Eating disorders

Atefeh Ghanbari JolfaeiAssistant professor of psychiatry, Iran

University of medical sciences

Bulimia Nervosa

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: – eating, in a discrete period of time (e.g., within any

2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

– 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)

• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.

• Self-evaluation is unduly influenced by body shape and weight.

Binge eating

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: – 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

– 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)

• The binge-eating episodes are associated with three (or more) of the following: – eating much more rapidly than normal – eating until feeling uncomfortably full – eating large amounts of food when not feeling

physically hungry – eating alone because of being embarrassed by how

much one is eating – feeling disgusted with oneself, depressed, or very

guilty after overeating

• Marked distress regarding binge eating is present. • The binge eating occurs, on average, at least once

a week for 3 months. • The binge eating is not associated with the

regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa

• Mild• 1-4• Moderate• 5-7• Severe• 8-13• Extreme• >14

Epidemiology

• 2 to 4 percent of young women• women >>> men• Onset = late adolescence, early adulthood• 20 % of college women experience transient

bulimic symptoms• present in women with normal-weight or

obesity

Binge eating disorder (BED)

• 40% in patients seeking treatment for obesity• 70% in patients presenting for surgery• 2.5% In the general population

.

Etiology• Monozygotic twins have a 50 to 80 percent

concordance rate for eating disorders• Ser & Nep• plasma endorphin levels are raised in some

bulimia nervosa patients who vomit

Etiology…

• bulimia nervosa may represents a failed attempt at anorexia nervosa

• sharing the goal of becoming very thin, but less able to sustain prolonged starvation

• efforts to restrict eating breakthrough eating episodes of giving in to hunger

Purging

• media information describes purging in detail • inappropriate educational programs aimed at

preventing eating disorders • receiving a “tip” from a friend

Complications

Gastrointestinal

• Parotid and submandibular salivary gland hypertrophy

• Loss of gag reflex• Esophageal dysmotility• Abdominal pain and

bloating • Mallory-Weiss syndrome

(esophageal tears)• Esophageal rupture

(Boerhaaves’ syndrome

• GERD• Gastric dilation• Diarrhea and

malabsorption• Steatorrhea• Protein-losing

gastroenteropathy• Hypokalemic ileus• Colonic dysmotility • Constipation• Melanosis coli• Pancreatitis

Renal and electrolytes

• Dehydration• Hypokalemia• Hypochloremia• Metabolic alkalosis• Hypomagnesemia• Hypophosphatemia• hyponatremia

Electrolyte Levels Usually Associated with Purging

Method of purging

Na K chloride bicarbonate

PH Na K chloride

D, I, N

Method of purging

Na K chloride bicarbonate

PH Na K chloride

vomiting D, I, N D D I I D D D

laxative I, N D I, D I, D I, D D D N, D

diuretics D, N D D I I I I I

Cardiac complications• are rare in patients with BN • Hypotension• Sinus tachycardia• Palpitations• Edema• ECG changes• Depressed ST segment• QT prolongation• Widened QRS complex• Increased P-wave amplitude• Increased PR interval• Arrhythmia

MEDICAL EVALUATION• Medical history • lethargy, irregular menses, abdominal pain and bloating,

constipation • Physical examination• Tachycardia• Hypotension (< 90 mm Hg systolic)• dry skin• Parotid gland swelling• Erosion of dental enamel• hair loss• Edema• scarring or calluses on the dorsum of the hand.

Laboratory assessment

• Serum electrolytes• Bun/Cr• CBCdiff• LFT• Urinalysis• Severely ill patients with BN warrant additional

tests• Serum calcium, magnesium, and phosphorous• ECG

• For patients with suspected pancreatitis: serum amylase, fractionated for salivary gland

isoenzyme • For patients with Persistent amenorrhea: LHFSHprolactin

• Bone mineral density in patients with a history of amenorrhea in women or weight loss with low testosterone in men

• No specific laboratory tests are indicated for patients with BED, unless they are obese and obesity-associated comorbidity is suspected.

Treatment

• Psychotherapy(CBT & Dynamic psychoterapy)• Cognitive-Behavioral Therapy• include about 18 to 20 sessions over 5 to 6

months, 50 minutes in length.• Individual or group • interrupt the self-maintaining behavioral cycle of

bingeing and dieting• alter the individual's dysfunctional cognitions;

beliefs about food, weight, body image; and overall self-concept.

CBT…

• Understand that binge eating does not occur spontaneously. Rather, it may occur when the patient:

• Breaks his or her dietary rule system• Ingests alcohol or another disinhibiting substance• Under-eats, which creates psychological and

physiological pressure to eat• Encounters an adverse event or becomes

dysphoric

CBT…

• diary • Recognize high risk situations for binge eating• Stimulus control (avoiding people, places, and

activities that trigger binge eating)• Alternative activities that are incompatible

with eating• Learning to recognize that the urge to eat is

temporary• Problem-solving

CBT…

• Develop a regular pattern of eating • three planned meals and two to three planned

snacks per day• no more than four hours elapsing between

eating episodes. • It may be necessary to gradually implement

the regular pattern over a few weeks.

CBT…

• Address food avoidance: • Identify those foods that the patient regards

as forbidden because of the belief that they will inevitably lead to binge eating

• Help the patient disconfirm this belief by introducing a small amount of the food into a planned meal or snack on a day when the patient feels in control of their eating and capable of resisting the urge to binge eat

• Address and restructure dysfunctional thoughts about body shape and weight

• address problems that maintain or reinforce binge eating (eg, low self-esteem, perfectionism, and interpersonal functioning).

• Avoid unusual weighing practices• educate the patient about weight, weight

changes, BMIand its importance to health. • Laps Vs Relapse

Medication

• First-line treatment is fluoxetine

• Second-line treatment for patients who do not tolerate or respond to fluoxetine is a different SSRI

• Third-line treatment, in order of preference, includes a TCA (eg, desipramine, imipramine, or nortriptyline), topiramate, trazodone, or a MAOI; eg, phenelzine

• Avoiding Bupropion

Beinge eting

• Fluoxetin• SSRI antidepressants (citalopram,

escitalopram, fluoxetine, fluvoxamine, and sertraline), antiepileptic drugs (topiramate and zonisamide), and atomoxetine

Medication management after bariatric surgery

• patients should be transitioned to immediate release or liquid preparations of medications