Eating

Disorder
T. Emprom, B. Kongsirikorn
May 4th, 2010
 Eating disorder
• Anorexia nervosa
• Bulimia nervosa
• Eating disorder not otherwise specified
Anorexia
Nervosa
http://www.youtube.com/watch?v=VS2mfWDryPE : INTERVIEW CBC
 Definition of
Anorexia Nervosa
 loss of appetite
 desire for thinness
 misinterpreting of
body and shape
 intense fear of weight
gain
 Epidemiology of
Anorexia Nervosa
 Lifetime prevalence of 1% .
 90-95% of patients are females.
 Most common age of onset between14 –18y/o
 10-20 times females than males
 Most prevalence in industrialized nations where food
abundant and thin body ideals are held.
 More prevalent in Caucasian, Hispanic, and Asian
Americans.
 Cross-cultural symptom presentation may differ.
Psychiatric Comorbidity

 Associated with
 Major depressive disorder : 46-80%.
 Dysthymic disorder : 19-93%.
 Any anxiety disorder : 71%.
 OCD : 44%.
 Social phobia : 34%
 Substance-related disorder : 22% .
 Etiology of
Anorexia Nervosa
Biological factors

• Genetic: presence of locus on chromosome 1p

 relatives 2-4%
 sibling 6%
 monozygotic twins 60%
 dizygotic twins 25%

• Neuroendocrine dysfunction (hypothalamic-pituitary axis)

 Serotonin, dopamine, norepineprine, opioid
 Regulating eating behavior in the paraventicular nucleus of hypothalamus
 ↓ norepineprine: reduce activity at feeding center

• Other humoral factors

 Corticotropin-releasing factor (CRF)
 Neuropeptide Y
 Gonadotropin-releasing hormone
 Etiology of
Anorexia Nervosa
Biological factors (ต่อ)
 Regulation of food intake
 กลไกในการควบคุม ความต้องการอาหารเปลีย่ นไป
 Peripheral hormone from GI tract
 ↑ CCK
 Satiety center

 Other factors
 CT scan : enlarged CSF space (sulci and ventricles)
 PET scan : ↑ caudate nucleus metabolism
Psychological factors
 Personal characteristic
 Perfectionism
 Rigidity
 Depression
 ไม่คอ่ ยแสดงอารมณ์ อารมณ์ไม่มนั่ คง
 มีจิตสำนึกสูง ระเบียบวินยั สูง
 Family dynamics
 High in enmeshment
 Overprotection
 Lack of intimacy
Socio-cultural factors

สังคม-วัฒนธรรมที่มีทศั นคติวา่ ผูห้ ญิงต้องมีความ

สามารถสูง ประสบความสำเร็ จในการงาน
มีความมัน่ ใจ และให้ความสำคัญเรื่ องความสวยงาม
มีความสมบูรณ์เรื่ องเพศ
ดังนั้นผูห้ ญิงจึงจำเป็ นต้องเอาใจใส่ ดูแลรู ปร่ างให้
มีลกั ษณะผอมบาง หน้าตาให้มีความน่ารัก
 High- Risk Populations
• Activities require focused on weight and appearance
– Ballet
– Long-distance running
– Gymnastics
– Ice-skating
– Modeling
• Other susceptible groups
– Homosexual men
– High standard women
– Chronic disease
 Clinical features of
Anorexia Nervosa
Physical presentation
• Look older than their years
• Cachexia and breast atrophy
• Body mass index less than 17.5 kg/m2
• Skin is dry and yellow-tinged due to carotenemia.
• Amenorrhea
• Bradycardia
• Hypotension
• Lanugo
• Alopecia
Physical presentation

