College of health Sciences

Department of Psychiatry
Eating disorder
1
Prepared by: Habtamu k.
Lecturer

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2 Feeding and eating Disorder

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3 Outline of the presentation

 Introduction
 Epidemiology
 Etiology
 Clinical presentation
 Diagnosis and differential diagnosis
 Prognosis
 management

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4 Feeding and Eating Disorders
 Feeding and eating disorders are characterized by persistent disturbances in
feeding and eating behaviours that significantly interfere with the afflicted
individual’s life, often by negatively and severely impacting physical health or
medical status, impairing psychosocial functioning, and causing intense
distress.
 Eating disorders are mental disorders defined by abnormal eating habits that
negatively affect a person’s physical or mental health.
 (DSM-5) includes six diagnoses: avoidant/restrictive food intake
disorder (ARFID), pica, rumination disorder, anorexia nervosa, bulimia
nervosa and binge eating disorder (BED).

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5 Epidemiology of eating disorder
 The prevalence of feeding and eating disorder is not clearly known.
 Between 15 and 35 percent of infants and young children have transient feeding
difficulties.
 Pica and rumination persists more frequently among children, adolescents, and
adults with intellectual disability.
 Up to 15 percent of persons with severe intellectual disability have engaged in
pica.

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6 Epidemiology CONTI…

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7 Epidemiology CONTI…
 Night-eating syndrome occurs in approximately 2 percent of the general
population; however, it has a higher prevalence among patients with insomnia,
obesity (10 to 15 percent), eating disorders, and other psychiatric disorders.
 In general rates of eating disorders appear to be lower in less developed
countries and typically they begin in late childhood or early adulthood.
 Historically, many consider eating disorder to be a disease of white, wealthy
women; however, it impacts individuals of all racial and socioeconomic
backgrounds.

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8 Etiology
Genetic and Biologic Factors
 There is strong evidence support for genetical risk for other eating disorders.
For instance the risk of developing AN is up to 11 times greater in individuals
with a first-degree relative who has experienced the illness.
 Twin studies have demonstrated that concordance rates of eating disorders are
substantially higher in monozygotic twins as compared to dizygotic twins.
 Several computed tomographic (CT) studies reveal enlarged CSF spaces
(enlarged sulci and ventricles) in anorectic patients during starvation, a finding
that is reversed by weight gain.
 In night-Eating Syndrome, researchers have studied the hormones melatonin,
leptin, ghrelin, and cortisol as they relate to this disorder.
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9 Conti…
Biochemical: in eating disorder dysregulation of the HPA axis has been
associated with eating disorders, such as
 irregularities in the manufacture,
 amount or transmission of certain neurotransmitters,
 hormones, or neuropeptides and amino acids such as homocysteine, elevated
levels of which are found in AN and BN as well as depression.
 Some studies have shown evidence for dysfunction in serotonin, dopamine,
and norepinephrine neurotransmitters involved in regulating eating behavior in
the paraventricular nucleus of the hypothalamus.

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10 Psychological Factors
 Several psychological factors appear to confer added risk for developing
anorexia nervosa.
 Certain personality traits, including high levels of perfectionism, self-
discipline, harm avoidance, and self-criticism, are common in individuals with
the illness.
 While those with bulimia nervosa tend to exhibit high levels of novelty
seeking and impulsivity.
 Cognitive inflexibility is usually prominent, as well in eating disorder.

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11 CONTI…
 conflicts surrounding the transition from girlhood to womanhood.
 The experience of going through puberty and experiencing changes to body
shape or weight may serve as a major stressor for some, triggering or
worsening body dissatisfaction and low self-esteem.
 Some have also suggested that psychological issues related to feelings of
helplessness and difficulty establishing autonomy also contribute to the
development of the disorder.

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12 Environmental influences
 Child maltreatment /child abuse which encompasses physical, psychological
and sexual abuse, as well as neglect has been shown by innumerable studies to
be a precipitating factor in eating disorders.
 Children who were placed in orphanages or foster homes are especially
susceptible to developing a disordered eating pattern. In a study done in New
Zealand 25% of the study subjects in foster care exhibited an eating disorder
(Tarren-Sweeney M. 2006).
 Peer pressure According to one study, 40% of 9- and 10-year-old girls are
already trying to lose weight due to peer pressure.
 Lack of supervision, as well as in adequate feeding of infants and toddlers,
may increase the risk of pica and other eating disorder in child.

