FEEDING AND

EATING DISORDER

Samia Mazhar
 Definition
 A persistent disturbance of eating or eating-related behavior that results

in the altered consumption or absorption of food and that significantly

impairs physical health or psychosocial functioning. (Source : DSM-5

pg. 329)

 E.g. pica, rumination disorder, avoidant/restrictive food intake disorder,

anorexia nervosa, bulimia nervosa, and binge-eating disorder

1. The term anorexia nervosa is derived from the Greek term for "loss
of appetite"
2. characterized by three essential criteria
3. The first is a self-induced starvation to a significant degree a
behaviour
4. The second is a relentless drive for thinness or a morbid fear of
fatness-a psychopathology.
5. The third criterion is the presence of medical signs and symptoms
resulting from starvation-a physiological symptomatology.
6. It is the oldest recognized feeding or eating disorder
 DSM-5 Criteria
A. 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 or adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes
with weight gain, even though at a significantly low weight.
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 persistent lack of recognition
of the seriousness of the current low body weight.
Specify whether:
Restricting type: During the last 3 months, the individual has not
engaged in recurrent episodes of binge eating or purging behavior
 Binge-eating/ purging type: During the last 3 months, the individual
has engaged in recurrent episodes of binge eating or purging behavior
Specify if:
In partial remission: In full remission:
Specify current severity:
Mild: BMI >1 7 kglm2 Moderate: BMI 1 6-1 6.99 kglm2 Severe: BMI
1 5-1 5.99 kglm2 Extreme: BMI
 SUBTYPES:
1) Restricting type
2) Binge-eating/ purging type

Both types may be socially isolated and have depressive disorder symptoms and
diminished sexual interest. Over exercising and perfectionistic traits are also common in
both types.
The suicide rate is higher in persons with the binge eating-purging type*
Patients are often secretive, deny their symptoms, and resist treatment
 D/d
1. ORGANIC PATHOLOGY (gastrointestinal disease, hyperthyroidism, malignancy, AIDS)
2. Depressive disorder
3. OCD
4. Schizophrenia
5. Bulimia nervosa
6. Substance induced disorder
7. Avoidant/restrictive food intake disorder

Course And Prognosis

 Varies spontaneous recovery without treatment, recovery after a variety of treatments, or a gradually deteriorating
course resulting in death caused by complications of starvation.
 30-50% full recovery
 10-20% remain chronically ill
 Reminder have improved but continue to struggle with certain disordered behaviors
Restricting-type seemed less likely to recover than those of the binge/purging
Favourable outcome if admission of hunger, lessening of denial and immaturity, and
improved self-esteem.
Childhood neuroticism, parental conflict, bulimia nervosa, vomiting, laxative abuse, and
various behavioural manifestations (e.g., obsessive-compulsive, hysterical, depressive,
psychosomatic, neurotic, and denial symptoms) have been related to poor outcome
Depression is a common comorbid diagnosis, with rates of up to 63 per cent in some
studies (Herzog et al., 1992),while obsessive-compulsive disorder (OCD) has been
found to be present in 35 per cent of patients with anorexia nervosa (Rastam, 1992).
 Epidemiology
1. Life time prevalence 2-4%
2. The most common age of onset is between 14 and 18 years
3. 10 to 20 times more often in females than in males
4. Most frequent in developed counties
5. It may be seen with greatest frequency among young women in
professions that require thinness, such as modelling and ballet.
6. Mortality rate 6:1 as compared to general population (20% death due
to suicide) (CTP-10th ed.)
 Etiology
1. Higher concordance rates in monozygotic twins than in dizygotic
twins.
2. Sisters of patients with anorexia nervosa are likely to be afflicted, but
this association may reflect social influences more than genetic
factors
3. Diminished norepinephrine, serotonine turnover
 BIOLOGICAL FACTORS
1. Increase secretion of endogenous opioids
2. Thyroid function suppression
3. lowered hormonal levels (luteinizing, follicle-stimulating, and gonadotropin
4. releasing hormones).
5. Several CT studies reveal enlarged CSF spaces (enlarged sulci and ventricles)
6. Caudate nucleus metabolism was higher in the anorectic state (PET)
7. Hypothalamic-pituitary axis (neuroendocrine) dysfunction
 SOCIAL FACTORS
 Support for their practices in society's emphasis on thinness and exercise
 Troubled, relationships with their parents
 Vocational ad avocational interests interact with other vulnerability factors to increase
the probability
 PSYCHOLOGICAL AND PSYCHODYNAMIC FACTORS

