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!