Eating disorders

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 Eating disorders
anorexia nervosa
This condition is not very common in the general
population. There are special populations where
the disease is more common such as ballet
dancers and models. More common in females
possibly 90% females and the peak age of onset
is about 18 years. It is more common in higher
socioeconomic states.
it is clear that since the 1960s there has been a
significant increase in eating disorders, of which
the two clearest syndromes are anorexia
nervosa and bulimia nervosa.
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 Eating disorders
anorexia nervosa
The etiology is multifactorial which is a
combination of genetic environmental and
sociocultural factors.
Sociocultural causes: The social pressures
which lead to dietary restraint include the
publication of books and magazines advising
weight-reducing diets, the fashion industry which
caters mainly for the slimmer figure, television
attaching sexual allure and professional success
to the possession of a svelte figure, and the
emphasis on physical fitness and athleticism.
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 Eating disorders
anorexia nervosa
Adverse life events and history of
childhood sexual abuse are contributing
factors.
There is a close relationship between
obsessional personalities and the later
development of anorexia nervosa.
Serotonin is thought to play an important
role in the regulation of food intake.

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 Eating disorders
anorexia nervosa
Clinical features :
The main features include anorexia,
weight loss, overexercizing, behaviours to
loose weight and amenorrhea. There is
distorted body image. They have
depression with guilt feeling after eating.
They have specific eating rituals as
selective food with low calories.

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 Anorexia Nervosa.MPG

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 Eating disorders
anorexia nervosa
Physical signs: Wasting is variable but may be
extremely severe, resulting in a skull-like
appearance of the head, stick-like limbs, and flat
breasts, buttocks, and abdomen.
The hands and feet feel cold and readily turn
blue in winter.
The skin is dry with an excess of downy hair
(lanugo) covering the cheeks, the nape of the
neck, the forearms, and the legs.
Heartbeat is slow (5060 beats/min) and the
blood pressure is low (e.g. 90/60 mmHg) with
orthostatic lability.
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 Eating disorders
anorexia nervosa
Complications include: dehydration,
hypokalemia, hyponatremia, alkalosis,
renal tubular dysfunction, osteoporosis,
hypothermia and anemia.

Patients can recover even in patients with

ten years duration of illness.

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 Eating disorders
anorexia nervosa
Treatment
Inpatient
Day patient
Family therapy
Drug therapy as chlorpromazine and
antidepressants.

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 Bulemia nervosa
Gerald Russell was the first who wrote about
this syndrome in the year 1979.

The diagnosis requires the presence of the

following:
1. Recurrent episodes of binge eating' .
2. The regular use of extreme methods of
weight control (e.g. highly restrictive dieting,
self-induced vomiting, the misuse of laxatives
and diuretics, or overexercising).

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 Bulemia nervosa
3. A characteristic set of attitudes to shape and
weight, at the heart of which is the judging of
self-worth in terms of shape and weight. These
attitudes are expressed as an intense
dissatisfaction with shape and weight, a fear of
weight gain and fatness, and, in many cases, a
pursuit of weight loss and thinness.
The patient must not meet the diagnostic criteria
for anorexia nervosa.

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 Bulemia nervosa
There is strict dieting with episodes of binge
eating.
The binges are a source of great stress and
induce shame and self disgust.
The disorder is divided into purging and non-
purging type.
Depressive symptoms are common but social
functioning is less impaired.
Two important features of their personality are
low self esteem and perfectionism.

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 Bulemia nervosa
Physical signs include: ammenorrhea,
hypokalemia, hyponatremia and
hypochloremia.

In about a quarter of the cases, the

condition is preceded by anorexia
nervosa.

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 Bulemia nervosa
Treatment
Antidepressants
Psychotherapy as
CBT, Interpersonal psychotherapy

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 Obesity
Obesity is a condition characterized by
excessive accumulation of fat in the body.

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 Obesity
clinical features
The patient has the metabolic syndrome of
dyslipidemia, hypertension and diabetes.
There is disparagement of body image,
This feeling is closely associated with self-
consciousness and impaired social
functioning.
Bouts of binge eating without attempts to
loose weight as in bulemia.

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 Obesity
The world is in the midst of an epidemic of
obesity, with the prevalence rising rapidly,
both in countries in which the prevalence
had been relatively low and in those in
which it had been high.
Age and gender are positively, and socio-
economic status negatively, associated
with obesity.

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 Obesity
Etiology
obesity results from an elevation of the
set-point about which body weight is
regulated, and that the aetiology of obesity
is to be found in the sources of this
elevated set-point. Three such sources are
genetic, environmental, and regulatory.

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 Genetics :
Genetic influences appear to play at least as
important a role in the distribution of body fat as
in the determination of total body fat or weight.
Twin and adoption studies supports the
importance of genetics.
Environment
Such as sedentary life style and low
socioeconomic status.

