Eating Disorders



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

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