the territory. 07:24.240 --> 07:29.340 The point behind the talk is similar for you folks as for the 07:29.343 --> 07:30.623 med students. 07:30.620 --> 07:34.740 I'm aiming to give you an understanding of what the eating 07:34.738 --> 07:38.348 disorders are but I'm sure you've heard about them: 07:38.350 --> 07:41.500 anorexia nervosa, bulimia, bulimia nervosa, 07:41.500 --> 07:43.310 maybe binge eating disorder. 07:43.310 --> 07:47.930 I want you to know a bit more about them, 07:47.930 --> 07:50.050 some more facts, some information, 07:50.048 --> 07:53.208 what they are, what the complications are and 07:53.211 --> 07:57.081 what--something of what we know about their treatment, 07:57.079 --> 08:00.739 a few snippets about how we can treat these folks. 08:00.740 --> 08:05.810 I want to give you a feel for this, for these disorders. 08:05.810 --> 08:10.040 You clearly will know people, you may already know people who 08:10.041 --> 08:14.031 struggle with these problems, and I'd like to give you a 08:14.029 --> 08:17.889 sense of what it is like to struggle with these problems. 08:17.889 --> 08:22.359 I'm going to spend a bit of time trying to take you inside 08:22.358 --> 08:27.138 an eating disorder and have a feeling for how difficult it can 08:27.141 --> 08:27.691 be. 08:27.689 --> 08:32.409 Then I will mention a little about the little we know about 08:32.412 --> 08:35.602 etiology, something about treatment, 08:35.599 --> 08:40.869 the treatment part is more just to illustrate how you can apply 08:40.865 --> 08:45.705 scientific methods to establish facts about treatment. 08:45.710 --> 08:48.960 How do we know that something works?--and just illustrate with 08:48.957 --> 08:50.287 a few examples of that. 08:50.289 --> 08:53.859 That's what--that's my plan. 08:53.860 --> 08:56.480 The things I'm going to be talking about, 08:56.480 --> 09:00.410 the entities that I'm going to talk about are listed here. 09:00.408 --> 09:03.838 There are really only two that are formally defined, 09:03.841 --> 09:06.531 the top two, anorexia nervosa and bulimia 09:06.532 --> 09:07.342 nervosa. 09:07.340 --> 09:10.900 Binge eating disorder I will talk about briefly towards the 09:10.900 --> 09:13.180 end; that's basically binge eating 09:13.177 --> 09:14.557 without the purging. 09:14.558 --> 09:19.648 Obesity, a few more words on that later, but at least right 09:19.645 --> 09:23.325 now, obesity is not a psychiatric disorder, 09:23.330 --> 09:26.400 it's not a psychiatric illness. 09:26.399 --> 09:28.959 It's a medical condition, excess body fat; 09:28.960 --> 09:32.360 and that's not a psychiatric problem, it's a physiological, 09:32.359 --> 09:33.589 physical diagnosis. 09:33.590 --> 09:37.750 Let me get started, and the way this thing is 09:37.748 --> 09:43.318 organized is I'm going to give you sort of a cross-sectional 09:43.323 --> 09:48.083 view of anorexia nervosa, then a cross-sectional view of 09:48.080 --> 09:51.550 bulimia, and then talk a little bit 09:51.554 --> 09:55.464 about etiology, where it comes from and then 09:55.464 --> 09:59.214 talk a little bit about treatment and finally talk a 09:59.206 --> 10:02.286 little bit about binge eating disorder. 10:02.289 --> 10:05.679 Anorexia nervosa. 10:05.678 --> 10:10.848 One of the remarkable things about anorexia nervosa--you 10:10.850 --> 10:15.550 still hear me?--is it's been around a long time. 10:15.548 --> 10:18.898 We tend to think of it and understandably in terms of the 10:18.898 --> 10:21.708 current cultural emphasis on being thin and fit, 10:21.707 --> 10:24.097 especially for women in our society; 10:24.100 --> 10:27.800 but there's lots of reasons to think its been around much 10:27.801 --> 10:30.711 longer than the current cultural emphasis. 10:30.710 --> 10:35.850 Way back in the fourteenth century some of the Italian 10:35.850 --> 10:38.850 saints, if they were to be dropped into 10:38.850 --> 10:42.700 our midst today, might get a diagnosis of 10:42.703 --> 10:44.713 anorexia nervosa. 10:44.710 --> 10:48.350 People have written a book--a book has been written about 10:48.354 --> 10:51.874 whether some of these folks might be viewed as having a 10:51.868 --> 10:53.168 wholly anorexia. 10:53.168 --> 10:54.268 They--like St. 10:54.273 --> 10:57.903 Catherine of Siena, what we know about her is a 10:57.899 --> 11:02.869 little suggestive of the eating disturbances we see today in our 11:02.865 --> 11:03.885 clinics. 11:03.889 --> 11:08.349 In 1689, Richard Morton, on a book called, 11:08.350 --> 11:10.430 A Treatise on Consumptions, 11:10.428 --> 11:13.708 consumption came to mean tuberculosis but way back in 11:13.705 --> 11:17.665 1689 it probably covered a whole host of infectious diseases and 11:17.674 --> 11:20.074 all kinds of wasting conditions. 11:20.070 --> 11:23.120 He described an eighteen year-old girl with what he 11:23.120 --> 11:26.660 called nervous consumption and she sure sounds like she had 11:26.658 --> 11:27.938 anorexia nervosa. 11:27.940 --> 11:32.410 He didn't have the benefit of the DSM criteria nor did 11:32.412 --> 11:36.592 Sir William Gall and Charles Leseque, an Englishman and a 11:36.586 --> 11:39.746 Frenchman; but these folks over a century 11:39.754 --> 11:43.934 ago described in the medical literature cases--like a half a 11:43.932 --> 11:48.182 dozen cases each--of young women who clearly had what we call 11:48.181 --> 11:49.741 anorexia nervosa. 11:49.740 --> 11:54.240 It was Sir William Gall's name that stuck and that's what we 11:54.239 --> 11:55.459 still call it. 11:55.460 --> 11:59.830 A tangent: Anorexia, it's a bad name, 11:59.826 --> 12:04.796 it really is literally not quite right. 12:04.798 --> 12:08.188 Anorexia is the technical term described for loss of appetite. 12:08.190 --> 12:11.340 So when you get the flu and you feel crummy, you don't want eat 12:11.337 --> 12:12.757 that's--you have anorexia. 12:12.759 --> 12:16.789 The problem with the term for this illness is that these guys, 12:16.789 --> 12:20.159 most of them really haven't lost their appetites. 12:20.158 --> 12:23.328 They're kind of suppressing food intake but if--there is a 12:23.331 --> 12:26.451 lot of indications that they still have some appetite. 12:26.450 --> 12:29.000 They don't lose the drive to eat. 12:29.000 --> 12:32.570 Anyway, the name has been around for a century, 12:32.570 --> 12:37.150 it stuck, and even though it's a little bit off it's not bad, 12:37.149 --> 12:40.229 and it's well recognized, so that's the name of this 12:40.226 --> 12:40.946 condition. 12:40.950 --> 12:46.340 The diagnosis of this condition is typically not hard. 12:46.340 --> 12:53.030 It is characterized by this relentless pursuit of thinness; 12:53.029 --> 12:56.889 a drive to be thin that sort of knows no bounds, 12:56.888 --> 12:59.678 and will brook no contradiction. 12:59.678 --> 13:03.708 Accompanied by an intense fear of gaining weight or becoming 13:03.711 --> 13:05.721 fat, and that's despite the fact 13:05.716 --> 13:09.276 that these folks by definition are significantly underweight, 13:09.278 --> 13:13.478 and often dramatically, as they lose weight they become 13:13.476 --> 13:15.806 more afraid of becoming fat. 13:15.808 --> 13:18.788 The skinnier they become, the more terrified they are of 13:18.788 --> 13:19.708 gaining weight. 13:19.710 --> 13:23.430 It's a real paradox, but very powerful. 13:23.428 --> 13:27.468 That's the core of it--always has been the core of it--and 13:27.466 --> 13:30.506 it's as I said, you don't mix it up with too 13:30.510 --> 13:32.070 many other things. 13:32.070 --> 13:36.460 Now, Kelly mentioned the good old DSM. 13:36.460 --> 13:39.530 The DSM that's the Diagnostic and 13:39.528 --> 13:43.328 Statistical Manual of The American Psychiatric Association 13:43.330 --> 13:46.730 and it's got it in a name and a number for every 13:46.731 --> 13:48.601 psychiatric diagnosis. 13:48.600 --> 13:53.150 When you go to the doctor and you see insurance forms, 13:53.148 --> 13:56.408 there's a space for diagnostic code. 13:56.408 --> 14:00.678 So if you go in with strep throat there is a code for strep 14:00.677 --> 14:01.337 throat. 14:01.340 --> 14:05.330 Well DSM has the codes and the names for all the 14:05.333 --> 14:08.963 psychiatric disorders and it's--as Kelly said, 14:08.960 --> 14:12.260 I've been involved somewhat frighteningly in the 14:12.260 --> 14:16.070 construction of these things, and the fear is people take 14:16.066 --> 14:19.406 this stuff much more seriously than they probably should. 14:19.408 --> 14:23.058 I mean that's another whole-a whole course on the politics and 14:23.056 --> 14:24.846 meaning of diagnostic codes. 14:24.850 --> 14:28.910 Anyway, these are the official current DSM criteria for 14:28.913 --> 14:32.843 anorexia nervosa and they-I'm not going to spend a long time 14:32.842 --> 14:36.442 going through these but what they try to capture, 14:36.440 --> 14:39.380 in somewhat more formal language, are those three things 14:39.380 --> 14:42.270 that I had on the previous slide: a refusal to maintain 14:42.269 --> 14:45.159 body weight at or above minimally normal weight for age 14:45.158 --> 14:48.098 and height--so they're underweight by definition; 14:48.100 --> 14:51.000 accompanied by an intense fear of gaining weight or becoming 14:51.004 --> 14:54.464 fat even though they're skinny; criterion (c) is the most 14:54.464 --> 14:58.574 awkward, at least in terms of language, the short hand is 14:58.573 --> 15:00.633 distortion of body image. 15:00.629 --> 15:06.359 What often happens--I mean this is a lot of multi-syllable words 15:06.364 --> 15:10.374 there--what often happens is things like, 15:10.370 --> 15:13.870 somebody despite weighing 80 pounds will say, 15:13.870 --> 15:16.030 oh my thighs still touch sometimes, 15:16.028 --> 15:18.868 I'm just not right, this isn't as it should be. 15:18.870 --> 15:22.770 Or they'll find a skin fold even at 80 pounds they can find 15:22.773 --> 15:26.613 a fold of skin and say this is not-- this isn't the way it 15:26.610 --> 15:28.600 should be, this isn't right, 15:28.596 --> 15:32.036 so they'll focus on a part of their bodies and say this isn't 15:32.044 --> 15:34.334 right, I need to keep losing weight or 15:34.325 --> 15:35.805 I can't stand to gain any. 15:35.808 --> 15:40.668 Women with anorexia nervosa don't have regular menstrual 15:40.673 --> 15:41.473 cycles. 