Eating Disorders

By Dr. Min Min Phyo

20 August 2019.
 Eating Disorders

• Characterized by abnormalities in the pattern of eating

and the amount and nature of food eaten.
• These behaviors are determined primarily by the
patients’ attitudes to their weight and shape.
• The disorders share a distinctive core psychopathology
which is best described as  over-evaluation of
weight and shape such that patients judge their self-
worth  in terms of their shape and weight and their
• The disorder covered in this  anorexia nervosa and bulimia
nervosa ,as well as a number of related conditions.
• Obesity  not a psychiatric disorder  although it is
associated with increased risk of various psychiatric disorders.
• Until late 1970s  eating disorder  uncommon
• Many eating disorders  clinically unrecognized  only about
50% of anorexia nervosa in general population are detected in
primary care  majority are untreated.
• Within secondary care  eating disorders are seen and
managed by general psychiatrists as well as by specialist eating
disorder services.
Classification
Classification

ICD-11 Feeding or eating disorders

• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder
• Avoidance/ Restrictive food intake disorder
• Pica
• Rumination-Regurgitation disorder
• Other specified
• Unspecified
Classification

Anorexia Nervosa
Bulimia Nervosa
 Anorexia Nervosa

• 1st named in 1868 by English physician William Gull  emphasized

the psychological causes of the condition, the need to restore weight
and the role of family.
• Other key description  by Charles Lasegue in Paris
• Main features of anorexia nervosa are:
 Very low body weight (defined as being 15% below the standard
weight or BMI of < 17.5 kg/m2) which is maintained by restriction
of energy intake.
 Extreme concern about weight and shape, characterized by an
intense fear of gaining weight and becoming fat and a strong
desire to be thin.
  A undue influence of body weight or shape on self-evaluation.
 Lack of recognition of the seriousness of low body weight.
 ICD-10 , but not DSM-5, includes amenorrhea as a criterion in
women.
• Most patient  young women  usually begin in adolescence.
• It generally begins with ordinary efforts at dieting  then get out of
control.
• The central psychological features overvalued ideas about body
shape and weight.
• The pursuit of thinness  take several forms.
• Patients generally eat little and take very low daily calorie limits (often
between 600 and 1000 kcal).
• Some try to achieve weight loss by inducing vomiting, exercising
excessively and misusing laxatives (purging).
• Patients are often preoccupied with thoughts of food and enjoy
elaborate meals for other people.
• Some patients with anorexia nervosa  admit to stealing food, either
by shoplifting or in other way
 Binge eating

• A subgroup of patients have repeated episodes of binge eating.

• A binge is an episode of eating when a large amount of food is
consumed in a short period of time, and during which there is a sense
of loss of control.
• This behavior becomes more frequent with chronicity and increasing
age.
• During binges  typically eats food that are usually avoided.
• After over eating, they feel bloated and may induce vomiting.
• Binges are followed by remorse and intensified efforts to lose weight.
• If other people encourage them to eat, the patient is often resentful
 they may hide food or vomit in private as soon as the meal is over.
 Amenorrhea
• Is one of several physical abnormalities  have traditionally been
incorporated in diagnostic criteria (not in DSM-5).
• It occurs early in the development of condition and ~20% of cases 
it precedes obvious weight loss.
• Some cases first come to medical attention with amenorrhea rather
than disordered eating.

Other symptoms
• Depressive, anxiety and obsessional symptoms, lability of mood, &
social withdrawal are all common.
• ¾ of patients report a lifetime history of major depressive disorder.
• Lack of sexual interest is usual.
Physical consequences
Physical consequences
 Epidemiology

• Incidence  5 per 100,000

Greatest among young women
40%  15-19 year-old females.
• Reported incidence rates  increased from the beginning of 20th
century up to 1970s  have remained fairly stable since then.
• Rare in children < 13 yr of age.
• Lifetime prevalence  between 0.9 and 4 % in women
Men are always lower.
• More common in upper social classes.
 Onset, Course and Prognosis

• In early stages  fluctuating course with exacerbations and periods

of partial remission.
• Long-term prognosis  difficult to judge owing to incomplete follow-
up or because there may be normalization in weight or menstrual
function but persistent abnormalities of eating habits and attitudes to
weight and shape.
• A review  119 studies  reported that weight and menstrual
function recover in ~60% of patients and eating behavior becomes
normalized in almost 50%.
• More recent population study  2/3 of women  full recovered at 5
years.
• Poor prognostic factors  onset before puberty or in adulthood
 long history (> 3years )
 premorbid personality problems
 comorbid substance misuse
 childhood obesity
• In addition to chronic psychopathology and physical health problems
 have significant impairments in social functioning and employment
and major burden on careers.
• Anorexia nervosa has the highest mortality rate of any major
psychiatric disorder, with a fourfold to fivefold increase in mortality.
• One in five deaths is from suicide, the others reflect the many adverse
health consequences of the disorder, (cardiac events and sepsis).
• In recent years  there is evidence that the excess mortality rate has
fallen.
 Aetiology