• Edema
• Dental erosion
• Dorsal surface hand lesions
• Cold intolerance
• Dehydration
• Dizziness
• Constipation
• Abdominal discomfort
Laboratory findings
• Mineral and electrolyte imbalance in particular
hypokalemia.
• High level of blood urea nitrogen (BUN)
• Proteinuria
• Mild anemia, leukopania and thrombocytopenia.
• Abnormal liver function
• Low level of Mg, Zn, P
Laboratory findings
• Hypoglycemia
• Hypercortisolemia
• Hypercholesterolemia
• Hypercarotenemia
• Abnormal endocrine functions
– abnormal vasopressin,
– decreased estrogens,
– immature LH,
– decreased T3 and T4,
– increased GH
 Medical complications of
Anorexia Nervosa
Cardiac Low voltage, bradycardia, T-wave inversions, ST segment
depression, arrhythmias, Prolonged QT intervals, myocardial
damage
Endocrine Amenorrhea, hypothyroidism, Reduce growth hormone-binding
protein, insulin-like growth factor, and serum leptin levels

Skeletal Low bone mineral density, resulting in osteopenia or

osteoporosis
Reproductive Infertility, premature births, perinatal complications
Gastrointestinal Decreased gastric motility, delayed gastric emptying,
constipation
Renal Elevated blood urea nitrogen, polyuria, peripheral edema (during
refeeding)
Neurological Decreased gray matter volume, increased sulcal cerebrospinal
fluid volumes
Hematological Anemia, leukopenia, thrombocytopenia
Psychological presentation

• Severe body distortion

• Preoccupation with food, weight and
shape
• Poor insight
• Depression
• Affect is restricted.
• Rigidly controlling of impulse
• Unsure of their identity
• Phobia of becoming overweight
Behavior

 Excessive exercise
 Food restriction
 Secretive about eating or exercise
 Social withdraw or being asocial
 Self-harm, substance abuse or suicide attempts
 Very sensitive to references about body weight
 Aggressive when forced to eat "forbidden" foods
 Weighing themselves and constantly checking
themselves in the mirror.
 DSM-IV-TR diagnostic criteria for
Anorexia Nervosa
A. Refusal to maintain body weight at or above a
minimally normal weight for age and height
B. Intense fear of gaining weight or become fat even
though underweight
 DSM-IV-TR diagnostic criteria for
Anorexia Nervosa
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
D. in postmenarcheal females, amenorrhea, i.e., the
absence of at least three consecutive menstrual
cycles.
 Specify type of
Anorexia Nervosa
• Restrictive type: during current epi-sode, has
not regularly engage binge-eating or purging
• Binge-eating/purging type: during current
episode, has regularly engage in binge-eating
or purging behavior
 Differential diagnosis for
Anorexia Nervosa
• Medical illness that can account for weight
loss
• Depressive disorder
• Somatization disorder
• Schizophrenia Schizophrenia
 Course and prognosis of
Anorexia Nervosa
• Spontaneous recovery without tx
• Recovery after variety of tx
• Fluctuate course of weight gain follow by relapse
• Gradually deteriorating course  death
– Restrictive type less likely to recover than binge eating
type
 Course and prognosis of
Anorexia Nervosa
• Short term response in patients to hospital
treatment program is good
• Often continue preoccupation with food and
body weight, poor social relationships, exhibit
depression.
• Prognosis is not good, generally
– Mortality rate 5-18 %
 Course and prognosis of
Anorexia Nervosa
• US ten-year outcome studies
– ¼ recover completely
– ½ markedly improved, fairly function
– ¼ included 7% mortality rate, poorly function with
chronic underweight condition
 Course and prognosis of
Anorexia Nervosa
• Swedish and English studies, 20 and 30 year
period
– Mortality rate 18%
– About ½ eventually develop symptoms of bulimia
within the first year after onset
 Course and prognosis of
Anorexia Nervosa
• Indicator of favarable outcome
– Admission of hunger
– Lessen denial and imaturity
– Improved self esteem
 Course and prognosis of
Anorexia Nervosa
• Factors relate to poor outcome
– Childhood neurotism
– Parental conflict
– Bulimia nervosa
– Vomitting
– Laxative abuse
– Behavioral manifestation (obsessive compulsive,
hysterical, depressive, psychosomatic, denial
symptoms)
 Treatment for
Anorexia Nervosa
Hospitalization
 Restore nutrition : dehydration, starvation,
e’lyte imbalance
 20% below expected weight
 Risk of death : compulsory admission
 Treatment for
Anorexia Nervosa
Psychotherapy
 Psychodynamic psychotherapy : ineffective
 Cognitive behavioral therapy
 Family therapy
 Treatment for
Anorexia Nervosa
Pharmacotherapy
 Antidepressants : Amitriptyline
- Precaution : hypotension, cardiac arhythmia, dehydration
 Antihistamine and antiserotonergic drug : Cyproheptadine
 SSRI : Fluoxetine
Bulimia
Nervosa
http://www.youtube.com/watch?v=VRPZko3DG_g : blair
http://www.youtube.com/watch?v=V5WRsr0cuI0&feature=related : jade
 Definition of
Bulimia Nervosa
Bulimia nervosa is an eating disorder in
which a person binges and purges. The
person may eat a lot of food at once and
then try to get rid of the food by
vomiting, using laxatives, or sometimes
over-exercising.
 Epidemiology of
Bulimia Nervosa
 Lifetime prevalence of 1-3% .
 90-95% of patients are females.
 Onset typically in late adolescent or early adulthood.
 Often present in normal weight young woman.
 Less common among African Americans women
compared with Caucasian and Hispanic Americans.
Psychiatric comorbidity

