Anorexia Nervosa def and types
Patients with anorexia nervosa are preoccupied with their weight, their body image, and being thin. There are two main sub types:
Restricting type: Has not regularly engaged in binge-eating or purging behavior; weight loss is achieved through diet, fasting, and/or excessive exercise.
Binge-eating/purging type: Eating binges followed by self-induced vomiting, and/or using laxatives, enemas, or diuretics. Some individuals purge after eating small amounts of food without binging.
AN DIAGNOSIS AND DSM-5 CRITERIA
- Restriction of energy intake relative to requirements, leading to significant low body weight—defined as less than minimally normal or expected.
- Intense fear of gaining weight or becoming fat. Repetitive behaviours are carried out to prevent weight gain, despite the already low weight.
- Distortions in an individual’s self perception of body weight or shape(Disturbed body image), associated with the denial of the serious consequences of the current low body weight.
Physical manifestations in AN
- Amenorrhea
- cold intolerance/hypothermia
- hypotension (especially orthostasic)
- bradycardia , arrhythmia
- acute coronary syndrome, cardiomyopathy , mitral valve prolapse
- Constipation
- lanugo hair, alopecia
- edema, dehydration
- peripheral neuropathy, seizures
- hypothyroidism
- osteopenia, osteoporosis.
Laboratory abnormalities in AN
Hyponatremia , hypochloremic hypokalemic alkalosis (if vomiting)
arrhythmia
hypercholesterolemia, leukopenia
anemia (normocytic normochromic),
elevated blood urea nitrogen (BUN)
↑ growth hormone (GH), ↑ cortisol,
reduced gonadotropins (luteinizing hormone [LH], follicle- stimulating hormone [FSH]), reduced sex steroid hormones (estrogen, testosterone)
hypothyroidism, hypoglycemia, osteopenia.
ETIOLOGY of AN
- Biological causes:
Genetic causes: Relatives of AN patients have an increase in risk in developing AN by 10 fold. MZ:DZ = 65%:32%
• Birth trauma: Cephalohaematoma, premature birth and small for gestation age are predisposing factors for AN.
• Hypothalamic dysfunction
Psychological causes:
• Development: Failure of identity formation and psychosexual development in adolescence.
• Personal events: Childhood obesity
• Family factors: Young AN patients may use the illness itself to overcome rigidity, enmeshment, conflict and overprotection in the family.
• Underlying personality traits: Perfectionistic and neurotic traits are predisposing factors.
3. Socio-cultural causes:
• Changes in nutritional knowledge and dietary fashion in the society
• Cult of thinness
• Changed roles and images in women to pursue thinness.
DIFFERENTIAL DIAGNOSIS of AN
- Medical conditions: Endocrine disorders (e.g., hypothalamic disease, diabetes mellitus, hyperthyroidism), gastrointestinal illnesses (e.g., malabsorption , inflammatory bowel disease), genetic disorders (e.g., Turner syndrome,), cancer, AIDS.
- Psychiatric disorders: Major depression, bulimia, or other mental disorders (such as somatic symptom disorder or schizophrenia).
TREATMENT of AN
-Food is the best medicine!
-Patients may be treated as outpatients unless they are dangerously below ideal body weight (>20–25% below)
-Treatment involves cognitive-behavioral therapy, family therapy
,and supervised weight-gain programs.
-Selective serotonin reuptake inhibitors (SSRIs) have not been effective in the treatment of anorexia nervosa but may be used for comorbid anxiety or depression.
-Little evidence that second-generation antipsychotics can treat preoccupation with weight and food, or independently promote weight gain.
in AN Range of mortality rates from 5 to 18 percent why ?
. due to starvation, suicide, or cardiac failure.
One-third of AN patients may attempt suicide or self harm.