Genetics

• Strongly familial
• Heritability 28-74 %
• A proportion of genetic risk is shared with other psychiatric
disorders, including OCD, schizophrenia.
• Genetic risk  may vary with age of onset, with a lesser
heritability of eating disorder symptoms in preadolescent and
early adolescent cases.
Neurobiology

• There have been many brain imaging & other neurobiological

studies & a range of structural, functional & biochemical
abnormalities reported.
• These include reductions in brain volume and alteration in 5-HT
(serotonin) system.
• However, it is often difficult to determine whether abnormalities
are causal or are the result of starvation and weight loss.
• Cognitively  there are difficulties in switching between tasks
and relative impairment of strategic planning compared detail
focusing on tasks.
Neurobiology

• Structurally  grey matter volume is increased in orbitofrontal

cortex and insula.
• Functional neuroimaging  indicates involvement of brain
regions involved in response to food rewards.
Sociocultural factors

• More common in certain societies  cultural factors play a part in

its development.
• Surveys  most schoolgirls and female college student  diet at
one time.
• People who develop anorexia nervosa  have no greater
exposure to factors that increase the risk of dieting.
• This suggests that the problem is more due to how an individual
reacts to dieting than to dieting itself.
Individual psychological causes

• Bruch (1974) was one of the 1st writers to discuss the

psychological antecedents of anorexia nervosa.
• She suggested that these patients are engaged in ‘a struggle for
control, for a sense of identity and effectiveness, with the
relentless pursuit of thinness as a final step in this effort.
• These clinical observations are supported by epidemiological
studies, which implicate low self-esteem and perfectionism in the
development of the disorder.
Causes of within the family

• Disturbed relationships  are often found in the families of

patients with anorexia nervosa and some authors have suggested
that they have an important causal role.
• Minuchin et al (1978)  specific pattern of relationship could be
identified, consisting of enmeshment, overprotectiveness, rigidity
and lack of conflict resolution.
• Epidemiological studies  people who develop anorexia nervosa
are more likely than healthy controls to be exposed to a range of
childhood adversities, including poor relationships with parents
and parental psychiatric disorder, particularly depression.
Causes of within the family

• However, these risk factors are not specific to anorexia nervosa,

but are found with equal frequency among people who
subsequently develop other psychiatric disorder.
• These general risk factors interact with specific factors within the
individual such as perfectionism and low self-esteem, to increase
the risk of developing anorexia nervosa.
 Assessment

• Most patients  reluctant to change their behavior  let alone see

a psychiatrist  so it is important to try to establish a good
relationship.
• Listening to the patient’s views, explaining the treatment
alternatives being willing to consider compromises.
• A thorough history should be taken of the development of the
disorder , the present pattern of eating and weight control and the
patients ideas about body weight.
• In MSE  particular attention should be given to depressive
symptoms as well as to the characteristic psychopathology of
anorexia nervosa.
• > one interview may be needed to obtain this information and gain
the patient’s confidence.
• In children and adolescents  gathering information on early
feeding and prenatal weight and shape concerns are important :
parents and teachers should be interviewed.
• Perform full PE  particular attention should be paid to the degree
of emaciation (including measurement of weight and BMI) ,
cardiovascular status (BP, HR) and temperature.
• Routine investigations  include FBC, urea and electrolytes, blood
glucose, LFT and ECG
• The results may reveal that the patient is at high risk of medical
complications and may require further urgent investigations or
impatient treatment.
Treatment
Psychotherapy

• Psychotherapies are mainstay of treatment.

• In the past  based on psychodynamic concepts, but these have
largely been superseded by CBT and related therapies.
• Both family and individual interventions have been used.
• Family therapy  has been widely advocated, reflecting the
belief that family factors are important in the origins of anorexia
nervosa.
• Various kind of family therapy have been used.
• For children and adolescents  family-based treatments that
focus on eating disorder and related issues are more effective than
individual psychotherapy.
• In adults  individual treatments predominate.
• Generic CBT has only modest benefits but specifically tailored
form (CBT-E) has efficacy in weight restoration and in weight
maintenance.
• CBT-E is also highly effective for bulimia nervosa and is the 1st
evidence- based ‘trans-diagnostic’ eating disorder therapy.
• Other psychological interventions  focal psychodynamic
psychotherapy, cognitive interpersonal therapy.
Medication

