EATING DISORDER

Eating disorders are complex conditions that arise from a combination of long-
standing behavioral, emotional, psychological, interpersonal, and social factors.
People with eating disorders often use food and the control of food in an attempt
to compensate for feelings and emotions that may otherwise seem over-whelming.

For some, dieting, bingeing, and purging may begin as a way to cope with painful
emotions and to feel in control of one’s life, but ultimately, these behaviors will
damage a person’s physical and emotional health, self-esteem, and sense of
competence and control. Eating disorders occur in both men and women, young
and old, rich and poor, and from all cultural backgrounds.

Many people who have eating disorders also present with depression, anxiety
disorders, personality disorders or substance abuse problems.A person with an
eating disorder may have disturbed eating behaviours coupled with extreme
concerns about weight, shape, eating and body image.

INCIDENCE

In a recent survey, 80 percent of 11-year-old girls said they feel overweight and are
dieting. Eating disorders are most likely to occur among young people, and both
boys and girls are susceptible.

Over one-half of teenage girls and one-third of teenaged boys use unhealthy
weight control behaviors such as skipping meals, smoking, fasting,
vomiting, or taking laxatives
42% of 1st-3rd grade girls want to be thinner
81% of 10 year olds are afraid of being fat
TYPES OF EATING DISORDER

There are four eating disorders that are recognised by the Diagnostic and Statistical
Manual of Mental Disorders (DSM), which are

1. Anorexia Nervosa
2. Bulimia Nervosa
3. Binge Eating Disorder .
4. Additional Eating and Feeding Disorders

 Avoidant/Restrictive Food Intake Disorder

 Pica
 Rumination Disorder
 Unspecified Feeding or Eating Disorder

5. Other Specified Feeding or Eating Disorder

(Described as Eating Disorder Not Otherwise Specified (EDNOS) DSM-IV)

 A feeding or eating disorder that causes significant distress or impairment,

but does not meet the criteria for another feeding or eating disorder.
 Examples include:

 Atypical anorexia nervosa (weight is not below normal)

 Bulimia nervosa (with less frequent behaviors)
 Binge-eating disorder (with less frequent occurrences)
 Purging disorder (purging without binge eating)
 Night eating syndrome (excessive nighttime food consumption)

ETIOLOGICAL IMPLICATIONS OF EATING DISORDER

1. BIOLOGICAL INFLUENCES
Genetics
Anorexia nervosa is more common among sisters and mothers of those with the
disorder than among the general population. Several studies have reported a higher
than expected frequency of mood disorders among first-degree biological relatives
of people with anorexia nervosa and bulimia nervosa and of substance abuse and
dependence in relatives of individuals with bulimia nervosa

Neuroendocrine Abnormalities
hypothalamic dysfunction in anorexia nervosa. Studies consistent with this theory
have revealed elevated cerebrospinal fluid cortisol levels and a possible
impairment of dopaminergic regulation in individuals with anorexia (Halmi, 2003).

Additional evidence in the etiological implication of hypothalamic dysfunction is

gathered from the fact that many people with anorexia experience amenorrhea
before the onset of starvation and significant weight loss.

Neurochemical Influences
Neurochemical influences in bulimia may be associated with the neurotransmitters
serotonin and norepinephrine. This hypothesis has been supported by the positive
response these individuals have shown to therapy with the selective serotonin
reuptake inhibitors (SSRIs).

Some studies have found high levels of endogenous opioids in the spinal fluid of
clients with anorexia, promoting the speculation that these chemicals may
contribute to denial of hunger (Sadock & Sadock, 2003). Some of these individuals
/have been shown to gain weight when given naloxone, an opioid antagonist.

Psychodynamic Influences
Psychodynamic theories suggest that eating disorders result from very early and
profound disturbances in development in the child and an unfulfilled sense of
separation– individuation. This problem is compounded when the mother responds
to the child’s physical and emotional needs with food. Manifestations include a
disturbance in body identity and a distortion in body image. When events occur
that threaten the vulnerable ego, feelings emerge of lack of control over one’s body
(self). Behaviors associated with food and eating serve to provide feelings of
control over one’s life.

