Chapter 36: Eating Disorder normal weight for age and

height
o Increased hospitalization
o Anorexia nervosa & bulimia
nervosa
o Hospitalizations in men have
increased
o 89% is still women
o Hospitalizations related to
mental health t eating disorder
also increased by almost 25%
for older adults
 Intense fear of gaining weight,
or becoming fat, although
significantly underweight
 Disturbance in the way in
which one’s body weight or
shape
 In whom and adolescence, the
absence of at least three
consecutive menstrual cycle

A. Anorexia Nervosa
 Generally do not lose their
appetite
 They suppress their appetite
in an effort to remain thin
or get thinner
 In fact they think about
food and eating much of the
time
 Weight or shape is often the
most important influence on
the eating disordered
person’s sense of worth
1. Restricting type
Women 2. Binge eating/purging type

 Menstruation might cease early

 Irregular & spotty
Behaviour
 Amenorrhea (lack of
nourishment)  Who is usually female
o Slows pituitary function  Common premorbid personality
fundamental to the profile is that of a
menstrual cycle perfectionistic and introverted
 Menarche has not been reach girl with self – esteem and peer
o Menstruation might not relationship problems
begin
Objective signs
Men
 Weight loss
 Low sex drive  Restrictors: young people in the
 Low testosterone normal or slightly above normal
weight range for height and
Nervosa
build before the eating disorder
 Refusal to maintain body begins
weight at or above a minimum
  This group views using weight
as more probable if they simply
eat less & avoid social
situations in which they are
expected treat
 Often withdraw to their rooms
& avoid family and friends
 Might participate in rigid
exercise program to help
reduce their weight.
Vomiters – purgers
 are more often overweight
before the eating disorder
begins and their weight tends
to fluctuate
 women who are prone to
dangerous methods of weight
reduction, such as induction of
vomiting or exercise use of
laxatives or diuretics
 commonly deny concerns about
weight and typically eat
normally in social situations
after meal, they retreat to the
near bathroom and purge
themselves of the consumed for
a, although the amount is not
excessive
 dental problem frequently
occur because acidic vomitus
decays enamel on their teeth
 hypotension, bradycardia,
hypothermia are common
 dry skin
 lanugo might appear
 refeeding syndrome – severe
shift of fluids and electrolyte
level from extracellular to
intracellular spaces
 pitting edema might occur
 osteopenia or osteoporosis
might occur as a consequence
of prolonged amenorrhea and
malnutrition
Subjective symptoms
 conscious feat that they might
lose control over the amount of
food eaten, resulting in
becoming fat
 they would rather be “dead”
that fat exhibit depression,
irritability, social withdrawal,
lessened sex drive, obsessional
symptoms
Etiology:
 multifactorial causes with
significant variance among
individuals
 biologic, sociocultural, family,
cognitive, behavioural and
psychodynamic factors
Biologic factors
 psychological disturbances
 increase serotonin level
 after a long term weight
restoration and recovery,
anorectics have
 increased CSF levels of 5
hydroxyindoleacetic acid the
major metabolite of serotonin
 disturbances in the serotonin
system contribute to
vulnerability for restricted
eating, behavioural inhibition,
and a bias toward anxiety and
error prediction, whereas
disturbances in the dopamine
system contribute to an altered
response to reward.
 SSRI’s which regulate serotonin
levels in depressed patients,
has not been as effective in
treating anorexia as in treating
bulimia
 Malnutrition of anorexia might
negate the positive effects of
 SSRI medication in early
treatment
 If SSRI’s is used to treat
anorexia, they should not be
started until weight restoration
has been achieved.
Sociocultural factors
 Unrealistically thin beauty
ideas for women
 Almost a culture if thinness
 Importance of physical
attractiveness in obtaining
approval and because of the
thin beauty ideal, some girls
believes that thinness will lead
to approval by others.
Family factors
 Identical & fraternal twins have
suggested a genetic component
to the causation of anorexia
 Emotional restraint, enmeshed
relationship rigid organization
in the family, tight control of
child behaviour by parents and
avoidance of conflict are other
etiologies
Cognitive behavioural factor
 Rejecting food and losing
weight might be reinforced by
