FEEDING AND EATING DISORDERS
NRSG 362: Mental Health and Psychiatric Nursing
CLAIRE
DSM-5 CLASSIFICATION
• Characterized by a persistent disturbance of
eating or eating-related behavior
• Results in the altered consumption or
absorption of food and that significantly impairs
physical health or psychosocial functioning.
• Some individuals present with craving and
patterns of compulsive use.
• This may reflect the involvement of the neural
systems In self-control and reward
DSM-5 CLASSIFICATION CONT..
• Pica
• Rumination disorder
• Avoidant/restrictive food intake disorder
• Anorexia nervosa
• Bulimia nervosa
• Binge-eating disorder.
PICA
Diagnostic Criteria
• Persistent eating of nonnutritive, nonfood substances
over a period of at least 1 month
• Inappropriate to the developmental level of the
individual
• Not culturally supported or socially normative
practice.
• If the eating behavior occurs in the context of
another mental disorder or medical condition its
sufficiently severe to warrant additional clinical
attention.
Diagnostic Criteria Cont..
• Assessment should include consideration of
the possibility of gastrointestinal
complications, poisoning, infection, and
nutritional deficiency.
Rumination Disorder
• Repeated regurgitation of food over a period of at least 1
month
• The repeated regurgitation is not attributable to an
associated gastrointestinal or other medical condition (e.g.,
gastroesophageal reflux, pyloric stenosis)
• The eating disturbance does not occur exclusively during
the course of anorexia nervosa, bulimia nervosa, binge-
eating disorder, or avoidant/restrictive food intake disorder
• If the symptoms occur in the context of another mental
disorder (e.g., intellectual disability [Intellectual
developmental disorder] or another neurodevelopmental
disorder), they are sufficiently severe to warrant additional
clinical attention.
S&S among Infants
• Position of straining and arching the back with the
head held back.
• They may give the impression of gaining satisfaction
from the activity.
• They may be irritable and hungry between episodes
of regurgitation.
• Weight loss and failure to make expected weight
gains
• Malnutrition may occur despite the infant's
apparent hunger and the ingestion of relatively
large amounts of food
Avoidant/Restrictive Food Intake Disorder
• An eating or feeding disturbance (e.g., apparent lack of
interest in eating or food; avoidance based on the
sensory characteristics of food; concern about aversive
consequences of eating) as manifested by persistent
failure to meet appropriate nutritional and/or energy
needs associated with one (or more) of the following:
Significant weight loss
Significant nutritional deficiency
Dependence on enteral feeding or oral nutritional
supplements
Marked interference with psychosocial functioning.
Avoidant/Restrictive Food Intake Disorder
• The disturbance is not better explained by lack of
available food or by an associated culturally
sanctioned practice
• Does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa, and there is
no evidence of a disturbance in the way in which
one’s body weight or shape is experienced
• Rule out medical condition or mental disorder.
• warrants additional clinical attention if concurrent
with a medical condition or mental disorder.
S&S among Children
• Very young infants may present as being too sleepy,
distressed, or agitated to feed
• Infants and young children may not engage with the
primary caregiver during feeding or communicate
hunger in favor of other activities
• In older children and adolescents, food avoidance
or restriction may be associated with more
generalized emotional difficulties that do not meet
diagnostic criteria for an anxiety, depressive, or
bipolar disorder
ANOREXIA NERVOSA
• Eating disorder characterized by obsessional
with loss in weight without an identifiable
organic course.
• Onset: average age of onset is 13 to 14 years,
the onset is often preceded by a period of
mild obesity or mild eating
ANOREXIA NERVOSA
• Restriction of energy intake relative to requirements,
leading to a significantly low body weight
• 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.
Diagnostic Criteria Cont..
Specify current severity
• Mild: BMI > 17kg/m2
• Moderate: BMI 16-16.99 kg/m
• Severe: BMI 15-15.99 kg/m
• Extreme: BMI < 15 kg/m
NB use corresponding BMI percentiles for children
Behavioral features
1. Over activity/hyperactivity
2. obsessions and rituals with food and food
preparation
3. Purging (self-induced vomiting, diuretic abuse,
laxative abuse)
4. Secretiveness
5. Extreme behavioral rigidity and inflexibility
6. Cognitive preoccupations and distortions
regarding body weight
Diagnostic Makers
• Hematology: Leukopenia, mild anemia,
thrombocytopenia,bleeding problems.