2. FAMILY INFLUENCES
Conflict Avoidance
In the theory of the family as a system, psychosomatic symptoms, including
anorexia nervosa, are reinforced in an effort to avoid spousal conflict. Parents are
able to deny marital conflict by defining the sick child as the family problem. In
these families, there is an unhealthy involvement between the members
(enmeshment); the members strive at all costs to maintain “appearances”; and the
parents endeavor to retain the child in the dependent position. Conflict avoidance
may be a strong factor in the interpersonal dynamics of some families in which
children develop eating disorders.

3. PSYCHOLOGICAL INFLUNECES

Research into Anorexia Nervosa and Bulimia Nervosa specifically, has identified a
number of personality traits that may be present before, during, and after recovery
from an eating disorder.

These include:

 perfectionism
 obsessive-compulsiveness
 neuroticism
 negative emotionality
 harm avoidance
 core low self-esteem
 traits associated with avoidant personality disorder

4. SOCIO-CULTURAL INFLUENCES

Evidence shows that socio-cultural influences play a role in the development of

eating disorders, particularly among people who internalise the Western beauty
ideal of thinness. Images communicated through mass media such as television,
magazines and advertising are unrealistic, airbrushed and altered to achieve a
culturally perceived image of ‘perfection’ that does not actually exist.
The most predominant images in our culture today suggest that beauty is equated
with thinness for females and a lean, muscular body for males. People who
internalise this ‘thin ideal’ have a greater risk of developing body dissatisfaction
which can lead to eating disorder behaviours.

RISK FACTORS

 Low self-esteem
 Body dissatisfaction
 Internalisation of the thin socio-cultural ideal
 Extreme weight loss behaviours

Self esteem:Low self esteem has been identified by many research studies as a
general risk factor for the development of eating disorders. Strong self-esteem has
been described as essential for psychological well-being and for strengthening the
ability to resist cultural pressures.

Body dissatisfaction or negative body image:Poor body image can contribute to

impaired mental and physical health, lower social functionality and poor lifestyle
choices. Body dissatisfaction, the experience of feelings of shame, sadness or
anger associated with the body, can lead to extreme weight control behaviours and
is a leading risk factor for the development of eating disorders.

Internalisation of the thin socio-cultural ideal

People who internalise and adopt the Western beauty ideal of thinness as a
personal standard have a higher risk of developing an eating disorder.

Extreme weight loss behaviours

 Disordered eating

Disordered eating is the single most important indicator of onset of an eating

disorder. Disordered eating is a disturbed pattern of eating that can include
fasting and skipping meals, eliminating food groups, restrictive dieting
accompanied by binge eating and excessive exercise. Disordered eating can
 also include purging behaviours such as laxative abuse and self-induced
vomiting.

Disordered eating can result in significant mental, physical and social

impairment and is associated with not only eating disorders but also health
concerns such as depression, anxiety, nutritional and metabolic problems
and weight gain.

 Dieting

While moderate changes in diet and exercise have been shown to be safe,
significant mental and physical consequences may occur with extreme or
unhealthy dieting practices.

Dieting is associated with the development of eating disorders. It is also

associated with other health concerns including depression, anxiety,
nutritional and metabolic problems, and, contrary to expectation, with an
increase in weight.

 Dieting and adolescents at risk

Puberty is a time of great change biologically, physically and psychologically.

Teenagers are often vulnerable to societal pressures and can often feel insecure and
self conscious, factors that increase the risk of engaging in extreme dieting
behaviour.

The act of starting any diet increases the risk of eating disorders in adolescent girls.
Research shows that young people who engage in unhealthy dieting practices are
almost three times as likely as their healthy-dieting peers to score high on measures
assessing suicide risk.

