Eating disorders (ED) Václav Krmíček MD Department of Psychiatry: University Hospital Brno-Bohunice Faculty of Medicine, Masaryk University Classification of ED •Anorexia nervosa (AN) • •Bulimia nervosa (BN) • •Atypical AN or BN • •Binge eating disorder • Anorexie nervosa - behaviour •Restricting type: –food restriction (dieting, shrinking portions, periods of starvation) • •Binge-eating/purging type: –alternation of periods with food restriction and periods of overeating –followed by self-induced vomiting, abuse of laxatives, appetite suppressants and diuretics Anorexia nervosa - behaviour •Common symptoms –excessive exercise –body checking •mirror gazing, repaeted weighing •or avoidance the mirror and refusal to weigh –increased preoccupation with food •strict rules regarding food intake –counting the caloric value of foods –eating at precise time intervals •cooking for household members Anorexia nervosa - psychopathology •Intrusive dread of fatness and weight gain –even during severe malnutrition –leads to a self-imposed low weight threshold –remorse after eating – •Body image disturbance –overestimation of weight and body shape •particularly the buttocks, abdomen and thighs Anorexia nervosa - psychopathology • •Fluctuations of mood –reduction of social contacts –disrupted concentration – •Deny the severity of symptoms –they tend to lie and manipulate other people • Anorexia nervosa ICD-10 criterions •Body weight –decreases in BMI <17.5 – •Self-induced weight loss –food restriction (restricting type) –self-induced vomiting, abuse of laxatives, appetite suppressants and diuretics – (binge-eating/purging type) –excessive exercise – – Anorexia nervosa ICD-10 criterions • •Psychopathology –intrusive dread of fatness –body image disturbance •negative emotional evaluation of their body –self-imposed low weight threshold • Anorexia nervosa ICD-10 criterions •Primary or secondary amenorrhea –usually not present when using hormonal contraceptives •Delay or absence of pubertal symptoms •Changes in hormone level –↑ kortisol –secondary hypothyroidism Anorexia nervosa - epidemiology •Lifetime prevalence –for women it is about 0.5-2% –for men 0.3% •Just ½ are observed by specialists •Beginning –between 12 and 15 years –1. hospitalizazion between 15 and 19 years –rarely from 8 year Anorexia nervosa – personality •Perfectionism –low selfesteem –performance orientation • •Neurotic and introversion personality –anxious, inner insecure • •Dissatisfaction with one's body Anorexia nervosa – risk factors •Family constelation –predominant and hyperprotective mother –emotional distant and passive father •Lingering problems in the family –divorce –performance pressure –competition with sibling for attention • Anorexia nervosa - course •1 or a few episodes with healing –complete remision 19% • •More episodes during long period of life –partial remision 60% – •Chronic course with any remision –persistent illness 21% – •Mortality > 10% Anorexia nervosa - comorbidities •Depressive syndrom –symptom of malnutrition – •Anxiety disorders • •Obsedant compulsive disorder –intrusive thought of body shape, food –urge to exercise, vomit Health complications – general I • •Absence of sensations –hunger, satiety, fatigue –insensitive about pain • •Oedema –from hypoproteinemia Health complications – general II • •Deceleration or stopping of growth –hormonal stimulation after restoration of weight • •Cortical atrophy –deteoriation of cognition and emotions –infantile behaviour • Dermal complications •Acrocyanosis –cold and violet hands and foots •Hair loss •Lanugo hair –fine pale hair –back, forearm •Dry skinn •Fragile nails – Cardiovascular complications •Bradycardia –by 94% of patients –50% under 40 beats per minute –to 28 beats per minute –decreased response to exercice •Postural hypotension •Risk of malignant arrhythmia –cause of 1/3 death – Gastrointestinal complications •Hypomotility –slow gastric empthying (tension of stomach) –constipation and flatulence –correction of motility over 2 weeks of regular eating • •Salivary gland hypertrophy –from vomitting or persistnat feel of hunger Hormonal dysregulation •Amenorhea, infertility •Secondary hypothyroidism –↓ tyroxin (T4) a T3 –normal level of TSH •Osteoporosis –neuroendocrine inhibition of blastogenesis –↑ kortisol –50% on densitometry – Maternity complications •Perinatal problems –higher perinatal mortality –more ofen anxiety and depression symtoms –relationship problems with newborns • •Assisted