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13 Laboratory and examination used to Dx.
 Some individuals with bulimia nervosa exhibit mildly elevated levels of serum
amylase, probably reflecting an increase in the salivary isoenzyme.
 On physical examination usually inspection of the mouth permanent loss of
dental enamel (ragged and "moth-eaten)
 particularly the parotid glands, may become notably enlarged.
 Serious cardiac and skeletal myopathies have been reported among individuals
following repeated use of syrup of ipecac to induce vomiting.
 several laboratory abnormalities may occur as a consequence of purging and
may increase diagnostic certainty.

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14 Conti…

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15 Pica
 Pica refers to the recurrent eating of non food, non nutritive items by
individuals who are at a developmental stage at which this behavior is
inappropriate.
 Many times it was discovered when medical problems such as intestinal
obstruction, intestinal infections, or poisonings arise, such as lead poisoning
due to the ingestion of lead-containing paint chips.
 We only diagnose pica when it is of sufficient severity and persistence to
warrant clinical attention.
 Among adults, certain forms of pica, including geophagia (clay eating) and
amylophagia (starch eating), have been reported in pregnant women.

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16 Diagnosis and Clinical Features
 Eating nonedible substances repeatedly after 18 months of age is not typical;
however, DSM-5 suggests a minimum age of 2 years when making a diagnosis
of pica.
 Pica behaviours, however, may begin in infants 12 to 24 months of age.
 Specific substances ingested vary with their accessibility, and they increase
with a child’s mastery of locomotion, and the resultant increased independence
and decreased parental supervision.

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17
Conti…
The clinical implications can be benign or life-threatening, depending on the
objects ingested.
Among the most severe complications are
 lead poisoning (usually from lead-based paint),
 intestinal parasites after ingestion of soil or feces, anaemia and zinc deficiency
after ingestion of clay,
 severe iron deficiency after ingestion of large quantities of starch, and
 intestinal obstruction from the ingestion of hairballs, stones, or gravel.

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18 Differential Diagnosis
The differential diagnosis of pica includes avoidance of food, anorexia, or rarely
iron and zinc deficiencies. Pica may occur in conjunction with failure to thrive
and be comorbid with
 schizophrenia,
 autism spectrum disorder, and
 Kleine–Levin syndrome.
 In psychosocial dwarfism, a dramatic but reversible endocrinologic and
behavioural form of failure to thrive, children often show bizarre behaviours,
including ingesting toilet water, garbage, and other

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19 Course and Prognosis
 The prognosis for pica is usually good, and typically in children with normal
intellectual function, pica generally remits spontaneously within several
months.
 In childhood, pica usually resolves with increasing age;
 In autism spectrum disorder and intellectual disability, pica often remits by
adolescence.
 Pica associated with pregnancy is usually limited to the pregnancy itself.

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20 Treatment
 Treatments emphasize psychosocial, environmental, behavioural, and family
guidance approaches which is focus on education and behavior
modification.
 In treating Pica when lead is present in the surroundings, it must be eliminated
or rendered inaccessible, or the child and their family should move.
 በehavioural ተechniques include positive reinforcement, modelling,
behavioural shaping, and overcorrection treatment.
 Increasing parental attention, stimulation, and emotional nurturance may yield
positive results.

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21 RUMINATION DISORDER
 Rumination is an effortless and painless regurgitation of partially digested
food into the mouth soon after a meal, which is either swallowed or spit out.
 We can observe rumination in developmentally normal infants who put their
thumb or hand in the mouth, suck their tongue rhythmically, and arch their
back to initiate regurgitation.
 We may observe this pattern in infants who receive inadequate emotional
interaction and have learned to soothe and may stimulate themselves through
rumination.

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22 Conti…
 Although spontaneous remissions are common, secondary complications can
develop, such as progressive malnutrition, dehydration, and lowered resistance
to disease.
 Failure to thrive, with the absence of growth and developmental delays in all
areas, can occur in the most severe cases.

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23 Diagnosis and Clinical Features
 The DSM-5 notes that the essential feature of the disorder is repeated
regurgitation and re-chewing of food for at least 1 month after a period of
normal functioning.
 Patients bring partially digested food into their mouth without nausea,
retching, or disgust; on the contrary, it may appear to be pleasurable.
 This activity may be distinguished from vomiting by painless and purposeful
movements observable in some infants who induce it. The food is then ejected
from the mouth or swallowed.
 A characteristic position of straining and arching of the back, with the head
held back, is observed.