ANOREXIA NERVOSA

The term anorexia nervosa comes from two Latin words that mean "nervous
inability to eat."
Anorexia nervosa- characterized by a pursuit of thinness that leads to self-
starvation

A serious, potentially life threatening eating disorder characterized by self-

starvation/excessive weight loss

INCIDENCE OF ANOREXIA NERVOSA

Anorexia nervosa occurs predominantly in females aged12 to 30 years. Less than

10 percent of the cases are males (American Psychiatric Association [APA],
2000).Anorexia nervosa was once believed to be more prevalent in the higher
socioeconomic classes, but evidences lacking to support this hypothesis

Characteristic of Anorexia nervosa

Anorexics have the following characteristics in common: inability to maintain

weight at or above what is normally expected for age or height

• intense fear of becoming fat

• distorted body image
• in females who have begun to menstruate, the absence of at least three
menstrual periods in a row, a condition called amenorrhea

TYPES OF ANOREXIA NERVOSA

1. RESTRICTING TYPE, characterized by strict dieting and exercise

without binge eating; Restricting certain food groups (e.g. carbohydrates,
fats)
2. Counting calories
3. Skipping meals
4. Obsessive rules and rigid thinking (e.g. only eating food that is one colour)

These restrictive behaviours around food can be accompanied by excessive

exercise.
2. BINGE-EATING/PURGING TYPE, marked by episodes of compulsive
eating with or without self-induced vomiting and/or the use of laxatives or enemas.

A binge is defined as a time-limited (usually under two hours) episode of

compulsive eating in which the individual consumes a significantly larger
amount of food than most people would eat in similar circumstances.

DSM-IV Criteria for Anorexia Nervosa

 Refusal to maintain body weight at or above a minimally normal weight for

age and height
 Intense fear of gaining weight or becoming fat, despite being underweight
 Distortions in the perception of one’s body weight or shape, undue influence
of body weight or shape on self-evaluation, or denial of the seriousness of
the current low body weight

In females who have reached menarche, amenorrhea (absence of at least three

consecutive menstrual cycles

Anorexia Nervosa Symptoms

Primary Symptoms

• Resistance to maintain body weight at or above a minimally normal body

weight for age/height
• Intense fear of weight gain or being “fat”, even though underweight

Primary Symptoms (cont)

• Disturbance in the experience of body weight/shape or denial of seriousness

of low body weight.
• Loss of menstrual periods in girls and women post-puberty.

Warning Signs Of Anorexia Nervosa

• Dramatic weight loss

• Preoccupation with weight, food, calories, fat grams, and dieting
 • Refusal to eat certain foods/groups

Ex. No Carbs

• Frequent comments about being fat or overweight despite weight loss

• Denial of hunger
• Development of food rituals (excessive chewing, rearranging)
• Consistent excuses to avoid mealtimes/situations involving food
• Excessive exercise routine
• Withdraw from usual friends & activities

Consequences Of Anorexia Nervosa

• Abnormally slow heart rate/low blood pressure, increased risk of heart

failure over time
• Reduction in bone density
• Muscle loss/weakness
• Severe dehydration which can result in kidney failure
• Dry hair & skin, hair loss is common
• Growth of downy hair layer called lanugo all over body

DIFFERENTIAL DIAGNOSIS OF ANOREXIA NERVOSA

Superior Mesenteric Artery Syndrome

Major Depressive Disorder

Schizophrenia
BULIMA NERVOSA

Bulimia nervosa is more prevalent than anorexia nervosa with estimates up to 4

percent of young women (Andreasen & Black, 2006). Onset of bulimia nervosa
occurs in late adolescence or early adulthood. Cross cultural research suggests that
bulimia nervosa occurs primarily in societies that place emphasis on thinness as the
model of attractiveness for women and where an abundance of food is available
(Bryant-Waugh & Lask, 2004).

