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MEDICAL JOURNAL OF COSTA RICA AND CENTRAL AMERICA LXX (607) 475 - 482, 2013

PSYCHY AT RY

CONDUCT DISORDERS
FOOD

María Jesús Vargas Baldares*

YesUMMARY The most common ED are humanity, both because of the

anorexia nervosa, bulimia number of people affected that is
The eating behavior disorders nervosa and binge eating increasing, and because of the
(ED) constitute a public health disorder (BED). This article deaths it causes. These are
problem because of its gives a brief description diseases that require treatment
prevalence, increasing of the ED, and the specific long, which can become
incidence, severity, prolonged characteristics of the approach chronic diseases and lead to
clinical course, and tendency of these pathologies. death. (8) EDs are real and
to chronicity, need specialized treatable diseases. They often
treatment and frequent YoINTRODUCTION coexist with other illnesses
hospitalization. The ED has as such as depression, substance
main dissatisfaction with EDs generally appear during abuse, or anxiety disorders.
weight and/or personal image adolescence or adulthood
by overvalued ideas or early, but also (12) The TCAs are framed between
distortions of the concept of They can occur during childhood those social and cultural
what should be the perfect or late adulthood. (3) EDs phenomena that transcend
shape and weight. Pathological currently represent, according to beyond the medical and scientific
behaviors cause social the World Health Organization field, to society. These disorders
dysfunction and help maintain (WHO), the most important are affected by the ideal of
a healthy weight. To handle health problem in the world. beauty promoted by the media
intervention
these cases, require and
specialized
coordinated interdisciplinary. * General practitioner. National Psychiatric Hospital. CCSS. e-mail: marjvb@yahoo.es
476 MEDICAL JOURNAL OF COSTA RICA AND CENTRAL AMERICA

of communication of extreme that can only be understood by dIAGNOSTIC

thinness, an idea of beauty the interaction of very diverse
represented by models, women psychological and physiological The etiopathogenesis of EDs is
and men whose proportions, factors that interact with each not yet known. It is admitted that
weight and height are a true other. Sociocultural factors play it is a disorder of multifactorial
statistical exception. We are an essential etiological role and cause, (2, 13, 15, 17) In the broad
faced with ideals that show both body dissatisfaction existing scientific discussion on
thinness as a symbol of such as the desire for thinness are the etiology of the disease,
independence, social, personal necessary characteristics for the sociocultural factors such as the
and professional success. (19) appearance of an eating disorder. (12) imperative of thinness, the
normativity of gender roles,
dEFINITION ANDPIDEMIOLOGY experiences of sexual abuse and
conflicts in the family environment
EDs constitute a group of The data epidemiological are identified as causes of EDs.
mental disorders characterized on EDs support a greater Biological factors such as a genetic
by altered behavior regarding vulnerability of young women to predisposition, the presence of
food intake and/or the suffering from them, particularly in previous psychopathology or its
appearance of behaviors aimed adolescence or early adulthood. development as a side effect of
at controlling weight. This The presence of body malnutrition, as well as personal
alteration causes physical and dissatisfaction or abnormal eating characteristics such as low self-
psychosocial functioning behaviors is common among esteem and a high level of self-
problems. (9) EDs are diseases middle adults. (1) The maximum demand, have also been proposed.
whose main characteristics are incidence occurs between 15-25 (13)
distorted eating behavior and years of age. Demographic factors • Factors Biological:
extreme concern about self- related to eating disorders include Abnormality in the function of
image and body weight. The sex, age, being an only child, the hypothalamus, alteration of
main representatives of this single-parent family, and death of the neurotransmitter system
group are anorexia nervosa a parent. Patients with ED have a (decrease in norepinephrine,
(AN), bulimia nervosa (BN) and higher incidence of affective serotonin, dopamine),
ED not otherwise specified, disorders than the general decreased basal
which includes binge eating population, with a metabolism. (2)
disorder. New trends in fashion higher prevalence of depression • Genetic Factors: The
and new standards in physical elderly. (4) The population at factors genetic are
appearance and eating patterns greatest risk is made up of athletes, fundamental in he
are pointed out as possible models, sportspeople, those with a development of these
triggers for the increase in the family history of eating disorders or entities, mainly the AN. (18)
frequency of these disorders. a history of obesity in childhood, a • Factors Psychological:
(18) EDs are serious history of sexual abuse, Personality types or traits,
psychosomatic diseases, of maltreatment, a history of cognitive and emotional factors.
multifactorial etiology, depression and alexithymia. (18) (2) In the case of adolescents, it
has been described
 VARGAS: EATING DISORDERS 477

