Eating disorders-2

Dr. Bhumika Patel

Second year resident,
Department of psychiatry,
GMERS Medical College and hospital Sola, Ahmedabad.
Contents
 Bulimia Nervosa
 Epidermiology
 Etiology
 Diagnostic criteria
 Clinical features
 Physical and laboratory examination
 Differential diagnosis
 Course and prognosis
 Treatment

 Binge eating disorder

 Other specified feeding or eating disorder
 Night eating syndrome
 Purging disorder
Bulimia Nervosa
Introduction

 Episodes of binge eating terminated by physical discomfort like abdominal

pain or nausea f/b feeling of guilt, depression or self-disgust.
 Term derived from “ox-hunger” in greek and “ nervous involvement” in latin.
 Patients with bulimia maintain Normal body weight
 Eating binges provoke panic in patients and unwanted binges leads to
secondary attempts to avoid feared weight gain by compensatory behaviours.
Epidemiology

 More prevalent than Anorexia Nervosa

 More common in females
 Onset is in adolescence and early adulthood
 Present in Normal weight young women, they sometimes have a history of
obesity
 Prevalence is 1 percentage in general population.
Etiology
 Biological factors
 As serotonin is linked with satiety, serotonin and norepinephrine have been
implicated In this. Antidepressants often benefit patients with bulimia.
 Feeling of well being after vomiting that some pateints experience may be
mediated by raised endorphin levels.
 Increase frequency is found in first degree relatives of patients.
 fMRI suggests that overeating results from exaggerated perception of hunger signals
realated to sweet taste by anterior insula area of the brain.
 Social factors
 Tend to be high achievers and respond to societal pressure to be slender.
 Many pateints are depressed and have increased familial depression.
 Families of patients are less Close and more conflictual, pateints described their
parents as neglectful and rejecting.
 Psychological factors
 Pateints have difficulties with adolescence demands, but they are more outgoing,
angry and impulsive.
 Alcohol dependence, shoplifting and emotional liability including suicidal
attempts are associated with BN
 Pateints experience their uncontrolled eating as more egodystonic than do pts of
AN and so seek help readily.
 They lack superego control. Had difficulties In controlling their impulses and often
manifested by substance dependence and self destructive sexual relationships.
 Many pateints have histories of difficulties separating from caretaker as
manifested by the absence of transitional objects during their early childhood
years.
 The struggle for separation from a metarnal figure is played out in the ambivalence
towards food; eating may represent a wish to fuse with caretaker, and
regurgitating may unconsciously express a wish for separation.
Diagnosis and clinical features
 Binging
 Binging usually precedes vomiting by 1 year.
 During binges, patients prefer food that is sweet, high in calories and generally soft and
smooth in textured, such as cake and pastry. Some prefer bulky food without regard to
taste.
 The binge eating often continues until the individual is uncomfortably, or even painfully,
full.
 Compansatory behaviours
 Vomiting is the most common inappropriate compensatory behavior. The immediate effects
of vomiting include relief from physical discomfort and reduction of fear of gaining weight.
 Laxative abuse, diuretics, enemas, abuse of emetics
 Severe dieting and strenuous exercise
 Patients has a morbid fear of fatness, a relentless drive for thinness, or both and a
disproportionate amount of self evaluation that depends on body weight and shape.
 Clinician should explore possibility that patient has experienced a brief or prolonged prior bout of
AN, which is present in half of those with BN.
 Diagnostic criteria
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.
Specifier
 Specify if:
 In partial remission: After full criteria for bulimia nervosa were previously met, some, but not
all, of the criteria have been met for a sustained period of time.
 In full remission: After full criteria for bulimia nervosa were previously met, none of the
