EATING DISORDER

DR AKINJOLA
BSUTH
 Outline
• Introduction
• History
• Classification
Anorexia nervosa
Bulimia nervosa
Eating disorder NOS
o Binge eating disorder
o Obesity
o Psychogenic vomiting
 Introduction
• Disorders characterized by
abnormalities in the pattern of
eating which are determined by
the attitude a person takes to
their weight and shape
• They are real, treatable medical
illnesses & not due to a failure
of will or behavior
• Uncommon until late 1970
 History
• Begins with descriptions of religious fasting in
the 13th & 14th centuries.
• Women practice self-starvation in the name of
religious piety and purity
• Women became prominent in religious cycle &
named saints by the Catholic Church
• Many women who ultimately became saints
engaged in self-starvation
• Church later became concerned about extreme
fasting & advised a female saint to pray that
she would be able to eat again, but she was
unable to give up fasting
• Cases were continuously described afterwards
• Anorexic illnesses was first described by
English physician Richard Morton, in 1689
• Anorexia Nervosa was named by sir William
Gull in 1873 who gave a detailed case
description & tx
• Later popularized by
The Golden Cage: the Enigma of Anorexia Nervosa,
a book by Hilde Bruch in 1978
death of the popular singer Karen Carpenter in
1983
• Bulimia Nervosa was first described by
Gerald Russell in his paper “Bulimia
Nervosa: An Ominous Variant of Anorexia
Nervosa” (1979)
 Classification
• Eating disorders
1. Anorexia Nervosa
2. Bulimia Nervosa
• Eating disorder not otherwise
specified
1. Binge eating disorder
2. Obesity
3. Psychogenic vomiting
 Anorexia Nervosa
• Hilda Bruch (1965) described the 3
core psychological features
Body image disturbance.
Interoceptive disturbance i.e. the
inability of such individuals to
accurately identify and respond to
internal sensations (e.g. hunger,
fullness, mood states and sexual
arousal)
Pervasive feelings of ineffectiveness
• Eating disorder characterized by
Distorted body self-perception
Obsession with having a thin figure
Immoderate food restriction
Irrational fear of weight gain
Inappropriate eating habits or rituals
Very low body weight (15% < normal,
BMI < 17.5)
Preoccupation with food
Amenorrhea
• Despite thin
appearance, they
see themselves as
fat or overweight
• Critical &
perfectionistic in
regard to
themselves
• Urge to achieve a
perfect body can
become a life-
• They direct several
efforts towards their
pursuit of thinness
Very low daily
calorie limit
Excessive
exercises
Purging behavior
• Begin with efforts at dieting but get
out of hand
Types of anorexia nervosa
1. Restricting type:
 Only restrict intake
 No binge-eating
 No purging behavior
2. Binge-eating :
 Regular binge-eating
 Purging behavior
o Self-induced vomiting
o Misuse of laxatives, enemas
o Diuretics
Physical consequences
• Symptoms
Heightened sensitivity to cold
GIT symptoms: fullness, constipation,
bloatedness
Dizziness & fainting
Poor sleep
Irritability
Amenorrhea, ↓ sexual interest, loss of potency
• Signs
Emaciated, stunted growth & failure of breast
dev
Dry skin, lanugo hair, orange discoloration of
skin, palm & soles, petechial rash
  Swelling of parotid & submandibular glands
 Erosion of inner surface of front teeth
 Cold hands & feet
 Hypotension, bradycardia & cardiac
arrhythmias
 Dependent edema
 Weak proximal muscles
Abnormalities of physical investigation
• Endocrine:
 ↓ LH, FSH & Oestradiol
 ↓ T3, ↑ T4 & normal TSH
 ↑ Plasma cortisol
 ↑ GH
 hypoglycemia
• CVS • OTHER
 ECG abnormalities METABOLIC
 Q-T prolongation  Hypercholesterole
• GIT mia
 Delayed gastric  ↑ serum carotene
emptying  Hypophosphatemia
 ↓ colonic motility
 Electrolyte
 Acute gastric
dilatation (due to
disturbance
binge eating) • OTHERS
• HEAMATOLOGICAL  Osteoporosis &
 Moderate normocytic, osteopenia
normochromic
anaemia
 Mild leucopenia with
relative lymphocytocis
 Thrombocytopenia
• Epidemiology
Prevalence is 0.5 – 1%
Age of onset commonly 14 - 18years
Commoner in females than males (10:1)
Commoner in young females
Commoner in upper class
Seen mostly in developed countries
Mostly seen in young women in
professions that require thinness
(modelling & ballet)
Etiology
• Biological
Genetics
o Family study: 5-10% in sibling & 0.5-1% in the gen.
