Eating Disorders Flashcards
Historical differences between AN and BN: Anorexia
Anorexia Nervosa
- Gull later changed the name to “nervosa” to avoid confusion with hysteria
- Although quite descriptive, the word anorexia is a misnomer, as the term literally means “lack of appetite,” which is, in fact, rare.
- Not simply a product of the modern society
- Both Anorexia Nervosa and Bulimia Nervosa patients share an intense preoccupation with body weight and shape
Historical differences between AN and BN: Bulimia
Bulimia Nervosa
- Bulimia Nervosa (BN), by contrast, was first clinically described in 1979
- Historical accounts date to 1398, when “true boulimus” was described in an individual having an intense preoccupation with food and over eating at very short intervals, terminated by vomiting (Stein & Laakso, 1988).
- The word bulimia is derived from Greek and means “ravenous hunger,” the opposite of anorexia.
- Much less has been historically made of bulimic behavior, and consequently, we have significantly less knowledge of this disorder.
DSM-5 Diagnostic Criteria: AN
i. Marked self-induced weight loss or failure to make expected weight gain during growth, resulting in body weight less than 85% expected
ii. Intense fear of weight gain or becoming fat, despite being underweight
iii. Fundamental disturbance in the way in which one perceives his or her body weight or shape, such that one feels overweight despite evidence to the contrary and harshly evaluates oneself based on body weight and shape
iv. Endocrine changes resulting in amenorrhea in females for at least 3 consecutive months and a lack of sexual interest, virulence, and potency in males
DSM-5 Diagnostic Criteria: BN
i. Recurrent episodes of binge eating
ii. Repeated compensatory behaviors in an effort to counteract weight gain, such as vomiting, misusing laxatives, diuretics, enemas, or other medications, fasting, or exercising excessively (twice a week for at least 3 months)
iii. One’s self evaluation is overly influenced by body weight and shape
Subtypes of AN and BN
2 major subtypes of anorexia:
(1) Restricting Type: fasting, itroverted, decreased risk of substance abuse, family conflict is covert
(2) Bulimic Type: binge eating or purging, more volatile, family frequently disengaged, prone to substance abuse
One type of bulimia
Anorexia vs Bulimia
- Anorexia denies abnormal eating behavior, bulimia recognizes abnormal eating behavior
- anorexia introverted, bulimia extroverted
- anorexia turns away food in order to cope, bulimia turns to food in order to cope
- anorexia has preoccupation with losing more and more weight, bulimia has a preoccupation with attaining an “ideal” but often unrealistic weight.
Mortality rates with AN:
50% of deaths due to complications of anorexia, 25% die by suicide, and 25% die of unrelated causes
Long-term follow-up studies of anorexics show death rates of over 10% after 10 years and 18-30% at 30 yr f/u – highest mortality rate in psychiatry***
- Bulimics face an increased risk of depression; anxiety d/o may also be increased
- The lifetime prevalence of substance abuse/dependence among bulimics (particularly alcohol and stimulants) is at least 30% (25% among all patients with an eating disorder)
- The diagnosis of a personality d/o among bulimics is not uncommon (especially Borderline PD)
Psychosocial Etiology of Eating Disorders
i. Numerous, yet unproven theories, as to why people develop anorexia.
ii. Early psychological theories proposed that anorexia represents a phobic avoidance to food and an association with the sexual tensions generated during puberty
iii. Psychodynamic formulations have suggested that anorexic patients have fantasies of oral impregnation.
iv. Social theories stress the importance of conforming to the American ideal of youth, beauty, and slimness.
v. Modern psychological theories stress that these patients are avoidant of maturational challenges which are perceived as insurmountable; concretization and avoidance of psychological discord follow thereafter.
vi. They aim for the antithesis of puberty—these kids are unprepared and exert control by not eating, thereby staying young and immature; they experience profound self-loathing, along with the illusion of competence because of the ability to follow rules.
vii. They feel incompetent, out of control, and delight in their weight loss because they’re really good dieters.
viii. Family theory suggests that AN results from a cry for help from a child enmeshed in a conflicted and disfunctional family (Minuchin et al, 1978)
ix. Unconscious collusion among family members perpetuates the child’s symptoms because focus on the child defuses the parental conflicts.
x. Cognitive-behavior theory, meanwhile, proposes that individuals are rewarded by peers and society for being slender, which for some can be sufficiently powerful to maintain the illness despite the health risks.
xi. Finally, the social and cultural emphasis upon being thin and the associated pressures that are overtly and covertly placed upon children are believed to contribute in some way to the genesis of Eating Disorders (Brumberg, 1988).