• Serum chemistry: elevated blood urea nitrogen
level, Hypercholesterolemia, elevated Hepatic
enzyme levels, Hypomagnesemia,
hypophosphatemia, metabolic alkalosis
hypochloremia, and hypokalemia, laxative abuse
may cause a mild metabolic acidosis.
Diagnostic Makers cont..
• Endocrine: low (T4) and (T3), Females have low
serum estrogen levels, whereas males have low
levels of serum testosterone.
• Electrocardiography: Sinus bradycardia, rarely
arrhythmias are noted.
• Bone mass: Low bone mineral density, with specific
areas of osteopenia or osteoporosis, is often seen.
• Electroencephalography: Diffuse abnormalities,
reflecting a metabolic encephalopa thy, may result
from significant fluid and electrolyte disturbances.
• Resting energy expenditure: There is often a
significant reduction in resting energy expenditure.
Diagnostic Makers cont..
Physical signs and symptoms.
• Amenorrhea
• Menarche maybe delayed
• Constipation
• abdominal pain
• cold intolerance
• lethargy
Diagnostic Makers cont..
Physical signs and symptoms.
• Emaciation
• hypotension
• Hypothermia
• Bradycardia
• Lanugo
• Peripheral
• Rarely, petechiae or ecchymoses
• Hypercarotenemia
• hypertrophy of the salivary glands
• dental enamel erosion
• scars or calluses on the dorsal surface of the hand from
Complications of anorexia nervosa
Neonate hair ( thin-wiry hair)
CVA – hypotension, bradycardia, arrhythmias
Hematopoietic system – normochromic, normocytic anemia,
leukopenia, elevated blood urea nitrogen and creatinine
clearance, hypokalemia, hyponatremia, alkalosis.
GIT - elevated serum concentration of liver enzyme, delayed
gastric emptying, constipation
Endocrine – diminished T4 with normal TSH, elevated plasma
cortisol levels, diminished secretion of LH, FSH, estrogen or
testosterone
MSS – osteoporosis.
Epidemiology
• Anorexia nervosa prevalence is about 0.4 % of the female
population and is about 10 times higher in women compared with
men.
• Onset is more commonly during adolescent (85% of case).
• High rates are reported among ballet dancers and models
• The highest prevalence is reported in middle and upper
socioeconomic classes
Differential diagnosis
Medical conditions
1. Addison’s disease. Listlessness and depression are
frequent findings in contrast to the hyperactivity of
anorexia nervosa.
2. Hypothyroidism, weight loss (and accompanying fear of
weight gain) and hyperactivity are not usual.
3. Hyperthyroidism. Patients with hyperthyroidism are not
obsessive about food.
Differential diagnosis… Cont..
• Schizophrenia. Although schizophrenics may be delusions
about food, the delusion are more bizarre than those seen
in anorectics (e.g. there is poison in this verses will make
fat).
• Bulimia nervosa. Binge eating is usually followed by some
form of purging in a patient who otherwise maintains
weight.
• Depression. Anorexia is one of the neurovegetative sign
and a depressed mood is usually pronounced.
Treatment
• Hospital admission; May be necessary if weight loss
is rapid or severe (<25% of ideal body weight.
• Other indications for admission include metabolic
disturbances eg hypokalemia, severe depression
and/or suicidal idealation.
• Inpatient treatment depends on high quality
nursing care, and comprises bed rest, restriction of
activities and high caloric diets.
• Parenteral nutrition may be necessary if weight loss
is life threatening,
Treatment Cont..
• The main aim of treatment is the restoration of a
healthy weight and healthy eating habits. This is
best achieved gradually and success depends on
establishing a therapeutic alliance with the patient.
• Family therapy may be helpful when the patient is
an adolescent living with parents.
• The aim is to understand the role that the illness
plays in the family life and to help the family
towards less destructive means of conflict
resolution.
Treatment Cont..
• Psychotherapy – patient should understand that
his/her perception of self (body weight/shape) is
unrealistic.
