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Eating Disorders
Jess P. Shatkin, MD, MPH
Director of Education and Training
New York University School of Medicine
NYU Child Study Center
Learning Objectives
Residents will be able to:
1. Distinguish between Anorexia and Bulimia
Nervosa
2. Describe the primary clinical findings in Anorexia
and Bulimia Nervosa
3. Identify rational diagnostic evaluation methods
for affected children and adolescents and their
families
4. Determine evidence-based treatments for patients
affected by Eating Disorders
Facts and Stats
Among normal weight female teens, 40-60% view
themselves as too heavy
Up to 60% of female teens diet regularly
Over 50% of teens exercise in order to improve
their shape or lose weight
Approximately 45% of female teens smoke
cigarettes to control weight
Most female teens are preoccupied with their
food intake
70% of girls report that body shape is important to
their self-esteem (Strober and Schneider, 2005).
History
In Western Europe of the 12th and 13th centuries, miracle
maidens, or women who starved themselves, were highly
regarded, and their behavior was imbued with religious
interpretations.
Catherine of Siena (1347 1380), whose complete control over
her food intake was seen as a sign of religious devotion, was
regarded as a saint (Heywood, 1996).
Holy anorexia was, however, short-lived
By the 16th century the Catholic Church began to disapprove
of asceticism.
Some anorexics were subsequently viewed as witches and
burned at the stake (Brumberg, 2000).
History contd
First cases reported in 1689 by Richard
Morton wasting disease of nervous
etiology in one male and one female
(Gordon, 2000).
The first formal description of AN, however,
is credited to Sir William Gull, physician to
Queen Victoria, who in 1868 named the
disorder anorexia hysterica, emphasizing
what he believed to be its psychogenic
origins.
History: Anorexia Nervosa
Gull later changed the name to nervosa to
avoid confusion with hysteria
Although quite descriptive, the word anorexia
is a misnomer, as the term literally means
lack of appetite, which is, in fact, rare.
Not simply a product of the modern society
Both Anorexia Nervosa and Bulimia Nervosa
patients share an intense preoccupation with
body weight and shape
History: Bulimia Nervosa
Bulimia Nervosa (BN), by contrast, was first
clinically described in 1979
Historical accounts date to 1398, when true
boulimus was described in an individual having an
intense preoccupation with food and over eating at
very short intervals, terminated by vomiting (Stein &
Laakso, 1988).
The word bulimia is derived from Greek and means
ravenous hunger, quite the opposite of anorexia.
Much less has been historically made of bulimic
behavior, and consequently, we have significantly
less knowledge of this disorder.
Eating Disorders
Anorexia Nervosa
Restricting Type
Binge Eating/Purging (Bulimic) Type
Bulimia Nervosa
Purging Type
Nonpurging Type
Eating Disorder NOS
Anorexia Nervosa
Diagnosis requires:
Refusal to maintain body weight at or above a minimally normal
weight for age and height (e.g., weight loss leading to maintenance
of body weight less than 85% of that expected; or failure to make
expected weight gain during period of growth, leading to body
weight less than 85% of that expected)
Intense fear of gaining weight or becoming fat, even though
underweight
Disturbance in the way in which ones body weight or shape is
experienced, undue influence of body weight or shape on self-
evaluation, or denial of the seriousness of the current low body
weight
In post-menarcheal females, amenorrhea, i.e., the absence of at
least 3 consecutive menstrual cycles. (A woman is considered to
have amenorrhea if her periods occur only following hormone,
e.g., estrogen, administration)
AN: Characteristics
The discrepancy between weight and perceived body image is
key to the diagnosis of anorexia; anorexic patients delight in
their weight loss and express a fear of gaining weight
Have changes in hormone levels which, in females, result in
amenorrhea (if the weight loss occurs before puberty begins,
sexual development will be delayed and growth might cease)
Feel driven to lose weight because they experience themselves
as fat, even when at a subnormal weight
Intensely afraid of becoming fat and preoccupied with worries
about their body size and shape
Direct all their efforts towards controlling their weight by
restricting their food intake, but may also binge eat, self induce
vomiting, misuse laxatives or diuretics (purging behaviors),
exercises excessively or misuse appetite suppressants
Bulimia Nervosa
Diagnosis requires:
Recurrent episodes of binge eating. An episode of binge eating is
characterized by both of the following:
eating, in a discrete period of time (e.g., within any 2-hour period),
an amount of food that is definitely larger than most people would
eat during a similar period of time and under similar circumstances
a 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)
Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting; misuse of laxatives,
diuretics, enemas, or other medications; fasting; or excessive exercise
The binge eating and inappropriate compensatory behaviors both
occur, on average, at least twice 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
BN: Characteristics
Frequent episodes of binge eating, during which they
consume a large amount of food within a short period of
time
Feels overwhelmed by the urge to binge and can only
stop eating once it becomes too uncomfortable to eat any
more
Feels guilty, anxious and depressed, because they have
been unable to control their appetite any they fear weight
gain
Tries to regain control by getting rid of the calories
consumed ( the most common method is vomiting, but
they might misuse laxatives, diuretics or appetite
suppressants, fast or excessively exercise
Subclassification
2 major subtypes of anorexia:
(1) Restricting Type: fasting, introverted, decreased
risk of substance abuse, family conflict is covert
(2) Bulimic Type: binge eating or purging, more
volatile, family frequently disengaged, prone to
substance abuse
2 major subtypes of bulimia:
(1) Purging Type: self-induced vomiting or use of
laxatives, diuretics, or enemas
(2) Nonpurging Type: use of other compensatory
mechanisms, such as fasting or excessive exercise
Anorexia vs. Bulimia
Denies abnormal Recognizes abnormal
eating behavior eating behavior
Introverted Extroverted
Turns away food in Turns to food in order
order to cope to cope
Preoccupation with Preoccupation with
losing more and more attaining an ideal
weight but often unrealistic
weight
Eating Disorders NOS
Likely to be similar to people with AN or BN but
not quite meet the diagnostic criteria
Might vomit after eating small amounts of food
Might chew food and then spit it out
Might binge eat, but not attempt to get rid of the
calories consumed (this behavior is now called
Binge Eating Disorder [BED], the phrase
compulsive eating is sometimes used, but has
never been adequately defined)
Obesity
Defined as 20% over ideal body weight
or BMI > 30
Not an eating disorder per se and unlike
an eating disorder is not an mental illness.
However, many people who binge eat
become obese and can have mental health
problems
1/3 of NYC public high school students
are overweight or obese
What is a healthy weight?
Body Mass Index (BMI) is the best currently
accepted measure
BMI (kg/m) = (pounds x 703) height in inches
or = kilograms height in meters
BMI Parameters
Underweight = < 18.5
Normal weight = 18.5 24.9
Overweight = 25 29.9
Obese = > 30
Books
Strober and Schneider Just A Little Too Thin, 2005
Pipher Hunger Pains - The Modern Womans Tragic
Quest For Thinness, 1995
Natenshon When Your Child Has An Eating
Disorder, 1999