Eating Disorders

Haitham Ismail
• Definition and Classification
• Suicide and DSH risk
• Evaluation
Definition and Classification
Definition
• Feeding and eating disorders are characterized by a persistent
disturbance of eating or eating-related behavior that results in the
altered consumption or absorption of food and that significantly
impairs physical health or psychosocial functioning.
• DSM-5 provides diagnostic criteria for (pica), rumination disorder,
avoidant/restrictive food intake disorder, anorexia nervosa, bulimia
nervosa, and binge-eating disorder.
• a classification scheme that is mutually exclusive, so that during a
single episode, only one of these diagnoses can be assigned.
Pica
A. Persistent eating of non-nutritive, non-food substances over a
period of at least 1 month.
B. The eating of non-nutritive, non-food substances is inappropriate to
the developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially
normative practice.
D. If the eating behavior occurs in the context of another mental
disorder (e.g., intellectual disability [intellectual developmental
disorder], autism spectrum disorder, schizophrenia) or medical
condition (including pregnancy), it is sufficiently severe to warrant
additional clinical attention.
Rumination Disorder
A. Repeated regurgitation of food over a period of at least 1 month.
Regurgitated food may be re-chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated
gastrointestinal or other medical condition (e.g., gastroesophageal reflux,
pyloric stenosis).
C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa, bulimia nervosa, binge-eating disorder, or
avoidant/restrictive food intake disorder.
D. If the symptoms occur in the context of another mental disorder (e.g.,
intellectual disability [intellectual developmental disorder] or another
neurodevelopmental disorder), they are sufficiently severe to warrant
additional clinical attention.
Avoidant/Restrictive Food
Intake Disorder
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance
based on the sensory characteristics of food; concern about aversive consequences of eating)
as manifested by persistent failure to meet appropriate nutritional and/or energy needs
associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally
sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or
bulimia nervosa, and there is no evidence of a disturbance in the way in which one's body
weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not bet ter
explained by another mental disorder. When the eating disturbance occurs in the context of
another condition or disorder, the severity of the eating disturbance exceeds that routinely
associated with the condition or disorder and warrants additional clinical attention.
Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a
weight that is less than minimally normal or, for children and
adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior
that interferes with weight gain, even though at a significantly low
weight.
C. Disturbance in the way in which one's body weight or shape is
experienced,
undue in fluence of body weight or shape on self-evaluation, or
persistent lack of recognition of the seriousness of the current low body
weight.
• Mild: BMI <!: 17 kg!m2
• Moderate: BMI 1 6-1 6.99 kg/m2
• Severe: BMI 1 5-1 5.99 kg/m2
• Extreme: BMI < 1 5 kg/m2
• Restricting type: During the last 3 months, the individual has not engaged
in re current episodes of binge eating or purging behavior (i.e., self-induced
vomiting or the mis use of laxatives, diuretics, or enemas). This subtype
describes presentations in which weight loss is accomplished primarily
through dieting, fasting, and/or excessive exercise.
• Binge-eating/purging type: During the last 3 months, the individual has en
gaged in recurrent episodes of binge eating or purging behavior (i.e., self-
induced vomiting or the misuse of laxatives, diuretics, or enemas).
• In partial remission: After full criteria for anorexia nervosa were previously
met, Criterion A (low body weight) has not been met for a sustained
period, but either Criterion B (intense fear of gaining weight or becoming
fat or behavior that interferes with weight gain) or Criterion C
(disturbances in self-perception of weight and shape) is still met.
• In full remission: After full criteria for anorexia nervosa were previously
met, none of the criteria have been met for a sustained period of time.
Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is
definitely larger than what most individuals would eat in a similar period of time under similar
circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such
as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting;
or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average,
at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
• Mild: An average of 1 -3 episodes of inappropriate compensatory
behaviors per week.
• Moderate: An average of 4-7 episodes of inappropriate compensatory
behaviors per week.
• Severe: An average of 8-1 3 episodes of inappropriate compensatory
behaviors per week.
• Extreme: An average of 1 4 or more episodes of inappropriate
compensatory behav iors per week.
Binge Eating Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely
larger than what most people would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or
control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia
nervosa or anorexia nervosa.
Other Specified Feeding or
Eating Disorder
1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met,
except that despite significant weight loss, the individual's weight is within or
above the normal range.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria
for bulimia nervosa are met, except that the binge eating and inappropriate
compensatory behaviors occur, on average, less than once a week and/or for
less than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the
criteria for binge-eating disorder are met, except that the binge eating occurs,
on average, less than once a week and/or for less than 3 months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape
(e.g., self induced vomiting; misuse of laxatives, diuretics, or other
medications) in the absence of binge eating.
Other Specified Feeding or
Eating Disorder
5. Night eating syndrome: Recurrent episodes of night eating, as
manifested by eating after awakening from sleep or by excessive
food consumption after the evening meal. There is awareness and
recall of the eating. The night eating is not better explained by
external influences such as changes in the individual's sleep-wake
cycle or by local social norms. The night eating causes significant
distress and/or impairment in functioning. The disordered pattern
of eating is not better explained by binge-eating disorder or another
mental disorder, including substance use, and is not attributable to
another medical disorder or to an effect of medication.