criteria have been met for a sustained period of time.
 Specify current severity:
The minimum level of severity is based on the frequency of inappropriate compensatory
behaviors (see below). The level of severity may be increased to reflect other symptoms and the
degree of functional disability.
 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 8-13 episodes of inappropriate compensatory behaviors per week.
 Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per
week.
Subtypes
 PURGING TYPE
 Who regularly engage in self
induced vomiting or use of
laxatives or diuretics
 More body image disturbances
 More anxiety concerning eating
 Normal weight or underweight
 Risk of medical complications are
more
 NON PURGING TYPE
 Who use strict dieting, fasting, or
vigorous exercise
 Less body image disturbances
 Less anxiety concerning eating
 Normal weight or Obese
 Risk of medical complications are
less.
 Physical examination
 Normal weight or overweight range (body mass index [BMI] > 18.5
and < 30 in adults).
 Hypotension and bradycardia
 Significant and permanent loss of dental enamel, especially from
lingual surfaces of the front teeth due to recurrent vomiting.
These teeth may become chipped and appear ragged and "moth-
eaten.“
 Dental caries
 The salivary glands, particularly the parotid glands, may become
notably enlarged.
 Calluses or scars on the dorsal surface of the hand from
repeated contact with the teeth (Russell’s sign)
Laboratory examination
 Fluid and electrolyte disturbances resulting from the purging behavior are
sometimes sufficiently severe to constitute medically serious problems.
 Hypokalemia (which can provoke cardiac arrhythmias)
 Hypochloremia
 Hyponatremia
 Hypomagnesemia
 Metabolic alkalosis- elevated serum bicarbonate(Due to loss of gastric acid through
vomiting)
 Metabolic acidosis (due to frequent induction of diarrhea or dehydration through
laxative and diuretic abuse.
 Hyleramylasemia
 Thyroid function remains intact.
Associated Features Supporting
Diagnosis
 Menstrual irregularity or amenorrhea often present.
 Rare but potentially fatal complications include esophageal tears, gastric
rupture, and cardiac arrhythmias.
 Serious cardiac and skeletal myopathies have been reported among
individuals following repeated use of syrup of ipecac to induce vomiting.
 Individuals who chronically abuse laxatives may become dependent on their
use to stimulate bowel movements.
 Gastrointestinal symptoms are commonly associated with bulimia nervosa,
and rectal prolapse has also been reported among individuals with this
disorder.
Associated comorbidities
 Patients more concerned about their body image, their appearance, worried
about how others see them and their sexual attractiveness. Most are sexually
active.
 Patients with BN have concurrent seasonal affective disorder and patterns of
atypical depression may menifest seasonal worsening of BN and depressive ft.
 Increse frequency of depressive symptoms and anxiety disorders, bipolar
1disorder, dissociative disorders.
 Multiple comorbide impulsive behaviours
 Substance abuse – alcohol and stimulant use ( life time prevalence is 30%)
 Impulsive buying and shopping
 Sexual relationships
 Self mutilation, borderline personality disorders and other mixed personality
disorders.
Differential diagnosis
 Anorexia nervosa, binge-eating/purging type : diagnosis of BN can’t be made
if binging and purging behaviour occur exclusively during episodes of AN.
Duration criteria of 3 months for BN.
 Binge-eating disorder : No regular inappropriate compensatory behaviors.
 Kleine-Levine syndrome: Periodic hypersomnia for 2-3 weeks and
hyperphagia. More common in male. Overconcern with body shape and weight
not present.
 Major depressive disorder, with atypical features : No regular inappropriate
compensatory behaviors, No overconcern with body shape and weight.
 Borderline personality disorder
 Klüver-Bucy syndrome : very very rare. Symptoms includes visual agnosia,
compulsive licking and biting, examination of objects by mouth, inability to
ignore any stimulus, hypersexuality, hyperphagia.
Course and prognosis

 Higher rates of partial and full recovery compared to AN.

