Eating disorders / Anorexia Nervosa / Psychiatry

1-Eating Disorders
2-Anorexia Nervosa
-Definition
-Subtypes
-Etiology
-Ebdimyology
-Physical findings and complications
-DSM-5 Diagnostic Criteria
-Course and Prognosis
-Treatment

1. Eating Disorders Eating disorders are characterized by a persistent disturbance of eating that impairs health or psychosocial functioning. The disorders include anorexia nervosa , binge eating disorder , bulimia nervosa , pica , and rumination disorder . and affect both females and males .

2. Eating disorders can develop during any stage in life but typically appear during the teen years or young adulthood. Although these conditions are treatable, the symptoms and consequences can be detrimental and deadly if not addressed. Eating disorders commonly coexist with other conditions, such as anxiety disorders , substance abuse , or depression . https://www.eatingdisorderhope.com/information/eating-disorder

3. Anorexia Nervosa Rachael Farrokh http://www.be-a-woman.com/en/saude-sexo/rachael-farrokh-a-americana-que-esta-a-vencer-a-anorexia-nervosa-esta-em-portugal-pesa-20-quilos-e-pede-ajuda/

4. Definition: Anorexia nervosa (AN) is an eating disorder defined as an abnormally low body weight associated with intense fear of gaining weight and distorted cognitions regarding weight, shape, and drive for thinness. It is often associated with obsessive-compulsive personality traits . Anorexia nervosa has the highest mortality of any psychiatric disorder.

5. There are two main sub types: Restricting type: Has not regularly engaged in binge-eating or purging behavior; weight loss is achieved through diet, fasting, and/or excessive exercise. Binge-eating/purging type: Eating binges followed by self-induced vomiting, and/or using laxatives, enemas, or diuretics. Some individuals purge after eating small amounts of food without binging.

6. Multifactorial. Genetics: Higher concordance in monozygotic ( 55 %) than dizygotic twin studies ( 5 %). Psychodynamic theories: Difficulty with separation and autonomy (e.g., parental enmeshment ), and struggle to gain control. Social theories: Exaggeration of social values (achievement, control, and perfectionism). Idealization of thin body. ↑ prevalence of dieting at earlier ages. Etiology

7. Epidemiologiy 10 : 1 female to male ratio Average age is 17 years. More common in industrialized countries where food is abundant and a thin body ideal is held. Common in sports that involve thinness, revealing attire, subjective judging, and weight classes (e.g., running, ballet, wrestling, diving, cheerleading, figure skating).

8. PHYSICAL FINDINGS AND MEDICAL COMPLICATINS With pure food restriction, once weight loss below approximately 15–20 percent of ideal body weight occurs, there is often the development of gastroparesis. Bradycardia (pulse <60) and hypotension are among the most common physical findings in patients with anorexia nervosa, with bradycardia seen in up to 95% of patients. As weight loss worsens due to the nutritional deprivation, it is common for the patient with anorexia nervosa to have dry skin which can fissure and bleed especially in the fingers and toes.

9. PHYSICAL FINDINGS AND MEDICAL COMPLICATINS The bone marrow is adversely affected by anorexia nervosa. All three cell lines, namely red blood cells, white blood cells and platelets, may be affected by anorexia nervosa. Specifically, anemia and leukopenia occur in approximately one-third of the patients and thrombocytopenia occurs in ten percent. Severe cases of anorexia nervosa may appear, on magnetic resonance imaging (MRI), to be indistinguishable from the brain of a person with Alzheimer’s disease; ventricles are enlarged and cortical substance is decreased.

10. PHYSICAL FINDINGS AND MEDICAL COMPLICATINS

11. DSM-5 Diagnostic Criteria Restriction of energy intake relative to requirements --> leading to significant low body weight. Defined as less than minimally normal or expected. Intense fear of gaining weight or becoming fat , or persistent behaviors that prevent weight gain Disturbed body image , undue influence of weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

12. COURSE AND PROGNOSIS Chronic and relapsing illness. Variable course May completely recover, Have fluctuating symptoms with relapses, Or progressively deteriorate. Most remit within 5 years. Mortality rate is cumulative and approximately 5% per decade due to starvation, suicide, or cardiac failure. Rates of suicide are approximately 12 per 100,000 per year.

13. TREATMENT Food is the best medicine! Patients may be treated as outpatients unless they are dangerously below ideal body weight (>20–25% below) or if there are serious medical or psychiatric complications, in which case they should be hospitalized for supervised refeeding. Treatment involves: cognitive- behavioral therapy , family therapy (e.g., Maudsley approach), and supervised weight-gain programs . Selective serotonin reuptake inhibitors (SSRIs) have not been effective in the treatment of anorexia nervosa but may be used for comorbid anxiety or depression.

14. Family-Based Treatment for AN Developed in London at the Maudsley Hospital (1980s) First line treatment for medically stable children and adolescents with AN Outpatient treatment to restore weight and return adolescent to developmental track Team approach, i.e., parents, therapist, paediatrician and psychiatrist

15. MCQs Which of the following is not a common feature of Anorexia Nervosa? Binge eating Amenorrhoea Self perception of being ‘fat` Under weight Which of the following is a diagnostic criterion for anorexia nervosa in DSM-IV-TR? A refusal to maintain a minimal body weight A pathological fear of gaining weight A distorted body image in which, even when clearly emaciated, sufferers continue to insist they are overweight All of the above

16. MCQs In Restricted Type anorexia nervosa, self-starvation is NOT associated with which of the following? Concurrent purging Socialising Body dysmorphic issues Eating only certain food types What are common anorexia symptoms? Anxiety and depression Weakness and shortness of breath Unhealthy complexion and brittle skin Any of the above

17. References : American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013. https://www.eatingdisorderhope.com/information/eating-disorder Ganti , Latha . (2005). First aid for the psychiatry clerkship : a student-to-student guide. New York :McGraw-Hill, Medical Pub. Div., Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry 2006;19:389-94. Marwick, K. (2013). Crash Course Psychiatry (4th edition). Elsevier Ltd. Kaplan Test Prep: USMLE Step 2 CK Lecture Notes 2017 - Psychiatry, Epidemiology, Ethics, Patient Safety Vol. by Kaplan Medical Staff. Mehler , P. S., & Brown, C. (2015). Anorexia nervosa - medical complications. Journal of eating disorders, 3, 11. doi:10.1186/s40337-015-0040-8. https://www.eatingdisorders.org.au/eating-disorders/anorexia-nervosa