1. Critical challenges at this time of life include the need to establish independence, a
well-defined personal identity, fulfilling relationships, and clear values and principles
to govern one’s life. Family struggles, conflicts regarding sexuality
2. Certain personality traits including high levels of perfectionism, self-discipline, harm-
avoidance, and self-criticism are common in individuals with the illness
3. Bruch (1973, 1982) suggested that anorexia nervosa stems from failures in early
attachment, attempts to cope with underlying feelings of ineffectiveness and
inadequacy, and an inability to meet the demands of adolescence and young adulthood.
 Managements
TREATMENT GOAL:
1) To disrupt disordered behaviors, specifically, problematic pattern of feeding
and eating
2) Altering the problematic cognitions , attitude and beliefs
3) To address associated psychiatric comorbidity
OPTIONS FOR MANAGEMENT
Hospitalization
Psychological intervention
Pharmacotherapy
HOSPITALIZATION
 Stabilize all complication
 Target weight gain : 0.9-2.5 kg / week
 In-patient care for anorexia nervosa is not a predictor of better outcomes than treatment in less intensive settings and
is substantially more expensive
PSYCHOLOGICAL INTERVENTION
• Different forms of self-help and group treatments are less effective than face-to-face individual therapy
• Electronic media (e.g., smartphone apps) for delivering therapy has little robust evidence that this is an effective
approach
1. family-based treatment (FBT)
2. family-based treatment (FBT)
3. Fairburn’s enhanced form of CBT (CBT-E)
4. Specialist supportive clinical management (SSCM)
5. The Maudsley model of anorexia nervosa treatment for adults (MANTRA) (less
effective than CBT-E)
6. Dialectical behaviour therapy (DBT) focusing on the compulsive pathology of such
cases.
7. PHARMACOTHERAPY
 2. BULIMIA NERVOSA
The term bulimia nervosa derives from the terms for "ox hunger" in Geek
(1) Episodes of binge eating
(2) Compensatory behaviors are practiced after binge eating to prevent weight gain,
primarily self-induced vomiting, laxative abuse, diuretics, enemas, abuse of emetics
and, less commonly, severe dieting and strenuous exercise
(3) Weight is not severely lowered as in anorexia nervosa;
(4) The patient has a morbid fear of fatness, a relentless drive for thinness, or both and a
disproportionate amount of self-evaluation that depends on body weight and shape.
Physical discomfort-for example, abdominal pain or nausea terminates the binge eating,
which is often followed by feelings of guilt, depression, or self-disgust.
 DSM-5 Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1 . Eating, in a discrete period of time (e.g., within any 2-hour time period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under similar
circumstances.
2 . A sense of lack of control over eating during episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating).
B. 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.
C. Atleast once 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.
Specify current severity:
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 8-1
3 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 1 4 or more
episodes of inappropriate compensatory behaviors per week.
 D/d:
1. Anorexia nervosa, binge eating-purging type
2. Neurological disease, such as epileptic-equivalent seizures, central nervous system
tumours, Kliver-Bucy syndrome, or Kleine-Levin syndrome.
3. Atypical depression
4. Impulse control disorder
5. Substance induced disorder
6. Bulimia nervosa is characterized by higher rates of partial and full recovery compared
with anorexia nervosa
 Epidemiology
1. BN more common than AN
2. Prevalence 1-4% in young women
3. F> M 10:1
4. Onset is often later in adolescence than that of anorexia nervosa
Etiology
BIOLOGICAL FACTORS
• ↑ endorphin level, ↓ serotonin and norepinephrine
• ↑ frequency of BN is found in first-degree relatives
• Exaggerated perception of hunger signals related to sweet taste
mediated by the right anterior insula area of the brain. (MRI)
 SOCIAL FACTORS
1. The families of patients with bulimia nervosa are generally less close and more conflictual than the families of
those with anorexia nervosa.
PSYCHOLOGICAL FACTORS
• Patients with BN are more outgoing, angry, and impulsive than those with AN.
• Patients with BN lack superego control and the ego strength of their counterparts with AN.
• The struggle for separation from a maternal figure is played out in the ambivalence toward food;
eating may represent a wish to fuse with the caretaker, and regurgitating may unconsciously
express a wish for separation
 3. BINGE EATING DISORDER
 Eat an abnormally large amount of food over a short time without any compensatory
act
 It is the most common eating disorder. 2-6%
 F: M 1.75: 1
 Appears in approximately 25 percent of patients who seek medical care for obesity
 50 to 75 percent of those with severe obesity (body mass index [BMI] greater than 40).
 Impulsive and extroverted personality styles
 It may be used to reduce anxiety, stress or depressive moods.
 DSM-5 Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1 . 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.
2 . 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).
B. The binge-eating episodes are associated with
1 . Eating much more rapidly than normal.
