EATING DISORDERS
Amer Rawajfeh. MD. JB.Psych
Pyschiatrist
National Center for Mental Health
Ministry of Health
EATING DISORDERS
Eating disorders include :
1. anorexia nervosa
2. bulimia nervosa
3. binge-eating
Anorexia Nervosa
Patients with anorexia nervosa are preoccupied with their
weight, their body image, and being thin. There are two main
sub types:
Restricting type: Has not regularly engaged in binge-eating or
purging behavior; weight loss is achieved through diet,
fasting, and/or excessive exercise.
Binge-eating/purging type: Eating binges followed by self-
induced vomiting, and/or using laxatives, enemas, or
diuretics. Some individuals purge after eating small amounts
of food without binging.
DIAGNOSIS AND DSM-5 CRITERIA
-Restriction of energy intake relative to
requirements, leading to significant low body
weight—defined as less than minimally normal
or expected.
-Intense fear of gaining weight or becoming fat.
Repetitive behaviours are carried out to prevent
weight gain, despite the already low weight.
- Distortions in an individual’s self perception of
body weight or shape(Disturbed body image),
associated with the denial of the serious
consequences of the current low body weight.
Physical manifestations
-Amenorrhea
-cold intolerance/hypothermia
-hypotension (especially orthostasic)
-bradycardia , arrhythmia
-acute coronary syndrome, cardiomyopathy , mitral
valve prolapse
-Constipation
-lanugo hair, alopecia
-edema, dehydration
-peripheral neuropathy, seizures
-hypothyroidism
-osteopenia, osteoporosis.
Laboratory abnormalities
Hyponatremia , hypochloremic hypokalemic alkalosis (if vomiting)
arrhythmia
hypercholesterolemia, leukopenia
anemia (normocytic normochromic),
elevated blood urea nitrogen (BUN)
↑ growth hormone (GH), ↑ cortisol,
reduced gonadotropins (luteinizing hormone [LH], follicle- stimulating
hormone [FSH]), reduced sex steroid hormones (estrogen,
testosterone)
hypothyroidism, hypoglycemia, osteopenia.
EPIDEMIOLOGY
-The most common age of onset is between 14 and 18
years.
- Anorexia nervosa is estimated to occur in about 0.5 to 1
percent of adolescent girls.
- It occurs 10 to 20 times more often in females than in
males.
-More common among the upper classes and in developed
countries where food is abundant and a thin body ideal is
held.
ETIOLOGY
2. Psychological causes:
1. Biological causes:
• Genetic causes: Relatives of • Development: Failure of
AN patients have an identity formation and
psychosexual development in
increase in risk in adolescence.
developing AN by 10 fold. • Personal events: Childhood
MZ:DZ = 65%:32% obesity
• Birth trauma: • Family factors: Young AN
Cephalohematoma, patients may use the illness
itself to overcome rigidity,
premature birth and small enmeshment, conflict and
for gestation age are overprotection in the family.
predisposing factors for AN. • Underlying personality traits:
• Hypothalamic dysfunction Perfectionistic and neurotic
traits are predisposing factors.
ETIOLOGY
3. Socio-cultural causes:
• Changes in nutritional knowledge and dietary
fashion in the society
• Cult of thinness
• Changed roles and images in women to
pursue thinness.
DIFFERENTIAL DIAGNOSIS
-Medical conditions: Endocrine disorders (e.g.,
hypothalamic disease, diabetes mellitus, hyperthyroidism),
gastrointestinal illnesses (e.g., malabsorption , inflammatory
bowel disease), genetic disorders (e.g., Turner syndrome,),
cancer, AIDS.
-Psychiatric disorders: Major depression, bulimia, or other
mental disorders (such as somatic symptom disorder or
schizophrenia).
COURSE AND PROGNOSIS
Chronic and relapsing illness. Variable course—may
completely recover, have fluctuating symptoms with
relapses, or progressively deteriorate. Most remit
within 5 years.
Range of mortality rates from 5 to 18 percent. due to
starvation, suicide, or cardiac failure.
One-third of AN patients may attempt suicide or self
harm.
About half of patients with anorexia nervosa
eventually will have the symptoms of bulimia ,
usually within the first year after the onset of
TREATMENT
-Food is the best medicine!
-Patients may be treated as outpatients unless they are dangerously
below ideal body weight (>20–25% below)
-Treatment involves cognitive-behavioral therapy, family therapy
,and supervised weight-gain programs.
-Selective serotonin reuptake inhibitors (SSRIs) have not been effective
in the treatment of anorexia nervosa but may be used for comorbid
anxiety or depression.
-Little evidence that second-generation antipsychotics can treat
preoccupation with weight and food, or independently promote
weight gain.
Bulimia Nervosa
Bulimia Nervosa
- Bulimia nervosa is characterized by episodes of
binge eating combined with inappropriate
ways of stopping weight gain. Physical
discomfort for example, abdominal pain or
nausea terminates the binge eating, which is
often followed by feelings of guilt,
depression, or self disgust. Unlike patients
with anorexia nervosa , those with bulimia
nervosa typically maintain a normal body
weight
• Bulimia nervosa, in many ways, represents a
failed attempt at anorexia nervosa, sharing
the goal of becoming very thin, but occurring
in an individual less able to sustain prolonged
semi-starvation or severe hunger as
consistently as classic restricting anorexia
nervosa patients.