reproduction –1/3 client with eating disorder –don´t admit desease Differential diagnosis of anorexia nervosa • •GIT deseases –esofagitis, gastritis, gastric ulcer –inflammatory bowel disease (Crohn's desease, ulcerative colitis) –celiac desease, food intolerance •Tumour •Hyperthyroidism Treatment of anorexia nervosa •Ambulatory –general practitioner –psychological care –psychiatric care –nutritive consultant •Hospitalization –malnutrition (under 15 BMI) –somatic complications (collapse) –failure of ambulatory care – Treatment during hospitalization •Regime therapy –food 5-6x a day –weekend permit only in a case of weight gain •Psychotherapy –individual, group or family (by children) •Drug therapy •Ergotherapy Anorexia mentalis - drug therapy •Antidepressants –SSRI, mirtazapin, trazodon –anxiety and depressive disorders, OCD •Anxiolytics –reduction of fear from wight gain and remorse after eating •Antipsychotics –olanzapin: massive anxiety, excessive exercise –sulpirid: stomach ache after eating Anorexia nervosa - psychotherapy •Individual –admit the severity of illnes –attitude to the body and food –personality and interpersonal problems •Group •Family –separation, competition with sibling •Education –patient and relatives Complications of psychotherapy •Effort to maintain the disease –feeling of uniqueness take self-confidence –need of attention (rivarly, divorce) • •Formal cooperation –ambivalnce to treatment and change –often change their attitude –they refer what we anticipate •not that they realy mean Bulimia nervosa - behaviour • •Typically –daily starvation with evening episodes of overeating of large amount of food –followed by self-induced vomiting Bulimia nervosa - psychopathology • •Intrusive dread of fatness and weight gain –leades to a self-imposed low weight threshold • •Strong desire to eat • •Depressive moods and remorse –after episodes of overeating Bulimia nervosa - somatic • •No significant malnutrition –even overweight can occur –weight fluctuations are greater than in anorexia nervosa Bulimia nervosa ICD-10 criteria •An intrusive dread of fatness •Permanently busy of the food –strong desire to eat –episodes of overeating of large amount food •Effort to suppress nutritious effect –self-induced vomiting –daily starvation –abuse of laxatives, appetite suppressants or diuretics, excessive exercise Bulimia nervosa - epidemiology •Lifetime prevalence –for women it is about 1.5-2,5% –for men 0.2% • •Just 1/8 s recognise by general practitioner • •Beginning –between 16 and 25 years • Bulimia nervosa - personality •Impulsive –behaviour without consideration –feeling of lower self-control –reduction of uncomfortable feelings • •Inclination –depressive disorder, unstable mood –drug abuse, promiscuity –self-harm behaviour, suicide attempt Health complications •Mineral imbalance –tetania, epileptoform seizures, arrhythmia –complication of •excessive vomiting •abuse of diuretics or overdrinking • •Due to frequent vomiting –tooth erosion –esophagitis Bulimia nervosa - treatment • •Don´t search professional help –often come for depression –after suicide attempts • •Psychotherapy –better motivation and cooperation than by anorexia nervosa Bulimia nervosa – drug treatment • •Antidepressants –SSRI: fluoxetin 60mg/day •heigher dosage than by depressive disorder • •Effect –comorbidities •depression, anxiety –heal itself disease •reduce frequency of bulimic episodes Binge eating disorder - behaviour • •Episodes of overeating of large amount of food • •Absence of compensatory behaviour –patients do not vomit –do not exercise –do not starve •due to dissatisfaction with their body, however, they may unsuccessfully diet Binge eating disorder -psychopathology • • • • • •Permanently busy of the food –strong desire to eat • • •Feeling of loss of control over food intake –reduction of uncomfortable feelings •maladaptive treating of stressful situations Binge eating disorder – somatic and comorbidites • • •Overweight or even morbid obesity • •Depressive and axiety disorders • – Binge eating disorder – treatment • •Psychotherapy • •Lifestyle changes –diet –exercise •Bariatric surgical interventions • Eating disorders by diabetes mellitus • •2x higher risk of eating diorder by DM I • •Manifest by noncompliance in healing of diabetes –„diabulimia“: reduce of dosage of insulin •weight depletion despite enough intake of food •inexplicable hypergylkemia •polyuria –binge eating diorder: 10-20x more frequent • Thank you for attention!