15:41.470 --> 15:46.600 Those are the core criteria, the official criteria, 15:46.599 --> 15:52.649 but what they don't do very well is give you a sense of what 15:52.652 --> 15:55.322 this disorder is like. 15:55.320 --> 15:59.150 What I'm going to do is spend a few minutes reading from a 15:59.149 --> 16:02.629 letter that I got, to date myself over thirty 16:02.629 --> 16:06.769 years ago when I was a psychiatric research fellow or 16:06.768 --> 16:10.188 resident I think, at Montefiore Hospital in the 16:10.192 --> 16:13.882 Bronx just learning psychiatry and was just getting introduced 16:13.879 --> 16:16.719 by people like this one to anorexia nervosa. 16:16.720 --> 16:20.250 What this woman does is--she was-she had heard of a research 16:20.245 --> 16:23.715 project that we were doing, and wrote a letter of 16:23.715 --> 16:28.495 introduction to describe what was troubling her in hopes that 16:28.500 --> 16:32.250 we might be able to provide some assistance. 16:32.250 --> 16:34.730 In doing so, she really wrote one of the 16:34.726 --> 16:38.406 best descriptions from the inside of what it's like to have 16:38.408 --> 16:42.218 anorexia nervosa followed by the development of bulimia. 16:42.220 --> 16:47.360 Permit me to read for a few minutes from her letter. 16:47.360 --> 16:50.160 "Several years ago in college I started using 16:50.163 --> 16:51.713 laxatives to lose weight. 16:51.710 --> 16:54.270 I started with a few and increased the number as they 16:54.274 --> 16:55.314 became ineffective. 16:55.308 --> 16:59.148 After two years I was taking 250 to 300 Ex-Lax pills at one 16:59.154 --> 17:02.274 time with a glass of water, twenty at a gulp. 17:02.269 --> 17:05.129 I'd lose as much as ten pounds in a 24-hour period, 17:05.126 --> 17:08.436 mostly water and some food, dehydrated so I couldn't stand, 17:08.442 --> 17:09.702 could barely talk. 17:09.700 --> 17:12.810 I ended up in the university infirmary several times with a 17:12.807 --> 17:14.787 diagnosis of food poisoning or flu. 17:14.788 --> 17:17.178 Bland diets, medications and I was released 17:17.182 --> 17:18.212 in a day or two. 17:18.210 --> 17:22.170 I wouldn't eat for days and then would eat something and 17:22.172 --> 17:25.852 overcome by guilt at eating and by hunger would eat, 17:25.846 --> 17:27.356 and eat, and eat. 17:27.358 --> 17:30.438 A girl on my dorm floor told me that she occasionally forced 17:30.442 --> 17:32.902 herself to vomit so she wouldn't gain weight. 17:32.900 --> 17:35.220 I did this every once in a while, and discovered that I 17:35.219 --> 17:37.669 could consume large amounts of food, vomit, and still lose 17:37.666 --> 17:38.136 weight. 17:38.140 --> 17:42.340 I lost nearly 50 pounds over a few months to 90 pounds. 17:42.338 --> 17:45.708 My hair started coming out in handfuls and my teeth were 17:45.709 --> 17:46.199 loose. 17:46.200 --> 17:51.660 I never felt lovelier and more confident about my appearance. 17:51.660 --> 17:55.850 Physically streamlined, liberated, close to the bone. 17:55.848 --> 17:59.238 I was flat everywhere except my stomach when I'd binged, 17:59.240 --> 18:01.200 when I'd be full blown and distended, 18:01.200 --> 18:04.280 so I was bent over with each rib and back vertebrae outlined. 18:04.278 --> 18:07.538 After vomiting my stomach is once more flat and empty. 18:07.538 --> 18:11.438 The more weight I lost the more I was afraid of getting fat. 18:11.440 --> 18:14.630 I was afraid to drink water for days at a time because it would 18:14.628 --> 18:17.708 add pounds on the scale and make me miserable--yet I drank or 18:17.714 --> 18:20.854 drink easily a half a gallon of milk and other liquids at once 18:20.852 --> 18:21.832 when binging. 18:21.828 --> 18:25.448 I exercised for hours each day to tone my figure from the 18:25.450 --> 18:28.750 weight fluctuations, and joined the university track 18:28.748 --> 18:29.328 team. 18:29.328 --> 18:32.668 I wore track shoes all the time and ran to classes and around 18:32.673 --> 18:34.683 town, stick legs and arms pumping. 18:34.680 --> 18:37.500 I went to track practice daily after being sick, 18:37.500 --> 18:39.240 until I was forced to quit. 18:39.240 --> 18:42.320 A single lap would make me dizzy, cramping my stomach and 18:42.315 --> 18:42.695 legs. 18:42.700 --> 18:46.500 At some point during my last semester before dropping out, 18:46.502 --> 18:49.642 I came across an article on anorexia nervosa. 18:49.640 --> 18:51.800 Its application frightened me. 18:51.798 --> 18:54.958 My own personal obsession with food and body weight was shared 18:54.961 --> 18:56.001 with other people. 18:56.000 --> 18:59.160 I hadn't menstruated in two years, so I forced myself to eat 18:59.157 --> 19:00.547 and digest healthy food. 19:00.549 --> 19:02.199 I hated it. 19:02.200 --> 19:04.870 I studied nutrition and gradually forced myself to 19:04.872 --> 19:07.542 accept a new attitude towards food, as vitalizing, 19:07.544 --> 19:09.184 something needed for life. 19:09.180 --> 19:12.800 I gained weight fighting panic and in a rigid controlled way 19:12.798 --> 19:15.798 I've maintained myself nutritionally ever since at 19:15.803 --> 19:17.953 about 110 pounds at 5 foot six. 19:17.950 --> 19:20.850 I know what I need to survive and I eat it, 19:20.848 --> 19:23.298 a balanced diet with the fewest possible calories, 19:23.298 --> 19:24.288 mostly vegetables, fruit, fish, 19:24.290 --> 19:25.250 fowl, whole grain products. 19:25.250 --> 19:28.730 In five years I haven't eaten anything like pizza, 19:28.730 --> 19:31.860 pastas or pork, sweets or anything fattening, 19:31.855 --> 19:34.835 fried or rich without being very sick. 19:34.838 --> 19:38.308 Once I allowed myself an ice cream cone but I'm usually sick 19:38.313 --> 19:40.553 if I deviate by as much as one bite. 19:40.548 --> 19:44.578 It was difficult for me to face people at school and I dropped 19:44.577 --> 19:47.467 courses each semester, collecting incompletes, 19:47.470 --> 19:50.330 but finishing well in the few classes I stayed with. 19:50.328 --> 19:53.468 The absurdity of my reclusiveness was evident even 19:53.472 --> 19:56.662 to me during my last semester, when I signed up for 19:56.655 --> 19:59.795 correspondence courses while living only two blocks from the 19:59.800 --> 20:02.360 correspondence university building on campus. 20:02.358 --> 20:06.178 I felt I'd be able to face people when I lost just a few 20:06.178 --> 20:07.148 more pounds. 20:07.150 --> 20:09.330 Fat. 20:09.329 --> 20:10.409 I can't stand it. 20:10.410 --> 20:13.190 This feeling is stronger and more desperate than any horror 20:13.191 --> 20:14.631 or what I'm doing to myself. 20:14.630 --> 20:17.610 If I gain a few pounds, I hate to leave the house and 20:17.614 --> 20:20.304 let people see me, yet I'm sad to see how I've 20:20.298 --> 20:22.938 pushed aside the friends, activities, and state of 20:22.941 --> 20:25.071 energized health that once rounded my life. 20:25.068 --> 20:28.308 For all this hiding, it'll surprise you to know that 20:28.314 --> 20:30.164 I am by profession a model. 20:30.160 --> 20:32.670 Last year when I was more in control of my eating and 20:32.670 --> 20:35.620 vomiting, I enjoyed working in front of a camera and was doing 20:35.615 --> 20:36.045 well. 20:36.048 --> 20:38.838 Lately I've been sick too much and feel out of shape and 20:38.837 --> 20:41.777 physically unself-confident for the discipline involved. 20:41.779 --> 20:46.609 The more I threw up when I was in college the longer it took, 20:46.606 --> 20:48.776 and the harder it became. 20:48.779 --> 20:52.169 I needed to use different instruments to induce vomiting. 20:52.170 --> 20:55.400 Now I double two electrical cords and shove them several 20:55.402 --> 20:56.992 feet down into my throat. 20:56.990 --> 21:00.100 This is preceded by six to ten doses of Epicat which is the 21:00.096 --> 21:03.146 stuff you can get in drugstores over the counter to induce 21:03.150 --> 21:06.260 vomiting in kids who have had something they shouldn't have 21:06.257 --> 21:06.897 eaten. 21:06.900 --> 21:10.560 My knees are calloused from the time spent kneeling sick. 21:10.558 --> 21:13.628 The eating, vomiting process takes usually two to three 21:13.632 --> 21:15.682 hours, sometimes as long as eight. 21:15.680 --> 21:18.740 I dread the gagging and the pain, and sometimes my throat is 21:18.740 --> 21:22.010 very sore and I procrastinate using the Epicat and the cords. 21:22.009 --> 21:26.549 After emptying my stomach completely, I wash thoroughly. 21:26.548 --> 21:30.488 In a little while I'll hydrate myself with a bottle of diet 21:30.489 --> 21:33.749 soda and take a handful of 40 milligram Lasix. 21:33.750 --> 21:37.190 Lasix is a powerful fluid pill, water pill by prescription 21:37.191 --> 21:40.151 only, for which she has numerous prescriptions. 21:40.150 --> 21:42.430 Sometimes I am faint and very cold. 21:42.430 --> 21:45.530 I splash cool water on my face, smooth my hair, 21:45.526 --> 21:47.676 but my hands are shaking some. 21:47.680 --> 21:50.780 I'll take some aspirin if my hands hurt sharply, 21:50.780 --> 21:52.300 so I can sleep later. 21:52.298 --> 21:55.428 My lips and fingers are blue and cold and I see in the mirror 21:55.429 --> 21:58.909 that blood vessels are broken, leaving red spots over my eyes, 21:58.914 --> 22:01.084 but they always fade in a day or two. 22:01.078 --> 22:04.438 There's a certain relief when it's over that the food is gone 22:04.440 --> 22:06.400 and I'm not horribly fat from it. 22:06.400 --> 22:09.910 I cry often for some rest, some calm, 22:09.910 --> 22:12.280 but it's foolish for me to cry for someone, 22:12.278 --> 22:14.718 for someone to help me when it's only me who is hiding and 22:14.722 --> 22:15.712 hurting myself." 