Download EATING DISORDERS

EATING DISORDERS
THE ISLAMIC UNVIRSTY OF GAZA
Prepared by:_ : Ahmed Abu sheer
Ahmad Fayyad
Under supervision Dr. Abdalkarim Radwan
OBJECTIVES
 Discuss
the signs and symptoms of eating
disorders, the appropriate evaluation, and treatment
options:
 Anorexia
 Bulimia
nervosa
nervosa
Anorexia Nervosa











Definition
Epidemiology
Diagnostic criteria
Comorbidity
Clinical picture
Risk factor
Etiology
Medical complication
Assessment
Treatment
Prognosis
What is Anorexia Nervosa
Anorexia nervosa is a serious, potentially lifethreatening eating disorder characterized by selfstarvation , excessive weight loss and body image
distortion with an obsessive fear of gaining weight.
Anorexia Nervosa- Epidemiology
















One of the top three chronic conditions of adolescence(asthma,obesity)
Incidence rate 8/100 000 of total population.
Prevalence 0.2-1% of young women
Mainly affects females (95%)
Female-to-male ratio is 10:1
Mean age of onset is 17,mid-teens
Predominates in Western/industrialized countries- and in white, middle and upper class
Median duration of illness:six years.
One of the top three chronic conditions of adolescence(asthma,obesity)
Incidence rate 8/100 000 of total population.
Prevalence 0.2-1% of young women
Mainly affects females (95%)
Female-to-male ratio is 10:1
Mean age of onset is 17,mid-teens
Predominates in Western/industrialized countries- and in white, middle and upper class
Median duration of illness:six years.
DSM-IV CRITERIA-Anorexia Nervosa
Refusal to maintain minimal normal weight
for age and height (< 85% of expected body
weigh
 INTENSE FEAR of gaining weight or
becoming FAT.
 Increased emphasis on weight/shape, body
image distortion, OR denial of the
seriousness of the current low body weig
 Amenrrohea at least for three consecutive
menstrual cycle

2 types of Anorexia Nervosa

Restricting type





Primarily accomplishes weight loss through dieting, fasting, exercise
No regular bingeing or purging
Binge-eating-purging engages in binges (large amount of food consumed)
following by purging (vomiting or use of laxatives)
Binge-Purge type
includes all of the features of Anorexia Nervosa (restriction, low
weight, fear of fat, etc.)



Regular bingeing and purging
Methods of purging may include self-induced vomiting, laxative, diuretic, or
enema use
You may think- “isn’t that Bulimia?” but the key is they’re underweight
Anorexia Nervosa ICD criteria

Body weight is consistently 15% less (or lower) than
that expected for height and age, or body mass
index is 17.5 or less.
 Weight loss is caused by the avoidance of foods
perceived to be fattening, along with one or more
of the following behaviors: self-induced
vomiting, purging, excessive exercise, use of
appetite suppressants and/or diuretics.
 Distorted body image perception driven by an
intense, irrational fear of becoming fat, leads to
the desire to remain at a low body weight.
Anorexia Nervosa ICD criteria
Amenorrhea (abnormal absence of a minimum of three
successive menstrual cycles) in women, and loss of libido
in men. There may be changes in growth hormone,
cortisol, thyroid hormone and insulin.
 Puberty in girls and boys may be delayed if the onset of
anorexia nervosa is prepubertal, but once recovery from
the illness is made, it will often progress normally.

Psychiatric Comorbidity
Consequence of starvation
 50% have major affective disorder
 33% have social phobia
 25% have obsessive compulsive disorder
Binge-purge sub-type
 80% have depression
 10-20% have alcohol and substance misuse
Personality disturbance
 25% of restricting anorexia nervosa have avoidant ,dependent or
obsessional personalities
 40% of binge-purge sub-type of anorexia nervosa have borderline or
histrionic personality disorder.

The clinical picture of Anorexia Nervosa












Food restriction
Excessive exercise
Preoccupations with food, eating, and calories
Social Isolation
Mood irritability, Depression, Obsessive-compulsive behavior
Avoiding social situations that involve food
Unusual eating habits (ie. cutting food into tiny pieces, picking at food)
Going to the bathroom right after meals
Eating alone, at night, or in secret
Cooking for others, but not eating themselves
Wearing baggy clothes to hide weight loss
Frequently checking weight on scale
Risk Factors for Anorexia
Female
 Adolescent
 Living in industrialized
nation
 Family history of obesity or addiction
 Early puberty
 Childhood obesity
 Low self-esteem
 Activities with weight/shape demands