pop.
o Twin study: MZ twin (55%) & DZ twin (5%)
Neuroendocrine disorder affecting
hypothalamus– ant. Pituitary-gonadal axis
o Feeding Centre: in lat. Hypothalamus
o Satiety Centre in ventromedial hypothalamus
o Imaging studies: cerebral lesions, especially
tumors of the hypothalamus
Endogenous opioids contribute to denial of
hunger
5HT, DA, NA regulate pain in paraventricular N
Other humoral factors (CRF, GRH, TSH) involved
• Social factors
Thinness is desirable and attractive
• Psychological causes
Individual:
o Patient involved in struggle for control, for a
sense of identity & effectiveness
o Relentless pursuit for thinness is the final step
in the struggle
Family:
o Disturbed relationship: over protection,
rigidity, lack of conflict resolution
Course & prognosis
• Course vary widely • Predictors of good
 Spontaneous recovery prognosis
 Recovery after tx  Short history
 Fluctuating course  Younger age of onset
 Gradual deteriorating  Admission of hunger
course  lessening of denial
• Generally  Improved self esteem
 1/5 recovers • Predictors of bad
 1/5 remain severely ill
 The remainder shows
prognosis
fluctuating course  Childhood obesity
 Low self esteem
• Mortality rate is 5-
 Personality disturbance
18%
 Parental conflict
• Generally, prognosis  Vomiting
is good  Laxative abuse
Management
• Establish good rapport
• Thorough history
Eating pattern & weight control
Patients idea of body weight
Depressive symptoms
• Physical examination
• Investigation
• Educate patient & relatives
• Explain tx alternatives
• Bargain with patients
Treatment
1. Psychotherapy:
o Interpersonal therapy: to improving
interpersonal relationship
o Family therapy: in cases in which family problem
is relevant
o CBT: to change abnormal cognition about weight
Aims of Psychotherapy
 Reduce risk,
 Encourage weight gain and healthy eating,
 Reduce other symptoms related to an eating disorder, and
 Facilitate psychological and physical recovery.

2. Medication: may be needed to treat

depression
3. Restoring weight: hallmark of treatment
Weight restoration
• A process of improving the weight of an
individual to a state of stability i.e weight
that is healthy for them, meet their
nutritional & growth needs
• Can be done on
• Outpatient
• Inpatient basis
• Indication for admission
• Dangerously low weight
• Severe depression & suicidal risk
• Failed outpatient care
• Outpatient treatment
Aim: to achieve weight ↑ of 0.5kg weekly
Requires about extra 500-1000 calories
per day
Target weight is btw normal (BMI ˃20) &
patients idea of what her weight should
be.
Balanced diet of about 3000kcal should
be taken as 3-4 meals per day.
Prescribe vitamin supplements if
necessary
Monitor patients physical state regularly
• Inpatient treatment
Patient must understand the need to stay
till when weight is restored
If there is threat to life & patient is
unwilling to stay, then compulsory
admission is undertaken
Eating must be supervised by a nurse to:
o Reassure patient of the agreed target
o To reassure patient against risk of loosing
control over her weight
o To ensure patient does not induce vomiting
etc.
 Aim: to gain btw 0.5-1kg per week
 Bulimia nervosa
• Episodes of uncontrolled
excessive eating (binges)
• First described by Russell
(1979)
• He described it as an
ominous variant of A.N.