22:15.710 --> 22:19.580 That remains thirty years later, one of the most 22:19.578 --> 22:24.518 compelling descriptions of what these illnesses are like, 22:24.519 --> 22:28.159 starting with anorexia nervosa and developing into what we now 22:28.157 --> 22:29.527 call bulimia nervosa. 22:29.528 --> 22:35.798 It illustrates that this woman, though tortured by her 22:35.797 --> 22:41.007 obsession and by her behavior, is clearly smart, 22:41.009 --> 22:44.019 clearly articulate, and her thinking is otherwise 22:44.019 --> 22:44.689 pretty clear. 22:44.690 --> 22:47.750 She's not crazy, she's not psychotic, 22:47.748 --> 22:52.928 and it also illustrates the peculiar ambivalence she feels. 22:52.930 --> 22:56.210 She understands what's smart and sensible, 22:56.210 --> 22:59.490 tries to do it, but struggles mightily. 22:59.490 --> 23:03.980 A couple other things: one, the history she gives of 23:03.977 --> 23:08.197 vomiting getting harder and harder as she did it, 23:08.200 --> 23:09.520 is unusual. 23:09.519 --> 23:13.399 Most folks who start to induce vomiting find it gets easier and 23:13.404 --> 23:15.164 easier, so that's unusual. 23:15.160 --> 23:18.870 The other thing that's worth noting is the last I heard from 23:18.871 --> 23:20.571 her was as long time ago. 23:20.568 --> 23:22.378 She did come, she was part of the research 23:22.382 --> 23:24.402 study, went back to the Midwest where 23:24.402 --> 23:27.052 she was from--and the last I heard from her was an 23:27.053 --> 23:28.733 announcement of her wedding. 23:28.730 --> 23:31.480 As far as I know, she made a very full recovery 23:31.480 --> 23:34.710 from these disorders which illustrates that despite the 23:34.709 --> 23:37.819 severity of these kind of behavioral problems and the 23:37.818 --> 23:40.568 physical problems associated with them, 23:40.568 --> 23:43.858 people can get all the way better from these eating 23:43.859 --> 23:44.649 disorders. 23:44.650 --> 23:47.400 They are not life sentences and she--her history, 23:47.400 --> 23:49.520 as far as I know, illustrated that. 23:49.519 --> 23:54.599 23:54.599 --> 23:58.569 Back to more technical things. 23:58.568 --> 24:02.318 One of the things that you discover taking care of people 24:02.315 --> 24:06.725 of anorexia nervosa is there's a lot you've got to worry about, 24:06.730 --> 24:09.310 and they worry about, and their families worry about 24:09.311 --> 24:12.351 that is--than is part of the official diagnostic criteria. 24:12.348 --> 24:15.938 There's a lot of stuff that's going on that gets in people's 24:15.943 --> 24:16.313 way. 24:16.308 --> 24:20.828 This slide summarizes some of the behavioral things that go 24:20.829 --> 24:25.039 wrong and some of the physical things that go wrong. 24:25.039 --> 24:27.119 Not always but quite often. 24:27.118 --> 24:29.678 Behaviorally and psychologically people, 24:29.676 --> 24:32.756 with anorexia nervosa are obsessed with food. 24:32.759 --> 24:34.619 There are good foods, there are bad foods: 24:34.623 --> 24:36.443 if I eat a good food I'm a better person, 24:36.442 --> 24:39.172 if I eat a bad food I'm a worse person, so moral values. 24:39.170 --> 24:42.550 They often develop, typically develop strange 24:42.550 --> 24:45.780 eating patterns: certainly diets that avoid 24:45.779 --> 24:50.389 calories, but also strange concoctions, strange flavors. 24:50.390 --> 24:53.070 On our inpatient unit down at Columbia, 24:53.068 --> 24:56.738 we really have to basically prohibit artificial sweeteners 24:56.744 --> 24:59.844 like Sweet N' Low because these folks really, 24:59.838 --> 25:02.718 really want to get their hands on these artificial sweeteners. 25:02.720 --> 25:05.950 They add vast quantities of--some of them add vast 25:05.949 --> 25:09.579 quantities of artificial sweeteners to things like salad 25:09.575 --> 25:10.625 and lettuce. 25:10.630 --> 25:12.990 Some of them will binge eat. 25:12.990 --> 25:15.460 The kind of binge eating that that letter illustrated, 25:15.460 --> 25:20.140 is a characteristic of maybe half of patients with anorexia 25:20.142 --> 25:22.452 nervosa, who sometime their illness 25:22.453 --> 25:24.923 whether underweight will start to binge eat. 25:24.920 --> 25:28.200 Some of them will abuse laxatives and fluid pills like 25:28.200 --> 25:28.820 she did. 25:28.818 --> 25:33.618 Compulsive behavior is commonly observed. 25:33.618 --> 25:36.458 A lot of the compulsive behavior is around food and 25:36.462 --> 25:39.862 exercise and things like that, but sometimes it starts to get 25:39.857 --> 25:42.577 into other areas, rituals with clothes and 25:42.576 --> 25:45.426 makeup, and how the room is organized. 25:45.430 --> 25:50.990 People with anorexia nervosa, if they talk about their mood, 25:50.991 --> 25:55.141 which can be hard for them, are depressed. 25:55.140 --> 25:57.120 Again, that letter kind of illustrates it. 25:57.118 --> 26:00.398 There's this unhappiness that pervades much of their life. 26:00.400 --> 26:03.850 They become socially isolated typically, 26:03.848 --> 26:08.298 so a kid who's been an outgoing sixth grader and in ninth grade 26:08.300 --> 26:12.610 develops anorexia nervosa and becomes more of a bookworm, 26:12.608 --> 26:15.568 and someone who's running track long distance. 26:15.568 --> 26:19.878 Increased physical activity is a common feature, 26:19.877 --> 26:23.547 at some point, of many people who develop 26:23.545 --> 26:25.465 anorexia nervosa. 26:25.470 --> 26:29.650 The right side of the slide are physical problems, 26:29.650 --> 26:34.460 and this is again more for the med student types, 26:34.460 --> 26:37.530 but just to illustrate, almost every system in the body 26:37.529 --> 26:40.259 gets something wrong with it in anorexia nervosa, 26:40.258 --> 26:41.848 if you look hard enough. 26:41.848 --> 26:45.868 This means body temperature is down, 26:45.868 --> 26:47.818 heart rate is down, blood pressure is down, 26:47.818 --> 26:51.358 lanugo is this interesting soft hair that some folks 26:51.355 --> 26:55.375 regrow--I'll show you a picture in a minute--it's normal in 26:55.377 --> 26:58.597 infancy, but in some people it reappears 26:58.598 --> 27:00.168 in anorexia nervosa. 27:00.170 --> 27:04.390 Edema, fluid retention and ankle swelling happens 27:04.386 --> 27:06.966 sometimes, blood counts are down, 27:06.969 --> 27:09.519 liver function tests can be abnormal, 27:09.519 --> 27:14.019 the reproductive axis--actually it's interesting. 27:14.019 --> 27:17.799 It's a brain based shut down of the reproductive axis. 27:17.798 --> 27:21.548 The way, believe it or not, and you guys may already know 27:21.554 --> 27:25.384 this which I probably didn't know until I finished medical 27:25.375 --> 27:28.505 school, the way the reproductive 27:28.508 --> 27:32.678 hormones are controlled is from the brain. 27:32.680 --> 27:37.680 The brain puts out a hormone which hits the pituitary gland 27:37.682 --> 27:41.172 right below the brain, which secretes things like 27:41.174 --> 27:44.004 glutenizing hormone and follicle stimulating hormone, 27:44.000 --> 27:48.040 and it's these things that have the ovaries make estrogen. 27:48.038 --> 27:51.188 What happens in anorexia nervosa is the brain stops 27:51.192 --> 27:55.102 making this key release hormone so there's top-down amenorrhea, 27:55.103 --> 27:56.683 and this is profound. 27:56.680 --> 27:59.050 I mean this is why these folks don't menstruate. 27:59.049 --> 28:01.339 Thyroid's a little messed up. 28:01.338 --> 28:03.948 Cholesterol can be high for reasons I've never understood. 28:03.950 --> 28:08.700 If you look at brain mass with things like MRI imaging it 28:08.696 --> 28:12.766 appears to be down, and bone density starts to go 28:12.766 --> 28:13.526 down. 28:13.528 --> 28:18.688 So a lot goes haywire, and this stuff can be serious 28:18.685 --> 28:19.895 medically. 28:19.900 --> 28:25.890 Now one of the things that's worth knowing, 28:25.890 --> 28:28.890 among the things worth knowing from this is--and it probably 28:28.894 --> 28:31.854 wouldn't surprise you is the stuff on the right side of the 28:31.848 --> 28:34.248 slide, all these physical things are 28:34.246 --> 28:36.396 seen in any form of malnutrition. 28:36.400 --> 28:38.680 This is what happens to humans when they're starved, 28:38.679 --> 28:40.019 these sort of complications. 28:40.019 --> 28:44.849 What problem isn't as obvious is that statement is also true 28:44.853 --> 28:48.543 of the stuff on the left side of the slide. 28:48.538 --> 28:53.788 Human starvation creates a lot of psychological and behavioral 28:53.788 --> 28:57.748 change and the best documentation for this is a 28:57.749 --> 29:02.909 remarkable study done during World War II in the late--mid to 29:02.912 --> 29:06.072 late 40s, mid-1940s, published a few 29:06.066 --> 29:08.796 years later called The Minnesota Study. 29:08.798 --> 29:11.028 You've heard about this apparently, 29:11.028 --> 29:15.018 what it documents is the remarkable changes that occur 29:15.023 --> 29:19.703 with starvation and there is a paper that--maybe you can add to 29:19.695 --> 29:23.395 next year's class, there's a paper coming 29:23.403 --> 29:28.703 out--that came out of it called Induction of Experimental 29:28.699 --> 29:32.019 Neurosis in Man by Starvation. 29:32.019 --> 29:36.649 They describe in these men a whole bunch of physical changes, 29:36.650 --> 29:38.840 behavior and psychological changes, 29:38.838 --> 29:42.588 including some really irrational strange behavior that 29:42.593 --> 29:45.783 these guys developed because of starvation. 29:45.779 --> 29:49.929 One of the things that implies is that therefore a lot of what 29:49.931 --> 29:53.471 people with anorexia nervosa are struggling with, 29:53.470 --> 29:55.700 are the psychological and behavioral effects of 29:55.699 --> 29:56.329 starvation. 29:56.328 --> 29:59.288 It isn't just sort of a part of the illness, this is an affect 29:59.292 --> 30:00.122 of the illness. 30:00.118 --> 30:04.128 So to get these folks better we got to fix the starvation. 30:04.130 --> 30:06.780 In other words, it doesn't make sense that we 30:06.781 --> 30:09.861 can fix the problems of starvation without--by doing 30:09.856 --> 30:12.506 anything else but fixing the starvation. 