Eating Disorders

Question 1

What is a purge?

Answer 1

Use of vomiting, laxatives, diuretics or enemas to eliminate calories

Question 2

What is a binge?

Answer 2

Definition of a Binge:
• Eating a large amount within a discrete period (i.e. an amount “definitely larger than most people would eat under a similar circumstance”)

• Eating is out of control during the episode

Question 3

What are the types of eating disorders?

Answer 3

1. Anorexia nervosa
2. Bulimia nervosa
3. Binge-eating disorder
4. Unspecified eating disorder
   These disorders are under the “Feeding & Eating Disorders” category of DSM-5

Question 4

What are the Anorexia nervosa diagnostic criteria?

Answer 4

Diagnostic Criteria:
1. Restriction of food that leads to a person being significantly underweight.
• Underweight is defined as having a body mass index (BMI) < 18.5 kg/m2.

2. Intense fear of gaining weight (evidenced by extreme preoccupation, frequent assessment, behaviors that interfere with weight gain etc.)
3. Body image disturbance (e.g. belief of being overweight, denying seriousness of low weight)

Question 5

What is a normal BMI ?

Answer 5

(Normal BMI range: 18.5 – 24.9 kg/m2)

Question 6

What are the classifications of Anorexia Nervosa?

Answer 6

Mild- 17 – 18.49 (grey zone, use clinical judgement

Moderate- 16 – 16.99 (“clearly” below normal)

Severe- 15 – 15.99

Extreme- less than 15

Question 7

What are the subtypes of Anorexia Nervosa?

Answer 7

Based on recent behavior over the last 3 months

1. Binge-eating/purging Type:
   • If the person recurrently binges AND/OR purges
2. Restricting Type:
   • The person does NOT recurrently binge or purge
   • Weight loss is maintained through dieting, fasting +/- over exercising

Question 8

What are the epidemiology of the Anorexia Nervosa?

Answer 8

Over 90% of affected persons are females however, the prevalence data for males is scarce.

• Onset: Bimodal (average: 17 years)
• First peak (12-15 years) and
• Second peak (15-21 years)

Interests/Occupations:
• Modeling, beauty competitions 
• Gymnastics
• Ballet dancing
• Wrestling

Question 9

What are the contributing factors?

Answer 9

Psychological and Social Factors
• Cultural pressures to be thin
• Difficulty establishing autonomy from parents during adolescence ( a “control”
issue)
• Perfectionist trait
• Low self-esteem
• Weight loss is reinforced (internally & externally)

Biological Factors
• Genetic susceptibility to anorexia
• A person may inherit biochemical alterations that leads to obsessiveness.
• Cultural pressures may direct the obsessiveness to body image.

Question 10

Whaat are the associated features Anorexia Nervosa?

Answer 10

Symptoms:
• Amenorrhea
• Decreased sex drive 
• Constipation
• Hair loss

• PhysicalExamination:
• LowBMI
• Hypothermia,bradycardia,hypotension
• Lanugo(soft,finebaby-likehair)
• Dry skin, brittle nails
• Investigations:
• Anemia, leukopenia, low bone mineral density, hypercholesterolemia

Question 11

What are the main physical features of Anorexia Nervosa?

Answer 11

Indicators of excessive vomiting (Binge eating/purging subtype):

1. Calloused knuckles → Russell’s sign
2. Dental enamel erosion
3. Salivary gland inflammation
   a) Parotid gland hypertrophy
   b) Chipmunk cheeks
4. Subconjunctival hemorrhage
5. Hypochloremia, hypokalemia

Question 12

How is Anorexia Nervosa treated?

Answer 12

Typically, a patient is not self-referred, since anorexia tends not to distress the patient.

• Treatment is typically family initiated.

➢ In-patient Hospitalization:

• Weight gain is the immediate goal for in-patient care.
• Combined with behavioral principles (e.g., operant conditioning) to encourage
weight gain.
• An attendant often supervises the patient to thwart attempts to lose weight

Question 13

How can therapy lead to Anorexia Nervosa?

Answer 13

➢ Cognitive-Behavioral Therapy
• In-patient or out-patient
• It is an essential component of treatment
• Used to change the patient’s attitude about food and weight and learn how to
break destructive eating habits.

➢ Pharmacological Therapy
• No FDA approved drug for treating anorexia
• Limited to treatment of medical complications and comorbid psychiatric conditions

Question 14

What are the outcomes of Anorexia Nervosa?

Answer 14

• In a controlled environment such as in-patient care, there is good short-term prognosis.
• However, long-term prognosis tends to be poor after patients are released home.

• Outcome is variable: some may fully recover, have relapses, or progressively
deteriorate.

• Many medical complications can result, ranging from minor to major (hormone deficiency, organ failure, brain changes, suicide) with approximately 20% mortality rate

Question 15

Describe the diagnostic criteria of the Bullimia Nervosa

Answer 15

1.Recurrent binge eating

2. Recurrent inappropriate compensatory behavior for binge
   • Purging (e.g. vomiting, laxatives, diuretics, enemas)
   • Non-purging (fasting and/or excessive exercise)
3. The binge/inappropriate compensatory behaviors must occur
   ≥ once a week for 3 months
4. Self-evaluation is unduly influenced by body shape and weight

Question 16

What are the features of Bullimia Nervosa?