CHARACTERISTICS OF BULIMA NERVOSA

Bulimia is characterised by repeated episodes of binge eating followed by

compensatory behaviours.

Excessive emphasis on body shape or weight in their self-evaluation.

Eating out of control and attempts to compensate which can lead to feelings
of shame, guilt and disgust. These behaviours can become more compulsive
and uncontrollable over time, and lead to an obsession with food, thoughts
about eating (or not eating), weight loss, dieting and body image.
Weight fluctuations and do not lose weight; they can remain in the normal
weight range, be slightly underweight, or may even gain weight.

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.

DSM-IV-TR Criteria for Bulimia Nervosa

 Recurrent episodes of binge eating characterized by
o eating in a 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
o a sense of lack of control over eating during the episode
 Recurrent inappropriate behaviors to prevent weight gain such as self-
induced vomiting or misuse of laxatives.
 The binge eating and inappropriate purging behaviors both occur, on
average, at least twice a week for 3 months.
 Self-evaluation is unduly influenced by body shape and weight.

Bulimia Nervosa Symptoms

Primary Symptoms
• Regular intake of large amounts of food accompanied by a sense of loss of
control over eating behavior.
• Regular use of inappropriate compensatory behaviors such as self-induced
vomiting, laxative/diuretic abuse, fasting, and/or obsessive compulsive
exercise.
• Extreme concern with body weight and shape.

Warning Signs of Bulimia Nervosa

• Evidence of binge eating (food wrappers)
• Evidence of purging behaviors (frequent trips to bathroom after meals)
• Excessive, rigid exercise regimen
 • Unusual swelling of cheeks/jaw area

Consequences of Bulimia Nervosa

• Electrolyte imbalances can lead to irregular heartbeat, heart failure and
death.
• Inflammation and possible rupture of esophagus from frequent vomiting.
• Tooth decay and staining from stomach acids released during vomiting.
• Chronic irregular bowel movements and constipation as result of laxative
abuse.
• Gastric rupture is possible.
•
Binge-Eating Disorder
Another eating disorder that resembles bulimia nervosa in many ways,
except that the person with binge-eating disorder does not regularly engage
in purging, fasting, or excessive exercise to compensate for his or her binges.

Warning Signs of Binge Eating Disorder

• Frequent episodes of eating large quantities of food in short periods of time.
• Feeling out of control over eating behavior.
• Feeling ashamed or disgusted by behavior.
• Eating when not hungry and eating in secret

Health Consequences of Binge Eating Disorder

 High blood pressure

 High cholesterol levels
 Heart disease
 Diabetes
 Gallbladder disease
 *All of these symptoms commonly associated with clinical obesity.

DIFFERENTIAL DIAGNOSIS FOR BULIMA NERVOSA

Kleine-Levin Syndrome
 Major Depressive Disorder

Borderline Personality Disorder

MANAGEMENT OF EATING DISORDER

ASSESSMENT

1. Physical Exam

Check weight

Blood pressure, pulse, and temperature

Heart and lungs

Tooth enamel and gums

2. Nutritional assessment/evaluation

Eating patterns

Biochemistry assessment—how chemistry with eating disorders

contributes to additional appetite decline and decreased nutritional intake

3. Lab & other diagnostic tests

Blood tests

X-rays

Other tests for heart and kidneys

4. Interviews

History of body weight

 History of dieting

Eating behaviors

All weight-loss related behaviors

Past and present stressors

Body image perception and dissatisfaction

5. Mental Health Assessment

Screen for depression

Self-esteem

Anxiety

Appearance, mood, behavior, thinking, memory

Substance, physical, or sexual abuse

Any mental disorders?

6. Screening Questions

Some sample questions to ask during an interview include:

How many diets have you been on in the past year?

Do you think you should be dieting?

Are you dissatisfied with your body size?

Does your weight affect the way you think about yourself?

