Eating Disorder

EATING DISORDERs

ANOREXIA NERVOSA

INTRODUCTION

Derived from the Greek term, Loss of appetite

Common in:

Female > male

Mid teens (14 to 18 years old)

Young women in professions that require thinness

-> The term anorexia nervosa is derived from the greek term which means loss of appetite

->The epidemiology is stated as follows;

->Female are more affected by this condition, it was stated that cases in female occurred 10 to 20 times more than male

-> according to DSM IV, the most common age of onset is between 14 and 18 years old

-> It also seems to be frequent in developed countries, and may be seen with greatest frequency among young women in professions that require thinness, such as modelling and ballet

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Aetiology

->Biological, social and psychological factors are implicated in the causes of anorexia nervosa.

->Endogenous opioids may contribute to the denial of hunger in patients with anorexia nervosa because when the patient was given opiate antagonists, they show dramatic weight gains

->Some authors have proposed a hypothalamic-pituitary axis, which is a neuroendocrine dysfunction. Some studies have shown evidence for dysfunction in serotonin, dopamine and norepinephrine. These three neurotransmitters actually involved in regulating eating behaviour in the paraventricular nucleus of hypothalamus

->Patients with anorexia find support for their practices in societys emphasis on thinness and exercise, simply said, the social stigma indirectly causes the ideation to exist and made them to follow what is best for other peoples eyes

->Again, hobby and profession of the patient could lead them to have this condition

->So patients with the disorder substitute their preoccupations, which are similar to obsessions, with eating and weight gain for other, normal adolescent pursuits.

-> some patient also may experience that their bodies as somehow under the control of their parents, so by using self starvation, they made it as an effort to gain validation as a unique and special person

->Many anorectic patients feel that oral desires are greedy and unacceptable; therefore these desires are projectively disavowed

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Three criteria

Self induced starvation to a significant degree

Relentless drive for thinness / morbid fear of fatness

Presence of medical signs and symptoms resulting from starvation

->So to find out whether the patient is having anorexic syndrome, not just having any diet control, this syndrome must met these three essential criteria before we can truly say that it is anorexia nervosa

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DSM IV diagnostic criteria

Refusal to maintain body weight at or above a minimally normal weight at or above a minimally normal weight for age and height

Intense fear of gaining weight or becoming weight or becoming fat, even though underweight

Disturbance in the way in which ones body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current body weight

In postmenarchal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles

->These three criteria were further explained in DSM IV diagnostic criteria which are.

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DSM IV diagnostic criteria (specific type)

Restricting type

During the episode, the person has not regularly engaged in binge-eating or purging behaviour

Bringe-eating/purging type

During the episode, the person has regularly engaged in binge-eating or purging behaviour

->Anorexia can be further divided into two subtype, according to the DSM IV diagnostic criteria, which are restricting type and bringe-eating / purging type

->In this restricting type, although the patient might not have the behaviour, the food intake in most of the time is highly restricted

-> in the second subtype, since patient has develop the behaviour, he or she may not restrict the amount of food intake since they can always vomit them out

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CLINICAL FEATURES

1. VOLUNTARILY REDUCES AND MAINTAINS AN UNHEALTHY DEGREE OF WEIGHT LOSS

2. FAILS TO GAIN WEIGHT PROPORTIONAL TO GROWTH

3. EXPERIENCES INTENSE FEAR OF BECOMING FAT

4. HAS RELENTLESS DRIVE FOR THINNESS DESPITE OBVIOUS MEDICAL STARVATION, OR BOTH

5. EXPERIENCES SIGNIFICANT STARVATION-RELATED MEDICAL SYMPTOMATOLOGY

6. BEHAVIOUR AND PSYCHOPATHOLOGY PRESENT FOR AT LEAST THREE MONTHS

->weight loss leading to maintenance of body weight less than 85% of that expected

->failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected

->patient has intense fear of gaining weight or becoming fat, even though being underweight

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PECULIAR BEHAVIOUR ABOUT FOOD

HIDE FOOD ALL OVER THE HOUSE

DISPOSE MEALS IN NAPKINS OR HIDE IN THE POCKETS

CUT MEAT INTO VERY SMALL PIECES, SPEND A LOT OF TIME REARRANGING PIECES ON PLATE

WHEN CONFRONTED, THEY DENIED THEIR BEHAVIOUR IS UNUSUAL, OR FLATLY REFUSE TO DISCUSS IT

WHEN PATIENT SEEK MEDICAL ATTENTION?