• Both antidepressants and antipsychotics  are used in anorexia

nervosa , with antidepressants sometimes prescribed in high
dosage.
• However, systemic review  show no clear effect of
antidepressants on weight gain, maintenance or psychological
symptoms during refeeding.
• Small trials  have suggested possible benefits from Olanzapine,
but overall the evidence is similarly negative for the use of
antipsychotics and are not recommended.
• Antidepressants are also used to treat depression in anorexia
nervosa.
• The evidence for their effectiveness in this situation  weak and
guidelines suggest that antidepressant should not be used until it
is apparent that the symptoms are not merely due to starvation
and that they persist during restoration of weight.
• Particular case  is required in patients under 18 years old and
because of high risks of medical complications and side effects in
underweight patients.
 Management

Starting treatment

• Success largely depend on establishing a good relationship with

the patient.
• Achieving an adequate weight is essential to reverse physical and
psychological effects of starvation.
• It is important to agree a specific dietary plan, while emphasizing
that weight control is only one aspect of the problem  and help
should be offered with the accompanying psychological problems
as well as dealing with any medical complications.
• Educating patients and their families about the disorder and
treatment is important.
• There is good evidence that early intervention (within 3 years of
onset ) is associated with better outcomes.
• In longstanding cases of anorexia nervosa, treatment goals may be
more modest and include helping patient and careers cope with a
serious and chronic illness.
Setting treatment

• Most cases  treated on an out-patient or day-patient basis,

ideally within a specialist eating disorder service.
• There is no good evidence that in-patient is more effective and
admission to hospital is now unusual.
• It may be indicated in 2 situations;
 To a medical ward, if there are serious and imminent
physical health risks or
 To psychiatric in-patient care, if there is acute suicidal
ideation or if sustained attempts at out-patient or day-
patient treatment have failed.
• Compulsory treatment for anorexia nervosa is controversial both
legally and ethically.
• For children and adolescents unable or unwilling to give informed
consent , either Mental Health Act or Child Act may be utilized.
Restoring Weight

• A reasonable aim is an increase of 0.5 kg a week, which will

usually require an extra 500-1000 calories a day.
• More rapid refeeding is potential dangerous.
• The target weight should be above a minimum healthy level ( a
BMI above 18.5)
• It is not a good idea to agree a compromise target lower than this
except in severe and refractory cases.
• It is good practice to monitor the patient’s physical state regularly
and to prescribe vitamin supplements.
• It is also important to assess and modify after weight-reducing
strategies, such as over-exercising and laxative misuse.
• Previously, inpatient treatment  patient would usually stay in
hospital until her agreed target weight was reduced and
maintained and strict behavioral regimes were often used.
• Currently, much shorter admission with a more collaborative
therapeutic approach followed by out-patient or day-patient care.
• Whilst in hospital  eating should be supervised by a nurse, who
has 3 roles.
 to reassure the patient
 to be clear about the agreed targets
 to ensure that the patient does not induce vomiting or
take laxatives.
 Bulimia Nervosa

• The term bulimia  refers to binge eating, defined earlier.

• Binge eating occurs in some cases of anorexia nervosa and is also the
hallmark of binge eating disorder.
• The $ of bulimia nervosa  was 1st described by Russell (1979)
• The central features of bulimia nervosa are:
 A preoccupation with eating, with an irresistible and recurrent
urge to overeat, manifesting in repeated ‘binges’ when large
amounts of food are consumed in a short time, accompanied
by a sense of loss of control.
  The use of extreme measures to control body weight,
especially self-induced vomiting and use of laxatives as well as
periods of starvation or excessive exercise.
 Overvalued ideas concerning shape and weight of the type
seen in anorexia nervosa.
• Patients with bulimia nervosa are usually of normal weight (BMI 18.5-
25).
• There is a profound loss of control over eating.
• Episodes of binge eating may be precipitated by stress or by breaking
of self-imposed dietary rules or may occasionally be planned.
• During the episodes, large amounts of food are rapidly consumed, on
average over 2000 kcal (eg. a loaf of bread, pot of jam, cake and
biscuits).
• The voracious eating usually takes place when the patient is alone.
• At first  it brings from tension, but this is soon followed by guilt and
disgust and the patient induces vomiting or engages in another
compensation behavior.
• Depressive symptoms are very common and usually secondary to the
eating disorder.
• A high proportion of patients meet the criteria for major depression.
• The depressive symptoms usually remit as the eating disorder
improves.
 Physical consequences

• Bulimia nervosa can impact on physical health, mostly due to

repeated vomiting or use of laxatives or other drugs.
• With vomiting  reflux symptoms are common and teeth become
pitted by acidic gastric contents.
• Rusell’s signs  describe callouses on the knuckles causes by putting
fingers down the throat to induce vomiting.
• More serious physical health problems can occur, but all are very rare.
• Physical complications are best treated by cessation of the causative
behavior, but symptomatic treatment are also available for some, eg.
PPI for esophageal reflux or spironolactone for peripheral edema.
• However, medication for these purposes should be used with caution
and only in severe cases.
 Epidemiology

