Module 1

Anorexia Nervosa
Diagnostic Criteria
• Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than that minimally expected.
• Intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain, even though at a significantly low
weight.
• 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 persistent lack of recognition of the seriousness of the
current low body weight.
(DSM-V)
 Anorexia Nervosa
• Restricting type: During the last 3 months, the individual has not engaged in
recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting
or the misuse of laxatives, diuretics, or enemas). Weight loss is accomplished
primarily through dieting, fasting, and/or excessive exercise.
• Binge-eating/purging type: During the last 3 months, the individual has engaged in
recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting
or the misuse of laxatives, diuretics, or enemas).

• In partial remission: After full criteria for anorexia nervosa were previously met,
Criterion A (low body weight) has not been met for a sustained period, but either
Criterion B (intense fear of gaining weight or becoming fat or behavior that
interferes with weight gain) or Criterion C (disturbances in self-perception of
weight and shape) is still met.
• In full remission: After full criteria for anorexia nervosa were previously met, none
of the criteria have been met for a sustained period of time.
 Severity of Anorexia
• The minimum level of severity is based, for adults, on current body mass
index (BMI) or, for children and adolescents, on BMI percentile. The level of
severity may be increased to reflect clinical symptoms, the degree of
functional disability, and the need for supervision.

• Mild: BMI ≥ 17
• Moderate: BMI 16–16.99
• Severe: BMI 15–15.99
• Extreme: BMI < 15

By comparison, normal rates for BMI are:

• 18.5 - 24.9 = Normal
• 25 - 29.9 = Overweight
• 30 and above = Obese
 Anorexia Nervosa
Subtypes
• Most individuals with the binge-eating/purging type of anorexia who binge
eat also purge through self-induced vomiting or the misuse of laxatives,
diuretics, or enemas. Some individuals with this subtype of anorexia nervosa
do not binge eat but do regularly purge after the consumption of small
amounts of food.
• Often, the individual is brought to professional attention by family members
after marked weight loss (or failure to make expected weight gains) has
occurred. If individuals seek help on their own, it is usually because of
distress over the somatic and psychological sequelae of starvation. It is rare
for an individual with anorexia nervosa to complain of weight loss per se. In
fact, individuals with anorexia nervosa frequently either lack insight into or
deny the problem. It is therefore often important to obtain information from
family members or other sources to evaluate the history of weight loss and
other features of the illness.
 Anorexia Nervosa
Associated Features Supporting Diagnosis
• The semi-starvation of anorexia, and the purging behaviors sometimes associated
with it, can result in significant and potentially life-threatening medical conditions.
The nutritional compromise affects most major organ systems and can produce a
variety of disturbances.
• Physiological disturbances, including amenorrhea and vital sign abnormalities, are
common.
• While most of the physiological disturbances associated with malnutrition are
reversible with nutritional rehabilitation, some, including loss of bone mineral density,
are often not completely reversible.
• When seriously underweight, many individuals with anorexia nervosa have depressive
signs and symptoms such as depressed mood, social withdrawal, irritability,
insomnia, and diminished interest in sex. These features are also observed in
individuals without anorexia who are significantly undernourished, and thus may be
secondary to the physiological sequelae of semi-starvation, although they may also be
sufficiently severe to warrant an additional diagnosis of major depressive disorder.
 Anorexia Nervosa
• Obsessive-compulsive features, both related and unrelated to food, are often prominent.
Most individuals with anorexia nervosa are preoccupied with thoughts of food. Some collect
recipes or hoard food. Obsessions and compulsions related to food may be exacerbated by
undernutrition.
• Other features sometimes associated with anorexia nervosa include concerns about eating in
public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible
thinking, limited social spontaneity, and overly restrained emotional expression. Those with
binge-eating/purging type have higher rates of impulsivity and are more likely to abuse
alcohol and other drugs.
• A subgroup of individuals with anorexia nervosa show excessive levels of physical activity.
Increases in physical activity often precede onset of the disorder, and over the course of the
disorder increased activity accelerates weight loss. During treatment, excessive activity may
be difficult to control, thereby jeopardizing weight recovery.
Prevalence
• The 12-month prevalence of anorexia nervosa among young females is approximately 0.4%.
Less is known about prevalence among males, but anorexia nervosa is far less common in
males than in females, with clinical populations generally reflecting approximately a 10:1
female-to-male ratio.
 Anorexia Nervosa
Development and Course
• Commonly begins during adolescence or young adulthood. Rarely begins before
puberty or after age 40.
• Onset is often associated with a stressful life event, such as leaving home for college.
• Older individuals more likely have a longer duration of illness, and they tend to have
more signs and symptoms of long-standing disorder.
• Many individuals have a period of changed eating behavior prior to full criteria for the
disorder being met. Some individuals with anorexia nervosa recover fully after a single
episode, with some exhibiting a fluctuating pattern of weight gain followed by relapse,
and others experiencing a chronic course over many years.
• Hospitalization may be required to restore weight and to address medical
complications.
• Most individuals with anorexia nervosa experience remission within 5 years of
presentation.
• Death most commonly results from medical complications associated with the disorder
itself or from suicide.
 Anorexia Nervosa
Risk and Prognostic Factors
Temperamental
• Individuals who develop anxiety disorders or display obsessional traits in childhood are at increased risk
of developing anorexia nervosa.
Environmental
• Association with cultures and settings in which thinness is valued. Occupations that encourage thinness,
such as modeling and elite athletics, are also associated with increased risk.
Genetic and physiological
• There is an increased risk of anorexia nervosa and bulimia nervosa among first-degree biological relatives
of individuals with the disorder. An increased risk of bipolar and depressive disorders has also been
found among first-degree relatives of individuals with anorexia nervosa, particularly relatives of individuals
with the binge-eating/purging type.
Culture-Related Diagnostic Issues
• Anorexia nervosa occurs across culturally and socially diverse populations.
• Anorexia nervosa is probably most prevalent in post-industrialized, high-income countries such as in the
United States, many European countries, Australia, New Zealand, and Japan, but its incidence in most low-
and middle-income countries is uncertain.
• Whereas the prevalence of anorexia nervosa appears comparatively low among Latinos, African
Americans, and Asians in the United States, clinicians should be aware that mental health service
utilization among individuals with an eating disorder is significantly lower in these ethnic groups and
that the low rates may reflect an ascertainment bias.
 Bulimia Nervosa
Diagnostic Criteria
• Recurrent episodes of binge eating. An episode of binge eating is characterized
by both of the following:
– Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food
that is definitely larger than what most individuals would eat in a similar period of
time under similar circumstances.
– A sense of lack of control over eating during the episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behaviors in order to prevent weight
gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other
medications; fasting; or excessive exercise.
• The binge eating and inappropriate compensatory behaviors both occur, on
average, at least once a week for 3 months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.
 Bulimia Nervosa
• In partial remission: After full criteria for bulimia nervosa were previously met, some,
but not all, of the criteria have been met for a sustained period of time.
• In full remission: After full criteria for bulimia nervosa were previously met, none of the
criteria have been met for a sustained period of time.

The minimum level of severity is based on the frequency of inappropriate compensatory

behaviors. The level of severity may be increased to reflect other symptoms and the degree
of functional disability.

• Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.

• Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per
week.
• Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per
week.
• Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors
per week.
 Bulimia Nervosa
Associated Features Supporting Diagnosis
• Individuals with bulimia typically are normal weight or overweight. The disorder
occurs but is uncommon among obese individuals.
• Between eating binges, individuals with bulimia nervosa typically restrict their
total caloric consumption and preferentially select low-calorie (“diet”) foods
while avoiding foods that they perceive to be fattening or likely to trigger a binge.
• Menstrual irregularity or amenorrhea often occurs among females with bulimia
nervosa; it is uncertain whether such disturbances are related to weight
fluctuations, to nutritional deficiencies, or to emotional distress.
• The fluid and electrolyte disturbances resulting from the purging behavior are
sometimes sufficiently severe to constitute medically serious problems.
• Rare but potentially fatal complications include esophageal tears, gastric rupture,
and cardiac arrhythmias
• Individuals who chronically abuse laxatives may become dependent on their use to
stimulate bowel movements.
 Bulimia Nervosa
Prevalence
• Twelve-month prevalence of bulimia nervosa among young females is 1%–1.5%.
• It is far less common in males than females, with an approximately 10:1 female-to-
male ratio.
Development and Course
• Bulimia nervosa commonly begins in adolescence or young adulthood.
• Onset before puberty or after age 40 is uncommon.
• The binge eating frequently begins during or after an episode of dieting to lose
weight. Experiencing multiple stressful life events also can precipitate onset
of bulimia nervosa.
• Disturbed eating behavior persists for at least several years in a high percentage of
clinic samples. The course may be chronic or intermittent, with periods of remission
alternating with recurrences of binge eating. Periods of remission longer than 1 year
are associated with better long-term outcome.
• Significantly elevated risk for mortality (all-cause and suicide) has been reported for
individuals with bulimia nervosa.
 Bulimia Nervosa
Risk and Prognostic Factors
• Temperamental
• Weight concerns, low self-esteem, depressive symptoms, social anxiety disorder, and
overanxious disorder of childhood are associated with increased risk for the development
of bulimia nervosa.
• Environmental
• Internalization of a thin body ideal has been found to increase risk for developing weight
concerns, which in turn increase risk for the development of bulimia nervosa. Individuals
who experienced childhood sexual or physical abuse are at increased risk for
developing bulimia nervosa.
• Genetic and physiological
• Childhood obesity and early pubertal maturation increase risk for bulimia nervosa.
Familial transmission of bulimia nervosa may be present, as well as genetic vulnerabilities
for the disorder.

• Severity of psychiatric comorbidity predicts worse long-term outcome of bulimia nervosa.

 Bulimia Nervosa
Culture-Related Diagnostic Issues
• Bulimia nervosa has been reported to occur with roughly similar frequencies in
most industrialized countries, including the United States, Canada, many
European countries, Australia, Japan, New Zealand, and South Africa.
• In studies in the United States, individuals presenting with bulimia are primarily
white. However, the disorder also occurs in other ethnic groups and with
prevalence comparable to estimated prevalences observed in white samples.
Gender-Related Diagnostic Issues
• Bulimia nervosa is far more common in females than in males. Males are
especially underrepresented in treatment-seeking samples, for reasons that
have not yet been systematically examined.

• Suicide risk is elevated in bulimia nervosa.

• A minority of individuals report severe role impairment, with the social-life
domain most likely to be adversely affected by bulimia nervosa.
 Binge-Eating Disorder
Diagnostic Criteria
• Recurrent episodes of binge eating, characterized by both of the following:
– Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is
definitely larger than what most people would eat in a similar period of time under similar
circumstances.
– A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating).
• The binge-eating episodes are associated with three (or more) of the following:
– Eating much more rapidly than normal.
– Eating until feeling uncomfortably full.
– Eating large amounts of food when not feeling physically hungry.
– Eating alone because of feeling embarrassed by how much one is eating.
– Feeling disgusted with oneself, depressed, or very guilty afterward.
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least once a week for 3 months.
• The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia
nervosa or anorexia nervosa.
 Binge-Eating Disorder
• In partial remission: After full criteria for binge-eating disorder were
previously met, binge eating occurs at an average frequency of less than
one episode per week for a sustained period of time.
• In full remission: After full criteria for binge-eating disorder were previously
met, none of the criteria have been met for a sustained period of time.