1. WEIGHT LOSS BECOMES APPARENT

2. SHOWED PHYSICAL SIGNS (HYPOTHERMIA, DEPENDANT OEDEMA, BRADYCARDIA, HYPOTENSION, LANUGO APPEARANCE

3. FEMALE PATIENT MAY COME DUE TO AMENORRHOEA

COMPLICATIONS RELATED TO WEIGHT LOSS

COMPLICATIONS RELATED TO WEIGHT LOSS

COMPLICATIONS RELATED TO PURGING

keyboard alphabet not responding

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Pathology and Lab Examination

Complete full blood count

reveals leukoplakia with relative lymphocytosis.

if binge eating/ purging present, serum electrolyte reveals hypokalemic alkalosis.

Fasting serum glucose concentration.

Serum salivary amylase concentration- elevated if the patient is vomiting.

ECG

BP - hypotension

Differential Diagnosis

BULIMIA NERVOSA

Medical conditions and substance use disorder

Depressive disorder

Somatization disorder

Schizophrenia

Treatment

Hospitalization

first consideration in the treatment of AN is to restore patients nutritional state.

patients who are below 20% of their expected BMI, are recommended for inpatient program.

patients who are below 30% of their expected BMI, require psychiatric hospitalization for 2 to 6 months

Treatment

Psychotherapy

Cognitive-behavioral therapy (CBT)

Dynamic psychotherapy

Family therapy

Pharmacotherapy

Cyproheptadine (Periactin)

Amitriptyline (Elavil)

Bulimia Nervosa

Definition (DSM-IV-TR)

Binge eating combined with inappropriate ways of stopping weight gain

Binge eating: Eating more food than most

persons in similar circumstances & in a similar

period of time, accompanied by a strong sense

of losing control

Epidemiology

More prevalent than anorexia nervosa

1-3 % of young women

Men: Women = 1: 10

Late adolescence @ early adulthood

Often in normal-weight person with history of obesity

1st degree of family history

- Bulimia nervosa also occur in people with high rate of mood disorders & impulse control disorders. It is also occur in people at risk for substance-related disorders & variety of personality disorders.

- Bulimia nervosa patients have increased rates of anxiety disorders, bipolar I disorder, dissociative disorders & histories of sexual abuse,

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Etiology

Biological FactorsSocial FactorsPsychological Factors serotonin & norepinephrin: food intake (binge eating) endorphin: feeling of well-being after vomitingHigh achievers: societal pressures to be slenderSelf-perceptions aboutbody image(size, shape & weightDepression, anxiety, anger & self-loathingObsessive traits

- Theory for development of bulimia nervosa: Cognitive behavior model" theory: Affected person is unhappy with his or her body size & shape & associates feeling full with being fat. This perceptiontriggers emotions ofanxiety,depression, anger & self-loathing. Purging or excessive exercise becomes a way of removing the "fat feeling & undesirable feelings & emotions that go with it.

- Some psychological risk factors, according to this model, are an individual's concern with his or her body size, shape, a propensity for perfectionism, and obsessive traits.