• Low doses of CPZ
• Spousal involvement if married
• CBT-assist pt stabilize aberrant behaviors as well as
identify and correct the thinking that has led to the
behavior
• Social care - evaluate the environment pt comes
from, societal expectation, fashion, dieting,
KEY POINTS
• Early recognition and treatment an anorexia
nervosa decreases the likelihood of a chronic, life
threatening course.
• Primary care clinicians should carefully question the
eating habits of children and adolescents who are
losing weight but do not seem concerned about
their thinness.
• A key question for a primary care clinician to ask a
child who is losing weight is if there is greater fear
about continued weight loss or about weight gain.
KEY POINTS Cont..
• In anorexia nervosa amenorrhea may occur before
the loss of substantial weight and may persist,
despite return of weight to normal electrolyte and
pH imbalance.
• Electrolyte and pH imbalances occur primarily in the
purging type of anorexia nervosa
• The mortality rate of anorexia nervosa is higher
than that of any other psychiatric illness, including
depression.
BULIMIA NERVOSA
Introduction
• Bulimia nervosa is more common than anorexia
nervosa.
• While the psychopathological features of bulimia
resemble those of anorexia the difference is in that
weight is either normal or increased.
• It’s characterized by repeated bouts of overeating
and an excessive preoccupation with the control of
body weight.
Diagnostic Criteria
• Recurrent episodes of binge 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.
Clinical features
• A sense of lack of control over eating
• Absence of anorexia nervosa
• Food craving
• Absence of physiologic conditions that explain
symptoms ( eg klein-levin syndrome).
Clinical features
• Sufferers of bulimia attempt to control their weight
through a variety of methods through which
vomiting and purging with laxatives or diuretics are
the most common methods
• Episodes of bingeing and purging may be
precipitated by feelings of depression, anxiety,
boredom or loneliness.
• During binges carbohydrate rich foods are
consumed rapidly.
Clinical features
• The absence of physical sequealae of anorexia, in
that the stigmata are those associated with purging
rather than starvation.
• These include
1. Salivary gland enlargement
2. Erosion of dental enamel
3. Calluses on the dorsum of the hand (Russel’s sign)
4. Metabolic disturbances, especially alkalosis and
hyperkalemia.
Epidemiology
• Probably affects 1% to 4% of young women in the
U.S.
• Although the rate of the disorder appears to be
lower among non-white and non-western cultures,
the frequency is increasing among these groups,
especially among the higher socio-economic
classes.
• Primarily affects women F:M ration 10:1
Etiology
• Predisposing factors
1. Adolescent girl or young adult woman
2. A personal or family history of obesity and mood
disturbance.
3. Genetic factors
4. Psychosocial factor
- Cultural aesthetic ideals of thinness & physical
fitness
- It also occurs more frequently in certain occupation
(e.g modeling) & sports (e.g running)
Differential diagnosis
• Binge-eating/purging type of anorexia – nervosa –
distinguished by its characteristic low body weight
and in women, amenorrhea.
• Atypical depression
• Personality disorder especially borderline PD
Management
• Indications for admission include severe
depression, risk of suicide, concurrent severe
physical ill-health as a result of bingeing and
purging
• SSRIs, may be helpful in some patients with
comorbid depression. Decrease food craving
• The mainstay of treatment is cognitive behavior
therapy, through which patients eating habit and
attitudes about their weight and physical
appearance are modified.
Special features influencing treatment
• Presence of other significant psychiatric or medical
illness
• Substance abuse
• Presence of personality disorder
• Insulin-dependent diabetes mellitus who “purge” by
omitting insulin doses.
Binge-Eating Disorder
Diagnostic Criteria
• Recurrent episodes of binge 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.
Other Specified Feeding or Eating Disorder
• Unspecified Feeding or Eating Disorder
References
• Ndetei D.M., Szabo P., Okasha T. and Mburu J.
(2006). The African Textbook of Clinical Psychiatry
and Mental Health. Nairobi. The African Medical
and Research Foundation.
• Jeste, V., Lieberman, A., Fassler, D., Peele, R.,
(2013). Dagnostic and Statistical Manual of
Mental Disorders (DSM-5). Washington:
American Psychiatric Publishing.
