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EATING DISORDERS
MUDr. Markéta Žáčková
Department of Psychiatry,
Masaryk University, Brno
 many
are still clinically
unrecognized
 it is estimated that general
practitioners recognize only 12% of
bulimia nervosa and 45% of
anorexia nervosa
Anorexia nervosa
Characteristics
 profound
disturbance of body image
with pursuit of thinness (often to the
point of starvation)
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%
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
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
 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
Clinical features
 the
onset usually occurs between 1320 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
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
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
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
Hospitalization in pts with:
 weight
20% bellow the expected
weight for their height
 rapid weight loss
 severe depression
 failed out-patient care
Bulimia nervosa
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
Epidemiology
 1-3%
of young women
 uncommon among men
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
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
 specific
types:
– purging
– non-purging
 differential
diagnosis:
– neurological diseases
 epileptic
ekvivalent seizure
 Kleine-Levine syndrom
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
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
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
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)
Eating disorders not otherwise
specified
 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
Obesity
Characteristics
 excess
body fat
 BMI exceeds 30%
 is associated with increased mortality
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
Course
 chronic,
indeed lifelong problem
 most untreated adults continue to
gain weight at the rate of
approximately 1 kg per year
Treatment
 behavioural
weight control
 diet
 physical
activity
 pharmacological treatment
 surgical treatment (indicated for very
severe obesity – BMI over 40)
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