Any positive responses to these questions should prompt further evaluation

using a more comprehensive questionnaire
7. ASSESSMENT TOOLS

There are numerous tests that can be used to assess eating disorders

EAT, EDI-2, PBIS, FRS, and SCOFF are some of the more popular tests

a) EAT (Eating Attitudes Test)

26 item self-report questionnaire broken down into 3 subscales

Dieting

Bulimia & food preoccupation

Oral control

Designed to distinguish patients with anorexia from weight-preoccupied, but

healthy, female college students

Has advantages & limitations

Subjects are not always honest when self-reporting

Has been useful in detecting cases of anorexia nervosa

b) EDI-2 (Eating Disorder Inventory)

A self-report measure of symptoms

Assess thinking patterns & behavioral characteristics of anorexia and bulimia

8 subscales

3 about drive for thinness, bulimia, & body dissatisfaction

5 measure more general psychological traits relevant to eating disorders

Provides information to clinicians that is helpful in understanding unique

experience of each patient
Guides treatment planning

c) PBIS (Perceived Body Image Scale)

Provides an evaluation of body image dissatisfaction & distortion in eating

disordered patients

A visual rating scale

11 cards containing figure drawings of bodies ranging from emaciated to obese

Subjects are asked 4 different questions that represent different aspects of body
image

d) FRS(Figure Rating Scale)

Widely used measure of body-size estimation

9 schematic figures varying in size

Subjects choose a shape that represents:

their "ideal" figure

how they "feel" they appear

the figure that represents "society’s ideal" female figure

Used to determine perception of body shape

Used for self and “target” body size estimation

e) SCOFF

Questionnaire to determine eating disorders

Sick

Control
 One stone

Fat

Food

1 point for every “YES” answer

Score greater than 2 means anorexia and/or bulimia

TREATMENT OF EATING DOSRDER

 Medical Treatment

 Medications can be used for:

o Treatment of depression/anxiety that co-exists with the eating disorder
o Restoration of hormonal balance and bone density
o Encourages weight gain by inducing hunger
o Normalization of the thinking process
 Drugs may be used with other forms of therapy
o Antidepressants (SSRI’s such as Zoloft)
 May suppress the binge-purge cycle
 May stabilize weight recovery

INDIVIDUAL THERAPY

 Allows a trusting relationship to be formed, Difficult issues are addressed,

such as:Anxiety, depression, low self-esteem, low self-confidence,
difficulties with interpersonal relationships, and body image problems
 Several different approaches can be used, such as:
o Cognitive Behavioral Therapy (CBT):Focuses on personal thought
processes
o Interpersonal Therapy:Addresses relationship difficulties with others
o Rational Emotive Therapy:Focuses on unhealthy or untrue beliefs
  Psychoanalysis Therapy:Focuses on past experiences

Nutritional Counseling

 Dieticians or nutritionists are involved

 Teaches what a well-balanced diet looks like
 This is essential for recovery
 Useful if they lost track of what “normal eating” is.
 Helps to identify their fears about food and the physical consequences of not
eating well.

Family Therapy

 Involves parents, siblings, partner.

 Family learns ways to cope with E.D. issues
 Family learns healthy ways to deal with E.D.
 Educates family members about eating disorders
 Can be useful for recovery to address conflict, tension, communication
problems, or difficulty expressing feelings within the family

Group Therapy

o Provides a supportive network

 Members have similar issues
o Can address many issues, including:
 Alternative coping strategies
 Exploration of underlying issues
 Ways to change behaviors
 Long-term goals
TREATMENT FOR ANOROEXIA NERVOSA

