ERLYN LIMOA

General introduction
 Eating disorders are characterized by marked
disturbance in eating behavior.
 Include : anorexia nervosa, bulimia nervosa,
and binge-eating disorders
 Patients with anorexia or bulimia have a
disturbed body image and use extensive
measures to avoid gaining weight
 Binge eating may occur in all of the eating
disorder
ANOREXIA NERVOSA

 Preoccupied with their

weight, their body image,
and with being thin
 Subdivision :
 Restrictive type
 Binge eating/purging
type
 Restrictive type :
 Eat very little
 May vigorously exercise
 More often withdrawn with OC traits
 Binge eating/purging type :
 Eat in binges followed by purging, laxatives,
excessive exercise, and/or diuretics
 Associated with increased of major depression
and substance abuse
 Diagnosis and DSM IV-TR criteria :
A. Refusal to maintain body weigh at or above a
minimally normal weigh for age and height.
B. Intense fear of gaining weight or becoming fat,
even though underweight
C. Disturbance 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.
D. In postmenarcheal females, amenorrhea (i.e. the
absence of at least 3 consecutive menstrual cycles).
A women is considered to have amenorrhea if her
periods occur only following hormone
administration.
 cont. Diagnostic Criteria (DSM-IV-TR)

Specify type :
 Restricting type : during the current episode of
anorexia nervosa, the person has not regularly
engaged in bing-eating or purging behavior (i.e.
self-induced vomiting or the misuse of laxatives,
diuretics, or enemas)
 Binge-eating/purging type : during the current
episode of anorexia nervosa, the person has regular
engaged in binge-eating or purging behavior (i.e.
self-induced vomiting or the misuse of laxatives,
diuretics, or enemas).
 ICD 10 criteria :
 There is weight loss or, in children, a lack of weight gain, leading
to a body weight at least 15% below the normal or expected
weight for age and height.
 The weight loss is self-induced by avoidance of fattening foods.
 There is self-perception of being too fat, with an intrusive dread
of fatness, which leads to a self-imposed low weight threshold.
 A widespread endocrine disorder involving the hypothalamic-
pituitary-gonadal axis is manifest in women as amenorrhea and
in men as a loss of sexual interest and potency. (An apparent
exception is the persistence of vaginal bleeding in anorexic
women who are on replacement hormonal therapy, most
commonly taken as a contraceptive pill.)
 The disorder does not meet Criteria A and B for bulimia nervosa.
 Comments
The following features support the diagnosis but are
not essential elements: self-induced vomiting, self-
induced purging, excessive exercise, and use of
appetite suppressants and/or diuretics.
If onset is prepubertal, the sequence of pubertal
events is delayed or even arrested (growth ceases; in
girls the breasts do not develop, and there is a primary
amenorrhea; in boys the genitals remain juvenile).
With recovery, puberty is often completed normally,
but the menarche is late.

Atypical anorexia nervosa

Researchers studying atypical forms of anorexia
nervosa are recommended to make their own
decisions about the number and type of criteria to be
fulfilled.
 Physical findings and complications
 Amenorrhea,
 Electrolyte abnormalitis
 Hypercholesterolemia
 Arrhythmias
 Cardiac arrest,
 Lanugo
 Melanosis coli
 Leukopenia
 Osteoporosis
 Epidemiology
 10-20 times more common in women than men
 Occurs in up to 4% of adolescents and young
adults (mainly females)
 Onset usually between ages 10 and 30
 More common in developed countries and
professions requiring thin physique
 Etiology involves environmental, social,
biological, and genetic factors
 Increased incidence of co-morbid mood
disorders
Differential Diagnosis

 Medical condition (such as cancer)

 Major depression
 Bulimia,
 Other metal disorder (such as somatization
disorder or schizophrenia)
Course and Prognosis
 Variable course – may completely recover,
have fluctuating symptoms with relapses, or
progressively deteriorate
 Mortality approximately 10% due to
starvation, suicide, or electrolyte disturbance.
Treatment
 Patients may be treated as outpatients unless
they are > 20% below ideal body weight, in
which case they should be hospitalized
 Treatment involves :
 Behavioral therapy
 Family therapy
 Supervised weight-gain program
 Some antidepressant may be useful as
adjunctive treatment to promote weight
gain.
 Bulimia nervosa

A. Definition
Episodic, uncontrolled, compulsive, and rapid
ingestion of large amounts of food within a short
period of time (binge eating) followed by self-
induced vomiting, use of laxatives or diuretics,
fasting, or vigorous exercise to prevent weigh gain
(binge and purge).
B. Diagnosis

 According to DSM-IV-TR, the essential features

of bulimia nervosa are :
 Recurrent episodes of binge eating
 A sense of lack of control over eating during the eating
binges
 Self-induced vomiting, the misuse of laxatives, or
diuretics, fasting, or excessive exercise to prevent
weight gain
 Persistent self-evaluation influenced by body shape
and weight.
 cont. Diagnosis

 There are 2 types of bulimia nervosa :

 Nonpurging type : patients tend to have less body-
image disturbances and less anxiety and tend to be
obese.
 Purging type : patients are at risk for medical
complications such as hypokalemia from vomiting
or laxative abuse and hypochloremic alkalosis.
Diagnostic Criteria (DSM-IV-TR)