30:12.509 --> 30:14.619 We can't give them a pill; we can't give them a 30:14.622 --> 30:16.362 psychotherapy that will make all that go away, 30:16.359 --> 30:17.479 if they're still starving. 30:17.480 --> 30:21.640 Reversing the starvation, the principle is, 30:21.640 --> 30:23.840 becomes part of the treatment, it's not the end result of 30:23.837 --> 30:25.837 successful treatment, it's part of the treatment. 30:25.839 --> 30:31.189 Here are a few illustrations. 30:31.190 --> 30:35.830 This is a picture of a patient on our unit some years ago, 30:35.828 --> 30:39.478 you can figure--you can detect how skinny she is by the hollow 30:39.483 --> 30:42.483 of her cheeks and how prominent her jawbone is, 30:42.480 --> 30:46.030 but these are the soft body hard called lanugos, 30:46.029 --> 30:48.489 it's on her cheek, it's on the back of her neck, 30:48.490 --> 30:50.110 and it appears in some folks, not all, during anorexia 30:50.105 --> 30:50.405 nervosa. 30:50.410 --> 30:57.690 This is bone density, so what this shows is by groups 30:57.694 --> 31:04.144 of kids by year of age, twelve to seventeen. 31:04.140 --> 31:08.510 This bone mineral density in the spine, so just a little 31:08.513 --> 31:13.133 beam--a reading to convey a little beam of how much calcium 31:13.125 --> 31:15.985 there is basically in the spine. 31:15.990 --> 31:20.710 The open circles on the top are normal kids, 31:20.710 --> 31:25.250 and you can see as you would expect--these are all girls--as 31:25.250 --> 31:28.790 adolescence precedes bone density increases. 31:28.788 --> 31:31.908 It's during adolescence and early adulthood that peak bone 31:31.913 --> 31:33.123 density is achieved. 31:33.118 --> 31:36.408 It's probably true for all of you. 31:36.410 --> 31:37.580 This is it! 31:37.578 --> 31:40.108 From here on it's downhill, like for many other parts, 31:40.108 --> 31:41.698 you've probably hit peak about now, 31:41.700 --> 31:45.130 and including bone density, let's hope you hit a high level 31:45.128 --> 31:47.138 because it's downhill from here. 31:47.140 --> 31:52.230 The next series are girls who've had anorexia nervosa but 31:52.226 --> 31:56.946 less then a year and their bones are still normal. 31:56.950 --> 32:01.190 The closed circles are bones from girls, 32:01.190 --> 32:04.480 bone density among girls who have had anorexic nervosa for 32:04.476 --> 32:06.976 more then a year, and you can see even in these 32:06.983 --> 32:08.903 youngsters there's a significant change. 32:08.900 --> 32:11.930 Now most of this isn't symptomatic in these youngsters, 32:11.930 --> 32:15.120 but the worry is, if there really is a window of 32:15.121 --> 32:19.061 opportunity to hit your--what nature intended for your peak 32:19.059 --> 32:22.189 bone density to be, and you miss it because you've 32:22.194 --> 32:25.094 got anorexia nervosa, it's possible you won't be able 32:25.088 --> 32:26.098 to play catch up. 32:26.098 --> 32:31.238 So that's one worry about permanent physical effects of 32:31.240 --> 32:33.050 anorexia nervosa. 32:33.048 --> 32:35.098 But everything else, all that other stuff that was 32:35.096 --> 32:37.966 on the right side of that slide, if you fix the starvation it 32:37.969 --> 32:40.989 gets fixed like the reproductive system it wakes up again, 32:40.990 --> 32:44.690 it goes back to normal, there's no reason we have to 32:44.693 --> 32:48.473 suspect that there's any permanent damage to anything 32:48.471 --> 32:52.251 except maybe bones from having anorexia nervosa. 32:52.250 --> 32:55.530 So a complete recovery physically and psychologically 32:55.529 --> 32:56.979 is entirely possible. 32:56.980 --> 32:59.900 It does happen; it happens a lot fortunately. 32:59.900 --> 33:03.590 Who gets this thing? 33:03.589 --> 33:07.039 I'm sure you already know this; it's mostly women, 33:07.038 --> 33:08.958 mostly girls but not all. 33:08.960 --> 33:11.310 Men, boys get the real item. 33:11.308 --> 33:13.698 Everything's parallel, they don't make much 33:13.696 --> 33:16.646 testosterone like the girls don't make much estrogen, 33:16.653 --> 33:18.873 but they get the real live illness. 33:18.868 --> 33:23.118 It tends to begin in adolescence, mid-adolescence, 33:23.118 --> 33:27.618 and start right around the time of puberty or even a little 33:27.615 --> 33:29.805 before, certainly fresh onset in the 33:29.813 --> 33:31.393 twenties, but rare after that. 33:31.390 --> 33:36.350 Still does tend to come from the middle-upper classes, 33:36.349 --> 33:38.689 though not exclusively. 33:38.690 --> 33:42.720 You certainly see people from poor families who present with 33:42.721 --> 33:44.021 anorexia nervosa. 33:44.019 --> 33:47.519 I assume because of the link to economic state, 33:47.519 --> 33:51.509 tends still to be Caucasian in this country, 33:51.509 --> 33:55.539 but again, not exclusively, all racial and ethic groups can 33:55.536 --> 33:56.296 get this. 33:56.298 --> 34:00.398 The folks who develop anorexia nervosa: are they sick? 34:00.400 --> 34:04.220 Do they look strange or peculiar prior to illness onset? 34:04.220 --> 34:08.030 Probably not much as best we know, it's very hard to know for 34:08.025 --> 34:09.925 sure, but probably not much. 34:09.929 --> 34:15.569 Maybe a little obsessional, a little more rule-bound than 34:15.568 --> 34:18.488 their peers, but not a lot. 34:18.489 --> 34:20.959 Typically, there are exceptions, but these are 34:20.963 --> 34:24.433 typically not kids who stand out as being troubled kids prior to 34:24.425 --> 34:25.355 this illness. 34:25.360 --> 34:30.010 It remains relatively uncommon despite what we hear about it 34:30.009 --> 34:32.609 and read about it in the press. 34:32.610 --> 34:36.510 It remains a relatively uncommon illness, 34:36.505 --> 34:37.865 fortunately. 34:37.869 --> 34:43.229 As I said, what happens to folks who develop this? 34:43.230 --> 34:49.270 Full recovery; a major chunk of the people get 34:49.268 --> 34:51.588 better period; psychologically, 34:51.590 --> 34:54.780 physically they get better and live happily ever after. 34:54.780 --> 34:57.420 On the other hand, people continue to die of 34:57.420 --> 35:01.110 anorexia nervosa and the best estimate--and I'll show you the 35:01.106 --> 35:04.426 data in a second--the best estimate is 5% of people who 35:04.425 --> 35:07.615 develop anorexia nervosa and--people who have serious 35:07.619 --> 35:11.059 anorexia nervosa so they go to a medical center; 35:11.059 --> 35:16.029 5% of them die per decade of being followed. 35:16.030 --> 35:18.270 If you just try to see what happened to them, 35:18.268 --> 35:24.138 five or ten years later 5% die per decade and that's mostly 35:24.141 --> 35:27.421 starvation, they just drop dead at a low 35:27.422 --> 35:29.022 body weight or suicide. 35:29.018 --> 35:35.128 The rest of the folks, a third to a half something 35:35.128 --> 35:39.688 like that, are alive but continue to have 35:39.693 --> 35:43.893 symptoms of some sort, including bulimia like the 35:43.889 --> 35:46.579 young woman whose letter I read from. 35:46.579 --> 35:49.789 She recovered from anorexia nervosa but then developed 35:49.788 --> 35:52.818 bulimia--which I hope, and think she eventually got 35:52.815 --> 35:53.355 over. 35:53.360 --> 35:57.420 It's very rare for anybody who's had anorexia nervosa to 35:57.420 --> 36:00.450 ever become obese which is interesting. 36:00.449 --> 36:05.649 These are the mortality--this is the backup data for that 5% 36:05.652 --> 36:10.942 per decade and also one of the reasons I put it in here is to 36:10.943 --> 36:16.503 illustrate to you how people in the medical field get data. 36:16.500 --> 36:19.210 It's still not a very sophisticated study but it's 36:19.210 --> 36:19.710 useful. 36:19.710 --> 36:23.320 What this fellow did, Pat Sullivan way back in 1995, 36:23.320 --> 36:27.430 he collected--he just looked up forty-two studies in the 36:27.432 --> 36:31.552 literature that had presented information on how long on 36:31.545 --> 36:35.505 average they had followed the group of patients, 36:35.510 --> 36:38.240 of individuals, and what fraction of the people 36:38.244 --> 36:38.904 had died. 36:38.900 --> 36:41.570 Each dot is a study. 36:41.570 --> 36:45.130 So this one way out here, I think is a study from Sweden, 36:45.130 --> 36:48.890 it was actually published many years ago where they managed to 36:48.891 --> 36:52.161 follow most of the patients for thirty-five years, 36:52.159 --> 36:57.209 and at that point almost 25% of that group had died. 36:57.210 --> 37:01.840 This straight line--now there's a lot of scatter but this 37:01.835 --> 37:06.455 straight line is the best approximation of these data and 37:06.460 --> 37:11.250 leads to roughly every decade you get about 5% of the folks 37:11.251 --> 37:13.731 die so that's that data. 37:13.730 --> 37:16.170 Now you think 1995, that was a long time ago, 37:16.170 --> 37:18.000 we're clearly doing better now. 37:18.000 --> 37:22.250 Well, the red dot is a study from Germany I think two years 37:22.251 --> 37:24.451 ago, and it remains a worry. 37:24.449 --> 37:27.429 That doesn't-it's very hard, there are all kinds of 37:27.425 --> 37:29.565 differences between these studies. 37:29.570 --> 37:32.850 I mean age of the patients, how they were picked up, 37:32.853 --> 37:36.463 all kinds of reasons to-for them not to be comparable. 37:36.460 --> 37:40.380 But we certainly don't have any strong reason to believe that 37:40.382 --> 37:44.162 the outcome of anorexia nervosa, I mean serious anorexia nervosa 37:44.155 --> 37:46.595 is dramatically better now then it was 25 years ago, 37:46.597 --> 37:47.697 I'm sad to tell you. 37:47.699 --> 37:57.239 Okay, so that's cross-section of anorexia nervosa. 37:57.239 --> 38:00.059 Another--this is a quick cross-section of bulimia 38:00.061 --> 38:00.651 nervosa. 38:00.650 --> 38:04.060 Again, like anorexia nervosa, the core features are really 38:04.061 --> 38:05.141 straightforward. 