Wrestling, dance, etc.
Diabetes
Personality Disorders (Cluster)
Sexual and physical abuse
Etiology of anorexia nervosa:
Genetic causes of anorexia :
Twin studies suggest that anorexic traits and the syndrome
have a significant genetic component.
If one identical twin has anorexia, the other has more than a
50% chance of also developing it.
Research suggests that a genetic predisposition to anorexia
may run in families..
Family studies have shown that the prevalence of anorexia
nervosa is 7 to 12 times higher among relatives of AN than
among controls.
In fact, it is common to discover that someone with
anorexia has a mother or sister with this eating disorder as
well.
Biological cause
Brain chemistry also appears to play a significant
role.
. Research has shown decreased levels of serotonin
in the brain (a chemical, or neurotransmitter used
by nerve cells to communicate and which controls
appetite and mood). and contribute to other
symptoms of anorexia nervosa such as depression,
impulsiveness, obsessive behaviors, or other mood
disorders.
The Psychological cause:




Severe trauma ,sever life event, difficulties and emotional stress
(such as the death of a loved one or sexual abuse) during puberty or
prepuberty.
People with anorexia may have psychological and emotional
characteristics that contribute to anorexia. They may have low selfesteem , feelings of insufficiency and rigid thought patterns .
They may have obsessive-compulsive personality traits that make it
easier to stick to strict diets and forgo food despite being hungry.
They may have an extreme drive for perfectionism, which means
they may never think they're thin enough.
Sociocultural cause:





Modern Western culture often cultivates , reinforces and puts a high
value on thin or lean bodies
The splashed with images of waif-like media are models and actors.
Success and beauty are often equated with being thin.
Peer pressure may fuel the desire to be thin, particularly among
young girls.
Teenagers are especially vulnerable to social and peer pressure,
which may explain why peak rates of anorexia occur in the teen
years.
social pressures that can contribute to anorexia. This includes
participation in an activity that demands slenderness, such as ballet,
gymnastics, or modeling.
Medical complications of anorexia:
starvation state







Dermatological: Dry Skin and Hair Loss , lanugos-like facial hair,
thinning scalp hair, edema, pale
Hematological: leucopenia, anemia, thrombocytopenia.
. Reproductive :Infertility ,Low-birth weight infant
Heart: arrhythmias, bradycardia , hypotension , weakened
heart muscle
Stomach and Intestines :slow movement in the intestinal tract
leading to fullness, bloating, nausea and constipation .
Bone: osteoporosis, pathological fracture
Other: Hypothermia, Poor immunity
Medical complications of anorexia:
starvation state

Endocrine: Reduced levels of estrogen, testosterone, and growth
hormones may explain growth retardation and delayed pubertal
changes seen in anorexic patient, amenorrhea

CNS: the brain shrinks,ventricular space increase in
size,cognitive impairment, Peripheral neuropathy

Renal :Renal calculi .
Dental changes: Tooth enamel erosion, dental caries ,dentinal
hypersensitivity

assessment



Clinical assessment of anorexia nervosa should include full
psychiatric and medical history.
Full physical examination include vital signs (height, weight,
temperature, supine & standing blood pressure and heart rate),
examine skin for langue (fine, downy hair that may grow as the
result of malnutrition) and/or scars on hands from self-induced
vomiting, check for enlargement of parotid gland, erosion of dental
enamel, and consider including the following tests:
CBC ,Glucose ,Liver Function, Thyroid Function, Analysis of
electrolyte levels, BUN, creatinine & albumin (blood and urine).
Monitor ketones Bone density tests.
assessment
 Physical
examination are required to exclude
organic disorder such as
 Malignancy, thyroid disorder, irritable bowel
disease.
 Ask the patient how do they feel about their body
 Ask a bout eating habits. Do they take
amphetamines to suppress appetite, laxatives,
ipecac
Treatment of Anorexia:
Interdisciplinary Approach
 Medical
Monitoring
 Nutritional Rehabilitation
 Psychotherapy
Medical treatment for anorexia



The first priority in anorexia treatment is to address and stabilize
any serious health issues. Hospitalization may be necessary to
prevent starvation, suicide, or a medical crisis. Dangerously thin
anorexics may also need to be hospitalized until they reach a less
critical weight. Outpatient treatment is an option when the patient is
not in immediate medical danger.
you may need to be admitted to hospital so that fluids and nutrients
that you have lost from your body can be replaced.
There are no medications specifically approved to treat anorexia.
However, antidepressants are often prescribed to treat depression
that may accompany anorexia.
Nutritional therapy for anorexia
 A second
component of anorexia therapy is
nutritional counseling. In nutritional counseling, a
nutritionist or dietician teaches the patient about
healthy eating, proper nutrition, and balanced
meals. The nutritionist also helps the person
develop and follow meal plans that include enough
calories to reach or maintain a normal, healthy
weight
Psychotherapy
Cognitive Behavioral therapy :
 Cognitive Behavioral therapy is one of the most effective
therapies for anorexia. In cognitive behavioral therapy, the
person learns to replace negative, unrealistic thoughts and
beliefs with positive, realistic ones. The person is also
encouraged to acknowledge their fears and to develop
new, healthier ways of solving problems, Cognitive
therapy also involves education about anorexia.

