EATING DISORDER

Introduction : Eating is controlled by several factors like physical health, voluntary control, appetite, habits, family cultural pattern, peer group influence and food availability. Eating disorders are treatable medical illnesses in which certain maladaptive patterns of eating observed and involves serious disturbances in eating behavior includes extreme and unhealthy reduction of food intake or severe or over eating : as well as distress feelings or extreme concern about body shapes, weight and body image. Many affected individual initially appear to function normally but it can cause significant physical and emotional turmoil. Eating disorders frequently occur with other psychiatric disorders such as depression, substance abuse and anxiety disorders. However, eating disorder includes alteration in eating pattern, dieting (skipping the meals, fasting) perfectionism, etc. Eating disorders frequently develop during adolescence or early adulthood. Cases were reported even during childhood or later in adulthood also. Females are much likely to develop the eating disorder than males. Causes : Genetic Biological Psychological Socio-Cultural Factors Altered functioning pattern of an individual Secondary to medical disorders – endocrinal metabolic disturbances, electrolyte imbalances. Specific disorders and its causes, clinical manifestations, investigations, treatments is described accordingly. F50.0 Anorexia Nervosa : Anorexia Nervosa is a disorder characterized by deliberate weight loss, induced and / or sustained by the patient. The disorder occurs most commonly in adolescent girls and young women, but adolescent boys and young men may be affected more rarely, as may children approaching puberty and older women up to the menopause. Anorexia nervosa constitutes an independent syndrome in the following sense : The clinical features of the syndrome are easily recognized, so that diagnosis is reliable with a high level of agreement between clinicians ; Follow up studies have shown that, among patients who do not recover, a considerable number continue to show the same main features of anorexia nervosa, in a chronic form. Annual Incidence of Anorexia and Bulimia Nervosa in women aged 10-39 years from 1988-2000 (error bars represent 95% confidence intervals). (Reproduced with permission from Currin et.al., 2005). Although the fundamental causes of anorexia nervosa remain elusive, there is growing evidence that interacting sociocultural and biological factors contribute to its causation, as do less specific psychological mechanisms and a vulnerability of personality. The disorder is associated with under nutrition of varying severity, with resulting secondary endocrine and metabolic changes and disturbances of bodily function. There remains some doubt as to whether the characteristic endocrine disorder is entirely due to the under nutrition and the direct effect of various behaviours that have brought it about (e.g. restricted dietary choice, excessive exercise and alterations in body composition, induced vomiting and purgation and the consequent electrolyte disturbances), or whether uncertain factors are also involved. Diagnostic Guidelines : For a definite diagnosis, all the following are required : Body weight is maintained at least 15% below that expected (either lost or never achieved), or Quetelet’s body – mass index is 17.5 or less. Prepubertal patients may show failure to make the expected weight gain during the period of growth. The weight loss is self – induce by avoidance of “fattening foods”. One or more of the following may also be present: self – induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and / or diuretics. There is body image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself. A widespread endocrine disorder involving the hypothalamic pituitary – gonadal axis is manifest in women as amenorrhoea and in men as a loss of sexual interest and potency. (An apparent exception is the persistence of vaginal bleeds in anorexic women who are receiving replacement hormonal therapy, most commonly taken as a contraceptive pill.) There may also be elevated levels of growth hormone, raised levies of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion. If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). With recovery, puberty is often complete normally, but the menarche is late. Differential diagnosis : There may be associated depressive or obsessional symptoms, as well as features of a personality disorder, which may make differentiation difficult and / or require the use of more than one diagnostic code. Somatic causes of weight loss in young patients that must be distinguished include chronic debilitating diseases, brain tumors, and intestinal disorders such as Crohn’s disease or a malabsorption syndrome. Quetelet’s body-mass index =weight (kg) to be used for age 16 or above. [height (m)] Excludes : loss of appetite (R 63.0) Psychogenic loss of appetite (F 50.8) F50.1 Atypical Anorexia Nervosa : This term should be used for those individuals in whom one or more of the key features of anorexia nervosa (F50.0), such as amenorrhoea or significant weight loss, is absent, but who otherwise present a fairly typical clinical picture. Such people are usually encountered in psychiatric liaison services in general hospitals or in primary care. Patients who have all the key symptoms but to only a mild degree may also be best described by this term. This term should not be used for eating disorders that resemble anorexia nervosa but that are due to known physical illness. F50.2 Bulimia Nervosa : Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the “fattening” effects of ingested food. The term should be restricted to the form of the disorder that is related to anorexia nervosa by virtue of sharing the same psychopathology. The age and sex distribution is similar to that of anorexia nervosa, but the age of presentation tends to be slightly later. The disorder may be viewed as a sequel to persistent anorexia nervosa (although the reverse sequence may also occur). A previously anorexic patient may fist appear to improve as a result of weight gain and possibly a return of menstruation, but a pernicious pattern of overeating and vomiting then becomes established. Repeated vomiting is likely to give rise to disturbances of body electrolytes, physical complications (tetany, epileptic seizures, cardiac arrhythmias, muscular weakness), and further severe loss of weight. Diagnostic Guidelines For a definite diagnosis, all the following are required : There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time. The patient attempts to counteract the “fattening” effects of food by one or more of the following : self – included vomiting; purgative abuse, alternating periods of starvation; use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. The psychopathology consists of a morbid dread of fatness and the patient sets herself or himself or himself a sharply defined weight threshold, well below the premorbid weight that constitutes the optimum or healthy weight in the opinion of the physician. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. This earlier episode may have been fully expressed, or may have assumed a minor cryptic form with a moderate loss of weight and / or a transient phase of amenorrhoea. Includes : Bulimia NOS Hyperorexia nervosa Differential diagnosis. Bulimia nervosa must be differentiated from : Upper gastrointestinal disorders leading to repeated vomiting (the characteristic psychopathology is absent) ; A more general abnormality of personality (the eating disorder may coexist with alcohol dependence and petty offences such as shoplifting) ; Depressive disorder (bulimic patients often experience depressive symptoms). F50.3 Atypical Bulimia Nervosa This term should be used for those individuals in whom one or more of the key features listed for bulimia nervosa is absent, but who otherwise present a fairly typical clinical picture. Most commonly this applies to people with normal or even excessive weight but with typical periods of overeating followed by vomiting or purging. Partial syndromes together with depressive symptoms are also not uncommon, but if the depressive symptoms justify a separate diagnosis of a depressive disorder two separate diagnoses should be made. Includes : Normal Weight Bulimia. F50.4 Overeating Associated with other Psychological Disturbances Overeating that has led to obesity as a reaction to distressing events should be coded here. Bereavements, accidents, surgical operations, and emotionally distressing events may be followed by a “reactive obesity”, especially in individuals predisposed to weight gain. Obesity as a cause of psychological disturbance should not be coded here. Obesity may cause the individual to feel sensitive about his or her appearance and give rise to a lack of confidence in personal relationships; the subjective appraisal of body size may be exaggerated. Obesity as a cause of psychological disturbance should be coded in a category such as F38. – (other mood [affective] disorders), F41.2 (mixed anxiety and depressive disorder), or F48.9 (neurotic disorder, unspecified), plus a code from E66. – of ICD – 10 to indicate the type of obesity. Obesity as an undesirable effect of long-term treatment with neuroleptic antidepressants or other type of medication should not be coded here, but under E66.1 (drug-induced obesity) plus an additional code from Chapter XX ( External causes) of ICD-10, to identify the drug. Obesity may be the motivation for dieting, which in turn results in minor affective symptoms (anxiety, restlessness, weakness, and irritability) or, more rarely, severe depressive symptoms (“dieting depression”). The appropritate code from F30-F39 or F40-F49 should be used to cover the symptoms as above, plus F50.8 (other eating disorder) to indicate the dieting, plus a code from E66. – to indicate the type of obesity. Includes : Psychogenic overeating Excludes : Obesity (E66. - ) Polyphagia NOS (R63.2) F50.5 Vomiting associated with other psychological disturbances A part from the self-induced vomiting of bulimia nervosa, repeated vomiting may occur in dissociative disorders (F44. - ), in hypochondriacal disorder (F45.2) when vomiting may be one of several bodily symptoms, and in pregnancy when emotional factors may contribute to recurrent nausea and vomiting. Includes : Psychogenic hyperemesis gravidarum Psychogenic vomiting Excludes : Nausea and vomiting NOS (R11) F50.8 Other eating disorders Includes : Pica of nonorganic origin in adults Psychogenic loss of appetite F50.9 Eating disorder, unspecified General Treatment Modalities of Eating Disorders : Eating disorders are treatable and restoration of weight can be possible. Early diagnosis and prompt treatment has shown good prognosis or better outcomes. Eating disorder requires a comprehensive treatment plan includes monitoring, psychosocial interventions, medical care, nutritional counseling and drug therapy. At a time of diagnosis, the clinician must determine whether the person requires immediate hospitalization or can overcome difficulty or can be treated as out patient cases. People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting and staying in hospital for treatment. Family members can be of helpful in ensuring that the person with an eating disorder receives needed care and rehabilitation. Prepare structured schedules and make a contract with the client about behavioural agreement. Provide consistent communication with the client. Manipulate the clients environment to have desirable behaviour (Milieu therapy). Nutritionist will prepare the specific menu plans and discusses with the client and to the unit staff. Encourage the client to keep dietary long noting the type and amount of food consumed, associated thoughts and feelings related to food. Unit activities includes – community meetings, family therapy, group therapy, stress management, recreational therapy, interpersonal therapy, etc . Privilege systems will be planned and implemented when his condition improves and regains the normal eating pattern. For example, for bulimia nervosa cases-unsupervised bathroom visits, unrestricted activities unsupervised eating meals etc. Cognitive approaches (e.g. problem solving techniques client education dietary logs: self monitoring and self control, assertiveness techniques, etc.) will be used to modify psychopathology; to regulate the feeding pattern to correct the misbelieves and preconceptions or myth related to body image, body structure and food, etc. Behavioural approaches like role modeling, shaping, reinforcement, etc. techniques will be used to modify the eating pattern or habits. Interpersonal therapies will be used to modify the eating pattern or habits. Interpersonal therapies will be used to correct the strained interpersonal relationships. Individual psychotherapy, in which guidance and counseling services will be provided to the client to alter the thinking processes and to practice healthy eating pattern. Family Therapy : Family therapist will focuses the family to develop good family interactions and assists the client to adopt to the family environment and resolves the conflicts if any. Group Therapy : It provides deeper insight into the feelings and behaviour supportive groups or self help groups will be of helpful in providing constructive / moral support and positive feedback. Drug Therapy : Based on behavioural manifestations, appropriate medications will be used to modify symptomatology and to regain healthy life style.