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24 Differential Diagnosis
To make the diagnosis of rumination disorder, clinicians must rule out
 primary gastrointestinal congenital anomalies, infections, and other medical
illnesses that could account for frequent regurgitation.
 Rumination occurs with both autism spectrum disorder and intellectual
disability in which stereotypic behaviours and eating disturbances are not
uncommon.
 Rumination disorder may also occur in patients with other eating disorders,
such as anorexia nervosa and bulimia nervosa and anxiety disorder.

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25 Course and Prognosis
 Rumination disorder has a high rate of spontaneous remission.
 Indeed, many cases of rumination disorder may develop and remit without
ever being diagnosed.
 Behavioural interventions using habit reversal techniques may significantly
lead to improved prognosis.

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26 Treatment
 The treatment of rumination disorder is often a combination of education and
behavioural techniques.
 Behavioural interventions, such as habit-reversal, can reinforce an alternate
behavior that becomes more compelling than the behaviours leading to
regurgitation.
 Aversive behavioural interventions, such as squirting lemon juice into the
infant’s mouth whenever rumination occurs, have been used in the past to
diminish rumination behavior.
 Medication is not a standard part of the treatment but metoclopramide,
cimetidine, and even antipsychotics such as haloperidol, as helpful as
respiredone.

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27 AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER
Avoidant/restrictive food intake disorder is characterized by a lack of interest in
food, or its avoidance based on the sensory features of the food or the perceived
consequences of eating.
 Significant weight loss or failure to achieve expected weight, nutritional
deficiency, dependence on enteral feedings or nutritional supplements, or
 Marked interference with psychosocial functioning.
 It may take the form of outright food refusal, food selectivity, eating too little,
food avoidance, and delayed self-feeding.

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28 Conti…
 Infants and children with the disorder may be withdrawn, irritable, apathetic,
or anxious.
 Because of the avoidant behavior during feeding, there is less touching and
holding between mothers and infants during the feeding process compared
with other children.

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29 Differential Diagnosis
 We should differentiate the disorder from structural problems with the infants’
gastrointestinal tract that may be contributing to discomfort during the feeding
process.
 Because feeding disorders and organic causes of swallowing difficulties often
coexist, it is essential to rule out medical reasons for feeding difficulties.
 A study of video fluoroscopic evaluation of children with feeding and
swallowing problems revealed that clinical evaluation was 92 percent accurate
in identifying those children at increased risk of aspiration.
 This type of evaluation is necessary before psychotherapeutic interventions in
cases where a medical contribution to feeding problems is suspected.

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30 Course and Prognosis
 When feeding disorders have their onset later, in children 2 to 3 years of age,
growth and development can be affected when the disorder lasts for several
months.
 About 70 percent of infants who persistently refuse food in the first year of life
continue to have some eating problems during childhood.
 Some reports suggest that food avoidance or restriction may be relatively
longstanding; however, in many cases, normal adult functioning is eventually
achieved.

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31 Treatment
 The psychiatrist helps the mother to become more aware of the infant’s
stamina for the length of individual feedings,
 Some experts have proposed a transactional model of intervention for
infants who exhibit the “difficult” temperamental traits of emotional intensity,
stubbornness, lack of hunger cues, and irregular eating and sleeping patterns.
 w/c includes education for the parents regarding the temperamental traits of
the infant, exploration of the parents’ anxieties about the infant’s nutrition, and
 training for the parents regarding changing their behaviours to promote
internal regulation of eating in the infant.

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32 ANOREXIA NERVOSA
 The term anorexia nervosa comes from the Greek term for “loss of appetite”
and a Latin word implying nervous origin. .

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33 Clinical presentation
Anorexia Nervosa has three essential criteria,
 behavioural (self-induced starvation to a significant degree)
 Psychopathological (relentless drive for thinness or a morbid fear of fatness )
 Physiological (presence of medical signs and symptoms resulting from
starvation )

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34 Conti…
Anorexia nervosa is often, associated with disturbances of body image, the
perception that one is distressingly large despite evident medical starvation
Two subtypes of anorexia nervosa exist:
 restricting type
 present in approximately 50 percent of cases,
 only eating at certain times of the day or a certain
amount of time after the last meal,
 following other rigid rules that govern eating behaviors.
 food intake is highly restricted (usually with attempts to consume fewer than
300 to 500 calories per day and no fat grams)
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35 Conti…
The second one is purging type which avoids weight gain by vomiting or using
laxatives and diuretics may also exercise to keep weight off.
Both types
 may be socially isolated
 have depressive disorder
symptoms
 diminished sexual interest
 May overexercising and
 May have commonly perfectionistic
(obsessive-compulsive ) traits
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36 Physiological consequences of AN

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37 DSM-5 diagnosis Criteria of Anorexia nervosa
 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.
 Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight.
 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 persistent lack
of recognition of the seriousness of the current low body weight.

