Dr Jackie Hoare

Liaison Psychiatry GSH

Eating Disorders

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,

Key is MDTDietician, psychology, medicine, psychiatry,

OT and social workerClearly defined case manager , roles of team

members in case defined

Conclusion