3. General warning signs
Preoccupied with food, eating and dieting
Compulsive exercising
Negative thoughts about self esp. body image
Social withdrawal
Difficult in tolerating cold
Weight leading to cessation of menses in women
4. Anorexia nervosa
Anorexia means prolonged loss of appetite.
Anorexia nervosa is characterized by a morbid fear of obesity. Symptoms
include gross distortion of body image, preoccupation with food, and refusal
to eat.
The distortion in body image is manifested by the individual’s perception of
being “fat” when he or she is obviously underweight or even emaciated
(excessively thin).
Weight loss is usually accomplished by reduction in food intake and often
extensive exercising. Self-induced vomiting and the abuse of laxatives or
diuretics also may occur.
Age at onset is usually early to late adolescence(14-18 years) and
psychosexual development is often delayed. Feeling of depression and anxiety
often accompany the disorder.
5. continued
Weight loss is excessive. For example, the individual may present for
healthcare services weighing less than 85 percent of expected weight.
Other symptoms include hypothermia, bradycardia, hypotension, edema,
lanugo, and a variety of metabolic changes. Amenorrhea (absence of
menstruation) usually follows weight loss, but sometimes it happens early on
in the disorder, even before severe weight loss has occurred.
Individuals with anorexia nervosa may be obsessed with food. For example,
they may hoard or conceal food, talk about food and recipes at great length,
or prepare elaborate meals for others, only to restrict themselves to a limited
amount of low-calorie food intake.
Compulsive behaviors, such as hand washing, may also be present.
6. Types
Restrictive: No binge eating or purging behavior
Binge eating/purging: binge eating or purging(induce-vomiting, use laxative,
diuretics or enemas).
7. Clinical presentation
Extreme wt loss: BMI ≤ 17.5 or ≤ 85% of expected wt for children
Bradycardia, reduced basal metabolic rate, anaemia, hypothermia, hypotension
Suppressed immunity, electrolyte imbalance, Lanugo hair, damage to
teeth/esophagus
Cardiac arrhythmias due to potassium loss
low threshold to cold
Personality traits: Inflexible, rigid and stubborn
8. Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a weight
that is less than minimally normal, or, for children and adolescents, less than
that minimally expected.
B. Intense fear of gaining weight or becoming fat, or persistent behavior that
interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced,
undue influence of body weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current low body weight.
9. Management- biopsychosocial model
Severe cases: hospitalization to focus on malnutrition and electrolyte balance
for ≤ 75 % body weight.
Pharmacotherapy: SSRIs, Anxiolytics for accompanying depressive, anxiety
symptoms.
Psychological interventions: Individual therapy, CBT, group therapy,
CBT: cognitive distortions of body image
Social interventions: Family and friends social support
10. Bulimia Nervosa
Bulimia means Excessive, insatiable appetite.
Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of
large quantities of food over a short period of time (binging), followed by
inappropriate compensatory behaviors to rid the body of the excess calories.
The food consumed during a binge often has a high caloric content, a sweet
taste, and a soft or smooth texture that can be eaten rapidly, sometimes
even without being chewed.
The binging episodes often occur in secret and are usually only terminated by
abdominal discomfort, sleep, social interruption, or self-induced vomiting.
Although the eating binges may bring pleasure while they are occurring, self-
degradation and depressed mood commonly follow.
11. To rid the body of the excessive calories, the individual may engage in purging
behaviors (self-induced vomiting, or the misuse of laxatives, diuretics, or
enemas) or other inappropriate compensatory behaviors, such as fasting or
excessive exercise.
Excessive vomiting and laxative or diuretic abuse may lead to problems
with dehydration and electrolyte imbalance. Gastric acid in the vomitus
also contributes to the erosion of tooth enamel.
In rare instances, the individual may experience tears in the gastric or
esophageal mucosa.
Some people with this disorder are subject to mood disorders, anxiety
disorders, or substance abuse, most frequently involving central nervous
central (CNS) stimulants or alcohol.
12. Begins in adolescence/early adult usually in females (15-24yrs)
Persons often hide their behaviour/illness
Women seek healthcare for GIT or menstrual problems
3 Patterns
Binge eating vs normal eating
Normal eating vs fasting
Binging and fasting
Key features are Binge eating within less than 2 hours, Compensate through
purging, exercise or use laxative and Secretive about their binging e.g. hide
food.
13. Types
Purging : vomiting, use laxative to ‘remove food’
Non-purging: excessive exercise or fasting to cope with binging
Bulimic maintain normal body weight while anorexics are characterized by
extreme weight loss.
14. Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period) an amount
of food that is definitely larger than most individuals would eat during a similar
period of time and under similar circumstances.
