ERLYN LIMOA

General introduction

Eating disorders are characterized by marked disturbance in eating behavior.

Include : anorexia nervosa, bulimia nervosa, and binge-eating disorders

Patients with anorexia or bulimia have a disturbed body image and use extensive measures to avoid gaining weight

Binge eating may occur in all of the eating disorder

ANOREXIA NERVOSA

Preoccupied with their weight, their body image, and with being thin

Subdivision : Restrictive type Binge

eating/purging type

Restrictive type : Eat very little May vigorously exercise More often withdrawn with OC traits

Binge eating/purging type : Eat in binges followed by purging,

laxatives, excessive exercise, and/or diuretics

Associated with increased of major depression and substance abuse

Diagnosis and DSM IV-TR criteria :

A. Refusal to maintain body weigh at or above a minimally normal weigh for age and height.

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 postmenarcheal females, amenorrhea (i.e. the absence of at least 3 consecutive menstrual cycles). A women is considered to have amenorrhea if her periods occur only following hormone administration.

cont. Diagnostic Criteria (DSM-IV-TR)

Specify type : Restricting type : during the current

episode of anorexia nervosa, the person has not regularly engaged in bing-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Binge-eating/purging type : during the current episode of anorexia nervosa, the person has regular engaged in binge-eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

ICD 10 criteria : There is weight loss or, in children, a lack of weight

gain, leading to a body weight at least 15% below the normal or expected weight for age and height.

The weight loss is self-induced by avoidance of fattening foods.

There is self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold.

A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeding in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill.)

The disorder does not meet Criteria A and B for bulimia nervosa.

CommentsThe following features support the diagnosis but are not essential elements: self-induced vomiting, self-induced purging, excessive exercise, and use of appetite suppressants and/or diuretics.If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop, and there is a primary amenorrhea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.

Atypical anorexia nervosaResearchers studying atypical forms of anorexia nervosa are recommended to make their own decisions about the number and type of criteria to be fulfilled.

Physical findings and complications

Amenorrhea, Electrolyte

abnormalitis Hypercholesterolemia Arrhythmias Cardiac arrest, Lanugo Melanosis coli Leukopenia Osteoporosis

Epidemiology 10-20 times more common in women

than men Occurs in up to 4% of adolescents and

young adults (mainly females) Onset usually between ages 10 and 30 More common in developed countries

and professions requiring thin physique Etiology involves environmental, social,

biological, and genetic factors Increased incidence of co-morbid mood

disorders

Differential Diagnosis

Medical condition (such as cancer) Major depression Bulimia, Other metal disorder (such as

somatization disorder or schizophrenia)

Course and Prognosis Variable course – may completely

recover, have fluctuating symptoms with relapses, or progressively deteriorate

Mortality approximately 10% due to starvation, suicide, or electrolyte disturbance.

Treatment Patients may be treated as

outpatients unless they are > 20% below ideal body weight, in which case they should be hospitalized

Treatment involves : Behavioral therapy Family therapy Supervised weight-gain program

Some antidepressant may be useful as adjunctive treatment to promote weight gain.

Bulimia nervosa

A. DefinitionEpisodic, uncontrolled, compulsive, and rapid ingestion of large amounts of food within a short period of time (binge eating) followed by self-induced vomiting, use of laxatives or diuretics, fasting, or vigorous exercise to prevent weigh gain (binge and purge).

B. Diagnosis

According to DSM-IV-TR, the essential features of bulimia nervosa are : Recurrent episodes of binge eating A sense of lack of control over eating during

the eating binges Self-induced vomiting, the misuse of

laxatives, or diuretics, fasting, or excessive exercise to prevent weight gain

Persistent self-evaluation influenced by body shape and weight.

cont. Diagnosis

There are 2 types of bulimia nervosa : Nonpurging type : patients tend to have

less body-image disturbances and less anxiety and tend to be obese.