Bulimia Nervosa description
- Bulimia nervosa is characterized by episodes of binge eating combined with inappropriate ways of stopping weight gain. Physical discomfort for example, abdominal pain or nausea terminates the binge eating, which is often followed by feelings of guilt, depression, or self disgust. Unlike patients with a norexia nervosa , those with bulimia nervosa typically maintain a normal body weight
Bulimia nervosa, in many ways, represents a failed attempt at anorexia nervosa, sharing the goal of becoming very thin, but occurring in an individual less able to sustain prolonged semi-starvation or severe hunger as consistently as classic restricting anorexia nervosa patients.
DIAGNOSIS AND DSM-5 CRITERIA of BN
- Recurrent episodes of binge eating.
- Recurrent, inappropriate attempts to compensate for overeating and prevent weight gain (such as laxative abuse, vomiting, diuretics, fasting, or excessive exercise).
- The binge eating and compensatory behaviors occur at least once a week for 3 months.
- Self-esteem is affected by self-evaluation of body weight and shape.
- Does not occur exclusively during an episode of anorexia nervosa
PHYSICAL FINDINGS AND MEDICAL COMPLICATIONS in BN
Physical examination findings
• CNS: epilepsy.
• Oral and oesophagus: parotid gland swelling, dental erosions, oesophageal erosions.
• CVS: arrhythmias and cardiac failure leading to sudden death.
• GIT: gastric perforation, gastric/duodenal ulcers, constipation and pancreatitis.
• muscle weakness
• Russell’s sign: abrasions over dorsal part of the hand because fingers are used to induced vomiting.
Laboratory/imaging abnormalities in BN
- FBC: leukopenia and lymphocytosis.
- U&Es: ↓in K+, Na+, Cl-, ↑bicarbonate
- ↑in serum amylase
- Metabolic acidosis due to laxative use
- Metabolic alkalosis due to repeated vomiting.
- High incidence of comorbidity as
in BN
High incidence of comorbid mood disorders, anxiety disorders, impulse control disorders, substance use, prior physical/sexual abuse, and ↑ prevalence of borderline personality disorder
BN ETIOLOGY
- Multifactorial, with similar factors as for anorexia .
Childhood obesity increase risk for bulimia nervosa.
TREATMENT of BN
- Most patients with uncomplicated bulimia nervosa do not require hospitalization.
- Both pharmacotherapy and psychotherapy could be considered.
- Pharmacological treatment: antidepressants (SSRIs such as fluoxetine or fluvoxamine) have been shown to be effective in treatment of BN. It would be able to help in reduction of binge eating and also the associated impulsive behavior. (The only FDA- approved drug for the treatment of bulimia nervosa is fluoxetine. In addition to reducing binging and purging episodes, fluoxetine might also be useful for the treatment of co-occurring depression and anxiety disorders.)
- Psychological treatment – Both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have been
used. CBT has been shown to be highly effective for BN. - Nutritional counseling and education.
Binge-Eating Disorder
-Patients with binge-eating disorder suffer emotional distress over their binge eating, but they do not try to control their weight by purging or restricting calories, as do anorexics or bulimics. Unlike anorexia and bulimia-Patients with binge-eating disorder are not as fixated on their body shape and weight
DIAGNOSIS AND DSM-5 CRITERIA of Binge-Eating Disorder
- Recurrent episodes of binge eating (eating an excessive amount of food in a 2-hour period associated with a lack of control), with at least three of the following: eating very rapidly, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, and feeling guilty after eating.
- Severe distress over binge eating.
- Binge eating occurs at least once a week for 3 months.
- Binge eating is not associated with compensatory behaviors (such as vomiting,laxative use, etc.), and doesn’t occur exclusively during the course of anorexia or bulimia
PHYSIC AL FINDINGS AND MEDIC AL COMPLICATIONS of binge eating
Patients are typically obese and suffer from medical problems related to obesity including metabolic syndrome, type II diabetes, and cardiovascular disease.
ETIOLOGY of binge eating
Runs in families, reflecting likely genetic influences
TREATMENT of binge
Both pharmacotherapy and psychotherapy could be considered.
Pharmacological treatment: antidepressants,SSRIs such as fluoxetine.
Psychological treatment – Both cognitive behavioural therapy (CBT) and interpersonal psychotherapy (IPT)