A. Recurrent episodes of binge eating. An episode of

binge eating is characterized by both of the
following :
1. Eating, in the discrete period of time, an amount of
food that is definitely larger than most people would
eat during a similar period of time and under similar
circumstances.
2. A sense of lack of control over eating during the
episode.
 cont. Diagnostic Criteria (DSM-IV-TR)

B. Recurrent inappropriate compensatory

behavior in order to prevent weight gain.
C. The binge eating and inappropriate
compensatory behaviors both occur, on
average, at least twice 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.
 cont. Diagnostic Criteria (DSM-IV-TR)

Specify type :
 Purging type : during the current episode of
bulimia nervosa, the person has regularly engaged
in self-induced vomiting or the misuse of laxatives,
diuretics, or enemas.
 Nonpurging type : during the current episode of
bulimia nervosa, the person has used other
inappropriate compensatory behaviors, such as
fasting or excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse of
laxatives, diuretics, or enemas.
 ICD 10 criteria :
 There are recurrent episodes of overeating (at least
twice a week over a period of 3 months) in which large
amounts of food are consumed in short periods.
 There is persistent preoccupation with eating and a
strong desire or a sense of compulsion to eat (craving).
 The patient attempts to counteract the fattening•effects
of food by one or more of the following:
 self-induced vomiting;
 self-induced purging;
 alternating periods of starvation;
 use of drugs such as appetite suppressants, thyroid
preparations, or diuretics; when bulimia occurs in diabetic
patients, they may choose to neglect their insulin treatment.
 There is self-perception of being too fat, with an
intrusive dread of fatness (usually leading to
underweight).
 Atypical bulimia nervosa
Researchers studying atypical
forms of bulimia nervosa, such as
those involving normal or
excessive body weight, are
recommended to make their own
decisions about the number and
type of criteria to be fulfilled.
 C. Epidemiology

 Prevalence is approximately 1% of the

general population and 1% to 3% in
young women.
 Age at onset is usually 16-18 years.
 Male-to-female ratio is 1 : 10
D. Etiology

1. Biologic. Metabolic studies indicate decreased

norepinephrine and serotonin activity and turnover.
2. Social. Reflects society’s premium on thinness.
Patients tend to be perfectionists and
achievement-oriented.
3. Psychological. Patient have difficulties with
adolescent demands, but patients with bulimia
nervosa are more outgoing, angry, and impulsice
than those with anorexia nervosa. They have
histories of difficulties in separating from
caretakers.
E. Differential diagnosis

1. Neurologic disease, e.g central nervous

system tumors
2. Borderline personality disorder
3. Major depressive disorder
F. Course and prognosis

 Course is usually chronic but not debilitating

when not complicated by electrolyte
imbalance and metabolic alkalosis.
 60% may recover with treatment; however,
relapse rate can approach 50% during a 5-
year period.
 In some cases of untreated bulimia nervosa,
spontaneous remission occurs in 1-2 years.
G. Treatment

1. Hospitalization
2. Psychological
a. Cognitive-behavioral therapy
b. Dynamic psychotherapy
3. Pharmacologic
 Eating disorder NOS

 This is a residual category in the DSM-IV-TR

used for eating disorders that do not meet the
criteria for a specific eating disorder.
 Included in this category is binge-eating disorder
– recurrent episodes of binge eating in the
absence of the inappropriate compensatory
behaviors characteristic of bulimia nervosa. Such
patients are not fixiated on body shape and
weight.
Diagnostic criteria for Eating
Disorders NOS (DSM-IV-TR)
The Eating Disorder NOS category is for disorders of
eating that do not meet the criteria for any specific
Eating disorders. Example include :
1. For females, all of the criteria for Anorexia nervosa
are met except that the individual has regular
menses.
2. All of the criteria for Anorexia nervosa are met
except that, despite significant weight loss, the
individual’s current weight is in the normal range.
 cont. Diagnostic criteria (DSM-IV-TR)

3. All of the criteria for Bulimia nervosa are

met except that the binge eating and
inappropriate compensatory mechanisms
occur at a frequency of less than twice a
week or for a duration of less than 3 months.
4. The regular use of inappropriate
compensatory behavior by an individual of
normal body weight after eating small
amounts of food.
 cont. Diagnostic criteria (DSM-IV-TR)

5. Repeatedly chewing and spitting out, but

not swallowing large amounts of food.
6. Binge-eating disorder : recurrent episodes
of binge eating in the absence of the
regular use of inappropriate compensatory
behaviors characteristic of Bulimia nervosa.
Research criteria for Binge-Eating
Disorder (DSM-IV-TR)

A. Recurrent episodes of binge eating. An episode

of binge eating is characterized by both of the
following :
1. Eating, in the discrete period of time, an amount of
food that is definitely larger than most people
would eat during a similar period of time and under
similar circumstances.
2. A sense of lack of control over eating during the
episode.
 Binge-Eating Disorder (DSM-IV-TR)

B. The binge eating episodes are associated with 3

(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 being embarrassed by how
much one is eating
5) Feeling disgusted with oneself, depressed, or very
guilty after overeating
 Binge-Eating Disorder (DSM-IV-TR)

C. Marked distress regarding binge eating is

present.
D. The binge eating occurs, on average, at least
2 days a week for 6 months.
E. The binge eating is not associated with the
regular use of inappropriate compensatory
behaviors and does not occur exclusively
during the course of anorexia nervosa or
bulimia nervosa.