Eating Disorders (EDs)

Anorexia Nervosa (AN)

The condition usually begins in adolescents, most often between the age of 16 and 17, with intense wish to be thin, fear of being fat, and the patient has distorted body image. Some try to achieve weight loss by induced vomiting, excessive exercise and misusing laxatives. Amenorrhea is one of the several physical features of the disorder, but depressive symptoms, liability of mood and social withdrawal are all common

Diagnoses: (DSM IV criteria)

body weight is less than 85% of the expected(loss 15% of body weight)

Intense fear of fatness. disturbance of body image amenorrhea, the absence of at least three consecutive

menstrual cycles Two types can be specified:

restrictive type: with reducing food intake and prolonged fasting binge eating type-purging type: with episodes of taking big

amounts of food (binge eating ) then self induced vomiting (purging ).

Epidemiology Anorexia Nervosa is estimated about 1% of adolescent girls, it occurs 10-20 times more often in females than in males. The disorder reported among the upper social classes, in developed countries and among young women in professions that require thinness, such as modeling and ballet.

Bulimia Nerovsa (BN)* Recurrent episodes of binge eating (eating a large amount of food given the context with an associated sense of loss of control) *Recurrent inappropriate compensatory behavior (purging, fasting, excessive, exercise)*Binge eating and compensatory behavior occur at least 2 times per week*Clients are usually normal body weight or overweight

Bulimia

Bulimia is a psychological eating disorder defined by food binges, or recurrent episodes of significant overeating, that are accompanied by a sense of loss of control.

Bulimia Statistics

Bulimia affects about 10% of college age women in the United States.

About 10% of individuals diagnosed with bulimia are men.

10% of individuals suffering from bulimia will die from either starvation, cardiac arrest, other medical complications, or suicide.

Compensatory behaviors like:

Self-induced vomitingExcessive exerciseAbuse laxativesDiureticsEnemas in order to prevent weight gain

CausesThe exact cause of bulimia is unknownFamily problemsHypothalamic dysfunction: suggested a primary

disorder of hypothalamusSocial causes: most cases appear in school girls,

female college students who have concern about their body shape and weight, especially in the middle and upper social class

Perfectionist personalityOveremphasis on physical appearanceAssociated with depression

Symptoms 

Binge eatingSelf-induced vomiting Inappropriate use of diuretics or laxatives Overachieving behavior Intense fear of gaining weight or

becoming fat.

Subtypes of BN

Purging typePerson regularly engages in self-induced

vomiting or the misuse of laxatives, diuretics, or enemas

Non-purging typePerson regularly engages in other

inappropriate compensatory behavior—fasting or excessive exercise

Signs and Tests   

Dental CavitiesGum infections(such as Gingivitis(Teeth may be eroded or pitted because of

excessive exposure to acid in vomitusElectrolyit imbalance(such as

hypokalimia(Dehydration

Who’s at Risk for AN and BN?

AdolescentsAthletesAppearance focused professionals

Demographic Factors

Females comprise 95% of those with EDsOnset of AN ranges from pre-puberty to

the 30s, but generally occurs between 12-18

Onset of BN typically begins during late adolescence or early adulthood

Statistical Data

10-18% mortality rateHighest mortality rate of any of the psychiatric

disordersDeath most frequently occurs by starvation,

electrolyte disturbances, or suicidePeople who have had the disease greater than

20 years have a 20-25% increased mortality rate

Long term data—no more than 50% recover completely

Risk Factors

Psychological Factors

Low self-esteemPerfectionism and unrealistically high

standardsDifficulties in self-soothing and mood

modulation

Biological Factors

8 times the risk if family member has ED50% concordance in monozygotic twins,

15% for dizygoticA family history of mood or anxiety

disorders or OCD increases the risk of EDs

Biological Factors

Many neurochemical changes occur with EDsLow NE levels are seen in clients during

periods of restricted intakeHigh levels of 5-HT and its precursor

tryptophan have been linked to satietyLow levels of 5-HT have been found in clients with

BN and the binge-purge subtype of AN

Family Factors

ANFamily is rigid about values and rulesOverprotectiveUnable to deal with conflict

BNFamily is chaotic with loose boundariesPerceived as less caringUnrealistic expectations for achievementParental concerns with weight

Sociocultural Factors

Cultural ideal of being thinMedia focus on beauty, thinness, and

fitnessChronic dieting, particularly among

young women

Comorbid Illnesses

Comorbid Illnesses

ANDepressionDysthymiaOCD/OCPDAnxiety DisordersAvoidant PD

Comorbid Illnesses

BNDepressionDysthymiaSubstance abuseAvoidant PD

Medical Complications of EDs Related to Weight Loss

Dermatologic Complications

Dry skinLanugo-like hairAlopeciaBrittle nailsPale skinCyanosis

Cardiac Complications

Low heat rate—30-40s commonLow BPDecrease in heart sizeCHF—biggest risk factor for deathMIArrhythmiasDeath

Hematologic Complications

LeukopeniaAnemiaThrombocytopeniaHypercholesterolemia

Neuropsychiatric Complications

Abnormal taste sensationApathetic depressionMild organic mental sxSleep disturbances

Medical Complications of EDs Related to Purging

Metabolic Complications

Electrolyte abnormalitiesParticularly hypokalemia and

hypomagnesemia

Elevated BUN

GI Complications

Salivary gland enlargementPancreatic inflammation with elevated

serum amylaseEsophageal irritationGastric erosion

Dental Complications

Erosion of dental enamel

Neuropsychiatric Complications

SeizuresMild neuropathiesFatigue WeaknessMild organic mental sx

Treatment of EDs

•First establish a good relationship with the patient in order to inverse the physical and psychological effects of starvation* Admission is needed if weight loss is more than 45%

* Restoring weight at least three thousand calories daily *Behavior principles are used *Family therapy *Cognitive therapy *Self help groups*Antidepressant drugs

CBT

Use strategies designed to change the client’s thinking (cognition) and actions (behaviors) about food

Focus on:Interrupting the cycle of dieting, binging,

and purgingAltering dysfunctional thoughts and beliefs

about food, weight, and body image

Recovery

Long-term study of AN50% fully recovered25% had intermediate outcomes10% still met criteria for AN15% had died of causes r/t ANBest indicator for recovery is return of

menses

Recovery

50 % recover fully20% continue to meet criteria for BN30% have episodic boutsDeath rate with BN is estimated to be 0-

3%