 Affective disorders : MDD, Bipolar disorder

 Anxiety disorders : OCD, Panic disorder,
social phobia, specific phobias,
GAD, and PTSD
 Substance use disorders : Alcohol, nicotine
and drug.
 Suicidal behaviors
 Other psychopathology : Borderline personality
disorder, Attention deficit hyperactivity disorder.
 Etiology of
Bulimia Nervosa
Biological factors
• Ganetics: present of chromosome 10p
– Dizygotic twins
– Monozygotic twins
– First-degree relatives
• The disruption of neuronal systems implicated in bulimia
nervosa.
– Serotonin play a role in appetite, satiety, food selection, and eating
pattern.
– Norepineprine
– Disrupted in appetite-inducing neuropeptide Y and peptide YY
– Low level of cholecystokinin associated with satiety and
discontinuation of eating behavior.
– Plasma endorphin levels are raised after vomiting, feeling of well-
being.
Psychological factor
 Personal characteristics
 Low self-esteem
 Self-destructiveness
 Alcohol dependence
 Sexual abuse
 Perfectionism
 Impulsive
 Ego-dystonic
 Lack superego control
 Family dynamics
 Less close and more conflict
 Neglectful and rejecting
 High parental expectation
Socio-cultural factor
• Industrialized nations
• Societal pressures to be slender
• Images of ideal beauty and thin body
• Weight and appearance are central
(e.g. ballet, long-distance running, wrestling)
 Clinical features of
Bulimia Nervosa
Physical presentation
• Dental erosion of upper front teeth
• Peliosis and calluses or abrations on dorsal surface of
the hand.
• Sore throat or mouth sores
• Weakness
• Fatigue
• Dehydration
• Hypotension
• Bradycardia
• Irregular or lack of menstrual periods
• Abdominal pain
 Clinical features of
Bulimia Nervosa
Behavior
• Binge eating of high-carbohydrate foods, usually in secret.
• Eating until you are painfully full
• Going to the bathroom during meals.
• Excessive exercise
• Loss of control over eating, with guilt and shame
Psychological
• Preoccupation with food, weight and shape
• Body dissatisfaction
• Low mood
• Demonstrate insight
• Evince shame bulimic behavior
• Aware of their feelings
Laboratory finding

• Fluid and electrolyte abnormalities

• Hypokalemia
• Hyponatremia
• Hypochloremia
• Hypomagnesemia
• Metabolic alkalosis
• Metabolic acidosis (misuse of laxatives)
• High level of serum amylase
 Table 76-1 Common Characteristics of Anorexia Nervosa and Bulimia
Nervosa

