Eating disorders

Question 1

What is purging?

Answer 1

Purging refers to using compensatory measures such as vomiting, misusing laxatives, taking diet pills, or engaging in excessive exercise as a means of managing calorie intake.

Question 2

How much higher is the mortality rate among women with anorexia compared to the normal population?

Answer 2

12 times

Question 3

What (three) criteria is requried for a definitive diagnosis of bulimia nervosa within ICD-10?

Answer 3

A. 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

B. The patient attempts to counteract the
fattening effects of food by one or more of
the following: self-induced 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.

C. The psychopathology consists of a morbid dread of fatness and the patient sets herself 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 minor cryptic form with a moderate loss of weight and/or a transient phase of amenorrhea.

Question 4

What are the (five) diagnostic criteria for bulimia nervosa within DSM-5?

Answer 4

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 individuals 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. Recurrent inappropriate compensatory
behaviours 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 behaviours 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.

Question 5

What (five) criteria is requried for a definitive diagnosis of anorexia nervosa within ICD-10?

Answer 5

For a definitive diagnosis the following are required:
A. Body weight is maintained at least 15% below that expected (either lost or never achieved) or a Quetelet’s body mass index of 17.5 or less (BMI =Weight(kg)/height(m2 )). Prepubertal patients may show failure to make the expected weight gain during the period of growth.

B. The weight loss is self-induced by the avoidance of fattening foods, self-induced vomiting, self-induced purging, excessive
exercise, use of appetite suppressants or diuretics.

C. There is a 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 him or her self.

D. A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women
as amenorrhea and in men as a loss of sexual interest and potency. There may also be elevated levels of growth hormone, raised cortisol levels, changes in the peripheral metabolism of the thyroid hormone and abnormalities of
insulin secretion.

E. If the onset is prepubertal, the sequence of pubertal events is delayed or arrested (growth ceases; in girls breasts do not develop and there is a primary amenorrhea; in boys the genitals remain juvenile). With recovery, puberty is often
completed normally but the menarche is late.

Question 6

What are the (three) diagnostic criteria for anorexia nervosa within DSM-5?

Answer 6

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 of becoming fat, or persistent behaviour
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 lack of recognition of the seriousness of the current low body weight.

Question 7

What is amenorrhea?

Answer 7

The absence of menstruation

Question 8

What is menarche?

Answer 8

The first menstruation

Question 9

What is the primary difference between bulimia and anorexia?

Answer 9

Anorexia is characterised primarily by weight loss, whereas bulimia is characterised primarily by a cycle of bingeing and purging.

Question 10

What is the difference between bulimia and binge-eating disorder?

Answer 10

Binge-eating disorder does not involve laxative-use or vomitting.

Question 11

What are common self-destructive behaviours in bulimia?

Answer 11

Non-suicidal self-harm, suicide attempts, drug misuse

Question 12

How many patients attempt suicide with bulimia and anorexia respectively?

Answer 12

Bulimia: 25%
Anorexia: 20%

Question 13

Are anorexia and bulimia more common in men or women?

Answer 13

More common in female adolescents and young women (some young men also suffer from the eating disorders)

Question 14

How many % of the adolescent and young female population suffer from eating disorders?

Answer 14

1-2%, with bulimia being more common than anorexia

Question 15

Average prevalence rates for anorexia and bulimia among young females?

Answer 15

Anorexia: 0.3-0.5%
Bulimia: 1-4%

Question 16

Lifetime prevalence rates of anorexia and bulimia?

Answer 16

Anorexia: 0.16-0.3%
Bulimia: 0.1-0.5%

Question 17

Male to femalie ratioe of lifetime prevalence rates for anorexia and bulimia?

Answer 17

The male to female ratio of lifetime prevalence rates is 1:3–1:12 for anorexia and
1:3–1:18 for bulimia

Question 18

What comorbid disorders are seen with anorexia?

Answer 18

In clinical rather than community populations, comorbid mood disorders and obsessive-compulsive disorders are common in cases of anorexia

Question 19

What comorbid disorders are seen with bulimia?

Answer 19

For bulimia comorbid drug misuse and borderline personality disorder are relatively common.

Question 20

How are the outcomes for anorexia?

Answer 20

About half of all cases have a good outcome, a third have moderate outcome and a fifth have a poor outcome

Question 21

How are the outcomes for bulimia?

Answer 21

For bulimia nervosa about half of all cases have a good outcome, a quarter have a moderate outcome and the remaining quarter have a poor outcome.

Question 22

Something to be very aware of when conducting the assesment?