that they tend to direct their thinness that makes our YoBODY MAGEN AND
concerns toward food and culture, is a factor of ASSERTIVENESS
weight gain and often lose undeniable importance for
their sense of autonomy and the generation of these In studies carried out on the
self-confidence. 3 affected paintings. Sociocultural relationship between eating
areas are described: a) A influences and “the desire for disorders and body image, it has
disorder of delusional thinness” constitute the main been observed that the older one
proportions in the image predisposition factor and is, the greater the influence of
and conceptcorporal, b) maintenance of these advertising and the internalization
Perception andinterpretation disorders. (18) of the thin ideal; However,
cognitive inadequate and • Factors Triggers: adolescent girls present greater
confusion of the stimuli that Changes corporal, reactivity to their possible greater
begin in the body, which would disease slimming, weight. Likewise, adolescent girls
lead one not to notice the trauma disfiguring, associate more inappropriate
sensation of hunger, c) A parental marital breakup, compensatory behaviors with
paralyzing sensation of sexual contacts, rapid losing weight. (1) Patients with ED
ineffectiveness that produces the weight gain, criticism about perceive themselves as very
conviction that one acts only in the body, increased controlled by their family and
response to the demands of physical activity and society, but they do not have the
others and not because of his starting a diet. (2) assertiveness to respond to this.
own initiative. (16) • Factors Maintainers: One form of non-assertive
• Family Factors: In the case of Consequences physical and behavior is aggression/hostility,
AN, they are observed with psychics of starvation, which can be self-directed. Various
certain characteristics as cognitions anorexic, authors have pointed out that
overwrapping, rigidity interaction family and patients with ED present before the
to change and adapt to new social isolation (2) development of the disease,
patterns and situations, TO the risks specific, issues of autonomy and
overprotection, avoidance certain by the independence and acceptance
and lack of conflict characteristics individual of life's difficulties
resolution. These families of the subject: family, biography or adult, interpersonal problems,
appear happy and are often genetics, environmental and cultural with introversion, insecurity,
of upper economic class and factors are added. (17) For a better dependency, social anxiety, lack of
oriented toward success and understanding of the etiopathogenesis assertiveness and difficulties with
achievement. that produce of eating disorders, it is necessary to interpersonal relationships, feeling
prestige. (18) take into account the biological, of ineffectiveness, failure and lack
• Factors Sociocultural: psychological, family and social aspects of control in their school, work or
Predisposition familiar, that can affect development. relationship life, tendencies
interaction father-children, and maintenance of are perfectionists with features
functioning familiar, pathologies. (fifteen) obsessives, rigidity and extremism
greater or lesser conflict (2) in the evaluation of problems.
The overvaluation of Many of these factors suggest
478 MEDICAL JOURNAL OF COSTA RICA AND CENTRAL AMERICA

a possible difficulty in showing about image alteration and its shape. (Table 1). This same
assertive behaviors or social body, the desire to lose weight, entity also highlights that the
skills, both to set limits for other the mechanisms used to achieve term anorexia (lack of appetite)
people and differentiate oneself it and repercussions in the is erroneous, since it rarely
from them, as well as to express personal and socio-family sphere. appears in the early stages of
discrepant judgments (2) the disease. (2, 18) It affects
independently, and in the own 0.5-1% of people throughout
expression of feelings and TONERVOUS NOREXIA their lives. (14) These patients
opinions. (5) (AN) voluntarily implement different
measures to achieve the
dIAGNOSTIC AN was first described by desired weight loss, such as a
Richard Morton in 1694 and very strict restrictive diet and
When the presence of an eating later, 2 centuries later, Gull in purgative behaviors (self-
disorder is suspected, a complete England and Lassegue in induced vomiting, abuse of
clinical history must be taken, France described other cases laxatives, use of diuretics, etc.).
ruling out organic and/or that corresponded to the Despite the progressive and
psychiatric pathology associated disease as it is currently intense weight loss, affected
with it or as a consequence of it. recognized. The etiology of AN people present a distortion of
The clinician's attitude towards is not yet known with body image and see themselves
the patient is essential to obtain certainty, but it is thought to as fat, which is why they persist
reliable information and be multifactorial, with genetic, with food avoidance behaviors
guarantee the continuity of the social, metabolic, along with
therapeutic process. The specific personality, hormonal, compensatory actions for
data that must be collected range sexual, way of expressing counteract the caloric intake of
from knowledge of the genesis of emotions, learning, history of what they ingest (excessive
the disease, weight fluctuations, abuse, mistreatment or physical activity, purging
to knowledge of the intake and perfectionism and coexistence with behaviors, etc.). They are
type of foods consumed or other psychiatric disorders, such as usually not aware of the disease
avoided, as well as their meal the depressive component, or the risk they run with their
times, methods used to lose obsessive-compulsive, the behavior. All their interest is
weight. , etc. It is necessary to anxiety disorders and loss of focused on losing weight, and
evaluate the patient's mental impulse control. (16) The to achieve this they do not mind
state to specify the psychiatric fourth edition of the falling into deficient nutritional
severity of the condition and the Diagnostic Manual of Mental states that can entail serious life
associated diagnoses. A physical Disorders (DSM-IV), defines risk. These people often have a
examination should be this entity as a disorder in the personality
performed that includes weight, that the person refuses to maintain with excessive need of
height, blood pressure, pulse, a minimal weight within the normal approval, high sense of
body mass index, and blood range, has an intense fear of gaining responsibility, perfectionism and
tests; and psychopathological weight and a significant feeling of personal ineffectiveness.
that investigates misinterpretation of his or her body (9, 18) It is a typical disease
 VARGAS: EATING DISORDERS 479
Table 1. Diagnostic Criteria of Anorexia Nervosa according to the DSM-IV