• Recent studies however
shows ¼ have preceding A.N
• Central features
 Irresistible urge to
overeat
 Extreme measures to
control weight
 Overvalued ideas
concerning weight, body
shape
Types
1. Purging type
 Characterized by the use of self induced vomiting,
laxative & diuretic to prevent weight gain
2. Non purging type
 Purging behavior do not occur regularly but the
ind. uses other means to prevent weight gain e.g
excessive exercise & fasting
• There is profound loss of control over eating
• Episodes may be precipitated by stress
• The initial ↓ tension gotten from eating gives
way to guilt and disgust
• Patient are usually of normal weight
• Mostly females & have normal menses
• Depressive symptoms are more
prominent than in A.N.
• Physical consequences
Potassium depletion: weakness,
arrhythmias, renal damage
Urinary infection
Tetany
Epileptiform fits
Pitting of the teeth due to corrosive
effect of gastric acid.
• Etiology
General risk factors
o Family hx of depression & substance use
o Adverse childhood experiences
Specific risk factors: factors promoting
dieting
o Childhood obesity
o Parental obesity
o Perfectionism
Genetic risk
o Cross familial transmission as in A.N
5HT:
o Neuro endocrine challenge test
o Brain imaging studies
• Treatment
 CBT: currently the most effective
 Antidepressants e.g SSRI also helpful but not as
much as CBT
 Combination of the two has no better advantage
• Course and prognosis
 Runs a chronic course
 Avg. length of hx at presentation is about 5yrs
 About 5-10yrs later 1/3 to ½ still have clinical
eating disorder
 Mortality is less than in A.N
 Strongly associated with depression & substance
use
 Improves during pregnancy but subsequently
relapses
 Prognosis worsened by childhood obesity, low self
esteem
 Eating disorder NOS
• Disorders of eating of clear clinical severity
which do not meet criteria for A.N or B.N
• Frequently diagnosed in 1/3 of referrals
• About ½ later evolve into A.N or B.N
Binge eating disorder
• Bulimic episodes with no counter
regulatory measures
• There may be depressive symptoms &
some dissatisfaction with their weight.
• Associated with risk factors for psychiatric
disorder and for obesity
• About 25% of presenting for obesity have features of
binge eating disorder
• It generally affect older age group
• It has a high rate of spontaneous remission
• There is reasonable responsiveness to CBT &
SSRI
Obesity
• Medical condition characterized by excessive body fat
• Diagnosed when BMI ˃30
• Associated with ↑mortality
• Severe obesity (BMI˃40) is associated with 12 fold
↑risk in the 25-35 age group
• USA: 300,000 deaths per year can be attributed to
obesity
• Public health problem second only to smoking as
potentially preventable cause of death
• Etiology
 Genetic factors exacerbated by social
factors that encourage overeating of high
calorie food, lack of exercise
 Psychological
 Drugs: psychotropic drugs
• Psychological consequence
 Distortion of body image
 Feeling grotesque
 Belief that others feel contempt
• Course
 Life long problem
 Obese children are unlikely to grow out of
it untreated
• Treatment
Goal: ↓body weight by 5-10% rather than
unrealistic attempt to attain ideal body weight
Behavioral modification:
o Aim at changing eating pattern & nature of food
o ↑physical activity gradually
o Evidence show that this is effective in the short term
Pharmacological
o Orlistat a lipase inhibitor
o SIBUTRAMINE A MIXED MONOAMINE
REUPTAKE INHIBITOR which ↓appetite centrally
Surgical: for (BMI˃40) or sig. medical
complication
o Gastric restriction: limits stomach size by stapling
o Intestinal bypass: ↓ length of gut available for
absorption
Psychogenic vomiting
• Chronic episodes of vomiting
without an organic cause
• Commonly occurs after meal in the
absence of nausea.
• Commoner in women
• Usually presenting in early or middle
life
• Responds to psychotherapy &
behavioral treatment
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