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38 CONTI…
Specifier weather
 Restricting type: During the last 3 months, the individual has not engaged in
recurrent episodes of binge eating or purging behaviour (i.e., self-induced
vomiting or the misuse 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
engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-
induced vomiting or the misuse of laxatives, diuretics, or enemas).

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39 Conti…
 Specify current severity:
The minimum level of severity is based, for adults, on current body
mass index (BMI) (see below) or, for children and adolescents, on
BMI percentile.
 Mild: BMI>17kg/m2
 Moderate: BM116-16.99 kg/m^
 Severe: BM115-15.99 kg/m^
 Extreme: BMI < 15 kg/m

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Differential Diagnosis
40

 Medical conditions (e.g., gastrointestinal disease, hyperthyroidism, occult

malignancies, and acquired immunodeficiency syndrome [AIDS] brain tumour or
cancer.
 Major depressive disorder, somatization
 Schizophrenia
 Substance use disorders
 Social anxiety disorder (social phobia), obsessive-compulsive disorder, and body
dysmorphic disorder
 Bulimia nervosa
 Avoidant/restrictive food intake disorder.

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41 prognosis
 The outcome of anorexia nervosa reveal that, at the time of assessment,
approximately 30 to 50 percent have achieved full recovery, 10 to 20 percent
remain chronically ill, and the remainder have improved but continue to
struggle with certain disordered behaviours.
 After treatment Lower BMI at discharge and weight loss in the first month
after treatment and being older in age predict poorer long-term outcome.
 On the other hand, individuals who demonstrate an ability to consume a diet
that is high in variety and energy density (i.e., a greater concentration of
kcal/g) and full weight-restoration prior to discharge seem to do better after
treatment.
 In general the outcome of anorexia nervosa varies from spontaneous
recovery to a waxing and waning course to death
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42 Bulimia Nervosa
 The term bulimia nervosa derives from the terms for “ox-hunger” in Greek
and “nervous involvement” in Latin.
 While sharing certain core features with anorexia nervosa, bulimia nervosa is
defined by recurrent episodes of binge eating followed by inappropriate ways
of stopping weight gain.
 This compensatory behaviours, which might include self-induced vomiting,
laxative, diuretic, or enema use, intense exercise, fasting, and medication
misuse or abuse.
 followed by feelings of guilt, depression, or self-disgust.
 Unlike patients with anorexia nervosa, those with bulimia nervosa typically
maintain average body weight.
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43 Clinical presentation and DSM-5
When making a diagnosis of bulimia nervosa, clinicians should explore the
possibility that the patient has experienced a brief or prolonged prior bout of
anorexia nervosa, which is present in approximately half of those with bulimia
nervosa.
 The binging behaviour commonly precedes vomiting by about 1 year.
 Vomiting is frequent and is often induced by sticking a finger down the throat
 >> which decreases the abdominal pain and the feeling of being bloated
 >> the acid content of vomitus can damage tooth enamel
 >> than post binge anguish (Depression) follows the episode.

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44 Conti…
Most patients with bulimia nervosa are
 concerned about their body image and their appearance, worried about how
others see them, and concerned about their sexual attractiveness.
 Most are sexually active, compared with anorexia nervosa patients, who are
not interested in sex.
 They may have a history of pica and struggles during meals.

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45 DSM-5 diagnosis of 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 behaviours 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 behaviours 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
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46 Conti…
 Specify current severity:
The minimum level of severity is based on the frequency of inappropriate
compensatory behaviours. 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 behaviours
per week.
 Moderate: An average of 4-7 episodes of inappropriate compensatory
behaviours per week.
 Severe: An average of 8-13 episodes of inappropriate compensatory
behaviours per week.
 Extreme: An average of > 14 episodes of inappropriate compensatory
behaviours per week
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47 Differential Diagnosis
 Anorexia nervosa, binge-eating/purging type
 Binge-eating disorder
 Kleine-Levin syndrome
 Major depressive disorder, with atypical features.
 Borderline personality disorder

