So you want to have an eating disorder?

ANOREXIA NERVOSA:

Starving: Starving often starts out as dieting. But it is dieting that has spun out of control. Eating less than 1,200 calories a day starves the body. People who undereat are actually obsessed with food. How could they not be when they’re depriving themselves? Their bodies will push them to focus on food with the hope that they’ll finally consume something. They become anorexic by ignoring hunger signals, and therefore losing a significant amount of weight.

Diagnostic Criteria:

• Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
• Intense fear of gaining weight or becoming fat even though underweight.
• 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 denial of the seriousness of the current low body weight.
• In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles (A woman is considered to have amenorrhea if her periods occur only following hormone administration, e.g., estrogen).
• Specify type:
  • Restricting Type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).
  • Binge-Eating/Purging Type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas).
• Differential Diagnosis:
  • General Medical Conditions – person has a disease or illness (e.g., gastrointestinal disease, brain tumors, occult malignancies, or AIDS) that causes serious weight loss, but the person does not have a distorted body image and a desire for further weight loss.
  • Superior Mesenteric Artery Syndrome – person has postprandial vomiting secondary to intermittent gastric outlet obstruction. This syndrome can also be a result of emaciation in anorexia nervosa.
  • Major Depressive Disorder – person has severe weight loss but does not have desire to lose weight or an excessive fear of gaining weight.
  • Social Phobia – person feels embarrassed or humiliated to be seen eating in public.
  • Obsessive-Compulsive Disorder – person exhibits obsessions or compulsions related to food (e.g., food is contaminated).
  • Body Dysmorphic Disorder – person is preoccupied with an imagined defect in bodily appearance.
  • Can have major depression, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder along with anorexia nervosa.
  • Schizophrenia – person exhibits odd eating behavior or significant weight loss, but rarely shows fear of gaining weight or disturbed body image.
  • Bulimia Nervosa – even with bingeing and purging (as in some anorexia nervosa, binge-eating/purging type), person is able to maintain normal weight.

COMPLICATIONS

• Enlarged Cerebral Ventricles and Sulci in the Brain
• Dermatologic:
  • Brittle nails
  • Carotenodermia (dry, flaky skin)
  • Lanugolike facial hair (fine hair growth)
  • Pruritus (itchy skin)
  • Thinning scalp hair
• Cardiovascular:
  • Arrhythmias (irregular heart beat)
  • Bradycardia (slowed heart rate, below 60)
  • ECG abnormalities
  • Hypotension (low blood pressure)
  • Left ventricular dysfunction
  • Mitral valve motion irregularities
  • Reduced work capacity
  • Refeeding cardiomyopathy (heart muscle disease that can lead to cardiac collapse due to food introduction)
• Immunologic:
  • Reduced bactericidal capacity of granulocytes (reduced ability for white blood cells to fight infection)
  • Impaired cell-mediated immunity
  • Reduced granulocyte adherence
  • Reduced number of CD4 and CD8 cells (white blood cells)
  • Reduced serum complement levels
• Hematologic:
  • Anemia
  • Leukopenia (reduced white blood cells)
  • Reduced erythrocyte sedimentation rate (reduced red blood cell sedimentation rate)
• Endocrine:
  • Amenorrhea/hypogonadism
  • Cold sensitivity
  • Diabetes insipidus
  • Euthyroid sick syndrome (bone marrow is producing fewer red and white blood cells)
  • Hypoglycemia (low blood sugar levels)
  • Hypothalamic-pituitary-adrenal axis dysfunction (should work together through hormone interaction so body menstruates, has strong bones, and has normal thyroid function)
  • Osteopenia/osteoporosis (occurs after six months of not menstruating)
• Gastrointestinal:
  • Abdominal pain
  • Constipation
  • Decreased intestinal motility
  • Delayed gastric emptying
  • Duodenal dilation
  • Postprandial fullness (post-eating fullness)
  • Refeeding hepatitis
  • Refeeding pancreatitis
• Metabolic (Electrolyte Imbalance):
  • Hypercholesterolemia (high cholesterol)
  • Hypocalcemia (low calcium)
  • Hypokalemia (low potassium)
  • Hypomagnesaemia (low magnesium)
  • Hypophosphatemia (low phosphates-mineral is stored in bones so bones are weakened)

