EATING DISORDERS

EATING DISORDERS

SAMI ADIL
15th Nov. 2015

References

Kaplan lectures from the youtube.com
Abou-Saleh M T, Younis Y, Karim L: Anorexia Nervosa in an Arab culture. Int J Eat Disord 1998, 23:207-212.

ANOREXIA NERVOSA

BULIMIA NERVOSA


ANOREXIA NERVOSA
characterized by failure to maintain normal body weight. Typically lose more than 15-20% of ideal body weight associated with fear and preoccupation with gaining weight. They have unrealistic self-evaluation as overweight (body image disturbance). They have amenorrhea for three cycles or more.

Subtypes are:

Restricting (no binge-eating or purging),
Binge-eating/purging (regularly engage in binge-eating/purging).

Risk factors/Etiology

Biologic factors are suggested by higher concordance for illness in monozygotic twins. Amenorrhea may precede abnormal eating behavior. Psychological risk factors include emotional conflicts concerning family, control, and sexuality. A cultural risk factor may be an emphasis on thinness.





The available literature indicates that anorexia nervosa is rare among females in the Arab culture. Traditional values and cultural norms regards thinness as socially undesirable, with plumpness considered a sign of wellbeing in both genders and viewed as a symbol of fertility and womanhood in females.

A positive relationship between body weight and higher social class has been observed in the Arab culture, contrary to Western ideals. It has been suggested that exposure to Western values regarding body shape and weight can be blamed for the occurrence of anorexia nervosa in the Arab region.

Prevalence: 0.5% in the USA. Occurs at a 1:10 male-to-female ratio.

Onset: average age is 17 years. Very late-onset anorexia nervosa has a poorer prognosis.

Presentation: onset is often associated with emotional stressors, particularly conflicts with parents about independence, and sexual conflicts. Restricted food intake and maintaining diets of low-calorie foods. Prefer to eat alone, and if forced to eat with others, will serve themselves more food to later dispose of it.

Collect food recipes and spend great deals of time in the preparation of food. Great concern with appearance. Significant amount of time spent examining: weighting the self and much time used in front of the mirror. Denial of emaciated conditions.

Associated symptoms: obsessive-compulsive symptoms, depressive symptoms.

Course: some individuals recover after a single episode and others develop a waxing-and-waning course.

Physical Examination:

signs of malnutrition include emaciation, hypotension, bradycardia, lanugo, peripheral edema. Signs of purging include eroded dental enamel caused by emesis, and scarred or scratched hands from self-gagging to induce emesis. General medical conditions caused by abnormal diets, starvation, and purging.

Diagnostic tests:

Signs of malnutrition: normochromic, normocytic anemia; elevated liver enzymes; abnormal electrolytes (they die from hypokalemia); low estrogen and testosterone levels; sinus bradycardia; reduced brain mass; and abnormal EEG.
Signs of purging: metabolic alkalosis; hypochloremia; hypokalemia caused by emesis; and metabolic acidosis caused by laxative abuse.

Treatment

Initial tr. should be a correction of significant physiologic consequences of starvation with hospitalization if necessary.
Behavioral therapy should be initiated, with rewards or punishments based on absolute weight, not on eating behaviors (e.g.: tell the patient to gain a half kilogram per week, and tell her that if she fails to do that you will put a nasogastric tube for her).
Family therapy designed to reduce conflicts about control by parents is often helpful.
Antidepressants may play a limited role in treatment when comorbid depression is present.


Differential Diagnosis
bulimia nervosa, General medical conditions that cause weight loss, major depressive disorder, schizophrenia, OCD, and body dysmorphic disorder

Bulimia Nervosa

Characterized by frequent binge-eating and purging and a self-image that is undulyبإفراط influenced by weight.
Subtypes:
Purging: self-induced vomiting or the use of laxatives, diuretics, or enemas.
Nonpurging: fasting or exercise, but no purging during bulimic episodes.

Risk Factors/ Etiology:

Psychological conflict regarding guilt, helplessness, self-control, and body image predispose.
Biological factors are suggested by frequent association with mood disorders.

Prevalence: 2% in young adult females. Occurs at a 1:9 male-to-female ratio.

Onset: usually during late adolescence or early adulthood and often follows a period of dieting.

Course: may be chronic or intermittent. 70% of cases have remitted after 10 years. Co-occuring substance abuse is associated with a poorer prognosis.

Presentation: recurrent episodes of binge-eating. Recurrent, inappropriate compensatory behavior. Self-evaluation is unduly influenced by body shape and weight.
They prefer to eat alone, and if forced to eat with others will serve themselves less food and hide the rest. Will eat hidden food when others are not around.


Associated problems: depressive symptoms, substance abuse, and impulsivity. Borderline personality disorder is present in about 50%.
Physical examination: evidence of purging.

Treatment

Cognitive and behavioral therapy are major treatment. Psychodynamic psychotherapies are useful accompanying borderline personality traits. Antidepressant medications, particularly SSRIs, are usually employed.

Differential diagnosis: Anorexia nervosa, major depressive disorder with atypical features, and borderline personality disorder.