 The course may be chronic or intermittent, with periods of remission
alternating with recurrences of binge eating.
 Periods of remission longer than 1 year are associated with better long-term
outcome.
 History of substance use problems and longer duration at presentation
predictes worse outcome.
 The CMR (crude mortality rate) for bulimia nervosa is nearly 2% per decade.
Treatment
 Outpatient treatment usually not difficult.
 Inpatient treatment if BN with eating binges out of control, suicidality,
substance abuse, and electrolyte and metabolic disturbances.
 PSYCHOTHERAPY
 CBT
 first line treatment, 18-20 sessions over 5-6 months.
 Interrupt the self maintaining behavioural cycle of binging and dieting
 Alter the dysfunctional cognitions; beliefs about food, weight,body
image and overall self-concept
 Dynamic psychotherapy
 Concretize inrojective and projective defence mechanisms.
Treatment cont.
 PHARMACOTHERAPY
 Antidepressants
 SSRI- Fluoxetine (60-80mg per day)
 Imipramine, desipramine, trazodone, MAOIs
 Mood stabilizer
 Carbamazepine and lithium : in pt of BN with comorbide BMD-1
 BRIGHT LIGHT THERAPY :
 Indicaed in pt with BN with concurrent seasonal affective disorder.
 10,000 lux for 30min, in early morning, at 18 to 22 inches from the eyes.
Binge eating disorder
 Recurrent Binge eating – abnormally large amount of dense caloric food over
short time without compensatory behaviours
 Most common eating disorder
 More common in females (4%) than in males (2%)
 Prevalence is higher in overweight population and individuals seeking
weight-loss treatment
 Patients with disorder are Obese and earlier onset of obesit and has
unstablee weight history
 Disorder associated with insomnia, early menarche,neck, shoulder,lower back
pain, chronic muscle pain and metabolic disorders.
Diagnostic criteria
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 nen/osa and does not occur exclusively during the course of bulimia nervosa or anorexia
nervosa.
Specifier
 Specify if:
 In partial remission: After full criteria for binge-eating disorder were previously met,
binge eating occurs at an average frequency of less than one episode per week for a
sustained period of time.
 In full remission: After full criteria for binge-eating disorder were previously met,
none of the criteria have been met for a sustained period of time.
 Specify current severity:
The minimum level of severity is based on the frequency of episodes of binge eating (see
below). The level of severity may be increased to reflect other symptoms and the
degree of functional disability.
 Mild: 1-3 binge-eating episodes per week.
 Moderate: 4-7 binge-eating episodes per week.
 Severe: 8-13 binge-eating episodes per week.
 Extreme: 14 or more binge-eating episodes per week.
 Etiology
 Unknown
 Impulsive and extroverted personality styles
 Binges occur during periods of stress and used to reduce anxiety or
alleviate depressive mood
 Diffrential diagnosis
 Bulimia neivosa
 Obesity – No overvaluation of body weight and shape, No
psychiatric comorbidities.
 Bipolar and depressive disorders - may or may not be associated
with loss of control.
 Borderline personality disorder
Treatment
 PSYCHOTHERAPY
 CBT
 Most effective
 Best results when combined with SSRIs or Exercise.
 Interpersonal psychotherapy
 PHARMACOTHERAPY
 SSRI – Fluvoxamine,citalopram, sertraline demonstrated improvement in mood as well as binge
eating.
 Desipramine, imipramine, topiramate,sibutramine
Other specified feeding
or eating disorders
 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.
 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.
 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.
Night eating syndrome
 In early adulthood (late Teens to late 20s)
 Occurs in 2% of Population, higher in pt with insomnia, obesity and eating
disorders.
 Run in families.
 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.
 Treatment includes SSRI, TOPIRAMATE, CBT,BRIGHT LIGHT THERAPY.
Purging disorder
 Recurrent purging behavior e.g., selfinduced vomiting:
misuse of laxatives, diuretics, enemas or other
medications.
 After small small amount of food consumption.
 In normal weight person with Distorted veiw of their
weight or Body image.
 in the absence of binge eating.
 Purging episodes should occur atleast once a week over 3
month period.
THANK YOU