Purging type : patients are at risk for medical complications such as hypokalemia from vomiting or laxative abuse and hypochloremic alkalosis.

Diagnostic Criteria (DSM-IV-TR)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following :

1. Eating, in the discrete period of time, 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.

cont. Diagnostic Criteria (DSM-IV-TR)

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain.

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.

cont. Diagnostic Criteria (DSM-IV-TR)

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 episode 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.

ICD 10 criteria : There are recurrent episodes of overeating (at least

twice a week over a period of 3 months) in which large amounts of food are consumed in short periods.

There is persistent preoccupation with eating and a strong desire or a sense of compulsion to eat (craving).

The patient attempts to counteract the fattening �effects of food by one or more of the following: self-induced vomiting; self-induced purging; alternating periods of starvation; use of drugs such as appetite suppressants, thyroid

preparations, or diuretics; when bulimia occurs in diabetic patients, they may choose to neglect their insulin treatment.

There is self-perception of being too fat, with an intrusive dread of fatness (usually leading to underweight).

Atypical bulimia nervosaResearchers studying atypical forms of bulimia nervosa, such as those involving normal or excessive body weight, are recommended to make their own decisions about the number and type of criteria to be fulfilled.

C. Epidemiology

Prevalence is approximately 1% of the general population and 1% to 3% in young women.

Age at onset is usually 16-18 years.

Male-to-female ratio is 1 : 10

D. Etiology

1. Biologic. Metabolic studies indicate decreased norepinephrine and serotonin activity and turnover.

2. Social. Reflects society’s premium on thinness. Patients tend to be perfectionists and achievement-oriented.

3. Psychological. Patient have difficulties with adolescent demands, but patients with bulimia nervosa are more outgoing, angry, and impulsice than those with anorexia nervosa. They have histories of difficulties in separating from caretakers.

E. Differential diagnosis

1. Neurologic disease, e.g central nervous system tumors

2. Borderline personality disorder3. Major depressive disorder

F. Course and prognosis

Course is usually chronic but not debilitating when not complicated by electrolyte imbalance and metabolic alkalosis.

60% may recover with treatment; however, relapse rate can approach 50% during a 5-year period.

In some cases of untreated bulimia nervosa, spontaneous remission occurs in 1-2 years.

G. Treatment

1. Hospitalization2. Psychological

a. Cognitive-behavioral therapy

b. Dynamic psychotherapy3. Pharmacologic

Eating disorder NOS

This is a residual category in the DSM-IV-TR used for eating disorders that do not meet the criteria for a specific eating disorder.

Included in this category is binge-eating disorder – recurrent episodes of binge eating in the absence of the inappropriate compensatory behaviors characteristic of bulimia nervosa. Such patients are not fixiated on body shape and weight.

Diagnostic criteria for Eating Disorders NOS (DSM-IV-TR)

The Eating Disorder NOS category is for disorders of

eating that do not meet the criteria for any specific

Eating disorders. Example include :1. For females, all of the criteria for Anorexia

nervosa are met except that the individual has regular menses.

2. All of the criteria for Anorexia nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range.

cont. Diagnostic criteria (DSM-IV-TR)

3. All of the criteria for Bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.

4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food.

cont. Diagnostic criteria (DSM-IV-TR)

5. Repeatedly chewing and spitting out, but not swallowing large amounts of food.

6. Binge-eating disorder : recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia nervosa.

Research criteria for Binge-Eating Disorder (DSM-IV-TR)

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following :

1. Eating, in the discrete period of time, 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.

Binge-Eating Disorder (DSM-IV-TR)

B. The binge eating episodes are associated with 3 (or more) of the following :

1) Eating much more rapidly than normal2) Eating until feeling uncomfortably full3) Eating large amounts of food when not

feeling physically hungry4) Eating alone because of being embarrassed

by how much one is eating5) Feeling disgusted with oneself, depressed, or

very guilty after overeating

Binge-Eating Disorder (DSM-IV-TR)

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days a week for 6 months.

E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

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