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binge eating

recurrent compensatory behavior

guilt, depression (post-binge anguish), self-disgust

stop eating

social interruption/physical discomfort (abdominal pain, nausea)

non-purging: fasting, excessive exercise

purging: self-induced vomiting, repeated laxatives, enemas or diuretic uses

Warning Signs

Physical Signs Frequent changes in weight (loss @ gains) Signs of damage due to vomiting: swelling around the cheeks or jaw, calluses on knuckles, damage to teeth & bad breath Feeling bloated, constipated or developing intolerances to food Loss of or disturbance of menstrual periods in females Fainting or dizziness Tired

Psychological Signs Preoccupation with eating, food, body shape and weight Sensitive to comments relating to food, weight, body shape or exercise Low self esteem and feelings of shame, self loathing or guilt, particularly after eating Having a distorted body image (e.g. seeing themselves as fat even if they are in a healthy weight range for their age and height) Obsession with food & need for control Depression, anxiety or irritability

Behavioral Signs Evidence of binge eating Vomiting or using laxatives, enemas or diuretics Compulsive or excessive exercising (e.g. including exercising in bad weather, in spite of sickness, injury or social events & experiencing distress if exercise is not possible) Repetitive or obsessive behaviors relating to body shape & weight (e.g. weighing themselves repeatedly, looking in the mirror obsessively and pinching waist or wrists)

Other behavioral signs:

Anti social behaviour, spending more and more time alone

Eating in private and avoiding meals with other people

Secretive behaviour around food (e.g. saying they have eaten when they havent, hiding uneaten food in their rooms)

Dieting behaviour (e.g. fasting, counting calories/kilojoules, avoiding food groups such as fats and carbohydrates)

Frequent trips to the bathroom during or shortly after meals which could be evidence of vomiting or laxative use

Erratic behaviour (e.g. spending large amounts of money on food)

Self harm, substance abuse or suicide attempts

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DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa

Subtypes

PurgingNon-purging More body-image disturbance More anxiety concerning eating Normal/under-weight Risk for medical complications - Dehydration - Hypokalemia (muscle weakness, cardiac arrythmias, renal impairment) - Hypomagnesemia - Hypochloremic alkalosis - Hyperamylasemia - Gastric tear - Esophageal tear - Dental erosion (upper front teeth) - Hypotension - Bradycardia Less body-image disturbance Less anxiety concerning eating Obese

Investigations

FBC

BUSE

Amylase test: hyperamylasemia

Urinalysis: high urine specific gravity (dehydration)

RPT

ECG

Endoscopy

Differential Diagnosis

Anorexia nervosa

Binge eating purging eating

Course & Prognosis

Prognosis depends on severity of vomiting sequelae

Better prognosis than anorexia nervosa

50 % improve with treatment

OutpatientsInpatientsImprovement lasts 5 years with waxing & waning courses< 1/3: doing well at 3-year follow-up1/3: symptoms improve1/3: poor outcome with chronic symptoms

Management

Psychotherapy

CBT

1st line treatment

Aim:

- Interrupt the self-maintaining behavioral cycle of bingeing & dieting

- Alter their dysfunctional cognitions: beliefs about food, weight, body image & overall self-concept

Dynamic psychotherapy

Insight-oriented therapy

Aim:

- Clients self-awareness

- Understanding of the influence of the past

on present behavior

Psychodynamic tendency: reveal their tendency of introjective defense mechanism (ingested/retained nutritious food) & prohective defense mechanism (vomit out bad, junk food)

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Pharmacotherapy

Antidepressant (comorbid of depressive

disorders)

SSRI: fluoxetine ( binge eating & purging)

TCA: imipramine

Anti-convulsants (comorbid of bipolar I disorder)

Carbamazepine

lithium

Combined CBT & medications: most effective tx

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Eating Disorder Not Otherwise Specified (DSM-IV)

Residual category used for eating disorder that do not meet the criteria for a specific eating disorder

OBESITY

Obesity is a complex, multifactorial condition characterized by excess body fat.

The WHO definition is:

a BMI greater than or equal to 25 is overweight in men

a BMI greater than or equal to 30 is obesity in women

BMI

Body Mass Index (BMI) is the best currently accepted measure

BMI = kg/m

ClassificationBMI (kg/m)Risk of co-morbiditiesUnderweight