DIAGNOSIS AND DSM-5 CRITERIA
- Recurrent episodes of binge eating.
- Recurrent, inappropriate attempts to compensate
for overeating and prevent weight gain (such as
laxative abuse, vomiting, diuretics, fasting, or
excessive exercise).
- The binge eating and compensatory behaviors occur
at least once a week for 3 months.
- Self-esteem is affected by self-evaluation of body
weight and shape.
- Does not occur exclusively during an episode of
anorexia nervosa
PHYSICAL FINDINGS AND MEDICAL
COMPLICATIONS
Physical examination findings
• CNS: epilepsy.
• Oral and oesophagus: parotid gland swelling, dental erosions,
oesophageal erosions.
• CVS: arrhythmias and cardiac failure leading to sudden death.
• GIT: gastric perforation, gastric/duodenal ulcers, constipation and
pancreatitis.
• muscle weakness
• Russell’s sign: abrasions over dorsal part of the hand because fingers
are used to induced vomiting.
Laboratory/imaging abnormalities:
• FBC: leukopenia and lymphocytosis.
• ↓in K+, Na+, Cl-, ↑bicarbonate
• ↑in serum amylase
• Metabolic acidosis due to laxative use
• Metabolic alkalosis due to repeated vomiting.
EPIDEMIOLOGY
-prevalence in young females is 1-4%.
- Significantly more common in women than men
-Onset is in late adolescence or early adulthood.
- More common in developed countries.
- High incidence of comorbid mood disorders,
anxiety disorders, impulse control disorders,
substance use, prior physical/sexual abuse, and
↑ prevalence of borderline personality disorder.
ETIOLOGY
- Multifactorial, with similar factors as for
anorexia .
- Childhood obesity increase risk for bulimia
nervosa.
COURSE AND PROGNOSIS
-Chronic and relapsing illness.
- Better prognosis than anorexia nervosa. Bulimia
nervosa is characterized by higher rates of partial and
full recovery compared with anorexia nervosa.
- Symptoms are usually exacerbated by stressful
conditions.
- One-half recover fully with treatment; one-half have
chronic course with fluctuating symptoms
- Crude mortality rate is 2% per decade.
- Elevated suicide risk compared to the general
population.
TREATMENT
- Most patients with uncomplicated bulimia nervosa do not require
hospitalization.
-Both pharmacotherapy and psychotherapy could be considered.
-Pharmacological treatment: antidepressants (SSRIs such as fluoxetine
or fluvoxamine) have been shown to be effective in treatment of
BN. It would be able to help in reduction of binge eating and also
the associated impulsive behavior. (The only FDA- approved drug
for the treatment of bulimia nervosa is fluoxetine. In addition to
reducing binging and purging episodes, fluoxetine might also be
useful for the treatment of co-occurring depression and anxiety
disorders.)
-Psychological treatment – Both cognitive behavioral therapy (CBT) and
interpersonal psychotherapy (IPT) have been used. CBT has been
shown to be highly effective for BN.
-Nutritional counseling and education.
Binge-Eating Disorder
Binge-Eating Disorder
-Patients with binge-eating disorder suffer
emotional distress over their binge eating, but
they do not try to control their weight by
purging or restricting calories, as do anorexics
or bulimics. Unlike anorexia and bulimia-
Patients with binge-eating disorder are not as
fixated on their body shape and weight
DIAGNOSIS AND DSM-5 CRITERIA
- Recurrent episodes of binge eating (eating an excessive amount of
food in a 2-hour period associated with a lack of control), with at
least three of the following: eating very rapidly, eating until
uncomfortably full, eating large amounts when not hungry, eating
alone due to embarrassment, and feeling guilty after eating.
-Severe distress over binge eating.
-Binge eating occurs at least once a week for 3 months.
-Binge eating is not associated with compensatory behaviors (such as
vomiting,laxative use, etc.), and doesn’t occur exclusively during the
course of anorexia or bulimia
PHYSIC AL FINDINGS AND MEDIC AL
COMPLICATIONS
Patients are typically obese and suffer from
medical problems related to obesity including
metabolic syndrome, type II diabetes, and
cardiovascular disease.
EPIDEMIOLOGY
Binge eating disorder is the most common
eating disorder.
It appears in approximately 25 percent of
patients who seek medical care for obesity
and in 50 to 75 percent of those with severe
obesity (body mass index [BMI] greater than
40).It is more common in females (4 percent)
than in males(2 percent).
ETIOLOGY
Runs in families, reflecting likely genetic
influences
COURSE AND PROGNOSIS
-Typically begins in adolescence or young
adulthood
- Remission rates are higher than for other
eating disorders
- Higher rates of psychiatric comorbidities than
in obese individuals without binge eating
disorder.
TREATMENT
Both pharmacotherapy and psychotherapy could be considered.
Pharmacological treatment: antidepressants,SSRIs such as fluoxetine.
Psychological treatment – Both cognitive behavioural therapy (CBT) and
interpersonal psychotherapy (IPT)
THANK YOU
