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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