 Hospitalization (Inpatient)
o Extreme cases are admitted for severe weight loss
o Feeding plans are used for nutritional needs
 Intravenous feeding is used for patients who refuse to eat or the
amount of weight loss has become life threatening
 Weight Gain
o Immediate goal in treatment
o Physician strictly sets the rate of weight gain
 Usually 1 to 2 pounds per week
 In the beginning 1,500 calories are given per day
 Calorie intake may eventually go up to 3,500 calories per day
 Nutritional Therapy
o Dietitian is often used to develop strategies for planning meals and to
educate the patient and parents
o Useful for achieving long-term remission Anorexia
o Poorer prognosis with:
o Initial lower weight
o Presence of vomiting
o Failure to respond to previous treatment
o Bad family relationships before illness
o Being Married

PSYCHOLOGICAL TREATMENTS

 Behavioural therapy: Make rewards contingent upon eating. Teach

relaxation techniques
 Cognitive analytic therapy
  Cognitive behavioural therapy
 Ego-oriented therapy-adolescent focused individual therapy (for children
and adolescents)
 Focal psychodynamic therapy
 Family interventions focused explicitly on eating disorders
 Maudsley family-based treatment (for children and adolescents)
 Interpersonal psychotherapy
 Specialist supportive clinical management
 Techniques to help the patient accept and value his or her emotions: Use
cognitive or supportive-expressive techniques to help the patient explore the
emotions and issues underlying behavior.
 Raise the family’s concern about anorexia behavior. Confront the family’s
tendency to be overcontrolling and to have excessive expectations.

Other treatments

Antidepressants (specifically selective serotonin re-uptake inhibitors; e.g. SSRI) or

antipsychotics can also be used to treat Anorexia Nervosa.

 Anorexia
o Poorer prognosis with:
 Initial lower weight
 Presence of vomiting
 Failure to respond to previous treatment
 Bad family relationships before illness
 Being Married

Prognosis for Improvement

 Anorexia
o 50% have good outcomes
o 30% have intermediate outcomes
o 20% have poor outcomes

TREATMENT OF BULIMA NERVOSA

 Primary Goal
o Cut down or eliminate binging and purging
o Patients establish patterns of regular eating
 Treatment Involves:
o Psychological support
 Focuses on improvement of attitudes related to E.D.
 Encourages healthy but not excessive exercise
 Deals with mood or anxiety disorders
o Nutritional Counseling
 Teaches the nutritional value of food
 Dietician is used to help in meal planning strategies
o Medication management
 Antidepressants (SSRI’s) are effective to treat patients who also
have depression, anxiety, or who do not respond to therapy alone
 May help prevent relapse

THERAPIES TO BE CONSIDERED FOR THE TREATMENT OF BULIMIA NERVOSA

INCLUDE:

 Individual Therapy
o Allows a trusting relationship to be formed
o Difficult issues are addressed, such as:
 Anxiety, depression, low self-esteem, low self-confidence,
difficulties with interpersonal relationships, and body image
problems
 Cognitive behavioural therapy for Bulimia Nervosa: Focuses on personal
thought processes, Teach the client to recognize the cognitions around eating
and to confront the maladaptive cognitions. Introduce “forbidden foods” and
regular diet and help the client confront irrational cognitions about these.

 Rational Emotive Therapy:Focuses on unhealthy or untrue beliefs

 Supportive-expressive therapy Provide support and encouragement for the
client’s expression of feelings about problems associated with bulimia in a
nondirective manner
 Interpersonal psychotherapy: Addresses relationship difficulties with
others. Help the client identify interpersonal problems associated with
bulimic behaviors, such as problems in a marriage, and deal with these
problems more effectively.

 Psychoanalysis Therapy:Focuses on past experiences

 Guided imagery
 Crisis intervention
 Stress management
 Tricyclic antidepressant and selective serotonin reuptake inhibitors Help to
reduce impulsive eating and negative emotions that drive bulimic behavior

 Bulimia
o Poorer prognosis with:
 High number hospitalizations because of severity
 Extreme disordered eating symptoms at start of treatment
 Low motivation to change habits

 Bulimia prognosis improvement

o 45% have good outcomes
o 18% have intermediate outcomes
o 21% have poor outcomes