Biological Etiology of eating disorders
Biological Theory
- Biological theories focus on the role of the hypothalamus (the region concerned with the regulation of body functions, such as temperature, weight, appetite, & general homeostasis); support for this theory comes from neurotransmitter studies showing an increase in Corticotropin Releasing Factor (CRF) in the CSF of anorexic patients
- CRH is secreted by the hypothalamus in response to stress
- When administered to rats, CRF leads to a reduction in food intake, feeding time, & feeding episodes; it also leads to an increase in grooming time & grooming episodes
- The occurrence of amenorrhea before weight loss also suggests a hypothalamic disturbance (occurs in 20% of patients)
- Leptin, another hormone (the satiety hormone), may also have a role
- Low circulating levels of leptin are associated with key symptoms of anorexia, including amenorrhea and semistarvation-induced hyperactivity
- Leptin is secreted by adipose tissue and once fat levels drop precipitously low, no more leptin is released
- Leads to down regulation of hypothalamic-pituitary-gonadal (decrease sex hormones) and thyroid axes and up regulation of hypothalamic-pituitary-adrenal axis (increase stress hormones)
- Other peptides may also be involved, including adiponectin, resistin, ghrelin, peptide YY, neurotrophin brain-derived neurotrophic factor (BDNF), and endocanabinoid substances
- There is also evidence of a central neurotransmitter system dysregulation affecting 5HT, DA, and NOREPI; the strongest evidence supports reduced NOREPI activity and turnover
- Vomiting leads to an increase in DA levels which reinforces/rewards the vomiting behavior
- Theories of serotonergic hyperfunctioning in anorexia and serotonergic hypofunctioning in bulimia are attractive but don’t explain why SSRIs are sometimes helpful for both
FAMILIAL TRANSMISSION/GENETICS
Genetics
- Eating Disorders are familial.
- The risk of AN among mothers and sisters of probands is estimated at 3% or about six times the rate among the general population (Strober et al, 2000).
- A large twin registry study appears to confirm that BN and AN are related. One study found that the co-twin of a child with AN was 2.6 times more likely to have a diagnosis of BN than were co-twins of children without an Eating Disorder (Walters and Kendler, 1995).
- Twin studies confirm a genetic link. Studies of identical or monozygotic twins show concordance of up to 90% for AN and 83% for BN (Kaye et al, 2000).
- Nearly all women in Western society diet at some point in adolescence or young adulthood, yet fewer than 1% develop AN.
Comorbidities
a. Anoretics face an increased risk of depression, anxiety d/o (especially OCD and Social Phobia), and personality d/o (cluster C in anorectic restrictors; cluster B and C in anorectic bulimics)
b. Bulimics face an increased risk of depression; anxiety d/o may also be increased.
c. The lifetime prevalence of substance abuse/dependence among bulimics (particularly alcohol and stimulants) is at least 30% (25% among all patients with an eating disorder)
d. The diagnosis of a personality disorder among bulimics is no uncommon (especially Borderline PD).
Methods of purging
a. Misuse of Laxatives, diuretics
b. Exercises excessively
c. Self-induce vomiting
Health consequences of AN
i. Hypothermia
ii. Dependent edema
iii. Anemia
iv. Impaired renal function
v. Bradycardia
vi. Hypotension
vii. Cardiac arrhythmias
viii. Lanugo (soft downy hair on the skin)
ix. Osteoporosis
x. Brain atrophy
xi. Hormonal abnormalities
1. Elevated growth hormone
2. Plasma cortisol levels
xii. Amenorrhea
xiii. Constipation
xiv. Abdominal pain
xv. Cold intolerance
xvi. Lethargy
xvii. Excessive energy
Health consequences of BN
i. Calluses on the dorsal surface of their hands from self-induced vomiting
ii. Biting or clamping down of their jaw that follows the gag reflex.
iii. Dental caries due to corrosion of the enamel from stomach acid
iv. Esophageal erosion—risk of rupture.
v. Enlarged parotid glands—“chipmunk face”
vi. Bradycardia
vii. Hypotension
viii. Cardiac arrhythmias
ix. Hypokalemia (low potassium)
x. Lanugo hair
xi. Hypocalcemia (low calcium)
xii. Hypochloridemia (low chloride)
xiii. Hypokalemia
xiv. Metabolic alkalosis
xv. Electrolyte disturbances
xvi. Serum transaminase—increases reflecting fatty degeneration of the liver, lethargy, and seizures.
Risk factors for BN
Risk Factors for BN: dieting, puberty, transitions (e.g., college, new job, relationship break-up), various jobs (athletes, actors, models), anorexia, impulsivity, and anxiety