• Prevalence and incidence of bulimia nervosa  uncertain

• In the community, the prevalence is around 1% among women aged
between 16 and 40 years in Western societies.
• It is at least 10 times less common in men.
 Onset, course and prognosis

• Onset  late adolescence or early childhood

• It often follows a period of concern about body shape and weight.
• There is commonly an initial period of dietary restriction  after a
variable length of time  but usually within 3 years  breaks down,
with increasingly frequent episodes of overeating.
• Despite the original assertion by Russel (1979) that bulimia nervosa
was an ‘ ominous variant’ its outcome is clearly better than anorexia.
• Although in many of these cases  it will take an atypical form, ever
5-10 years later between 1/3 and 1/2 of individuals  still have a
clinical eating disorder.
• Although childhood obesity and low self-esteem may be associated
with a worse prognosis no convincing predictors of course or
outcome have been identified.
• The mortality rate is approximately doubled, but the excess is
significantly less than anorexia nervosa.
 Aetiology
• Like anorexia nervosa, bulimia nervosa  appears to be the result of
exposure to general risk factors for psychiatric disorder  including a
family history, especially depression and substance misuse and a range of
adverse childhood experiences.
• No risk genes have been identified.
• Epidemiological studies  suggest that  unlike anorexia nervosa 
patients with bulimia nervosa have increased exposure to factors that
specifically promote dieting, such as childhood obesity, parental obesity
and early menarche.
• Perfectionism appears to be less of a risk factor than anorexia nervosa.
• The neurobiological mechanisms  appear to be broadly similar to
anorexia nervosa.
 Treatment
Psychotherapy

• Both CBT and interpersonal therapy are effective in bulimia

nervosa.
• Of those who complete treatment (about 20% drop out )  60%
will have stopped binge eating , 80 % reduction overall.
• The most striking evidence  comes from a specifically tailored
CBT-based approach (CBT-E)
• CBT-E reduced or abolished core behavioral and psychological
symptoms of eating disorders and showed sustained efficacy.
• The treatment was delivered in 2 forms:
 a sample intervention  focused solely on eating disorder
 a complex intervention  personality, mood and
interpersonal issues were also addressed.
• CBT-E  superiority over psychoanalytic psychotherapy and
interpersonal psychotherapy.
• As with anorexia nervosa, family-based treatments may have
some advantages over individual therapy in adolescents with
bulimia nervosa.
Medication

• Antidepressants are effective  reduction of about 50% in

frequency of binge eating and cessation in 20% of cases.
• Long-term data  less encouraging and show poor compliance.
• Antidepressants should be used rarely  viewed as second-line
treatment and only if an effective psychological treatment is
unavailable or unsuccessful.
• Topiramate is effective in suppressing binge eating, but side effects
limit its usefulness and its use in bulimia nervosa is not advocated.
 Management

• Management of bulimia nervosa is easier than that of anorexia

nervosa because the patient is more likely to wish to recover , and
a good working relationship can often be established.
• There is no need to manage the complications of starvation nor
restore weight.
• However, it is necessary to assess the patient’s physical state and
to measure electrolyte status in those who are vomiting
frequently or misusing laxatives.
• Stepped-care approach;
 Step -1  - Identify the small minority (<5%) of individuals who
need urgent specialist care because of severe
depression, physical complications, or substance
abuse that requires treatment in its own right.

 Step -2  - Offer guided cognitive behavioral self-help using

a self- help book and with the guidance of a non-
specialist facilitator.
- Treatment usually takes about 4 months and
requires 8 to 10 meetings with the facilitator.
 - Guided self-help is appropriate for primary care and
appears to lead to good progress in about 1/3 of
patients.

 Step -3  - Patients who do not show benefit within 4-6 weeks

of commencing Step 2 require CBT-E.
- In a minority of cases, where concomitant
depressive symptoms are severe or persistent,
adding an antidepressant drug such as Fluoxetine in
dose of up to 60 mg daily.
 Step -4  - Patients who do not show improve with CBT 
require comprehensive specialist reassessment.
- In some cases, measures to provide more intensive
cognitive therapy or an antidepressant drug may be
useful.
- It is important to review the initial treatment with
the patient, with the aim of agreeing a treatment
approach that the patient finds acceptable.
Other Eating Disorder
 Other Eating Disorder
Avoidant / Restrictive food intake Disorder
 Other Eating Disorder
Pica
 Other Eating Disorder
Rumination regulation disorder
Thank You!