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48 Prognosis
 From review of 79 studies its outcome on average, around 45 percent of
individuals achieve full recovery and 23 percent remain chronically ill, with
the remainder experiencing some degree of improvement.
 Disturbed eating behavior persists for at least several years in a high
percentage of clinic samples.
 Periods of remission longer than 1 year and after treatment rapid symptom
reduction are associated with better long-term outcome.
 the CMR (crude mortality rate) for bulimia nervosa is nearly 2% per decade

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49 Binge-Eating Disorder
 Individuals with binge-eating disorder engage in frequent binges, often
independent of feeling hungry.
 However, different from the behavioural pattern of bulimia nervosa, these
episodes are not followed by compensatory behaviours rather than attempt to
some level of dietary restriction outside of binge eating.

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50 DSM-5 Diagnostic criterion
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 behaviour as in
bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia
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nervosa.
51 Conti…
 Specify current severity:
The minimum level of severity is based on the frequency of episodes of binge
eating. 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

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52 Prognosis
 Binge eating–purging persons are likely to be associated with substance abuse,
impulse control disorders, and personality disorders.
 Shorter-term follow-up studies have also found impressive recovery rates, with
over 50 percent of the sample experiencing full remission after just 6 months.
 From one long-term follow-up study over 80 percent of individuals who
initially met criteria for BED achieved full recovery 5 years later.

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53 Differential Diagnosis
 Bulimia nervosa
 Obesity
 Bipolar and depressive disorders
 Borderline personality disorder.

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 54 Other Specified Feeding or Eating Disorder
This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause
clinically significant distress or impairment in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic
class.
 Examples of presentations that can be specified using the “other specified” designation include the following:
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 behaviours 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
 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.
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55 Unspecified Feeding or Eating Disorder
 This category applies to presentations in which symptoms characteristic of a
feeding and eating disorder that cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the disorders in the
feeding and eating disorders diagnostic class.
 The unspecified feeding and eating disorder category is used in situations in
which the clinician chooses not to specify the reason that the criteria are not
met for a specific feeding and eating disorder, and includes presentations in
which there is insufficient information to make a more specific diagnosis (e.g.,
in emergency room settings).

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56 TREATMENT APPROACH FOR EATING
DISORDER
Given the complicated psychological and medical implications in eating disorder
like anorexia nervosa, a comprehensive treatment plan, including
 hospitalization when necessary
 both individual and family therapy, is recommended.
 In many cases, medication may also help.

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57 Hospitalization
The first consideration in the treatment of anorexia nervosa is to restore patients’
nutritional state; dehydration, starvation, and electrolyte imbalances can seriously
compromise health and, in some cases, lead to death.
In general, patients with anorexia nervosa who are 20 percent below the normal
weight for their height require inpatient programs, and patients who are 30 percent
below their expected weight require psychiatric hospitalization for 2 to 6 months.

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58 Conti…
Out patient is appropriate treatment in other eating disorder however,
hospitalization is necessary:
 if eating binges are out of control,
 outpatient treatment does not work, or a patient exhibits such additional
psychiatric symptoms as suicidality and substance abuse,
 electrolyte and metabolic disturbances resulting from severe purging .

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59 What should be done in inpatient of AN
 Patients should be weighed daily, early in the morning after emptying the bladder.
 record daily fluid intake and urine output.
 If vomiting is occurring, monitor serum electrolyte levels regularly and watch for the
development of hypokalaemia.
 Control vomiting by making the bathroom inaccessible for at least 2 hours after meals or by
having an attendant in the bathroom to prevent the opportunity for vomiting.
 Because of the risk of refeeding syndrome when patients immediately start eating an
enormous number of calories, start patients on a low-caloric intake initially (e.g., 1,000 to
1,400 kcals/day), and increase slowly by approximately 400 kcals every few days.
 It is wise to give these calories in six equal feedings throughout the day and liquid feeding is
helpful.

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60 Psychotherapy
FAMILY-BASED THERAPY. Family-based therapy (FBT) is an effective
treatment for anorexia nervosa and other such as BN particularly in patients
under the age of 18.
FBT or Maudsley method, generally consists of three phases of treatment.
 phase one, treatment focuses on the restoration of the patient’s physical
health, with decisions about what or when the patient will eat made by the
parents. Once the patient has begun to gain weight and shown improvement in
symptoms of anorexia nervosa, FBT moves on to.
 phase two the patient gradually begins to take responsibility for decisions
about eating.
 phase three, the focus shifts to the patient’s growth and development.