Psychotherapy
 Promotes
healthy eating behaviors through the use
of rewards, reinforcements, self-monitoring, and
goal setting. Teaches the patient to recognize
anorexia triggers and deal with them using
relaxation techniques and coping strategies.
Group therapy
 Group
therapy can be very beneficial to someone
trying to recover from anorexia nervosa.
Allows people with anorexia to talk with each
other in a supervised setting. Helps to reduce the
isolation many anorexics may feel. Group
members can support each other through recovery
and share their experiences and advice.
Family Therapy

Family therapy usually involves the people that are
living with or very close to the person with the
eating disorder. This could include parents, siblings,
spouses and even grandparents. Usually an eating
disorder indicates that there are problems within the
family. Some problems could include martial
problems, substance abuse, physical or sexual abuse,
lack of communication, or difficulty in expressing
feelings. All these issues can be discussed and
worked on in family therapy. In order to solve these
problems, the families must be willing to participate
in therapy and be willing to make changes in their
own behaviors.
Prognosis:
Median duration is six year.
 50 - 70% of people recover from anorexia nervosa
 30% have poor prognosis.
 Mortality rate: 5-18%
 Death is due to suicide in
24-50% of cases, and medical
complication in 50%

Bulimia
 episodic,
uncontrolled rapid ingestion of food over
a short period of time followed by purging.
 compensatory measure to rid the body of the
excessive calories.
 The food has a sweet taste, high calorie count. The
binging is done in secret and alone
Bulimia
induced purging
 use of laxatives,diuretics, or enemas
 weight fluctuations- but patient is usual of normal weight.

DSM-IV CRITERIA- Bulimia
Episodes of binge eating with a sense of loss of control
 Binge eating is followed by compensatory behavior of the
purging type (self-induced vomiting, laxative abuse,
diuretic abuse) or nonpurging type (excessive exercise,
fasting, or strict diets).
 Binges and the resulting compensatory behavior must
occur a minimum of two times per week for three months
 Dissatisfaction with body shape and weight

Symptoms
 dehydration
from the vomiting
 electrolyte imbalance
 erosion of tooth enamel from gastric acid
 tears in the esophagus or gastric mucosa.
 May also have depression ( 71%) anxiety
disorders, substance abuse.
EPIDEMIOLOGY
 Bulimia
 Occurs
in 1-5% of high school girls
 As high as 19% in college women
ASSOCIATED FACTORS
 History
of dieting in adolescent children
 Childhood preoccupation with a thin body and
social pressure about weight
 Sports and artistic endeavors in which leanness is
emphasized
 Women whose first degree relatives have eating
disorders– 6 to 10 fold increased risk for
developing an eating disorder
ASSOCIATED PSYCHIATRIC
CONDITIONS

affective disorders

anxiety disorders

obsessive-compulsive disorder

personality disorders

substance abuse.
Assessment
Bulimic patients often have hoarseness,parotid
gland enlargement (Chipmunk) ,tooth enamel
erosion,scarred fingers.
TREATMENT AND OUTCOME
Treatment







priority the restoration of nutritional status and life threatening
physical problems.
Behavior Modification
Family therapy
group therapy like a 12 Step approach
education about eating disorders, the causes, the effects on the body,
the issues and the situations that may trigger a sense of loss of
control and lead to acting out with food
relaxation techniques
medications (Prozac) Periactin is an appetite stimulant. Have tried
Lithium and Thorazine
HOSPITALIZATION
Severe malnutrition
 Dehydration
 Electrolyte disturbances
 Cardiac dysrhythmia
 Arrested growth and development
 Physiologic instability
 Failure of outpatient treatment
 Acute psychiatric emergencies
 Comorbid conditions that interfere with the treatment of
the ED

NUTRITION
 Goal:
regain to goal of 90-92% of IBW
 Inpatient treatment varies by facility
 Oral
liquid nutrition
 Nasogastric tube feedings
 Gradual caloric increase with “regular” food
 Parenteral nutrition rarely indicated
OUTCOME

50% good outcome


25% intermediate outcome


Return of menses and weight gain
Some weight regained
25% poor outcome
Associated with later age of onset
 Longer duration of illness
 Lower minimal weight
 Overall mortality rate: 6.6%