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 Obesity
Determinants of obesity
Adipose tissue
Adipose tissue is the organ primarily affected in obesity.
Adults of average weight have approximately 25 billion
fat cells whereas severely obese people may have as
many as 150 billion fat cells, as well as an increase in
the size of the cells. Genetic influences play a role in
excessive proliferation of fat cells, which occurs
particularly in people who have been obese since
childhood. When weight is lost, it is solely by a decrease
in fat cell size; fat cell number appears to be irreversible.
As a result, when fat cell size is reduced to normal levels
by dieting, people with excessive numbers of fat cells
remain significantly obese.
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 Obesity
Determinants of obesity
Brain damage
Infections, tumours and damage to the
hypothalamus mainly in children.
Medication
Steroids, antidepressants and less with
SSRIs, antipsychotics.
Psychological
Is thought to be a result rather than a
cause
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 Obesity/ Treatment
Treatment
many patients routinely treated for obesity may develop
anxiety or depression. A high incidence of emotional
disturbances has been reported among obese persons
undergoing long-term, in-hospital treatment by fasting or
severe calorie restriction
Diet
In general, the best method of weight loss is a balanced
diet of 1,100 to 1,200 calories. Such a diet can be
followed for long periods but should be supplemented
with vitamins, particularly iron, folic acid, zinc, and
vitamin B6.
Exercise

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 Obesity/ Treatment
Pharmacotherapy
Drug treatment is effective because it suppresses appetite, but
tolerance to this effect may develop after several weeks of use.
Amphetamine derivatives
Rimonabant
Rimonabant has not been studied in patients with psychiatric
disorders. It should thus be used with caution in that population
since the most frequent adverse events resulting in discontinuation
of the drug in clinical trials were nausea, depression, and anxiety.
However, since weight gain is such a common side effect of many
psychiatric drugs, and the use of rimonabant to mitigate drug-
induced metabolic disturbances may be justified in some patients.
Surgery
Psychotherapy

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CONCLUSIONS: These results suggest
that while menstrual irregularities are
common, bulimia nervosa appears to have
little impact on later ability to achieve
pregnancy.
Eating Disorders Am J Psychiatry
159:1048-1050, June 2002

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 Am J Psychiatry 162:415, February 2005
2005 American Psychiatric Association
Book Forum:
Eating Disorders
Eating Disorders: WPA Series Evidence and Experience in Psychiatry, vol. 6
Edited by Mario Maj, Katherine Halmi, Juan Jos Lpez-Ibor, and Norman
Sartorius. New York, John Wiley & Sons, 2003, 435 pp., $135.00.
LAURA L. POST, M.D., Ph.D.
Saipan, MP (USA) There is, perhaps, no other subspecialty in the area of mental
health that has developed as quickly or spread as broadly as that of eating
disorders. This is so because non-Western countries are clinically experiencing
morbidity and mortality from eating disorders in their societies and are doing their
own research and reporting. Moreover, general medicine has recognized that eating
disorders substantially overlap into their realm and are similarly contributing to
knowledge in the field. Finally, because eating disorders are complex mixes of
psychology and physiology and incorporate multiple distinct syndromes,
nonpsychiatric mental health professionals have accumulated their respective
expertise in recognition and treatment.

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 Am J Psychiatry 165:138, January 2008
doi: 10.1176/appi.ajp.2007.07071073
2008
Letter to the Editor
Obesity and Brain Disorder
BARBARA ALTMAN BRUNO, Ph.D.
Pleasantville, N.Y.
There is one approach that improves the physical and mental health of obese people as well as
people of smaller sizes: the health at every size approach. I have used this approach for many
years in my practice (6). The success of the health at every size approach has been documented
in an experiment (7) comparing it with the classic eat-less/exercise-more approach (which Drs.
Volkow and OBrien accurately acknowledged as incredibly difficult to sustain). Nondieters who
gave up restrained eating, accepted their size, and tuned in to body signals of hunger and satiety
improved their physical and mental health, independent of weight change and in contrast to
dieters.
If we are truly interested in helping people who are out of control around food, we should stop
creating more of them by continuing to push dieting. We should advocate for people taking good
care of themselves via such avenues as self- and size-acceptance, enjoyable movement, and
nourishment of ones body, soul, and relationships. Moreover, we should stop considering adding
to the tremendous amount of prejudice and stigma against individuals with unpopular body size by
presuming that they possess a psychiatric disturbance.

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 Am J Psychiatry 165:424, April 2008
doi: 10.1176/appi.ajp.2007.07081351

Issues for DSM-V: Night Eating Syndrome

Albert Stunkard, M.D., Kelly Allison, Ph.D., and Jennifer Lundgren, Ph.D.
Recent demonstration of an effective treatment for night eating syndrome (1) argues for wider recognition of the
disorder to benefit the many persons who suffer from it. These include 1.1%1.5% of the general population, 6%
16% of patients in weight reduction programs, and 8%42% of candidates for bariatric surgery. Viewed as a delay
in the circadian rhythm of food intake, night eating syndrome is defined by two core criteria: evening hyperphagia
(ingestion of at least 25% of daily calories after supper) and/or awakenings with ingestions at least three times a
week. These criteria have identified persons whose behavior manifests a coherent biobehavioral model of night
eating syndrome, supporting its construct validity. Single photon emission computed tomography has shown
significant elevation of serotonin transporters in the midbrain of night eaters (2). This elevation may result from a
genetic vulnerability transmitted as part of the established heritability of night eating syndrome (3), which is
triggered by the stress that night eaters report. Elevations in serotonin transporter levels lead to decreased
postsynaptic serotonin transmission and should impair circadian rhythms and satiety. These deficits suggest that
improvement in serotonin function should alleviate night eating syndrome, and the selective serotonin reuptake
inhibitors do precisely that. Reports of response to paroxetine and fluvoxamine have been accompanied by two
larger open-label trials with a strong response to sertraline. Finally, a placebo-controlled, double-blind study of
sertraline showed significant improvements in both of the criteria for night eating syndrome (1).
Night eating may be a pathway to obesity; it preceded the onset of obesity in three studies and predicted major
weight gain among female night eaters who were already obese (4). Five animal models, each of a different
etiology, have also shown a circadian dysrhythmia with hyperphagia and obesity. In addition to its contribution to
weight gain, night eating syndrome is a source of distress, making it worthy of treatment for its own sake.

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