is an illness characterised by extreme concern about body weight
with serious disturbances in eating behaviorleading to a self-imposed starvation stateSevere weight loss.Body image becomes the predominant
measure of self-worthdenial of the seriousness of the illness.
Anorexia nervosa (AN)
(a) refusal to maintain weight within the normal range for height and age
(b) fear of weight gain; (c) body image disturbance(d) absence of menstrual cycles oramenorrhea in women (and loss of sexual
interest in men).
International Classification of Diseases, revision 10(ICD-10) (WHO 1992),
Criterion A focuses on behaviors, like restricting calorie intake
But no longer includes the word ‘refusal’ in terms of weight maintenance since that
implies intention on the part of the patient The DSM-IV Criterion requiring amenorrhea, is
deleted. This criterion cannot be applied to males,
children, OC, and post-menopausal females. exhibit all other symptoms and signs of anorexia
nervosa but still report some menstrual activity
Important Changes in Eating Disorder Diagnoses in DSM-V
All 3 of the following:Energy restriction leading to significantly low
body weight Fear of weight gain or behavior interfering
with weight gainDisturbance in self perceived weight or shape
DSM V
Restricting type Binge eating /purging type; recurrent
episodes of bingeing or purging in the last 3 months
Mild BMI>17 kg/m2
Moderate 16-16.9Severe 15-15.9Extreme <15
Subtypes and severity
Few controlled trials to guide treatmentWeight restoration, family therapy and
structured psychotherapyImprove nutritional health – refeedingDrugs can be used to treat co-morbid
conditionsLimited role in weight restorationPhosphate, K+, thiamine, Mg, Ca2+
supplementation in oral form
General guidance
Can occur in any individual who has had negligible nutrient intake for >5 consecutive days
occurs within four days of starting to feeddevelop fluid and electrolyte disturbancesresults in a decrease in the serum levels of
phosphate, potassium, and magnesium, all of which are already depleted.
Causing cardiac arrhythmia, respiratory failure, neuromuscular junction conduction failure
Refeeding syndrome
hormonal and metabolic changes are aimed at preventing protein and muscle breakdown.
use fatty acids as the main energy source. increase in blood levels of ketone bodiesbrain to switch from glucose to ketone bodies as its main
energy source. The liver decreases its rate of gluconeogenesis, thus
preserving muscle protein. several intracellular minerals become severely depletedserum concentrations of these minerals (including
phosphate) may remain normal. reduction in renal excretion.
Starvation
During refeeding, glycaemia leads to increased insulin and decreased secretion of glucagon.
Insulin stimulates glycogen, fat, and protein synthesis.Insulin stimulates the absorption of potassium into the
cells through the sodium-potassium ATPase symporter, which also transports glucose into the cells.
Magnesium and phosphate are also taken up into the cells. Water follows by osmosis. These processes result in a decrease in the serum levels of
phosphate, potassium, and magnesium The clinical features of the refeeding syndrome occur as a
result of the functional deficits of these electrolytes and the rapid change in basal metabolic rate.
Refeeding
Refeeding syndrome can be fatal if not recognized and treated properly.
An awareness of the condition and a high index of suspicion are required in order to make the diagnosis.
The electrolyte disturbances can occur within the first few days
Close monitoring of blood biochemistry is therefore necessary in the early refeeding period.
rate of feeding should be slowed down and essential electrolytes should be replenished.
Fluid repletion should be carefully controlled to avoid fluid overload
Treatment
Bone loss complication serious consequencesHormonal treatment with oestrogen or
dehydroepiandrosterone (DHEA) no positive effect on bone density
Oestrogen not recommended in children and adolescents – risk premature fusion of bones
Osteoporosis
2009 Cochrane review: no evidence from 4 placebo controlled trials
On weight gain, eating disorder or associated psychopathology
Suggested neurochemical abnormalities in starvation may explain non-response
Co-prescribing supplementation incl. tryptophan with fluoxetine does not increase efficacy
Acute illness: antidepressants
Olanzapine, benzodiazepines or promethazine to reduce anxiety with refeeding
1 RCT showed 88% of patients given olanzapine achieved weight restoration (55% placebo)
Quetiapine may improve psychological symptoms but few data
Other psychotropic drugs
Small trial suggested that fluoxetine useful in improving outcome and preventing relapse after weight restoration
Other studies found no benefitAntidepressants often used to treat co-morbid
depression and OCDHowever these conditions may resolve with
weight gain alone
Relapse prevention and co-morbid disorders
Significant disturbance in eating manifested by persistent failure to meet nutritional/energy requirement associated with 1 of:
Significant weight lossSignificant nutritional deficiencyDependence on enteral feeding or supplements
Interference with psychosocial functioningNOT due to lack of food or body image
disturbance
Avoidant/restrictive food intake disorder
Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood and EDNOS which was described in the DSM-IV.
While few data on ARFID have been published, it appears that it usually presents in infancy or childhood, but it can also present or persist into adulthood.
The course of illness for individuals relatively unknown. Avoidance due to sensory characteristics of food,
emotional difficulties, food beliefs etc. ARFID may be associated with impaired social
functioning and affect family functioning, especially if there is great stress surrounding mealtimes.
Clinically Significant Restrictive Eating Problems Are Key
The presence of other psychological disorders may be risk factors for ARFID, such as anxiety disorders, obsessive-compulsive disorders, attention deficit disorders, and autism spectrum disorders
If an individual presents with one of these illnesses and an eating problem, a diagnosis of ARFID should be given only when the feeding disturbance itself is causing significant clinical impairment
individuals with a history of gastrointestinal conditions such as gastroesophageal reflux may develop feeding disturbances, but a diagnosis of ARFID should be assigned only when the feeding disturbances require significant treatment beyond that needed for the gastrointestinal problems.
Distinguishing ARFID from Other Disorders
Little is currently known about effective treatment interventions for individuals presenting with ARFID
given the prominent avoidance behaviors, it seems likely that behavioral interventions, such as forms of exposure therapy
depression or anxiety that affects feeding, cognitive behavioral therapy and other treatments for the underlying condition
Treating ARFID
Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food
feeling a lack of control over the eating. purging (e.g., vomiting, excessive use of
laxatives or diuretics), fasting and/or excessive exercise
DSM-5 criteria reduce the frequency of binge eating and compensatory behaviors to once a week from twice weekly as specified in DSM-IV.
Bulimia nervosa
Psychological treatments first choiceAdults mat be offered antidepressantsSSRI’s esp fluoxetine60mg effective doseCan reduce frequency of binge eating and purgingLong term effects unknownEarly response at 3 weeks strong indicator of
response overallUsed off licensed in adolescentsSome evidence for topiramate, duloxetine,
lamotrigine and sertraline reduce binges
BN treatment
Binge eating disorder will now have its own category as an eating disorder.
In the DSM-IV, under the category Eating Disorder Not Otherwise Specified
“recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes accompanied by feelings of lack of control.”
eat quickly and uncontrollably, despite hunger signals or feelings of fullness.
feelings of guilt, shame, or disgust behavior will have typically taken place at least once a
week over a period of three months.
Binge eating disorder
NICE recommendsEvidenced based self help programme of CBT
as first lineTrial of SSRI as an alternative or additional
first step
BED treatment
Although AN is not a common condition its morbidity and mortality are amongst the
highest psychiatric disordersdue to malnutrition, purgingbehavior and suicide.18-fold increase in mortality in patients with
AN
Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa
Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa: Implications for DSM-VKamryn T. Eddy,