• The minimum level of severity is based on the frequency of episodes of

binge eating (see below). The level of severity may be increased to reflect
other symptoms and the degree of functional disability.
• Mild: 1–3 binge-eating episodes per week.
• Moderate: 4–7 binge-eating episodes per week.
• Severe: 8–13 binge-eating episodes per week.
• Extreme: 14 or more binge-eating episodes per week.
 Binge-Eating Disorder
Associated Features Supporting Diagnosis
• Occurs in normal-weight/overweight and obese individuals. It is associated with overweight and obesity in
treatment-seeking individuals.
• Binge-eating disorder is distinct from obesity. Most obese individuals do not engage in recurrent binge
eating.
Prevalence
• Twelve-month prevalence of binge-eating disorder among U.S. adult (age 18 or older) females and males is
1.6% and 0.8%, respectively:
• Binge-eating disorder is as prevalent among females from racial or ethnic minority groups as has been
reported for white females. The disorder is more prevalent among individuals seeking weight-loss
treatment than in the general population.
Development and Course
• Little is known about the development of binge-eating disorder. Binge eating consumption occurs in
children and is associated with increased body fat, weight gain, and increases in psychological symptoms.
Binge eating is common in adolescent and college-age samples.
• Dieting follows the development of binge eating in many individuals with binge-eating disorder. (This is in
contrast to bulimia nervosa, in which dysfunctional dieting usually precedes the onset of binge eating.)
• Binge-eating disorder typically begins in adolescence or young adulthood but can begin in later adulthood.
• Remission rates are higher for binge-eating disorder than for bulimia or anorexia.
 Binge-Eating Disorder
Risk and Prognostic Factors
Genetic and physiological
• Binge-eating disorder appears to run in families, which may reflect additive genetic
influences.
Culture-Related Diagnostic Issues
• Occurs with roughly similar frequencies in most industrialized countries, including
the United States, Canada, many European countries, Australia, and New Zealand.
• In the United States, the prevalence appears comparable among non-Latino
whites, Latinos, Asians, and African Americans.
Functional Consequences of Binge-Eating Disorder
• Binge-eating disorder is associated with a range of functional consequences,
including social role adjustment problems, impaired health-related quality of life
and life satisfaction, increased medical morbidity and mortality, and associated
increased health care utilization. It may also be associated with an increased risk
for weight gain and the development of obesity.
 How Common Are Eating Disorders?
• According to Statistics Canada, in 2002 0.5% of Canadians aged 15 years
and over reported that they had been diagnosed with an eating disorder
in the previous 12 months.
• 1.7% of Canadians aged 15 and over reported symptoms that met the
12-month criteria for an eating attitude problem.
• Anorexia nervosa and bulimia nervosa are most predominant among
adolescent girls and young women
• However, 5-15% of anorexia nervosa and bulimia nervosa and 40% of
binge eating disorders are among boys or men.
• Approximately 3% of women will be affected by an eating disorder in
their lifetime.
• Binge eating disorder affects about 2% of the population.
(from http://www.phac-aspc.gc.ca/publicat/human-humain06/10-eng.php)
 Mental Illness
• There has been a drive to recognize eating disorders to be ‘‘serious
mental illnesses’’ (SMIs), ‘‘biologically based mental illnesses’’
(BBMIs), and in children, ‘‘serious emotional disturbances’’ (SEDs).
• SMI: a diagnosable mental disorder found in adults 18 years and
older that is so long lasting and severe that it seriously interferes with
a person’s ability to take part in major life activities.
• SED: a diagnosable mental disorder found in persons from birth to 18
years of age that is so severe and long lasting that it seriously
interferes with functioning in family, school, community, or other
major life activities
• BBMI: a condition caused by a neurobiological disorder of the brain
that significantly impairs cognitive function, judgment, and emotional
stability, and limits the life activities of the person with the illness.
 Inherited?
• Eating disorders are significantly heritable;
influenced by alterations of brain function;
significantly impair cognitive function, judgment,
and emotional stability; and restrict the life
activities of persons afflicted with these illnesses.
• According to twin studies, eating disorders seem
to have similar heritability compared to other
psychiatric conditions such as schizophrenia,
bipolar disorder, depression, OCD.
 Different Understandings of Eating
Disorders
• Different areas of the world have different
understandings of eating disorders (e.g.,
bulimia nervosa ignored in Romania, some
states in USA not recognizing eating disorders
as BBMI's, to a wider recognition of eating
disorders in Canada).
 Brain Alterations
• When malnourished and emaciated, individuals with anorexia
have alterations of brain structure, metabolism, and
neurochemistry. Similar brain structure alterations are found
in bulimia.