Suicide and DSH risk
• The reported occurrence of SIB in eating disorder patients ranged
between 25.4% and 55.2%. The figures for occurrence of eating
disorders in SIB patients ranged between 54% and 61%.
• In women with BN, parental, sexual, physical, and emotional abuse
(mostly in childhood) were significantly associated with the presence
of lifetime SAs
• A previous ED and familial history of an ED (any full sibling or cousin
with any ED), also predicted an elevated risk of SAs in these patients
• Overall, based on the current literature, it now seems more likely that
symptomatology (such as bingeing and purging that may have a
component of impulsivity) is more important than the actual
diagnostic category in determining the suicide risk of ED patients.
• A sub-type switch from restrictive to bingeing/purging was also a correlate
to SAs.
• Impulsivity and poor impulse and emotion regulation were found as
specific psychological features related to suicide. The engagement in self-
injurious behaviors together with poor impulse control may be a result of
the need to regulate intensive negative emotions.
• On the interpersonal level, ED patients are known to experience a
heightened sense of failure, loneliness, perceived burdensomeness, and
helplessness.
• a strong association was found in many studies between suicidal behavior,
depression, and EDs
• Collectively, these studies suggest that ED behaviors constitute
painful experiences, and by habituating to them, ED patients have an
increased acquired capability for suicide.
• It is important to note that due to the nature of AN and the low BMI
in AN patients, even SAs that may not be considered severe, can
ultimately prove lethal.
Evaluation of Patients with ED
History
• Weight, Body image & Diet
• Menstrual history
• Review of systems
• Dizziness, blackouts, weakness, fatigue
• Pallor, easy bruising/bleeding
• Cold intolerance
• Hair loss/dry skin, lanugo hair,
• Vomiting, diarrhoea, constipation, Fullness, bloating, abdominal pain, epigastric burning
• Abdominal pain
• Muscle cramps, joint pains, palpitations, chest pain.
• Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel disease
• Symptoms of depression, anxiety, OCD, Sleep disturbance
• Lethargy, Loss of concentration.
Examination
• General
• CVS
• Chest
• Abdomen
• Neuromuscular
Self-Administered Questionnaire
• EDE-Q is adapted from the EDE, is quicker to complete and does not
require training to administer
• Some clinical features, like binge eating, are reported more accurately
by questionnaire than interview. The reverse is true for restrictive
eating behaviours, which tend to be minimised on self-report.
• The EDE-Q has not been validated for children under the age of 12.
MARSIPAN Risk Assessment
• Red (high risk) Admit if one or more present
• Amber (high concern).
• Green (moderate risk)
• Blue (low risk)
Medical differential diagnoses for AN:
• Endocrine: Hyperthyroidism, glucocorticoid insufficiency, diabetes
• Gastrointestinal: Inflammatory bowel disease, coeliac disease, peptic
ulcer disease
• Neoplastic: Central nervous system tumours or other malignancies
• Other: Chronic infections such as tuberculosis
Psychological treatments
• The current evidence for adolescents <19 years who have had the
illness for <3years best supports family based therapy (FBT).
• Adolescent focused therapy (AFT) has been shown to be similarly
effective compared with FBT but outcomes are better for FBT in 6 and
12 months.
• when family dynamics are such that they interfere with treatment or
if the family is unable to commit to FBT.
• Enhanced cognitive behavioural therapy (CBT-E)
• DBT, parent groups,…
Medications for AN
• Despite the lack of evidence for effectiveness, psychotropic medications are
widely prescribed.
• Antipsychotics are often used in the treatment of AN with aim of reducing
anxiety, obsessional thinking and improving weight gain.
• RCTs conducted in adolescents showed that risperidone and olanzapine provided
no additional benefit during weight restoration.
• Open label RCT: Quetiapine provided psychological and physical improvements,
but the study was not adequately powered to draw firm conclusion
• No evidence of benefit for the use of selective serotonin reuptake inhibitors
(SSRIs) for the treatment of the symptoms of AN or for preventing relapse.
• When considering an SSRI for a comorbid illness, it is important to consider
whether starvation is driving the symptoms themselves.
Medications for BN
• Fluoxetine at a dose of 60 mg may be useful to reduce bingeing and
purging episodes and overall illness severity. Although evidence is
limited to one study in adolescent population, there is grade A
evidence for its use in the adult population.
• CBT, however, is felt to be more effective with longer-lasting effects
and is considered first line.
Medications ARFID
• Cyproheptadine, an antihistamine with appetite stimulation as a side
effect, can be considered when psychological and nutritional
interventions has not been effective.
Refences
• DSM-5
• Assessment and treatment of eating disorders in children and
adolescents
RMairs, DashaNicholls
• Self-Injurious Behavior and Eating Disorders: The Extent and Nature of
the Association
Elena Svirko, MSc, and Keith Hawton, DSc, FRCPsych