positive attention from others
Psychodynamic Factor
 Eating disorder might related to
an early history of sexual abuse
 Involves regression
 Obsession with weight
stemming
B. Bulmia Nervosa
 Usually begins in adolescence
or early adult life
 Primarily in women
Behaviour of bulimia
 Insatiable appetite
 Massive over eating
 Binge eating or bingeing
 Late onset
 Lack of control
 Considered to be a part of
anorexia nervosa, because
almost half of patients
diagnosed with anorexia were
observed to have binge eating
episodes
 Onset of illness usually
between 15 – 24 years
 Might develop after anorexia
nervosa
 Dieting predispose the
individual to binge eating,
purging develops as a means of
compensating for calories
ingested during binge in
attempt to prevent weight gain
Objective sign
 High calorie
 High carbohydrate “snack”
 Easily ingested
 Binges occur during evening
 After binge patient promise
themselves to adhere to a strict
diet and vow never to binge
again, only to return to this
behaviour because they find
themselves addicted to the high
they experience when binging
 Mechanical irritation and
dilation of stomach
 Fluid and electrolyte
abnormalities
 Dehydration, hyponatremia,
hypochloremia, hypokalemia
and metabolic alkalosis and
acidosis
 Enlarged salivary glands
(parotid)
 Erosion of dental enamel
  Russels sign – callusing of the
knuckles of the fingers used to
induced vomiting
 Pancreatitis has been reported
common.
Subjective symptoms
 Normal body weight
 Anxiety and tension during
binge
 Guilt after binge
 If anxiety is not relieved after
the binge patient feel angry,
agitated and might be
depressed
 Marker food at the beginning of
the binge
 Concerned about their body
shape and weight
 Loss of control
 Over eating
 Great anxiety and shame and,
similar to anorectic patients
 Expressed fear of becoming fat
 Mood vary considerably
 Feeling weak before a binge
 Followed by either by continued
anxiety or relief from tension
during the binge
 Uncontrolled cravings
 The anxiety present before
binge is replaced with guilt
after the binge
 Self – induced vomiting
Etiology:
 Causes are multifactorial
 Biologic
 Sociocultural
 Family
 Cognitive
 Behavioural
 Psychodynamic
Biologic factor
 Lowered serotonin activity in
the brain of bulimics
 Binge eating is seen by some as
a form of self-medication to
raise the levels of serotonin
 Treatment of bulimia with
SSRI’s antidepressants
 Particularly fluoxetine (Prozac)
appears to be helpful whether
or not patients have comorbid
depression
Sociocultural factors
 thought to be the same as
those for
 anorexia nervosa
Family Factors
 higher concordance rate for
bulimia in identical than in
fraternal twins
 mood disorders and substance
abuse disorders are found at a
higher rate in the families of
bulimics
Cognitive & behavioural factors
 bulimia nervosa is maintained
by cycles of low self-esteem,
extreme concerns about body
shape and weight, strict
dieting, binge eating, and
compensatory behaviour
Management (Anorexia)
 a weight to at least 90% of the
average body weight for
patients height
 helping patient re-establish
appropriate eating behaviour
 increase self-esteem, so patient
do not need to attain the
perfection that then believe
times provide
Management (Bulimics)
 same management
 stabilize weight without
purging
 normal weight
 Initial treatment: medical
stabilization
 TOC: psychotherapy
Differentiate Behaviour
Anorexia
 Early onset
 Very low weight
 Amenorrhea for some patients
 Hormonal imbalance
 Constipation if not using
laxatives
Bulimia
occurring on average at least
twice a week for 3 months
 Self - evaluation unduly
influence by body shape and
weight
o Purging type
 Regularly engages in
self – induced
vomiting or the use of
laxatives, diuretics
and enemas
o Non purging
 Regularly strict diet
 Fasting
 Vigorously exercise
 Does not engage
regularly in purging

 Develop DM
 Later onset
 More normal weight
 Menstrual irregularities
 Fluid and electrolyte imbalance
 GI problems related to purging

DSM – IV – TR Criteria

 Recurrent episodes of binge

eating in a short time period,
with intake much greater than
average
 A feeling of lack of control over
eating behaviours during eating
binges
 Recurrent inappropriate
compensatory behaviours in
order to prevent weight gain
 Self – induced vomiting used of
laxatives
 Enemas or diuretics, strict
dieting, vigorous exercise
taking diet pill
 Binge eating and inappropriate
compensatory behaviours both