38:05.139 --> 38:08.839 Its recurring episodes of binge eating, and recurring 38:08.835 --> 38:12.885 inappropriate compensatory behaviors to compensate for the 38:12.889 --> 38:14.879 binge eating, that's it. 38:14.880 --> 38:19.320 Again, in this case, as long as people will tell 38:19.318 --> 38:23.758 you, are willing to describe what they're doing, 38:23.759 --> 38:27.159 it's a simple diagnosis to make. 38:27.159 --> 38:29.409 But if they're not willing to tell you what they're doing, 38:29.409 --> 38:33.609 you can probably never be sure, despite a lot of circumstantial 38:33.614 --> 38:37.214 evidence that may make you think that they have it. 38:37.210 --> 38:42.250 Here again, is the DSM-IV criteria which 38:42.246 --> 38:48.486 just to articulate that in somewhat more formal terms, 38:48.489 --> 38:50.599 recurring episodes of binge eating, 38:50.599 --> 38:53.489 recurring and inappropriate compensatory behavior to prevent 38:53.485 --> 38:56.585 weight gain, the DSM-IV somewhat 38:56.592 --> 39:00.132 arbitrarily, but to keep a lot of people who 39:00.128 --> 39:04.498 probably don't have a mental disorder from getting this label 39:04.500 --> 39:07.210 potentially said, we're not going to give this 39:07.211 --> 39:09.081 label, the label should not be given 39:09.083 --> 39:12.263 to folks unless they are binge eating and doing inappropriate 39:12.257 --> 39:15.587 things to compensate at least twice a week for three months. 39:15.590 --> 39:18.570 There's a frequency cut, it has to be a recurrent, 39:18.565 --> 39:20.505 persistent behavioral problem. 39:20.510 --> 39:24.480 These people worry more then their peers about their shape 39:24.483 --> 39:25.393 and weight. 39:25.389 --> 39:30.549 Criterion (e) says this isn't just anorexia nervosa. 39:30.550 --> 39:34.820 This may be--one of these fine points--what it means is if 39:34.824 --> 39:39.554 somebody's got anorexia nervosa and they're underweight and they 39:39.550 --> 39:42.550 meet the criteria for that illness, 39:42.550 --> 39:44.820 but they're also binging and vomiting, 39:44.820 --> 39:46.770 they only have one eating disorder, 39:46.768 --> 39:49.468 they have anorexia nervosa with binge eating and vomiting. 39:49.469 --> 39:52.269 They don't have anorexia--they don't have two eating disorders, 39:52.273 --> 39:54.763 they don't have anorexia nervosa and bulimia nervosa. 39:54.760 --> 39:59.150 So this--what this does in the formal system is the trump. 39:59.150 --> 40:02.920 It means anorexia nervosa trumps bulimia nervosa so that's 40:02.916 --> 40:05.756 what--that somewhat confusing thing does. 40:05.760 --> 40:10.270 Now let me see what I've got next. 40:10.269 --> 40:12.699 Back to good old DSM. 40:12.699 --> 40:15.299 So Dr.***Walsh, what is a binge? 40:15.300 --> 40:22.300 Now the committee that I--I chaired this committee the last 40:22.295 --> 40:26.515 time this was done, that was about twenty years 40:26.521 --> 40:29.841 ago, so I have not been asked to get it right this time. 40:29.840 --> 40:31.760 I clearly have--I had to repeat the course. 40:31.760 --> 40:36.610 Anyway, this is maybe a part of the reason, 40:36.610 --> 40:42.010 a committee of wise people--I think they were wise, 40:42.010 --> 40:45.420 this is the wisest I could find--labored hard to come up 40:45.422 --> 40:47.782 with a definition of what's a binge. 40:47.780 --> 40:51.330 Eating in a discrete period of time like less then two hours an 40:51.331 --> 40:54.831 amount of food that's definitely larger then most people would 40:54.826 --> 40:58.546 eat in a similar period of time under similar circumstances, 40:58.550 --> 41:03.820 accompanied by a sense of lack of control. 41:03.820 --> 41:08.940 Now it's all right but its still--it's subjective. 41:08.940 --> 41:12.210 I mean it means that the clinician tries to get a history 41:12.210 --> 41:15.420 from the patient and makes a judgment about whether that 41:15.423 --> 41:18.933 amount of food that the patient said that they were currently 41:18.927 --> 41:22.257 eating is really more then somebody would appear to eat in 41:22.257 --> 41:23.307 that time. 41:23.309 --> 41:29.319 But just--and you see people who come to the clinic 41:29.320 --> 41:35.330 complaining of I didn't want to eat the cookie, 41:35.329 --> 41:37.629 I ate the cookie, I couldn't stand myself so I 41:37.628 --> 41:38.598 induced vomiting. 41:38.599 --> 41:42.399 Well a cookie's not--that's not--is that a binge? 41:42.400 --> 41:46.150 It's hard to draw the line, but just to make the point that 41:46.152 --> 41:49.192 many people with bulimia, in fact, really have a 41:49.193 --> 41:50.943 behavioral disturbance. 41:50.940 --> 41:55.640 I'll read to you a list of what one of our patients wrote down 41:55.637 --> 42:00.177 she consumed during the course of one binge between 4:30 and 42:00.181 --> 42:04.241 6:00 one afternoon, and that was five butterfly 42:04.239 --> 42:06.389 pastries, three barbequed chickens, 42:06.393 --> 42:08.703 three-quarters of a small jar of mayonnaise, 42:08.699 --> 42:10.939 a quarter of a loaf of Italian sliced bread, 42:10.940 --> 42:13.660 a quarter of a pound of margarine, a regular sized jar 42:13.655 --> 42:16.025 of peanut butter, a half a gallon of milk, 42:16.032 --> 42:19.302 twelve ounces of Sugar Crisp, a box of chocolate chip 42:19.295 --> 42:23.245 cookies, a liter of Diet Sprite and two cans of cake icing; 42:23.250 --> 42:26.740 and that was thrown up by the end of that period, 42:26.744 --> 42:29.954 and a similar binge was repeated at 10:00. 42:29.949 --> 42:35.289 I'm not--I don't think this is typical but what I would want 42:35.289 --> 42:40.809 you to understand that people with bulimia who come to clinics 42:40.811 --> 42:46.421 to get treatment and who get the diagnosis appropriately have a 42:46.423 --> 42:49.053 behavioral disturbance. 42:49.050 --> 42:52.560 It's not just I feel like I ate too much and I feel bad about it 42:52.563 --> 42:54.743 and I did something funny afterwards; 42:54.739 --> 42:57.859 their eating is not normal and we--it's still a problem of 42:57.862 --> 43:00.932 where to draw the line for sure and that is a problem. 43:00.929 --> 43:04.229 There's no question that there's a behavioral abnormality 43:04.228 --> 43:06.288 that's involved in this disorder. 43:06.289 --> 43:12.769 A few bits about the characteristics of folks with 43:12.773 --> 43:14.763 this illness. 43:14.760 --> 43:18.570 It's a lot like anorexia nervosa, and as I already said, 43:18.570 --> 43:21.650 a bunch of people who have had anorexia nervosa end up moving 43:21.648 --> 43:23.598 into bulimia when they gain weight, 43:23.599 --> 43:26.719 their weight becomes normal, but they keep binging and 43:26.722 --> 43:27.372 vomiting. 43:27.369 --> 43:30.269 It's mostly women. 43:30.269 --> 43:31.909 Weight's normal. 43:31.909 --> 43:36.089 Onset's a little bit older then anorexia nervosa. 43:36.090 --> 43:39.160 If typically anorexia nervosa is a high school illness this is 43:39.155 --> 43:41.865 typically a college illness with a lot of variation. 43:41.869 --> 43:45.739 Binges are large among people who come to clinics. 43:45.739 --> 43:50.179 What people binge on--I don't know if you folks hear it, 43:50.179 --> 43:53.729 but for awhile you were hearing about carbohydrate craving, 43:53.730 --> 43:56.870 and carbohydrate binging--people don't binge on 43:56.869 --> 44:00.829 pure carbohydrate that would be--I mean this group probably 44:00.827 --> 44:04.267 knows this better then I do, that would orange juice and 44:04.269 --> 44:05.239 grapes, and Kool-Aid. 44:05.239 --> 44:10.439 They binge on sweet fat foods, the kind of foods mammals like 44:10.442 --> 44:12.572 to eat, at least humans like to eat, 44:12.572 --> 44:14.742 they're combinations of sweet and fat, so donuts, 44:14.737 --> 44:17.487 ice cream, coffee cake; it's that sort of stuff that we 44:17.485 --> 44:20.025 all like and that's what people tend to binge on. 44:20.030 --> 44:24.570 Most people who come to clinics with--and meet criteria for 44:24.565 --> 44:28.705 bulimia induce vomiting afterwards so that for sure in 44:28.710 --> 44:33.090 the most common inappropriate compensatory behavior. 44:33.090 --> 44:37.850 About a third take laxatives, excessive amounts of laxatives. 44:37.849 --> 44:43.499 44:43.500 --> 44:44.760 Among normal weight people who do this, 44:44.760 --> 44:47.120 this is a physical complication, 44:47.121 --> 44:50.401 again maybe a more med student oriented, 44:50.400 --> 44:52.840 but the most important thing to know is that most people who do 44:52.835 --> 44:55.105 this regularly like for five or ten years, have no physical 44:55.112 --> 44:55.822 complications. 44:55.820 --> 45:02.010 This is impressively tolerated, as long as weight is maintained 45:02.012 --> 45:04.012 at a normal range. 45:04.010 --> 45:08.470 The body is able to tolerate this sort of stuff, 45:08.472 --> 45:11.512 on average, surprisingly well. 45:11.510 --> 45:14.400 Now it doesn't mean its good and it doesn't mean there aren't 45:14.398 --> 45:16.518 complications, it just means that fortunately 45:16.518 --> 45:17.528 they're uncommon. 45:17.530 --> 45:22.760 The things you do occasionally see are menstrual irregularity, 45:22.760 --> 45:24.670 problem with teeth, I'll show you that in a second, 45:24.670 --> 45:27.170 and large salivary glands like the glands that blow up when you 45:27.173 --> 45:29.723 get the mumps right in front of your ears, they get enlarged. 45:29.719 --> 45:34.389 People who abuse--anybody who abuses laxatives to induce bowel 45:34.389 --> 45:37.909 movements can become dependent on laxatives. 45:37.909 --> 45:41.099 Epicat is the stuff that I mentioned that the woman who 45:41.097 --> 45:42.807 wrote the letter had taken. 45:42.809 --> 45:46.669 If you take too much of that stuff you can make yourself sick 45:46.666 --> 45:47.306 from it. 45:47.309 --> 45:51.329 Rarely, very rarely fortunately, there are cases 45:51.327 --> 45:56.197 reported of people who consume so much during a binge that 45:56.199 --> 46:01.499 they'll rupture their stomach and that's got a mortality, 46:01.500 --> 46:04.830 that kills people, but fortunately it is extremely 46:04.833 --> 46:06.333 rare, knock on wood. 46:06.329 --> 46:11.079 The physical abnormalities I won't detail but they're the 46:11.081 --> 46:15.241 kind of--they result from the purging behavior. 