eating disorders

• a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning
• feeding and eating disorders

  • clinical descriptions can be traced back many years (1889)
  • however were not included in the DSM until 1980s
  • became a distinct category in DSM-IV
• types of eating disorders

  • anorexia nervosa
  • bulimia nervosa
  • binge eating
  • ARFID
  • pica
  • rumination disorder
• Pica

  • eating of one or more nonutritive, nonfood substances on a persistent basis over a period of at least 1 month (e.g. paper, soap, soil, paint, metal)
  • inappropriate to the developmental level of the individual
  • often comes to clinical attention following general medical complications (e.g. intestinal obstruction)
• rumination disorder

  • repeated regurgitation of food occuring after eating over a period of at least 1 month
  • regurgitated food may be re-chewed, re-swallowed, or spit out
  • not attributable to reflux
  • malnutrition might occur
• characteristics of ARFID

  • avoidance or restriction of food intake (lack of interest in eating or food, avoidance based on sensory characteristics of food)
  • significant weight loss and nutritional deficiency, growth delay
  • dependence on oral nutritional supplements
  • interference with psychosocial functioning
  • commonly develops in infancy or early childhood and may persist in adulthood
  • infants may be irritable and difficult to console during feeding, or may appear apathetic and withdrawn
• anorexia - characteristics and diagnostic criteria

  • significantly low body weight in the context of age, sex, developmental trajectory, and physical health (usually achieved through starvation and/or purging)
  • persistent behaviour that interferes with weight gain
  • intense fear of gaining weight or of becoming 'fat'
  • disturbance in self-perceived weight or shape; undue influence of body weight or shape on self-evaluation
• physical changes associated with anorexia nervosa

  • low blood pressure
  • slowed heart rate
  • kidney problems
  • hormonal changes
  • anemia
  • loss of hair, tooth decay
  • amenorrhea (loss of menstrual period)
• characteristics and diagnostic criteria

  • depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex
  • bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa
  • 0.1-3.6% lifetime prevalence among women; men 0-0.3%
  • commonly begins during adolescence or young adulthood (75-90% are women) - typical onset: 14-18 years of age
  • 70% recover (6-7 years); however elevated suicide risk
• characteristics of bulimia

  • recurrent episodes of binge eating (rapid consumption of a large amount of food, a sense of lack of control over eating)
  • followed by compensatory behaviour to prevent weight gain (fasting, vomiting, misuse of laxatives or exercising)
  • occur on average at least once a week for 3 months; usually in secrecy (attempt to conceal symptoms)
  • individuals are typically within the normal weight or overweight range
• Bulimia

  • an increased frequency of depressive symptoms(e.g., low self-esteem), and bipolar and depressive disorders,
  • 0.3-4.6% prevalence among women; men: 0.1-1.3%,
  • disorder peaks in older adolescence and young adulthood (90% are women),
  • 70% recover (10% remain fully symptomatic);elevated risk for mortality (all-cause and suicide),
• binge eating

  • recurret episdoes of binge eating; lack of control during binges (inability to refrain from eating or to stop eating once started)
  • marked distress about binging
  • occurs at least once a week
  • absence of compensatory behaviours (as in bulimia)
  • occurs in normal weight/overweight and obese individuals; is associated with obesity in treatment-seeking individuals
  • higher prevalence than anorexia and bulimia - 5.8% in women, 2% in men
  • common comorbid disorders: bipolar, depressive and anxiety disorders
• aetiology

  reward system which increases food intake

  • binge eating
  • obesity
• aetiology

  control over the reward system and food intake

  • anorexia nervosa
  • bulimia nervosa
• Aetiology of ana and mia

  • genetic factors: first degree relatives are 10% more likely than average of becoming anorectic; in bulimia
  • high heritability estimates for AN (48-88%) and for BN (28-83%_ derived from twin studies (hinney)
  • remaining variance due to individual specific environmental factors
• aetiology of ana and mia

  neurobiological factors: abnormal levels of...

  • cortisol, regulated by the hypothalamus (consequence of starvation)
  • serotonin (confounds with the comorbid depression) and dopamine - controls hypothalamus (regulation of appetite):
  • lack of pleasure associated with eating: eat more vs less motivated to eat
• aetiology ana and mia

  • social and family norms lead to cognitive distortions
  • self worth becomes dependent on being thin
  • weight gain decreases perceptions of control and self esteem
• aetiology - binge eating

  • binge eating as an instance of food addiction
  • pleasurable foods acts as drugs of abuse, activating the dopamine reward system
  • cues present at the time of the meal can associate to the rewarding effects of intake
  • these cues also anticipate the effects of food and activate a compensatory response which leads to food seeking behaviour
  • negative mood and hunger higher at prebinge times
• treatment - ana

  • step 1: in day hospital, focus on weight gain (support and high calorie diet)
  • force feeding controversy (30% require a naso-gastric tube) ; right to choose vs severe malutrition and cognitive impairment
  • step 2 out-patient, focus on long term cognitive and behavioural change
  • cognitive behaviour therapy (CBT) aims to alter the cycle and develop healthy eating patterns
  • challenge distortions
  • question societies standard of beuty
• treatment - ana

  • review of 16 studies: (galsworthy francis and allan) CBT demonstrated effectiveness; improvements in body mass index, eating disorder symptoms, broader mental health
  • outpatient CBT: significant weight gain after 12 months; however half of patients did not complete the treatment (frostad et al)
• treatment ana

  • training to realise that healthy weight can be maintained without extreme dieting
  • recognise the need for independence and teach patients more appropriate ways to exercise control
  • supportive clinical management, interpersonal therapy, body image interventions
  • pharmacotherapy - medication, influencing serotonin and dopamine activity
• treatment - anorexia nervosa

  • family based treatment for young people/ adolescents
  • part of the NHS protocol
  • therapist identifies troublesome family patterns, and helps the members make appropriate changes
  • might try to help the patient separate their feelings and needs from those of other members of her family
• treatment ana

  • conjoint and separated family therapy showed considerable and similar improvements in nutritional and psychological outcomes, including family functioning
  • effects maintained after 5 years - 75% of patients showed no eating disorder symptoms
• treatment - bulimia nervosa

  • cognitive behavioural approach
  • replace binge eating with 3 meals a day (without purging) and develop coping strategies
  • eat perviously avoided types of food
  • stop hiding body shape
  • learning relapse prevention strategies
• treatment - mia

  education - develop understanding that eating regularly will not result in weight gain

  pharmacotherapy - treatment with prozac decreases binge eating and vomiting as well as depression
• treatment - BED

  • behavioural treatment - cue exposure based on extinction procedures (without food); high risk of relapse
  • individual or group CBT reduces binge eating and improves abstinence rates for up to 4 months after treatment
  • substantial effectiveness of CBT and interpersonal therapy
  • limited effectiveness of self-help strategies
  • pharmacotherapy: antidepressants, appetite suppressents and anticonvulsants
• ed and covid 19

  • increase incidence of eating disorders during covid pandemic was 15.3% higher in 202 compared with previous years
  • higher rates of suicidal behaviour
  • urgent and routine referrals to the diagnostic child and adolescent eating disorder sevrices have almost doubled
• eating disorders and covid

  why:

  • social isolation, stay at home orders
  • food insecurity , changes to relationship with food
  • pressure to exercise
  • loss of routine and perceived control
  • difficulty accessing f2f clinical services, reduced access to usual support networks
• eating disorders and covid 19

  • future considerations
  • limited data on eating disorders in young people: behavioural changes vs exacerbations of symptoms in groups already at risk