2 . Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5 . Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. at least once a week for 3 months.
E. the binge eating is not associated with recurrent use of inappropriate compensatory behaviour
Specify current severity:
Mild: 1 -3 binge eating episodes per week.
Moderate: 4-7 binge-eating episodes per week.
Severe: 8-1 3 binge-eating episodes per week.
Extreme: 1 4 or more binge-eating episodes per week.
Better prognosis than BN and AN
T/t
• Psychotherapy
• SSRI
• Self-help groups
• Psychopharmacology
• Pharmacological approach to address weight loss , such as topiramate and orlistat,
may able to address both binge eating and weight loss.
 4. PICA
 Pica is defined as persistent eating of non-nutritive substances.
 More frequent in the context of autism spectrum disorder or intellectual disability
 A minimum of 2 years of age is required for making ∆ (DSM-5)
 Specific cravings (e.g. chalk or ice) commonly reported during pregnancy
 Equal prevalence in male and female
 Commonly associated with nutritive deficiency, poisoning, intestinal obstruction, perforation,
infections
 DSM-5 Criteria
A. Persistent eating of non-nutritive, non-food substances over a period of at least 1
month.
B. The eating is inappropriate to the developmental level
C. The eating behavior is not part of a culturally supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g.,
intellectual disability [intellectual developmental disorder], autism spectrum disorder,
schizophrenia) or medical condition (including pregnancy), it is sufficiently severe to
warrant additional clinical attention
 D/d
 Should be differentiated with anorexia nervosa, factitious disorder,
 nonsuicidal self-injury as in personality disorder
 Prognosis is good.
 Pica generally remits spontaneously within several months in normal intellectual function
 In pregnant women, pica is usually limited till pregnancy
 No definitive treatment exists for pica per se; most treatment is aimed at education and behavior modification.
 5. RUMINATION DISORDER
 Derived from the Latin word ruminare, which means, "to chew the cud."
 It is an effortless and painless regurgitation of partially digested food into the mouth soon after a meal, which is
either swallowed or spit out.
 It can occur in infancy, childhood, or adolescence.
 In infants, it typically occurs between 3 months -12 months of age
RISK FACTOR: Psychosocial problems such as lack of stimulation, neglect, stressful life situations, and problems in
the parent-child relationship
 DSM-5 Criteria
A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-
chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical
condition (e.g., gastroesophageal reflux, pyloric stenosis).
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia
nervosa, binge-eating disorder, or avoidant/ restrictive food intake disorder.
D. 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.
• Spontaneous remissions are common
• Secondary complications can develop, such as progressive malnutrition, dehydration, and lowered resistance to
disease. Failure to thrive, with absence of growth and developmental delays in all areas, can occur in the most severe
cases.
 T/t
1. Improvement in Mother child relationship
2. Improvement in child’s psychosocial environment
3. Must evaluate surgical cause
6. AVOIDANT/RESTRICTIVE FOOD INTAKE
DISORDER
 Formerly known as feeding disorder of infancy or early childhood
 In DSM-5 it also include adolescents and adults
 Characterized by a lack of interest in food, or its avoidance based on the sensory features of the
food or the perceived consequences of eating.
 Manifested by a persistent failure to meet nutritional or energy needs
 e.g.: significant weight loss or failure to achieve expected weight, nutritional deficiency,
dependence on enteral feedings or nutritional supplements, or marked interference with
psychosocial functioning.
 D/d
1. Other medical conditions (e.g., gastrointestinal disease, food allergies and Intolerances, occult malignancies)
2. Specific neurological/neuromuscular, structural, or congenital disorders and conditions associated with feeding
difficulties.
3. Reactive attachment disorder
4. Autism spectrum disorder.
5. Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders.
6. Anorexia nervosa
7. Obsessive-compulsive disorder
8. Major depressive disorder
9. Schizophrenia spectrum disorders
10. Factitious disorder
 7. NIGHT EATING SYNDROME
 Night eating syndrome is characterized by the consumption of large amounts of food after the
evening meal.
 Individuals generally have little appetite during the day and suffer from insomnia.
 Prevalence – 2%
 Five times more likely to have a first-degree relative with NES
 Nocturnal eating tends to occur during non-rapid eye movement (REM) sleep and is usually short
in duration
 Patients believe that they can only sleep if they eat
 8. PURGING DISORDER
 Recurrent purging behavior after consuming a small amount of food in persons of normal weight

who have a distorted view of their weight or body image.

 Purging behavior includes self-induced vomiting, laxative abuse, enemas, and diuretics

 Purging disorder is differentiated from bulimia nervosa because purging behavior occurs after

eating small quantities of food or drink and does not occur as a result of a binge episode
Thank you