 
Anorexia Nervosaa Bulimia Nervosa
 
Clinical Characteristics

Onset Mid-adolescence Late adolescence/early

adulthood

Female:male 10:1 10:1

Lifetime prevalence in 1% 1–3%

women

Weight Markedly decreased Usually normal

Menstruation Absent Usually normal

Binge eating 25–50% Required for diagnosis

Mortality 5% per decade Low

Physical and Laboratory Findingsa
Skin/extremities Lanugo  
Acrocyanosis
Edema
Cardiovascular Bradycardia  
Hypotension
Gastrointestinal Salivary gland enlargement Salivary gland enlargement
Slow gastric emptying Dental erosion
Constipation
Elevated liver enzymes
Hematopoietic Normochromic, normocyctic  
anemia
Leukopenia
Fluid/Electrolyte Increased BUN, creatinine Hypokalemia
Hypokalemia Hypochloremia
Alkalosis
Endocrine Hypoglycemia  
Low estrogen or testosterone
Low LH and FSH
Low-normal thyroxine
Normal TSH
Increased cortisol
Bone Osteopenia  
DSM-IV-TR diagnostic criteria for Bulimia
Nervosa
A. Recurrent episode if binge eating is characterized
by both of the following:

1) Eating, in a discrete period of time, an amount of food

that is definitely larger thann most people would eat
during a similar peroid of time and under similar
circumstance.
2) a sense of lack of control over eating during episode
 DSM-IV-TR Diagnostic criteria for
Bulimia Nervosa
B. Recurrent inappropriate compensatory behavior in
order to prevent weigh gain , such as self-induce
vomiting; misuse of laxative, diuretics, enemas, or
other medications; fasting; or excessive excercise
 DSM-IV-TR Diagnostic criteria for
Bulimia Nervosa
C. The binge eating and inappropriate compensatory
behaviors both occur, on average, at least twice a
week for 3 months
D. Self-evaluate is unduly influenced by body shape
and weigh
E. The disturbance does not occur exclusively during
episodes of anorexia
 Specify type of
Bulimia Nervosa
 Purging type: during current episode, has
regularly engage in self-induced vomiting or
misuse laxative, diuresis, or enema
 Nonpurging type: during current episode, use
other inappropriate compensatory behavior,
i.e. fasting or excessive exercise.
 Differential diagnosis for
Bulimia Nervosa
 Anorexia nervosa, binge eating-purging type
 Neurologic disease
 Epileptic-equivalent seizure
 Central nervous system tumor
 Kluver-Bucy syndrome
 Kleine-Levin syndrome
 Borderline personal disorder
 Course and prognosis of
Bulimia Nervosa
 fluctuate course, never symptom free during
improvement
 Prognosis depend on severity of purging sequlae
(e’lyte imbalance, vomiting resulted esophagitis,
amylasemia, salivary gland enlargement, dental
caries)
 Course and prognosis of
Bulimia Nervosa
 50% improve in binge-eating and purging in treated
patient
 At 3-year f/u in hospitalize patient, less than 1/3
doing well
 More than 1/3 have some improvement
 1/3 have poor condition
 5-10 years study, ½ recover fully
 20% still meet full criteria
 Treatment for
Bulimia Nervosa
Hospitalization
 Life threaten complication
 E’lyte imbalance
 Metabolic alkalosis
 Suicidal
 Treatment for
Bulimia Nervosa
Psychotherapy
 Therapy for motivation of self-control eating
 Individual psycho therapy
 Cognitive behavioral therapy
 Group therapy
 Treatment for
Bulimia Nervosa
Pharmacotherapy
 Anti-depressant :
 tricyclics (imipramine, amitriptyline)
 SSRIs (fluoxetine)
Eating Disorder
not otherwise specific
 Definition of
Eating Disorder not otherwise specific

EDNOS is described in the DSM-IV-TR as a

"category of disorders of eating that do not meet t
he criteria for any specific eating disorder".