2. 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).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain,
such as self-induced vomiting; misuse of laxatives, diuretics, or other medications;
fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on
average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
15. Management
Biological interventions- If in-patient, restrict available food, Treat any
health-related problem such as dental due to vomiting or electrolyte
imbalance, Pharmacotherapy such as SSRIs
Psychological interventions- Group therapy for social support CBT to boost r
self-esteem, modify body image distortions and controlling negative feelings
such as anxiety
Self-monitoring for precipitating factors
Psychoeducation
Social interventions- Family therapy for support
16. Predisposing Factors Associated with Anorexia
Nervosa and Bulimia Nervosa
Biological Influences- such as genetics, neuroendocrine abnormalities and
neurochemical influences.
Genetics A hereditary predisposition to eating disorders has been hypothesized on
the basis of family histories and an apparent association with other disorders
for which the likelihood of genetic influences exists.
Neuroendocrine Abnormalities Some speculation has occurred regarding a primary
hypothalamic dysfunction in anorexia nervosa. Studies consistent with this theory
have revealed elevated cerebrospinal fluid cortisol levels and a possible
impairment of dopaminergic regulation in individuals with anorexia nervosa.
Neurochemical Influences. Neurochemical influences in bulimia nervosa may be
associated with the neurotransmitters serotonin and norepinephrine. This
hypothesis has been supported by the positive response these individuals have
shown to therapy with the selective serotonin reuptake inhibitors (SSRIs). Some
studies have found high levels of endogenous opioids in the spinal fluid of clients
with anorexia nervosa, promoting the speculation that these chemicals may
contribute to denial of hunger.
17. Psychodynamic Influences
Psychodynamic theories suggest that eating disorders result from very early
and profound disturbances in mother-infant interactions
The result is delayed ego development in the child and an unfulfilled sense of
separation-individuation.
18. Family Influences
Conflict Avoidance - In the theory of the family as a system, psychosomatic
symptoms, including anorexia nervosa, are reinforced in an effort to avoid
spousal conflict. Parents are able to deny marital conflict by defining the sick
child as the family problem.
19. obesity
Obesity is not classified as a psychiatric disorder in the DSM-5, but because of
the strong emotional factors and the potential serious health consequences
associated with the condition, it may be considered under “Psychological
Factors Affecting Medical Condition.”
20. Binge-eating disorder (BED)
Obesity is a factor in BED because the individual binges on large amounts of
food (as in bulimia nervosa) but does not engage in behaviors to rid the body
of the excess calories.
21. Diagnostic Criteria for Binge-Eating
Disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. 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
2. 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)
B. The binge-eating episodes are associated with 3 (or more) of the following:
1. Eating much more rapidly than normal
2. Eating until feeling uncomfortably full
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating
5. Feeling disgusted with oneself, depressed, or very guilty after overeating
22. C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate
compensatory behavior as in bulimia nervosa and does not occur exclusively
during the course of bulimia nervosa or anorexia nervosa.
23. Based on criteria of the World Health Organization, obesity is defined as a
BMI of 30.0 or greater.
Individuals who are obese often present with hypertension and
hyperlipidemia, particularly elevated triglyceride and cholesterol levels.
They commonly have hyperglycemia and are at risk for developing diabetes
mellitus.
Osteoarthritis may be evident because of trauma to weight-bearing joints.
Workload on the heart and lungs is increased, often leading to symptoms of
angina or respiratory insufficiency.
24. Predisposing Factors Associated With
Obesity
Biological Influences
Genetics- heredity is a predisposing factor to obesity.
Physiological Factors - Lesions in the appetite and satiety centers in the
hypothalamus may contribute to overeating and lead to obesity. Hypothyroidism
is a problem that interferes with basal metabolism and may lead to weight
gain. Weight gain can also occur in response to the decreased insulin
production of diabetes mellitus and the increased cortisone production of
Cushing’s disease.
Lifestyle Factors On a more basic level, obesity can be viewed as the ingestion of
a greater number of calories than are expended. Weight gain occurs when caloric
intake exceeds caloric output in terms of basal metabolism and physical activity.
Many overweight individuals lead sedentary lifestyles, making it very difficult to
burn off calories.
25. Psychosocial Influences
The psychoanalytic view of obesity proposes that obese individuals have
unresolved dependency needs and are fixed in the oral stage of psychosexual
development.
The symptoms of obesity are viewed as depressive equivalents, attempts
to regain “lost” or frustrated nurturance and caring.
Depression and binge eating are strongly linked.
26. Binge-Eating Disorder diagnostic criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by
both of the following:
1. 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.
2. 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).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
27. C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of
inappropriate compensatory behavior as in bulimia nervosa and does not
occur exclusively during the course of bulimia nervosa or anorexia nervosa.
28. Pica diagnostic criteria
A. Persistent eating of nonnutritive, nonfood substances over a period of at least
1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the
developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially
normative practice.
D. If the eating behavior occurs in the context of another mental disorder
(e.g., intellectual developmental disorder [intellectual disability], autism
spectrum disorder, schizophrenia) or medical condition (including
pregnancy), it is sufficiently severe to warrant additional clinical attention.
