Eating Disorders
DEFINITIONS
Anorexia nervosa
is characterized by willful and purposeful behavior directed towards
losing weight, weight loss, preoccupation with body weight and food,
peculiar patterns of handling food, intense fear of gaining weight,
disturbance of body image, and amenorrhea. About half of these persons
will lose weight by drastically reducing their total food intake and some
will also develop heavy exercising programs. The other half of these
patients will also rigorously diet but will lose control and regularly
engage in binge eating followed by purging behaviors. Some patients
routinely purge after eating small amounts of food.
The onset is usually between 15 – 20 years, often associated with
psychosocial stresses or dieting behavior.
Anorexia nervosa occurs mainly in females (90 %) mostly in developed
countries and westernized families in developing countries. The incidence
is 7 per 100,000 .
Differential diagnosis includes:
1. Medical conditions:
a) Brain tumor
b) gastrointestinal diseases
c) Neoplasia
d) Endocrinopathies
e) Autoimmune diseases
2. Psychiatric: schizophrenia, depression, OCD…
DSM-IV Diagnostic Criteria for Anorexia Nervosa
A. Refusal to maintain body weight at or above a minimally normal
weight for age and height (e.g., weight loss leading to maintenance of
body weight less than 85% of that expected; or failure to make expected
weight gain during period of growth, leading to body weight less than
85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though
underweight.
C. Disturbance in the way in which one's body weight or shape is
experienced; undue influence of body weight or shape on self-evaluation,
or denial of the seriousness of the current low body weight.
D. In postmenarchal females, amenorrhea, i.e., the absence of at least
three consecutive menstrual cycles. (A woman is considered to have
amenorrhea if her periods occur only following hormone, e.g., estrogen,
administration.)
Specify type:
a- Restricting type: During the current episode of anorexia nervosa, the
person has not regularly engaged in binge eating or purging behavior
(i.e., self-induced vomiting or the misuse of laxatives, diuretics, or
enemas)
b- Binge eating/purging type: During the current episode of anorexia
nervosa, the person has regularly engaged in binge eating or purging
behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
DSM-V Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex,
developmental trajectory, and physical health. Significantly low
weight is defined as a weight that is less than minimally normal or,
for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent
behavior that interferes with weight gain, even though at a
significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight or shape on self-
evaluation, or persistent lack of recognition of the seriousness of the
current low body weight.
Prognosis: Mortality is high (40 % if not treated). When treated 30 %
improve, 30 % become chronic and 40 % recover.
Bulimia
Bulimia is more common than anorexia with an incidence of
between 8.6 and 14 per 100,000 of the total population, with
about 1 to 2% of adolescent girls and young women affected by
the disorder.
Bulimia
Is merely a term that means binge eating, which is defined as
eating more food than most people in similar circumstances and in a
similar period of time, accompanied by a strong sense of losing control.
When binge eating occurs in relatively normal weight or overweight
persons who are also excessively concerned with their body shape and
weight, and who regularly engage in behaviors to counteract the calorie
gain in binges, the binge eating is in the context of the disorder known as
bulimia nervosa.
DSM-V Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
(1) eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than most people would eat
during a similar period of time and under similar circumstances
(2) a sense of lack of control over eating during the episode (e.g., a
feeling that one cannot stop eating or control what or how much one is
eating)
B. Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both
occur, on average, at least twice a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of
anorexia nervosa.
Specify type:
Purging type: during the current episode of bulimia nervosa, the person
has regularly engaged in self-induced vomiting or the misuse of laxatives,
diuretics, or enemas
Nonpurging type: during the current episodes of bulimia nervosa, the
person has used other inappropriate compensatory behaviors, such as
fasting or excessive exercise, but has not regularly engaged in self-
induced vomiting or the misuse of laxatives, diuretics, or enemas
Biological Complications of Anorexia Nervosa and Bulimia Nervosa
Renal-electrolyte
Hypokalemia: Loss of potassium (vomiting, diarrhea, and diuretics)
Hypochloremic metabolic alkalosis, Increased blood urea, Edema,
Renal calculi
Gastrointestinal
Parotitis, Delayed gastric emptying , Constipation ,Salivary or
pancreatic hypersecretion, Gastric or esophageal rupture
Cardiovascular
Bradycardia, Hypotension , Arrhythmias , Anemia, Leukopenia
Hypercholesterolemia, Hypercarotenemia ,
Osteoporosis and
pathological fractures
.
Dermatological
Dry, cracking skin, loss of subcutaneous fat
Lanugo hair development, Callus on dorsum of hand: Common Friction
against teeth in inducing vomiting, Perioral dermatitis, Dental
Caries, Periodontitis.
Central nervous system
Nonspecific electroencephalo- gram (EEG) changes
Reversible cortical atrophy.
Neuroendocrine
Amenorrhea, Oligomenorrhea Common in bulimia
TREATMENT
The severity of illness will determine the intensity of treatment required
for the anorexia nervosa patient. Treatment levels can range from an
inpatient specialized eating disorder unit to a partial hospitalization or day
program to outpatient care depending on the weight, medical status, and
other psychiatric comorbidity of the patient.
1. Cognitive behavioral group therapy
2. Medication if necessary
3. Multiple group therapies, eg. social skills training
4. Nutrition counseling and meal planning
5. Structured meal
Medical management requires weight restoration, nutritional
rehabilitation, rehydration, and correction of serum electrolytes. Inpatient
hospitalization should include daily monitoring of weight, food, calorie
intake, and urine output. Patients should be monitored closely for
attempts to vomit. Outpatients should be weighed weekly in the
physician's office with periodic physical examinations and measurement
of serum electrolytes if the patient is purging.
Pharmacotherapy
Medications can be useful adjuncts in the treatment of anorexia nervosa.
The first drug used in treating anorectic patients was chlorpromazine.
helpful for severely ill patients who are overwhelmed with constant
thoughts of losing weight and behavioral rituals for losing weight. It may
be necessary to start at a low dosage of the liquid form such as 10 mg 3
times a day and to gradually increase the dosage. Cyproheptadine
(Periactin) in high dosages (up to 28 mg a day) can facilitate weight gain
in anorectic restrictors and also has an antidepressant effect. Some recent
studies indicate that SSRI may be effective in preventing relapse in
patients with anorexia nervosa.
Dr. Maytham Alyasiry