1. EATING DISORDERS
Dr. Y R Bhattarai
TMU

2. Introduction to eating disorders
Eating disorders are characterized by disturbances in eating behaviors and an over concern with body image or size.
Principal diagnostic distinction is based on ideal body weight.
If body weight is maintained in the presence of abnormal eating disorder, a diagnosis of bulimia nervosa is made. If body weight falls down, diagnosis of anorexia nervosa is made.

3. Anorexia nervosa
Definition: characterized by failure to maintain a normal body weight, fear and preoccupation with gaining weight, unrealistic self evaluation as overweight, and amenorrhea for three cycles or more.
Refusal to keep body weight at greater than 85% of ideal.
Patients with anorexia nervosa generally don't have a loss of appetite.
Sub types
-Restrictive type
-Binge eating/purging type

4. Prevalence & etiology 0.5% , occurs at a 1:10 male to female ratio.
Common in industrial societies and higher socioeconomic classes.
History of past physical or sexual abuse.
Social opinion of attractiveness in low body weight drives women to develop eating disorders.
Common in dancers and models.
Psychological risk factors include emotional conflicts concerning family control and sexuality.
Biological factors like prior amenorrhoea.
Genetic factors

5. onset Average age is 17 years.
Very late onset anorexia nervosa has a poorer prognosis.
Onset is often associated with emotional stressors, particularly conflicts with parents about independence and sexual conflicts.

6. Key symptoms
Restricted food intake and maintaining diets of low calorie foods. Weight loss may be achieved through purging( vomiting or taking laxatives) and exercise.
Great concern with appearance; significant amount of time spent examining for perceived signs of excess weight.
With binge eating/purging: self induced vomiting, laxatives abuse.

7. Anorexia nervosa

8. Associated symptoms
Obsessive compulsive symptoms
Depression symptoms

9. Physical examination
Signs of malnutrition: emaciation, hypotension, bradycardia, lanugo and peripheral edema
Signs of purging: eroded dental enamel caused by emesis and scarred or scratched hands from self gagging.

10. COURSE AND OUTCOME
Some individuals recover after a single episode, and others develop a waxing and waning course.
Long term mortality rate of hospitalized patients of anorexia nervosa is 10% from starvation or suicide.

11. Diagnostic tests
Signs of malnutrition: normochromic normocytic anemia, elevated liver enzymes, low estrogen and testosterone level, sinus bradycardia, and abnormal EEG.
Signs of purging: metabolic alkalosis, hypochloremia and hypokalemia.

12. Differential diagnosis
Major rule outs are bulimia nervosa
General medical conditions that causes weight loss
Major depressive disorder
OCD
Body dysmorphic disorder.

13. MANAGEMENT
Initial treatment of the medical complications due to starvation and purging.
Supervised meals, weight and electrolyte monitoring.
Behavioral therapy should be initiated, with rewards or punishment based on absolute weight.
Family therapy designed to reduce conflicts about control by parents is often helpful.
Antidepressants especially SSRIs when comorbid depression is present.

14. BULIMIA NERVOSA

15. BULIMIA NERVOSA
Bulimia nervosa is an eating disorder characterized by binge eating with the maintenance of body weight.
Types
-Purging: self induced vomiting or use of laxatives
-Non purging: fasting or exercise, but no purging during bulimic episodes.

16. Prevalence / etiology
2% in young adult females. Occur at a 1:9 male to female ratio.
Psychological conflicts regarding guilt, helplessness, self control and body image may predispose.
Biologic factors : association with mood disorders.
Abnormal serotonin metabolism is thought to play more of a role in bulimia nervosa.

17. Key symptoms
Recurrent episodes of binge eating: obsession with dieting but followed by binge eating of high calorie foods.
Recurrent , inappropriate compensatory behavior: after a binge, attempts to prevent weight gain through self induced vomiting, misuse of laxatives, fasting or excessive exercise.
Self evaluation is unduly influenced by body shape and weight

18. Associated problems Depressive symptoms Substance abuse
Impulsivity (kleptomania)

19. examinations Physical examination: evidence of purging
Diagnostic tests: evidence of laxatives.

20. Course and outcome Course: may be chronic or intermittent
Outcome:70% of cases have remitted after 10 years. Co existent substance abuse is associated with a poorer prognosis.

21. Differential diagnosis
Major depression with atypical features
Borderline personality
Differentiate from binge eating and purging subtype of anorexia nervosa.

22. Management Similar to that of anorexia nervosa
No medical complications of starvation present.
Psychotherapy for controlling eating behaviors
Cognitive therapy may be useful in treating over concern with body images.
Antidepressants, particularly SSRIs, are usually given.

23. Thank you!