Answer 16

There are no subtypes of bulimia nervosa

• Persons typically have a BMI in the normal range or are slightly overweight (normal BMI = 18.5 – 24.99 kg/m2).

• Compare this to AN where the BMI is low

Question 17

Describe Bullimia Nervosa Epidemiology

Answer 17

• More than 90% of persons with bulimia nervosa are women.

• Onset:
• Average age of onset: 18 – 20 years
• Women often have a history of both anorexia nervosa and bulimia nervosa, but at different times
• Occupations:
• Modeling, beauty competitions
• Gymnastics
• Ballet dancing
• Wrestling

Question 18

What are the contributing factors of the Bullimia Nervosa?

Answer 18

Psychological and Social Factors
• Societal pressures to be thin +/- a means to improve self-esteem
• Strict dieting results in a broken diet and impulsivity, “all or none” eating (i.e.
binging)
• Fear of weight gain after binge leads to inappropriate compensatory behavior

Biological Factors
• A person may inherit biochemical changes (low serotonin) that leads to impulse control problems.

Question 19

What are the associated features of Bullimia Nervosa?

Answer 19

• Indicators of excessive vomiting
• Seen in both bulimia and anorexia (subtype: binge-eating/purging
type)

• Physical Consequences:
• Electrolyte imbalance - ↓K, ↓Cl
• Consequences of excessive vomiting
• Enamel erosion
• Parotid gland enlargement - more likely in BN
• Knuckle calluses

Question 20

What is the treatment for Bullimia Nervosa?

Answer 20

A patient typically initiates treatment (after several years of symptoms)→the disorder is distressful to the patient.

• Treatment tends to be out-patient based.
• CBT is essential
• Fluoxetine is the only FDA-approved medication for bulimia
• With greater motivation to change, prognosis is better for bulimia nervosa than anorexia nervosa

Question 21

What is the prognosis of Bulimia Nervosa?

Answer 21

• Intervention soon after diagnosis has better prognosis

• Outcome: half recover fully with treatment; others have a chronic course
with relapsing symptoms.

• Having associated problems with depression or substance use has poorer prognosis
• Medical complications tend to be fewer and less severe than in anorexia, but morbidity and mortality may still result (e.g. from hypokalemia, suicide)

Question 22

What’s the diagnostic criteria of the binge-eating disorder?

Answer 22

1. Binge eating (as per bulimia criteria)
2. Bingeing is associated with features such as:
   A. Rapid eating
   B. Eating until uncomfortably full
   C. Eating when not physically hungry
   D. Eating alone due to shame about quantity
   E. Feeling disgusted/guilty/depressed after binge
3. No inappropriate compensatory behavior
4. The binge behavior must occur more than once a week for 3 months

Question 23

Describe onset of binge eating disorder

Answer 23

• Epidemiology:
• Approximately 2% with a less skewed female bias
• Onset & Course:
• Symptoms often start in adolescence
• Cross-over to other eating disorders is uncommon
• Etiology:
• Unknown but distinct from bulimia nervosa
• In binge-eating disorder, dysfunctional dieting tends not to precede bingeing

Question 24

What are the features of Binge Eating Disorders?

Answer 24

Associated with obesity (BMI ≥ 30 kg/m2)
• High BMI is not required for a diagnosis

• Obesity without bingeing is a distinct condition:
  
  • Not all obese people binge eat.
  • There is greater distress/functional impairment in binge-eating disorder than in non-bingeing obesity
    
    • Health consequences of binge-eating disorder are similar to those of obesity •

Question 25

How is binge eating treated?

Answer 25

Treatment: | • Cognitive-behavioural therapy, antidepressant drugs and the stimulant drug, lisdexamfetamine

Question 26

What is an unspecified eating disorder?

Answer 26

Many patients do not meet the criteria for either Anorexia Nervosa, Bulimia Nervosa or Binge-eating disorder but have subclinical eating problems. The diagnosis would be “unspecified eating disorder” 1. A woman with a BMI = 22 kg/m2 who frequently purges but does not binge eat • Purges→AN(binge-eating/purgingsubtype)orBN • Does not binge eat→not BN, not BED • Normal BMI→not AN 2. A woman with a BMI 25 kg/m2 binges and purges but only once a month • Binge and purge→AN (binge eating/purging subtype) or BN • Criteria for duration and frequency: >1 / week for 3 months

Question 27

How do we screen for eating disorders?

Answer 27

SCOFF Questions SCOFF Questions ❑Sick→Do you make yourself sick because you feel uncomfortably full? ❑Control→Do you worry you have lost control over how much you eat? ❑One→Have you recently lost more than one stone (14 lb.) in a 3-month period? ❑Fat→Do you believe yourself to be fat when others say you are too thin? ❑Food→Would you say that food dominates your life? A score of ≥ 2 indicates a likely eating disorder.