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61 Psychotherapy…
COGNITIVE-BEHAVIORAL THERAPY
It is the benchmark, first-line treatment for BN and binge eating effective for
others. The data supporting the efficacy of CBT based on strict adherence to
rigorously implemented,
 highly detailed,
 manual-guided treatments that include about 18 to 20 sessions over 5 to 6
months
 CBT implements several cognitive and behavioural procedures to
 (1) interrupt the self-maintaining behavioural cycle of binging and dieting and
 (2) alter the individual’s dysfunctional cognitions; beliefs about food, weight,
body image; and overall self-concept.
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62 Psychotherapy…
 It lead to decreases in binge eating and associated problems (e.g., depression) ;
however, studies have not shown marked weight loss as a result of CBT.
 Teaching the patients cognitive restructuring to identify automatic thoughts
and to challenge their core beliefs.
 Problem-solving is a specific method whereby patients learn how to think
through and devise strategies to cope with their food-related and interpersonal
problems.
 “stepped-care” programs and internet-based platforms, computer-facilitated
programs, email-enhanced programs, and administration of CBT via
telemedicine to remote areas.

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63 Psychotherapy…
 Interpersonal psychotherapy (IPT) is also effective in the treatment of
binge-eating disorder, AN, and BN; however, therapy focuses more on the
interpersonal problems that contribute to the disorder rather than disturbances
in eating behavior.
 Dialectical behavior therapy: is also some evidence for the use of dialectical
behavior therapy in eating disorder.

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64 Pharmacotherapy
 No pharmacotherapy is effective (definitive improvement of the core
symptoms) to treat eating disorder.
 However, Some reports support the use of atypical antipsychotics, particularly
olanzapine, for weight gain, although larger studies or meta analyses have not
supported this. When using atypical antipsychotics, the metabolic and cardiac
risks associated with these medications, particularly in a population already at
risk for cardiac complications, require close monitoring in AN.
 Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and
tricyclic antidepressants (TCAs), are not helpful while patients are in an
undernourished state.

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65
Pharmacotherapy
 However, SSRI like fluoxetine is effective in treating BN and binge eating.
 Fluoxetine can reduce binge eating and purging.
 Dosages of fluoxetine that are effective in decreasing binge eating, however,
may be higher (60 to 80 mg a day) than those used for depressive disorders in
BN.
 SSRIs showed improvement in night time awakenings, nocturnal eating, and
post-evening caloric intake of night-time eating disorder as well.
 Symptoms of binge eating may benefit from medication treatment, with strong
evidence supporting the use of lisdexamfetamine for both weight loss and
reduction of binge episodes.

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66 Pharmacotherapy …
 Antidepressant medications have demonstrated improvement in binge eating,
include fluoxetine, fluvoxamine, citalopram, escitalopram, sertraline,
duloxetine, and bupropion.
 The anticonvulsants topiramate and zonisamide may improve binge-eating
disorder, particularly with moderate weight loss.
 Topiramate may also reduce binge episodes.
 In most cases combination of medication added to CBT is more effective than
medication alone.

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67 Clinical history

 A full physical examination is needed

 Check for v/s derangement is essential
 Medical evaluation r/o is necessary
 Doing different lab investigation
 Dental examination
 Assessing for any comorbidity is essential

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68 summary
In general the following are the Red Flags for Eating Disorders among
adults that alarm as to consider eating disorder
 Menstrual irregularities
 Fertility problems
 Unexplained seizures
 “Funny turns”
 Chronic fatigue
 Callouses on hands
 Loss of dental enamel

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69 Prevention
Prevention aims to promote a healthy development before the occurrence of eating disorders. It
also intends early identification of an eating disorder before it is too late to treat. Prevention
comes in bringing these issues to the light.
 Emotional Bites: a simple way to discuss emotional eating is to ask children about why they
might eat besides being hungry.
 Say No to Teasing: another concept is to emphasize that it is wrong to say hurtful things
about other people's body sizes.
 Body Talk: emphasize the importance of listening to one's body. That is, eating when you are
hungry (not starving) and stopping when you are satisfied (not stuffed).
 Fitness Comes in All Sizes: educate children about the genetics of body size and the normal
changes occurring in the body. Discuss their fears and hopes about growing bigger. Focus on
fitness and a balanced diet.

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70 References

UpToDate
Internet for photos

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