• In anorexia and bulimia, there are profound disturbances of

brain serotonin, and brain neurocircuitry that frequently
persist after recovery from the illness.
• These alterations involve brain circuits known to modulate
appetite, mood, cognitive function, impulse control, energy
metabolism, and autonomic and hormonal systems.
• Individuals with anorexia and bulimia exhibit difficulties with executive
functioning (e.g., difficulties with set shifting) and a weakness in
contextual integration (i.e., getting the gist or the bigger picture).

• Individuals with bulimia also exhibit a disinhibited pattern of

responding, particularly in the context of negative emotions while
individuals with anorexia have impaired decision making ability and
social cognition.

• These effects are most pronounced during the acute phase of the
eating disorder and significantly interfere with judgment and
interpersonal relationships. They may also complicate therapy in
anorexia.
 Comorbid Conditions
• The most common comorbid psychiatric conditions in anorexia
include major depression and anxiety disorders (including,
but not limited to, OCD, social anxiety disorder, and
generalized anxiety disorder).
• Anxiety disorders often predate the onset of anorexia, and
depression and anxiety persist after recovery.
• Commonly comorbid conditions in bulimia include anxiety
disorders, major depression, dysthymia, substance use
disorders, and personality disorders.
• Approximately 80% of individuals with anorexia and bulimia
are diagnosed with another psychiatric disorder at some time
in their life.
 Quality of Life
• Individuals with anorexia and bulimia rate their quality of life
as low.
• Social adjustment tends to be impaired, as social
communication skills are poor and social networks tend to
be small.
• Vocational and educational functioning is below that
expected, with absences from work and school (e.g., only
5.5 months per year in school over a 2- year period)
• Social adjustment tends to remain poor even after recovery
from bulimia, highlighting the large ‘‘cost’’ of eating
disorders to individuals who have suffered from the disorder.
 Complications and Hospital Visits
• Women with anorexia have higher rates of pregnancy complications
than women without eating disorders, and their children may have
later emotional and nutritional problems.
• Carers of individuals with anorexia & bulimia have high levels of
psychological distress.

• Eating disorders tend to have the highest proportion of admissions

of all psychiatric disorders, with a length of stay over 90 days.
• More child and adolescent psychiatric beds are occupied by young
people with eating disorders than any other diagnostic group
• In the U.S., individuals with eating disorders have higher health care
utilization than individuals with other forms of mental illness,
including depression
 Medical Complications and Mortality
• Eating disorders have one of the highest rates of medical complications of
any psychiatric disorder.
• Medical complications include hair loss, growth retardation, osteoporosis,
loss of tooth enamel, gastrointestinal bleeding, bowel paralysis,
dehydration, electrolyte abnormalities, hypokalemia, hyponatremia, and
cardiac arrest

• Standardized mortality rates in anorexia are the highest of any psychiatric

disorder and are 12 times higher than the annual death rate from all causes
in females 15–24 years of age.
• Mortality rates in bulimia may not be elevated or only slightly elevated,
however, mortality in EDNOS may be as high as that observed for anorexia.
• Increased risk of death in eating disorders is frequently due to medical
complications or suicide.
 Conclusion:
• Like other BBMI, the cause of
eating disorders 'is multifactorial and
includes a combination of genetic, biological,
and temperamental vulnerabilities that
interact with environmental circumstances to
increase risk'.