EATING DISORDERS

1. EATING DISORDERS MUDr. Markéta Žáčková Department of Psychiatry, Masaryk University, Brno

2. many are still clinically unrecognized • it is estimated that general practitioners recognize only 12% of bulimia nervosa and 45% of anorexia nervosa

3. Anorexia nervosa

4. Characteristics • profound disturbance of body image with pursuit of thinness (often to the point of starvation)

5. Epidemiology • 1% of adolescent girls • 10-20 times more often in females than in males • the prevalence of young women with some symptoms of anorexia nervosa is 5%

6. Aetiology • biological factors: • family genetic studies shows an association between eating disorders and affective disorders • social factors: • society emphasis on thinnes and exercise • strained marital relationships in family • psychological and psychodynamic factors: • pts often lack a sense of autonomy and selfhood • low self-esteem • extreme perfectionism

7. Diagnosis • DSM-IV diagnostic criteria: • refusal to maintain body weight at or above a minimally normal weight for age and heiht (e.g. weight loss leading to maintenance of body weight less than 85% of that expected) • intense fear of gaining weight or becoming fat, even though underweight • disturbances in the way in which one’s 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-menarchal females, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles

8. specific types: • restricting type: • during the current episode, the person has not regularly engaged in binge-eating or purging behaviour • binge-eating/purging type: • during the current episode, the person has regularly engaged in binge-eating or purging behaviour • differential diagnosis: • medical illneses

9. Clinical features • the onset usually occurs between 13-20 years, most of aberrant behavior directed toward losting weight occurs in secret • some pts cannot control voluntary restriction of food and so they have eating binges followed by self induced vomiting, laxatives and diuretics abuse

10. Physical consequences • related to a weight loss: cachexia, sensitivity to cold, hypothermia • cardiac: small heart, arrythmias, bradycardia, ventricular tachycardia, sudden death • digestive-gastrointestinal: delayed gastric emptying, constipation • hormonal: reduced tri-iodthyronine, hypothalamic dysfunction, raised growth hormon levels • reproducitve: amonerrhea, low levels of LH and FSH • dermatological: lanugo, edema • hematological: leukopenia • neuropsychiatric: depression, mild cognitive disorder • skeletal: osteoporosis

11. Course and prognosis • in early stages, often fluctuating course with exacerbations and periods of partial remission • the course varies greatly, in genereal is not good - although weight and menstrual function usually improve, eating habits often remain abnormal and some patients develop bulimia nervosa • mortality rates are at around 15%, about a fifth of patients make a full recovery, and another fifth remain severely ill • bulimic symptoms may occur within 1-2 years after the beginning of anorexia nervosa

12. Treatment • restoration of weight and the nutritional state: • including treatment of dehydratation and electrolyte imbalance • weight gain of between 0,5-1 kg each week • combination of: • behavioral management approach • individual psychotherapy • family education and psychotherapy • psychotropic medication

13. Hospitalization in pts with: • weight 20% bellow the expected weight for their height • rapid weight loss • severe depression • failed out-patient care

14. Bulimia nervosa

15. Characteristics • recurrent episodes of eating large amounts of food (over 2000 kcal per episode) accompanied by a feeling of being out of control and an irresistible urge to overeat • the binge eating terminates by social interruption, physical discomfort, and most often by recurrent compensatory behaviour, such as purging (= self induced vomiting, laxative and diuretic abuse) or fasting • pts are usually of normal body weight, most patients are females and they often have normal menses

16. Epidemiology • 1-3% of young women • uncommon among men

17. Aetiology • biological factors: • raised endorphine levels? • social factors: • pts tend to be high achievers and to respond to social pressures to be thin • psychological factors: • also pts have difficulties with adolescent demands but are more outgoing, angry and impulsive than pts with anorexia (alcohol dependence, shoplifting, emotional lability) • predisposing factors include perfectionism and low self-esteem

18. Diagnosis • DSM-IV diagnostic criteria: • recurrent episodes of binge eating, characterized by: • eating in a discrete period of time (e.g. within any 2-hour period) an amount of foof that is larger than most people would eat • a sense of lack of control over eating during the episode • recurrent inappropriate compensatory behavior in order to prevent weight gain (self-induced vomiting, misuse of laxative, diuretic, fasting, excessive exercise) • the binge eating and inappropriate compensatory behavior occur at least twice a week for 3 month • the disturbances does not occur exclusively during episodes of anorexia nervosa

19. specific types: • purging • non-purging • differential diagnosis: • neurological diseases • epileptic ekvivalent seizure • Kleine-Levine syndrom

20. Clinical features • essential features are recurrent binge eating, lack of control over eating, selfinduced vomiting, binging usually precedes vomiting • episodes may be precipitated by stress or may occasionaly be planned • vomiting decreases pain and allow to continue eating without fear of gaining weight • binges consist of food high in calories (cakes, pastry), eaten secretly and rapidly • comorbidity with mood disorders and personality disorders

21. Physical consequences • electrolyte inballance: • potassium depletion resulting in cardiac arrhythmia, renal damage, urinary infections, tetany or epileptic fits • esophagitis • amylasemia • salivary gland enlargement • dental caries

22. Course and prognosis • the disorder is alrealy chronic, course is fluctuating • abnormal eating habits persist for many years, but they vary in severity • prognosis is better than anorexia nervosa, half the patients make a full recovery, the mortality rate is not raised

23. Treatment • patients are more likely to wish to recover • no need of weight restoration • usually out-patient treatment: • psychotherapy – cognitive behavioral therapy • pharmacoterapy – antibulimic effect of antidepressants (SSRI)

24. Eating disorders not otherwise specified

25. frequent disorders of eating that does not meet the criteria for anorexia nervosa or bulimia nervosa, but are of clinical severity • binge-eating disorder: • recurrent bulimic episodes in the absence of the other diagnostic features of bulimia nervosa • treatment similar to bulimia nervosa

26. Obesity

27. Characteristics • excess body fat • BMI exceeds 30% • is associated with increased mortality

28. Epidemiology and aetiology • almost 20% of the adults in the US meets this criteria • genetic factors exacerbated by social factors • psychological causes do not seem to be of great importance in most cases, sometimes excessive eating seems to be determined by emotional factors

29. Course • chronic, indeed lifelong problem • most untreated adults continue to gain weight at the rate of approximately 1 kg per year

30. Treatment • behavioural weight control • diet • physical activity • pharmacological treatment • surgical treatment (indicated for very severe obesity – BMI over 40)

31. References • Gelder M, Mayou R, Cowen P: Shorter Oxford Textbook of Psychiatry, Oxford University press, 2001 • Krch FD et al.: Poruchy příjmu potravy, Grada, 1999