46:15.239 --> 46:19.229 If you--if for whatever reason you're vomiting a lot, 46:19.230 --> 46:21.990 self-induced or otherwise, you start to--your fluid 46:21.985 --> 46:25.345 balance and salt balance gets messed up in characteristic ways 46:25.349 --> 46:27.719 and that's what happens to these folks; 46:27.719 --> 46:31.099 some of them but rare. 46:31.099 --> 46:35.079 You run standard lab tests on 100 people with bulimia, 46:35.077 --> 46:39.207 you get abnormalities in five, it's not anywhere near as 46:39.206 --> 46:41.456 common as you would think. 46:41.460 --> 46:50.420 46:50.420 --> 46:51.450 Uh oh, technical problem. 46:51.449 --> 46:55.559 46:55.559 --> 46:55.839 Stuck! 46:55.840 --> 47:01.770 47:01.768 --> 47:06.388 This is an example of an enlarged carotid gland, 47:06.387 --> 47:10.907 salivary gland, and people can--some people get 47:10.905 --> 47:12.375 swollen up. 47:12.380 --> 47:14.930 It's probably the stimulation, it's probably the repeated 47:14.927 --> 47:17.567 stimulation of the eating and the vomiting that causes some 47:17.565 --> 47:20.155 hypertrophy of these glands, growth, and enlargement. 47:20.159 --> 47:25.259 Teeth. 47:25.260 --> 47:30.420 This is a young lady who we saw at our clinic and she has a 47:30.422 --> 47:35.322 filling in her top right front tooth and that's probably 47:35.317 --> 47:37.717 related to the bulimia. 47:37.719 --> 47:43.569 What's more striking even then that is the size of her top 47:43.568 --> 47:44.388 teeth. 47:44.389 --> 47:48.929 Her top front teeth are actually shorter then her bottom 47:48.925 --> 47:53.625 front teeth and it turns out that any kind of acid softens 47:53.625 --> 47:55.105 dental enamel. 47:55.110 --> 47:57.340 Don't suck on too many lemons! 47:57.340 --> 48:02.870 So any kind of acid over time will soften dental enamel and 48:02.867 --> 48:07.817 eventually it'll get soft enough, it'll start to chip 48:07.822 --> 48:11.302 away; and some people with bulimia 48:11.298 --> 48:15.508 purge enough by inducing vomiting and wash, 48:15.510 --> 48:18.750 particular their front teeth, with stomach acid over and over 48:18.748 --> 48:21.338 and over again that they start to lose tooth, 48:21.340 --> 48:23.920 they start to lose dental enamel, and that's what happened 48:23.922 --> 48:24.242 here. 48:24.239 --> 48:29.409 So that's obviously a permanent complication of bulimia, 48:29.411 --> 48:32.421 rare but it obviously happens. 48:32.420 --> 48:37.540 This is just--this has some historical interest but I won't 48:37.543 --> 48:39.403 bore you with that. 48:39.400 --> 48:44.640 This illustrates just how prominent these behaviors can 48:44.637 --> 48:45.507 become. 48:45.510 --> 48:49.090 This is the back of somebody's hand with bulimia, 48:49.090 --> 48:53.340 and what you can see is a callous on the back of her hand, 48:53.342 --> 48:55.582 there and there, calluses. 48:55.579 --> 48:59.369 She got these by inducing vomiting, 48:59.369 --> 49:01.789 by tickling the back of her throat with her fingers, 49:01.789 --> 49:04.309 and every time she did that the back of her hand would bump 49:04.309 --> 49:06.959 against her front teeth so she got calluses on the back of her 49:06.958 --> 49:07.348 hand. 49:07.349 --> 49:10.819 It gives you some idea for some of these people just how 49:10.817 --> 49:13.227 recurrent and obsessive, if you will, 49:13.231 --> 49:16.791 the behaviors can become that you see things like--rarely see 49:16.793 --> 49:17.983 things like this. 49:17.980 --> 49:24.290 I've already told you that the prevalence of anorexia nervosa 49:24.291 --> 49:27.581 among women, lifetime prevalence remains 49:27.583 --> 49:29.393 pretty low, half a percent, 49:29.385 --> 49:32.115 a percent and real live bulimia nervosa, 49:32.119 --> 49:34.809 I mean card carrying, DMS-IV bulimia nervosa 49:34.806 --> 49:36.846 is one or two percent, so it's more. 49:36.849 --> 49:39.609 Certainly bulimia nervosa is more common. 49:39.610 --> 49:44.560 Now, you're probably thinking, wow it's got to be more then 49:44.557 --> 49:49.077 that, I know people or I've met people or whatever. 49:49.079 --> 49:53.689 What--I think a part of that impression is that these numbers 49:53.693 --> 49:57.923 are for full bore syndrome, with all the characteristics, 49:57.922 --> 50:01.372 the diagnostic characteristics that I've described. 50:01.369 --> 50:04.679 There are a lot of other people who have eating disorders, 50:04.679 --> 50:08.299 there's no question they have real clinically significant 50:08.300 --> 50:12.120 easting disorders that have features of anorexia nervosa and 50:12.117 --> 50:14.507 bulimia, but aren't full-fledged. 50:14.510 --> 50:20.000 If you look at atypical cases or sub-threshold cases, 50:20.000 --> 50:23.870 you probably at least double those kinds of numbers, 50:23.869 --> 50:27.149 but counts are hard because we don't have good labels for what 50:27.148 --> 50:28.168 those things are. 50:28.170 --> 50:33.430 Hardcore is relatively uncommon but certainly not unknown 50:33.429 --> 50:38.969 variants that are less severe are also significant in number 50:38.969 --> 50:43.759 and probably you get up to a 5% kind of number. 50:43.760 --> 50:45.650 Is that a question? 50:45.650 --> 50:47.890 Should I take a question, doctor? 50:47.889 --> 50:49.169 Prof: Well you have about twenty minutes left. 50:49.170 --> 50:50.600 Dr. Timothy Walsh: I got twenty minutes left. 50:50.599 --> 50:51.659 I'll take a question. 50:51.659 --> 51:02.799 Student: > 51:02.800 --> 51:03.590 Dr. Timothy Walsh: That's the problem with taking 51:03.588 --> 51:03.788 questions. 51:03.789 --> 51:06.789 The question is, so what do you mean by full 51:06.786 --> 51:08.106 recovery, doctor? 51:08.110 --> 51:11.870 Well that's complicated, and that's why the numbers are 51:11.871 --> 51:12.431 fuzzy. 51:12.429 --> 51:16.459 You can--it's relatively easy to define physical recovery from 51:16.458 --> 51:18.968 anorexia nervosa in terms of weight. 51:18.969 --> 51:20.469 You can pull a number. 51:20.469 --> 51:23.909 It's relatively easy to say, assuming someone's being 51:23.911 --> 51:27.621 truthful, that they've stopped vomiting and are no longer 51:27.617 --> 51:29.467 binging, so we got that. 51:29.469 --> 51:33.789 Where it gets really hard to know is psychological. 51:33.789 --> 51:36.479 I mean how much obsession with shape and weight is within 51:36.481 --> 51:37.251 normal limits? 51:37.250 --> 51:42.930 That--people have various criteria for that and it 51:42.931 --> 51:49.891 will--it seems very clear that many people with anorexia, 51:49.889 --> 51:53.039 who once had anorexia nervosa, will continue to be at least 51:53.043 --> 51:55.113 somewhat more concerned about body, 51:55.110 --> 51:57.520 shape, and weight, and eating than their peers. 51:57.518 --> 52:02.738 But is that--are they recovered or aren't they recovered? 52:02.739 --> 52:05.579 And then you can get into a debate of what constitutes full 52:05.581 --> 52:06.121 recovery. 52:06.119 --> 52:09.819 That's what you get for asking. 52:09.820 --> 52:15.130 That's a good question; I mean I wish I had a good 52:15.132 --> 52:15.532 question. 52:15.530 --> 52:17.510 The problem isn't the question, the problem is the answer. 52:17.510 --> 52:20.700 Anyone else want to pop in with a question? 52:20.699 --> 52:24.369 I'm kind of transitioning to a slightly different section I 52:24.373 --> 52:24.883 think. 52:24.880 --> 52:28.740 All right, let me keep rolling, I'm about on time. 52:28.739 --> 52:33.809 Why do these things happen? 52:33.809 --> 52:36.339 Why do people get anorexia nervosa and bulimia? 52:36.340 --> 52:39.610 The answer is: we do not know. 52:39.610 --> 52:42.560 I mean let's make this absolutely clear, 52:42.559 --> 52:45.329 and let me tell the med students and the psychiatric 52:45.333 --> 52:47.983 residents, we do not know why people get 52:47.976 --> 52:49.176 eating disorders. 52:49.179 --> 52:52.309 Now, it's not that we don't know something, 52:52.309 --> 52:54.529 and I'll give you some illustrations of the things we 52:54.527 --> 52:57.027 know, but it's far from rigorously 52:57.027 --> 53:01.007 predictive, so we go to a sixth grade class 53:01.005 --> 53:04.215 and talk to, get blood samples from all the 53:04.222 --> 53:07.782 girls and we know okay well these three girls are going to 53:07.780 --> 53:09.280 get anorexia nervosa. 53:09.280 --> 53:13.100 We are so far from our ability to do that, that it means we 53:13.101 --> 53:14.421 really don't know. 53:14.420 --> 53:18.790 We can--we know some things but we don't know anywhere like what 53:18.788 --> 53:19.618 we should. 53:19.619 --> 53:24.619 The theory that I would suggest to you that helps understand 53:24.617 --> 53:29.327 development of disorders, including eating disorders, 53:29.329 --> 53:33.929 thinks about things in areas and in different kinds of 53:33.925 --> 53:34.875 factors. 53:34.880 --> 53:37.870 There are things that increase the chances that someone's going 53:37.869 --> 53:39.219 to get an eating disorder. 53:39.219 --> 53:41.509 Being female, genes contribute, 53:41.505 --> 53:44.395 there's little question about that, 53:44.400 --> 53:48.270 environment matters and the kind of culture you're grown up 53:48.268 --> 53:51.068 in and the society--the family culture, 53:51.070 --> 53:53.890 the school culture, and the society you're in, 53:53.889 --> 53:56.149 and particularly our society which emphasizes, 53:56.150 --> 54:00.280 especially for women being thin as being some marker of 54:00.278 --> 54:01.578 attractiveness. 54:01.579 --> 54:05.649 Most people have those, most women in this country have 54:05.648 --> 54:08.328 those factors, or many of those factors, 54:08.333 --> 54:11.483 but most of them don't get anorexia nervosa or bulimia. 54:11.480 --> 54:14.180 Things precipitate the illness. 