“The failure to meet formal criteria does not necessarily

mean that the individual does not have a serious and
significant disorder”
 Epidemiology of
Eating Disorder not otherwise specific
 Approximately half of individuals presenting for
eating disorder treatment in the community meet the
EDNOS criteria.
 EDNOS appears to be particularly common among
adolescents or early adulthood.
 EDNOS is far more common in females.
 Etiology of
Eating Disorder not otherwise specific
• A combination of environmental and
biological factors that develop and expres
sion of these disorders.
• The psychological and social.
 Clinical features of
Eating Disorder not otherwise specific
 Overly driven to be thin
 Very disturbed body image
 Concern about food and weight
 Binge-eating disorder
 Guilt and shame, lead to purging
 Engage in chewing and spitting
 Regularly engage in nighttime eating
 Compensate and restrict their caloric intake
 Medical complications of
Eating Disorder not otherwise specific
Binge eating
• Cause the stomach to rupture
• Abdominal pain
Purging
• Electrolyte imbalance
• Dehydration
• Result in heart failure due to the loss of vital
minerals like potassium.
• Occasionally, sudden death
 Medical complications of
Eating Disorder not otherwise specific
Restricting
• low blood pressure
• slower heart rate
• disruption of hormones
• bone growth
• Mental and emotional disturbance
 DSM-IV-TR diagnostic criteria for
Eating Disorder not otherwise specific
Eating disorder that do not meet criteria
for any specific eating disorder.
1. All of criteria for anorexia nervosa except
amenorrhea
2. All of criteria for anorexia nervosa except
the individual weight is in normal range
 DSM-IV-TR diagnostic criteria for
Eating Disorder not otherwise specific
3. All of criteria for bulimia nervosa except that binge
eating and inappropriate compensatory mechanisms
occur less than twice a week or less than 3 months
4. Regular use of inappropriate compen-satory
behavior in normal body weight after eating small
amount of food
 DSM-IV-TR diagnostic criteria for
Eating Disorder not otherwise specific
5. Repleatedly chewing and spitting, but not
swallowing, large amount of food
6. Binge-eating disorder: recurrent episodes of binge
eating in the absence of the regular use of
inappropriate compensatory behaviors
 Differential diagnosis for
Eating Disorder not otherwise specific
• Bulimia Nervosa
• Major depressive disorder
• Neurologic disease
– Kleine-Levin syndrome
• Syndrome associated with hyperphagia
– Prader-Willi syndrome
 Course and prognosis of
Eating Disorder not otherwise specific
• Better than bulimia nervosa
• Less than 1/5 have any form of disorder at 5
years f/u
• Obesity, especially binge-eating disorder
 Treatment for
Eating Disorder not otherwise specific
• Cognitive-behavioral therapy
– self-monitoring of eating and purging behaviors
– changing the distorted thinking patterns
• Family threrapy
• Antidepressant
– fluoxitine
 Reference
สมภพ เรืองตระกูล. ตำราจิตเวชศาสตร์, พิมพ์ครัง้ ที่ 9. กรุงเทพฯ: โรงพิมพ์เรือนแก้วการ
พิมพ์; 2548: 280-97.

สมภพ เรืองตระกูล. จิตสังคมบำบัดในโรคทางจิตเวชและโรคทางกาย, พิมพ์ครัง้ ที่ 1.

กรุงเทพฯ: โรงพิมพ์เรือนแก้วการพิมพ์; 2552: 52-65.

Dr. Fauci's and Dr. Longo's works. 2008. Harrison‘s principle of internal
medicine. 17th ed. The United States of America: The McGraw-Hill
Companies, Inc. chapter 76

Sadock BJ, Sadock VA. Kaplan & Sadock’s synopsis of psychiatry. 10th ed.
Philadephia: Lippincott Williams & Wilkins; 2007: 739-51
 Reference
Sadock BJ, Sadock VA. Kaplan & Sadock’s pocket handbook of clinical
psychiatry. 2th ed. Philadephia: Lippincott Williams & Wilkins; 1996: 201-
4

Yager J, Powers PS. Clinical manual of eating disorder. 1st ed. Arlington,
VA:American Psychiatric Publishing, Inc; 2007: 1-29

NAMI: National Alliance on Mental Illness. Eating Disorder Not Otherwise

Specified (EDNOS). cited: 1 May 2010, cited
[http://www.nami.org/Template.cfm?
Section=By_Illness&template=/ContentManagement/ContentDisplay.cfm
&ContentID=65849]
 Thanks for
your attention
ANY
QUESTION
?