TO.Intense fear of gaining weight, which does not decrease with weight loss.
b.Alteration of the body silhouette, exaggerating its importance in self-evaluation and denying the
dangers caused by weight loss.
c.Loss of at least 25% of original weight. In children under 18 years of age, the amount that would increase
according to the growth process must be added to the initial weight and considering that a weight reduction
close to 15% is assessed as a medical risk.
d.Refusal to maintain body weight above the minimum, depending on age and height.
To these criteria the following can be added:
• Self-induced weight loss due to compensatory behaviors: vomiting, laxatives, diuretics and excess physical activity

• Delayed pubertal development: Lack of breast growth, primary or secondary amenorrhea. In men, the
genitals do not develop and there is a loss of sexual interest and potency.
2 types of anorexia are specified:
• RESTRICTIVE TYPE: Weight loss is obtained by dieting, fasting or excessive exercise. No binge eating or
purging
• COMPULSIVE-PURGATIVE TYPE: Purgatory measures such as induction of vomiting, use of laxatives, diuretics and
enemas are regularly used.

of women (90-95%) that occurs increased in recent decades. physical hyperactivity,) along with
mainly in adolescence and affects BN was described as a variant altered perception of body shape
1% of the population. The most of AN in 1979 by Russell. It is and weight. (2) The diagnostic
frequent ages of onset are defined as recurrent episodes criteria for this entity are
usually between 14-18 years; in of binge eating (voracious, described in Table 2. In BN,
recent years it has been observed uncontrolled eating), in which weight alterations do not
that the incidence tends to a large amount of food is necessarily occur; they can be
increase in males. ingested in a short period of normal, underweight, or
time, usually in secret, overweight, which is why it easily
bULIMIA NERVOSA followed by inappropriate goes unnoticed. (9). Bulimic
compensatory behaviors (self- symptoms are divided into
BN has been described since ancient induced vomiting, abuse of purgative and non-purgative. (7)
times and its prevalence has laxatives, use of diuretics, Bulimia affects 1.9% of

Table 2. Diagnostic Criteria of Bulimia Nervosa according to the DSM-IV

TO.Recurrent episodes of voracity:

• Eat a large amount of food in a short period of time
• Lack of control over eating during the episode
b.Average of 2 episodes of greed per week for 3 months
c.Self-assessment “unduly” influenced by body shape and weight
d.Compensatory behavior:
• PURGATIVE: Self-induced vomiting, laxatives, diuretics
• NON-PURGATIVE: Fasting, strenuous physical exercises
480 MEDICAL JOURNAL OF COSTA RICA AND CENTRAL AMERICA

