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EATING DISORDERS. Dr. Y R Bhattarai TMU. Introduction to eating disorders. Eating disorders are characterized by disturbances in eating behaviors and an over concern with body image or size. Principal diagnostic distinction is based on ideal body weight.
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EATING DISORDERS Dr. Y R Bhattarai TMU
Introduction to eating disorders • Eating disorders are characterized by disturbances in eating behaviors and an over concern with body image or size. • Principal diagnostic distinction is based on ideal body weight. • If body weight is maintained in the presence of abnormal eating disorder, a diagnosis of bulimia nervosa is made. If body weight falls down, diagnosis of anorexia nervosa is made.
Anorexia nervosa • Definition: characterized by failure to maintain a normal body weight, fear and preoccupation with gaining weight, unrealistic self evaluation as overweight, and amenorrhea for three cycles or more. • Refusal to keep body weight at greater than 85% of ideal. • Patients with anorexia nervosa generally don't have a loss of appetite. • Sub types -Restrictive type -Binge eating/purging type
Prevalence & etiology • 0.5% , occurs at a 1:10 male to female ratio. • Common in industrial societies and higher socioeconomic classes. • History of past physical or sexual abuse. • Social opinion of attractiveness in low body weight drives women to develop eating disorders. • Common in dancers and models. • Psychological risk factors include emotional conflicts concerning family control and sexuality. • Biological factors like prior amenorrhoea. • Genetic factors
onset • Average age is 17 years. • Very late onset anorexia nervosa has a poorer prognosis. • Onset is often associated with emotional stressors, particularly conflicts with parents about independence and sexual conflicts.
Key symptoms • Restricted food intake and maintaining diets of low calorie foods. Weight loss may be achieved through purging( vomiting or taking laxatives) and exercise. • Great concern with appearance; significant amount of time spent examining for perceived signs of excess weight. • With binge eating/purging: self induced vomiting, laxatives abuse.
Associated symptoms • Obsessive compulsive symptoms • Depression symptoms
Physical examination • Signs of malnutrition: emaciation, hypotension, bradycardia, lanugo and peripheral edema • Signs of purging: eroded dental enamel caused by emesis and scarred or scratched hands from self gagging.
COURSE AND OUTCOME • Some individuals recover after a single episode, and others develop a waxing and waning course. • Long term mortality rate of hospitalized patients of anorexia nervosa is 10% from starvation or suicide.
Diagnostic tests • Signs of malnutrition: normochromic normocytic anemia, elevated liver enzymes, low estrogen and testosterone level, sinus bradycardia, and abnormal EEG. • Signs of purging: metabolic alkalosis, hypochloremia and hypokalemia.
Differential diagnosis • Major rule outs are bulimia nervosa • General medical conditions that causes weight loss • Major depressive disorder • OCD • Body dysmorphic disorder.
MANAGEMENT • Initial treatment of the medical complications due to starvation and purging. • Supervised meals, weight and electrolyte monitoring. • Behavioral therapy should be initiated, with rewards or punishment based on absolute weight. • Family therapy designed to reduce conflicts about control by parents is often helpful. • Antidepressants especially SSRIs when comorbid depression is present.
BULIMIA NERVOSA • Bulimia nervosa is an eating disorder characterized by binge eating with the maintenance of body weight. • Types -Purging: self induced vomiting or use of laxatives -Non purging: fasting or exercise, but no purging during bulimic episodes.
Prevalence / etiology • 2% in young adult females. Occur at a 1:9 male to female ratio. • Psychological conflicts regarding guilt, helplessness, self control and body image may predispose. • Biologic factors : association with mood disorders. • Abnormal serotonin metabolism is thought to play more of a role in bulimia nervosa.
Key symptoms • Recurrent episodes of binge eating: obsession with dieting but followed by binge eating of high calorie foods. • Recurrent , inappropriate compensatory behavior: after a binge, attempts to prevent weight gain through self induced vomiting, misuse of laxatives, fasting or excessive exercise. • Self evaluation is unduly influenced by body shape and weight
Associated problems • Depressive symptoms • Substance abuse • Impulsivity (kleptomania)
examinations • Physical examination: evidence of purging • Diagnostic tests: evidence of laxatives.
Course and outcome • Course: may be chronic or intermittent • Outcome:70% of cases have remitted after 10 years. Co existent substance abuse is associated with a poorer prognosis.
Differential diagnosis • Major depression with atypical features • Borderline personality • Differentiate from binge eating and purging subtype of anorexia nervosa.
Management • Similar to that of anorexia nervosa • No medical complications of starvation present. • Psychotherapy for controlling eating behaviors • Cognitive therapy may be useful in treating over concern with body images. • Antidepressants, particularly SSRIs, are usually given.