54:14.179 --> 54:17.999 The things that appear to precipitate these illnesses 54:18.001 --> 54:20.871 appear to be stresses of adolescence. 54:20.869 --> 54:25.229 But typically the people who develop these illnesses aren't 54:25.231 --> 54:28.541 exposed to dramatically stronger stresses. 54:28.539 --> 54:32.419 Adolescence is stressful, you got to learn to maneuver 54:32.416 --> 54:35.116 all kinds of things, get into college, 54:35.121 --> 54:39.051 go to Yale; that's stressful, 54:39.045 --> 54:42.365 but they're normal. 54:42.369 --> 54:45.789 I mean part of growing up is learning to navigate the 54:45.789 --> 54:48.419 stresses of growing up in adolescence. 54:48.420 --> 54:52.160 For some people that--some of the stresses for adolescents, 54:52.159 --> 54:56.199 of adolescence seem to trigger an eating disorder in a way that 54:56.201 --> 54:59.071 I think fundamentally is a bit mysterious. 54:59.070 --> 55:02.990 Then once the thing gets started, it seems to take on a 55:02.989 --> 55:07.419 life of its own and a simple example might be for bulimia, 55:07.420 --> 55:12.190 folks continually diet, food deprivation tends to make 55:12.190 --> 55:15.590 you want more food, so that could lead to binge 55:15.585 --> 55:18.465 eating which could lead to more vomiting and dieting, 55:18.469 --> 55:20.639 which could set the stage for more binge eating. 55:20.639 --> 55:24.909 There's the sense that once the illness or these illnesses get 55:24.911 --> 55:28.841 started there's a vicious cycle that keeps them going and 55:28.835 --> 55:33.175 what's--what I think is true is the clinician's job taking care 55:33.177 --> 55:35.907 of patients is to interrupt that. 55:35.909 --> 55:40.249 I mean it's my job to help people get over the illness. 55:40.250 --> 55:43.400 That doesn't mean necessarily figuring out why they got it; 55:43.400 --> 55:45.690 only if figuring out why they got it helped. 55:45.690 --> 55:49.080 If that isn't going to help me help them get over the illness, 55:49.077 --> 55:50.187 it doesn't matter. 55:50.190 --> 55:53.390 It's a little extreme but it-the focus has to be, 55:53.387 --> 55:56.777 as best we can figure out, what's keeping this thing 55:56.782 --> 55:57.452 going. 55:57.449 --> 56:04.109 That's how we tend to think about the development of eating 56:04.110 --> 56:05.490 disorders. 56:05.489 --> 56:08.619 Multifactorial interactions making some people more 56:08.615 --> 56:10.175 vulnerable then others. 56:10.179 --> 56:14.049 Stress, illness develops and then persists and takes on a 56:14.045 --> 56:16.665 life of its own, that's the picture. 56:16.670 --> 56:21.380 A lot of unknowns that I wish we had a better handle on. 56:21.380 --> 56:25.970 To talk about one: culture. 56:25.969 --> 56:32.639 So what are the images that we see? 56:32.639 --> 56:35.899 I don't know if Kelly goes through any of this sort of 56:35.904 --> 56:39.664 stuff elsewhere in the course, anyway, so images of women that 56:39.661 --> 56:41.141 are presented to us. 56:41.139 --> 56:42.949 Whatever you may or may not think of Sports 56:42.949 --> 56:44.639 Illustrated and the swimsuit issue, 56:44.639 --> 56:48.139 here's the 1965 cover and the 1999 cover, 56:48.139 --> 56:50.909 and again telling you more then I probably should, 56:50.914 --> 56:52.844 this is when I was in your seat. 56:52.840 --> 56:56.200 I was in where you're sitting back in 1965, 56:56.195 --> 57:01.145 so if I picked up and I have no idea whether I saw that or not, 57:01.152 --> 57:03.952 this is what I would have seen. 57:03.949 --> 57:09.529 I have no recollection, I deny, absolutely deny. 57:09.530 --> 57:15.550 This woman, I would suspect has--she's a normal cover girl, 57:15.545 --> 57:18.755 that's (a) normal cover girl. 57:18.760 --> 57:21.780 She's got more--there are more indications she has subcutaneous 57:21.782 --> 57:24.222 and normal body fat then there are on this lady. 57:24.219 --> 57:28.399 She's posed in a certain way and she looks very lean compared 57:28.398 --> 57:31.878 to this woman who has obviously normal body fat. 57:31.880 --> 57:38.600 You would tend to believe that the images we're seeing are 57:38.599 --> 57:41.429 changing have changed. 57:41.429 --> 57:46.409 These are data from a letter to the editor to JAMA, 57:46.409 --> 57:48.379 The Journal of the American Medical Association from 57:48.378 --> 57:49.698 2000, showing the BMI, 57:49.697 --> 57:52.667 the body mass index, which I assume you are familiar 57:52.672 --> 57:55.642 with, the indication of normality of 57:55.643 --> 57:57.223 weight in adults. 57:57.219 --> 58:03.289 The BMIs of Miss America pageant winners over whatever 58:03.289 --> 58:05.399 this is, eighty years, 58:05.396 --> 58:08.386 going down, and there's variation of course, 58:08.389 --> 58:11.959 but the Miss Americas have gotten skinnier. 58:11.960 --> 58:15.170 There is a cultural trend. 58:15.170 --> 58:18.530 Now, precisely what this trend has to do with the development 58:18.532 --> 58:23.662 of eating disorders to nail it, to say this is why there's more 58:23.659 --> 58:29.889 eating disorders then there used to be is very hard to-- in a 58:29.889 --> 58:34.769 rigorous scientific way but I--in my heart, 58:34.768 --> 58:38.798 I think it's got to be that the emphasis on being thin and being 58:38.802 --> 58:42.642 fit and the push on people to diet increases the chances that 58:42.643 --> 58:46.743 people are going to get into trouble of one sort or another. 58:46.739 --> 58:50.009 Whether it causes more anorexia nervosa or not is unclear, 58:50.012 --> 58:52.942 it's hard to think it doesn't cause some trouble. 58:52.940 --> 58:57.230 Now, just a few words about obesity, 58:57.230 --> 59:02.760 I mean there is no question that compared to obesity eating 59:02.757 --> 59:08.187 disorders are a much less severe public health problem. 59:08.190 --> 59:13.430 I mean you--it's easy too--because of the numbers, 59:13.429 --> 59:16.559 the fraction of people who are obese in our country are far, 59:16.559 --> 59:19.599 far higher and have medical complications associated with 59:19.601 --> 59:22.211 that than the folks who have eating disorders. 59:22.210 --> 59:25.590 I mentioned the DSM a bunch of times, 59:25.592 --> 59:29.212 for DSM V, and that work is now going on 59:29.211 --> 59:32.911 for reconstructing DSM for V; 59:32.909 --> 59:35.429 and Nora Volkow who is head of NIDA, 59:35.429 --> 59:37.089 The National Institute of Drug Abuse, 59:37.090 --> 59:40.710 and Chuck O'Brien who runs the psychiatry department at The 59:40.708 --> 59:44.128 University of Pennsylvania, in an editorial in The 59:44.128 --> 59:47.038 American Journal of Psychiatry last year, 59:47.039 --> 59:48.939 wondered should obesity be included as a brain disorder, 59:48.940 --> 59:49.840 i.e., a mental disorder. 59:49.840 --> 59:54.930 I honestly don't think so, I think there are a bunch of 59:54.925 --> 1:00:00.765 reasons--a whole bunch of--Kelly and I could perhaps discuss--I 1:00:00.766 --> 1:00:05.096 think it's a bad idea on multiple levels, 1:00:05.099 --> 1:00:08.069 but it's gotten to this point that people are starting to 1:00:08.068 --> 1:00:11.798 think what are the connections, and that's a very interesting 1:00:11.797 --> 1:00:14.617 question, is what are the links between 1:00:14.617 --> 1:00:16.777 obesity and eating disorders? 1:00:16.780 --> 1:00:19.260 How would we understand those which is a great question but I 1:00:19.257 --> 1:00:21.817 don't think we're going to get-- I don't think obesity is going 1:00:21.818 --> 1:00:23.138 to make it for DSM-V. 1:00:23.139 --> 1:00:26.139 Ten minutes, we're going to make it, 1:00:26.139 --> 1:00:28.709 we're all right ten minutes. 1:00:28.710 --> 1:00:31.860 Binge eating disorder, recurrent binge eating, 1:00:31.856 --> 1:00:35.066 no compensatory behavior, feeling bad about it, 1:00:35.072 --> 1:00:37.242 so binge eating no purging. 1:00:37.239 --> 1:00:42.569 Interesting, these guys and girls are older, 1:00:42.570 --> 1:00:44.430 these tend to be middle age people, 1:00:44.429 --> 1:00:49.249 more males, maybe a little bit more female, 1:00:49.250 --> 1:00:53.700 but a lot more males have this then anorexia or bulimia. 1:00:53.699 --> 1:00:57.689 Most are overweight or obese and most have mood and anxiety 1:00:57.686 --> 1:00:58.646 disturbance. 1:00:58.650 --> 1:01:02.510 Now--that was it, that's all I'm going to say 1:01:02.512 --> 1:01:07.082 about binge eating disorder other then it's status in 1:01:07.079 --> 1:01:08.659 DSM-IV. 1:01:08.659 --> 1:01:10.669 In DSM-IV it's in the back of the book, 1:01:10.670 --> 1:01:12.380 it's a maybe it should be a disorder category, 1:01:12.380 --> 1:01:16.590 in DSM-V it's up for grabs and that's--it is a hot 1:01:16.588 --> 1:01:19.968 topic and we could talk a while about that. 1:01:19.969 --> 1:01:22.919 A few words about treatment. 1:01:22.920 --> 1:01:25.870 One of the reasons labels are important, should be important, 1:01:25.871 --> 1:01:28.431 is they tell you about what treatments might work. 1:01:28.429 --> 1:01:31.329 For eating disorders, I believe, that the labels, 1:01:31.327 --> 1:01:34.347 imperfect though they are for anorexia and bulimia, 1:01:34.346 --> 1:01:36.516 tell you about different things. 1:01:36.518 --> 1:01:40.658 I think it supports some validity of the DSM 1:01:40.663 --> 1:01:43.153 system for eating disorders. 1:01:43.150 --> 1:01:47.390 These are treatments for--let's talk anorexia nervosa first. 1:01:47.389 --> 1:01:50.389 These are treatments proposed for anorexia nervosa. 1:01:50.389 --> 1:01:52.929 On the left physical treatments, on the right 1:01:52.929 --> 1:01:55.819 psychological treatments, a great history of mental 1:01:55.817 --> 1:01:58.717 health treatment; hormones, lobotomy, 1:01:58.717 --> 1:02:01.827 shock treatment, Thorazine, insulin, 1:02:01.829 --> 1:02:05.389 Prozac is at the bottom, and all kinds of 1:02:05.385 --> 1:02:09.025 psychotherapies, meaning two things. 1:02:09.030 --> 1:02:11.940 One: people--this illness can be very difficult to treat, 1:02:11.940 --> 1:02:14.910 people will throw at it anything that's in their tool 1:02:14.905 --> 1:02:17.295 bag in trying to help people get better. 