women in the general population, we are facing a disorder the choice of treatment
it is common among adolescents. different from the rest of the It will depend on the
unspecified EDs or simply a characteristics of the person who
TRASTOR mild form of BN. The main suffers from it, its severity and
OF CONDUCT difference with BN is the type of disease. EDs are complex
NON-FOOD absence of compensatory diseases with a chronic course.
SPECIFIED mechanisms for binge eating, They usually require long-term
so over time the patient treatment, with an average of 5-6
TCAs do not specified becomes
leads inexorably towards years. early intervention
They are usually incomplete AN a problem of overweight or It is essential to avoid
OR BN pictures, either because obesity. (9) Binge eating permanent physical damage
they are starting or because they disorder, also called caused by the disease during
are in the process of resolution. compulsive overeating, is a the stages of growth and
Therefore, in them we will see third category that was development. (14) Due to the
similar symptoms but without established in the DSM-IV to complexity of its management,
creating a complete picture, delimit EDs not specifically the treatment must be carefully
coordinated
although no less serious. Within defined as AN and BN. (11) by a multidisciplinary group
this group of disorders, disorders Binge eating disorder that, according to each case
such as the habitual use of and availability, could
inappropriate compensatory (BED) appears in 30% of the include doctor, psychiatrist,
behaviors (after eating small patients who are in weight psychologist, social worker and
amounts of food, chewing them loss programs and 2-5% in the nutritionist. There are cases
and expelling the food) and general population. It is more that require evaluation of the
compulsive and recurrent common in overweight women gynecologist, endocrinologist and
episodes of eating but without who are younger than obese of the gastroenterologist, among
compensatory behaviors are patients without BED and older others. (14, 18) The main goal of
included. The diagnostic criteria than patients with BN. (10) treatment should be to promote
for this group of disorders are a healthy state of life: (14)
described in Table 3. Binge eating TTREATMENT • Restore appropriate weight
disorder is an entity under study according to body mass
to determine whether Once the diagnosis is made index and metabolism

Table 3. Diagnostic Criteria for Unspecified Eating Disorder according to the DSM-IV

TO.Degree Distinctions:
• Women who meet the diagnostic criteria for anorexia, but with regular menstruations
• All diagnostic criteria for anorexia are met, but the person's weight is within normal limits

• The diagnostic criteria for bulimia are met, but less frequently
b.Irregular use of inappropriate compensatory behaviors after eating small amounts of food by a
normal weight individual (e.g., induction of vomiting after eating 2 cookies)
 VARGAS: EATING DISORDERS 481

normal of the body strategies are of character and impulsive action. (16)
• Normalize feeding patterns educational and have basically
and reverse the starvation focused on the following cONCLUSION
process aspects: (6)
• Treat any resulting medical • Information to the general The TCA and its relationship with the
complications population and in particular to current consumer society, make up
• Eliminate behaviors the population at risk one of the most important examples
compensatory maladaptive • Identification of risk groups of the existence of friction between
Treatment of eating disorders different social interests: the
must address nutrition • Directed performances to health, beauty and productive
(refeeding, education, modify those behaviors and advertising interests. It is in
obtaining and maintaining an that could favor the onset childhood, through education,
adequate weight), possible of the disease, particularly that the challenge of educating
medical complications, as well in relation to diet in conscious and responsible
as the psychiatric aspects of the consumption can be faced.
patient and their family. (2, 18) • Interventions on those of the individual. In many cases,
The sick person must take stereotypes cultural, TCAs are developed
responsibility for his or her slimming and beauty by people who imitate the
weight and diet. In some cases aesthetic patterns prevailing in
medication must be used to FRISK ACTORS consumer society. EDs require
prevent relapses. careful multidisciplinary
Antidepressants are the most In studies carried out, it is described treatment, which should begin
used, with Fluoxetine being the that trait anxiety, difficulty in as soon as possible to avoid
one with the most evidence in identifying and expressing consequences.
the treatment of EDs. emotions, low self-esteem, future in development. Each
Anxiolytics from the negative attitude towards expression treatment plan must
benzodiazepine family can be emotional, negative perception be individualized. Exists
used to treat anxiety symptoms of emotions, influence of diet, unanimity regarding the role of
or as a hypnotic. Likewise, weight and body shape on prevention as a fundamental
mood stabilizers can also be mood, need for control and pillar in addressing the problem
used due to their anxiolytic certain ways of regulating of eating disorders.
effect and their effectiveness on emotions, can be considered
impulsivity. The treatment risk factors for eating disorders. RSUMMARY
includes psychotherapy, which (16) The variables that above all
can be individual and/or group. warn about a greater risk of Eating disorders (ED)
developing an eating disorder constitute a Public Health
QREVENTION are the influence of diet, weight problem due to their
and body shape on mood, low prevalence, increasing
Regarding primary prevention, self-esteem and coping incidence, severity, prolonged
action is taken on the risk variables called emotional clinical course, tendency
factors, the main expression. towards chronicity, need for
482 MEDICAL JOURNAL OF COSTA RICA AND CENTRAL AMERICA

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