Answer 22

Many patients with bulimia or anorexia will be unsure of whether they want to get help; some might deny that they have a problem

Question 23

Which features are required to be present, if we are to provide inpatient treatment? (like re-feeding and weight restoration programmes)

Answer 23

• A BMI of 15 or less or a rapid fall in weight of more than 20% in 6 months;
• Bradycardia (less than 40 beats per minute);
• Hypotension (blood pressure less than 90/60 mmHg if over 16 years or 80/50 mmHg if
  under 16 years);
• Orthostatic drop greater than 10–20 mmHg;
• Severe dehydration;
• Hypoglycaemia;
• Poor diabetic control;
• Severe electrolyte imbalance (e.g. K+
  less than 2.5 mmol/L; Na+
  less than 130 mmol/L);
• Petechial rash and significant platelet suppression;
• Organ compromise – hepatic, renal, bone marrow;
• Uncontrolled vomiting;
• Gastrointestinal bleeding;
• Self-injurious or suicidal behaviour;
• Severe depression or OCD;
• Low motivation for treatment and lack of insight;
• Lack of response to outpatient treatment;
• Intolerable family situation (highly critical, abusive or collusive family);
• Unsupportive social situation (social isolation).

Question 24

Who should carry out the assesment, and what should it include?

Answer 24

Assessment should be carried out by a multidisciplinary
team and cover the client’s physical, nutritional and psychological states.
Assessment should include individual interviews with clients and collateral or conjoint interviews with partners, parents or concerned others.

Question 25

Name some things, that the assesment interview may cover

Answer 25

Assessment interviews may cover the circumstances of referral; the primary concerns of the client and of the concerned person if such a person prompted the referral; the client’s current daily eating, starving, bingeing and exercising patterns and cognitions related to these; history of dieting, weight and menstruation; use of diuretics; medical, psychological and social history; history of previous psychological and psychiatric treatment for eating disorders and other disorders; history and current status of possible comorbid disorders including depression, anxiety, obsessive-compulsive disorder (OCD), drug and alcohol misuse, or borderline personality disorder; and possible predisposing, precipitating and maintaining factors relevant to the eating disorder. Where appropriate, dietary histories may be taken in conjoint interviews with a nutritionist.

Question 26

How does bulimia nervosa and binge-eating disorder differ from eachother?

Answer 26

Binge eating will often be present in bulimia nervose, however, in binge-eating disorder the binge eating occurs without the compensatory behaviors found in bulimia nervose (such as extensive exercise, food restriction or purging)

Question 27

How many patients with anorexia also have bulimia?

Answer 27

40%-50%

Question 28

… may give way to …, but the reverse pattern is much rarer

Answer 28

1. Anorexia nervose
2. Bulimia nervosa

Question 29

Describe the psycodynamic understanding of anorexia nervosa (Gabbard, 2014)

Answer 29

To summarize our psychodynamic understanding of anorexia nervosa, the overt behavior of self-starvation is a multiply determined symptom. It is
1) a desperate attempt to be special and unique,
2) an attack on the false sense of self fostered by parental expectations,
3) an assertion of a nascent true self,
4) an attack on a hostile maternal introject viewed as equivalent to the body,
5) a defense against greed and desire,
6) an effort to make others—rather than the patient—feel greedy and helpless,
7) a defensive attempt to prevent un- metabolized projections from the parents from entering the patient,
8) an es- calating cry for help to shake the parents out of their self-absorption and make them aware of the child’s suffering, and
9) in some cases a dissociative defense into separate self-states as a way of regulating intense affec

Question 30

What is the prevalence of binge-eating disorder in community samples?

Answer 30

3.5%

Question 31

Describe some of the psycodynamic understanding of bulimia nervosa (Gabbard, 2014)

Answer 31

A common theme in the developmental history of bulimic patients is the absence of a transitional object, such as a pacifier or blanket, to help the child separate psychologically from her mother (Good- sitt 1983). This developmental struggle to separate may be played out in- stead by using the body itself as a transitional object (Sugarman and Kurash 1982), with the ingestion of food representing a wish for symbiotic merger with the mother and the expulsion of food an effort at separation from her.

The bulimic family system apparently involves a strong need for everyone to see themselves as “all good.” Unacceptable qualities in the parents are often projected onto the bulimic child, who becomes the re- pository of all “badness.”

In many instances, then, bulimic patients concretize the object relations mechanisms of introjection and projection. Ingestion and expulsion of food may directly reflect the introjection and projection of aggressive, or “bad,” introjects.