1:02:17.300 --> 1:02:20.410 Two: the only way you know something's going to work in 1:02:20.414 --> 1:02:22.384 general, is you got to do a control 1:02:22.382 --> 1:02:25.192 trial, you got to, got to, got to apply scientific 1:02:25.186 --> 1:02:28.156 methods to know whether any of this stuff works or is 1:02:28.164 --> 1:02:28.914 worthless. 1:02:28.909 --> 1:02:32.199 You need data, good data; it's very hard to come by. 1:02:32.199 --> 1:02:36.969 What we know is people have to gain weight, I mean from the 1:02:36.969 --> 1:02:41.579 rationale I gave you a while back, believe it or not it's 1:02:41.576 --> 1:02:43.546 hard to gain weight. 1:02:43.550 --> 1:02:45.430 I mean that's an unbelievable statement but for these people 1:02:45.429 --> 1:02:46.289 it's hard to gain weight. 1:02:46.289 --> 1:02:50.639 To gain--you scholars and Dr. Brownell will agree with 1:02:50.639 --> 1:02:54.569 these calculations, but a human pound is worth 1:02:54.567 --> 1:02:57.877 about 4,000 kilocalories thermodynamically. 1:02:57.880 --> 1:03:01.570 If you want to lose a pound you've got to create a caloric 1:03:01.570 --> 1:03:04.030 deficit of about 4,000 kilocalories. 1:03:04.030 --> 1:03:07.430 To gain a pound it's the opposite--you got to create an 1:03:07.425 --> 1:03:10.065 excess of intake over expenditure of around 1:03:10.067 --> 1:03:11.637 3,500/4,000 calories. 1:03:11.639 --> 1:03:14.119 We get people who are 30 pounds underweight. 1:03:14.119 --> 1:03:16.729 We want them to gain two or three pounds a week, 1:03:16.730 --> 1:03:20.610 that's an excess beyond what's needed for maintenance which is 1:03:20.614 --> 1:03:25.944 more like 2,000 calories a day, they've got to take in an extra 1:03:25.943 --> 1:03:29.623 8,000 to 12,000 calories per week, 1:03:29.619 --> 1:03:32.729 so an extra 1,000 or 2,000 calories per day, 1:03:32.730 --> 1:03:35.520 day in and day out, that's very hard. 1:03:35.518 --> 1:03:37.308 It's very hard for any us believe it or not, 1:03:37.313 --> 1:03:39.443 very hard for people with these eating disorders. 1:03:39.440 --> 1:03:41.080 We can do it. 1:03:41.079 --> 1:03:44.659 We can do it in structured treatment programs with just 1:03:44.657 --> 1:03:48.297 having them eat and you rarely--parenteral role means IV 1:03:48.304 --> 1:03:50.694 or NG--not parental, parenteral; 1:03:50.690 --> 1:03:54.530 parenteral methods mean you don't usually have to put an IV 1:03:54.527 --> 1:03:57.107 in, people can be talked into eating. 1:03:57.110 --> 1:04:00.510 We don't have a silver bullet for psychotherapy; 1:04:00.510 --> 1:04:03.830 one of the things that's really interesting is the development 1:04:03.833 --> 1:04:06.673 of this Maudsley Method of family treatment for young 1:04:06.668 --> 1:04:09.228 non-chronic patients with anorexia nervosa. 1:04:09.230 --> 1:04:12.460 It puts the parents in charge of their treatment. 1:04:12.460 --> 1:04:14.730 You got a sick kid, you really got to get this kid 1:04:14.726 --> 1:04:16.156 eating again, we're to help you, 1:04:16.161 --> 1:04:17.691 but it's your responsibility. 1:04:17.690 --> 1:04:20.600 It's wild but it works apparently. 1:04:20.599 --> 1:04:24.369 We need more data but the early returns are very encouraging. 1:04:24.369 --> 1:04:27.689 No pills work, I mean we got--I'm a 1:04:27.693 --> 1:04:31.803 psychiatrist, we got pills for almost every 1:04:31.800 --> 1:04:33.560 human ailment. 1:04:33.559 --> 1:04:35.369 I mean we're good. 1:04:35.369 --> 1:04:39.649 For anorexia nervosa we got nothing, it's really a stunner. 1:04:39.650 --> 1:04:41.940 For example, this is a study that we did in 1:04:41.943 --> 1:04:44.313 our unit, people who are hospitalized 1:04:44.309 --> 1:04:47.569 with anorexia nervosa, seven weeks--this is the weight 1:04:47.572 --> 1:04:50.182 just in pounds, gaining weight we can help 1:04:50.179 --> 1:04:52.909 people gain weight on Prozac and placebo, 1:04:52.909 --> 1:04:55.829 didn't help didn't hurt, made no difference. 1:04:55.829 --> 1:05:00.189 Even more remarkably perhaps Prozac--this is the Prozac group 1:05:00.192 --> 1:05:02.802 and the placebo group, and a measure of 1:05:02.800 --> 1:05:05.670 depression--this is a self rating form for mood--there's no 1:05:05.668 --> 1:05:08.638 difference and mood gets better in both groups but it doesn't 1:05:08.637 --> 1:05:11.457 get more better on Prozac then placebo, it doesn't seem to 1:05:11.456 --> 1:05:12.046 work. 1:05:12.050 --> 1:05:17.360 It's a real disappointment and a real problem, 1:05:17.364 --> 1:05:19.614 but this is data. 1:05:19.610 --> 1:05:23.490 One of the reasons to show this to you is you can get data to 1:05:23.490 --> 1:05:27.050 evaluate utility of interventions and you need data, 1:05:27.050 --> 1:05:29.280 otherwise you're just making stuff up. 1:05:29.280 --> 1:05:32.860 For bulimia it's a different picture. 1:05:32.860 --> 1:05:36.530 One of the remarkable things is that for bulimia the data are 1:05:36.534 --> 1:05:37.274 different. 1:05:37.268 --> 1:05:40.628 We have a good--for example we have a good form of 1:05:40.628 --> 1:05:44.188 psychotherapy called cognitive behavioral therapy and 1:05:44.192 --> 1:05:46.182 medications clearly work. 1:05:46.179 --> 1:05:49.109 Just to illustrate I mean I could--we could go on for a 1:05:49.110 --> 1:05:50.990 while, but just to illustrate some of 1:05:50.994 --> 1:05:54.224 these kind of data, these are the drug data, 1:05:54.217 --> 1:05:59.177 these are each--so each trial--each set of bars is one 1:05:59.179 --> 1:06:03.019 trial in which people were randomized. 1:06:03.018 --> 1:06:06.518 These are typically outpatients randomized to active drug in 1:06:06.516 --> 1:06:08.826 dark blue and placebo in light blue, 1:06:08.829 --> 1:06:12.529 followed for eight weeks and what I'm measuring here is 1:06:12.534 --> 1:06:15.284 percent reduction in binge frequency, 1:06:15.280 --> 1:06:17.550 where obviously--I mean for 100% reduction on binge 1:06:17.547 --> 1:06:19.087 frequency we want it to go away. 1:06:19.090 --> 1:06:22.750 We'll take statistically significant differences between 1:06:22.751 --> 1:06:26.081 drug and placebo as the indicator of utility and it 1:06:26.081 --> 1:06:27.681 almost always works. 1:06:27.679 --> 1:06:30.519 Different drugs, each--these are by and large 1:06:30.523 --> 1:06:34.143 different drug per trial but drugs work, they help people 1:06:34.143 --> 1:06:35.893 reduce binge frequency. 1:06:35.889 --> 1:06:39.999 This is a Prozac trial, 60 milligrams of Prozac 1:06:39.996 --> 1:06:44.816 compared to placebo clearly reduced binge frequency. 1:06:44.820 --> 1:06:48.390 Prozac's the only pill for any eating disorder. 1:06:48.389 --> 1:06:51.089 Prozac for bulimia, FDA has given a stamp of 1:06:51.088 --> 1:06:51.778 approval. 1:06:51.780 --> 1:06:54.170 It's interesting, you can get data, 1:06:54.170 --> 1:06:58.320 you can learn things from the data but treatment and you can 1:06:58.318 --> 1:07:01.058 hopefully improve folk's treatment. 1:07:01.059 --> 1:07:06.309 Binge eating disorder is more--is interesting and more 1:07:06.311 --> 1:07:07.701 complicated. 1:07:07.699 --> 1:07:10.779 For binge eating disorder we want people to stop binging, 1:07:10.780 --> 1:07:13.030 we'd like their obesity to get better, 1:07:13.030 --> 1:07:15.220 we'd like them to lose weight and we'd like them to feel 1:07:15.215 --> 1:07:17.875 better psychologically so you're kind of aiming at three targets. 1:07:17.880 --> 1:07:21.800 1:07:21.800 --> 1:07:25.390 There's more words here, I should have made this 1:07:25.385 --> 1:07:27.945 simpler; but the bottom line is, 1:07:27.951 --> 1:07:32.571 what's confusing about binge eating disorder is anything you 1:07:32.574 --> 1:07:35.634 give people makes them stop binging. 1:07:35.630 --> 1:07:39.960 I mean it's easy relatively to have them stop binging, 1:07:39.960 --> 1:07:43.330 but there doesn't appear to be anything like a tight link 1:07:43.333 --> 1:07:47.133 between stopping binging and losing weight which is puzzling. 1:07:47.130 --> 1:07:52.390 I don't--I think we're a bit in a muddle about what exactly to 1:07:52.393 --> 1:07:57.493 know about how to treat binge eating disorder but it's--this 1:07:57.485 --> 1:07:59.465 is a moving target. 1:07:59.469 --> 1:08:02.169 I mean this is something people are working hard these days. 1:08:02.170 --> 1:08:05.510 Okay, to sum up, anorexia nervosa: 1:08:05.505 --> 1:08:09.445 a disorder recognized for centuries, 1:08:09.449 --> 1:08:11.909 still poorly understood, and sometimes, 1:08:11.909 --> 1:08:14.309 not always but sometimes still difficult to treat. 1:08:14.309 --> 1:08:17.729 Bulimia nervosa: more recently recognized, 1:08:17.725 --> 1:08:21.805 first clearly identified as a syndrome in 1979. 1:08:21.810 --> 1:08:25.960 Useful treatments rapidly developed, psychotherapies, 1:08:25.956 --> 1:08:28.026 medication, interesting. 1:08:28.029 --> 1:08:31.339 Binge eating disorder: a lot of questions I think 1:08:31.335 --> 1:08:32.295 still exist. 1:08:32.300 --> 1:08:37.050 We still really don't know for sure that it's a real disorder, 1:08:37.045 --> 1:08:42.175 so that's my sense of the state of the field as of October 20th. 1:08:42.180 --> 1:08:47.600 Finally, I wanted to say thank you to Dr. Brownell for 1:08:47.604 --> 1:08:52.824 inviting me to do this, it is a kick to come to Yale 1:08:52.823 --> 1:08:55.693 and be with you folks. 1:08:55.689 --> 1:09:00.909 I wanted to before I closed finally, I wanted full 1:09:00.905 --> 1:09:02.285 disclosure. 1:09:02.288 --> 1:09:04.618 You may have noticed--I got a lot of blue, 1:09:04.618 --> 1:09:06.988 I got the blue shirt, I got the blue background on 1:09:06.992 --> 1:09:09.402 the slides, there's a lot of orange that's 1:09:09.403 --> 1:09:14.063 been prominently displayed, so I cannot leave you without 1:09:14.059 --> 1:09:18.269 one final recommendation for beating Yale, 1:09:18.270 --> 1:09:20.120 my true colors. 1:09:20.119 --> 1:09:21.019 Thank you. 1:09:21.020 --> 1:09:22.740 I'm happy to take questions. 1:09:22.739 --> 1:09:28.999