In addition to the symptoms above, other complications include:

• Body Mass Index (BMI), a gauge of total body fat:
  • Underweight: BMI < 18.9 
  • Moderate to severe anorexia: BMI ≤ 15 (Eagles et al., 1999)
• Loss of brain volume (Swayze, 1997)
• Slowed metabolic rate
• Malnutrition
• Loss of muscle mass
• Fatigue
• Dizziness
• Impaired attention, retention, and concentration
• Poor short- and long-term verbal memory performance (may be due to higher plasma homocysteine levels which are associated with cognitive decline in dementia and healthy elderly people) (Frieling et al., 2005)
• Depression
• Anxiety
• Obsessive-compulsive tendencies

Prevalence and Comorbidity Statistics:

• .5%-1% of general population (American Psychiatric Association, 1994)
• 50%-75% have major depression and/or dysthymia (American Psychiatric Association, 2000)
• 13% have bipolar disorder (American Psychiatric Association, 2000)
• 10%-13% have obsessive-compulsive disorder with a lifetime prevalence of 25% (American Psychiatric Association, 1993)
• 12%-18% report substance abuse (American Psychiatric Association, 2000)
• 20%-50% report sexual abuse, rates similar to other psychiatric populations (American Psychiatric Association, 2000).
• Personality Disorders, 42%-75% of individuals (American Psychiatric Association, 2000):
  • Avoidant
  • Obsessive-Compulsive
  • Dependent
  • Borderline

Recovery Rates (Mehler, 1996):

• 50% of patients recover completely
• 40% regain normal weight
• 25% remain emaciated
• 20% remain thin, although not dangerously so
• 15% become overweight
• 10-15% die prematurely due to complications of the illness

BULIMIA NERVOSA

Diagnostic Criteria:

• Recurrent episodes of binge eating as characterized by:
  • Eating, in a discrete period (i.e., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar time frame and under similar circumstances.
  • A sense of lack of control over eating during the episode (i.e., a feeling that one cannot stop eating or control what or how much one is eating).
• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
• Self-evaluation is unduly influenced by body shape and weight.
• The disturbance does not occur exclusively during episodes of anorexia nervosa.
• Specify type:
  • Purging Type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
  • Nonpurging Type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
• Differential Diagnosis:
  • Anorexia Nervosa, Binge-Eating/Purging Type – person has lost weight down to 85% of what is considered normal, and has stopped menstruating.
  • Kleine-Levin Syndrome – person has disturbed eating behavior but is not overly concerned with body shape or weight.
  • Major Depressive Disorder with Atypical Features – person overeats but does not binge or engage in compensatory behaviors and is not overly concerned with body shape and weight.
  • Borderline Personality Disorder – binge eating is included in impulsive behavior criteria. Both diagnoses can be given if bulimic symptoms present.
  • Binge First versus Diet First – most people with bulimia nervosa began dieting prior to binge eating; some started binge eating before they dieted. The binge first group more closely resembles individuals with binge-eating disorder than the group that dieted first (Haiman and Devlin, 1999).
  • Purging Disorder- is characterized by recurrent purging in the absence of objective binge episodes among normal-weight individuals. These individuals had significantly lower eating concerns, hunger, or disinhibition. Purging disorder may potentially be a clinically significant and distinct eating disorder (Keel, Haedt, et al., 2005)

BULIMIA NERVOSA

Physical Complications: Medical problems are directly related to the method and frequency of purging. Because most bulimics are within a normal weight range, they look healthy, but may have health concerns that need to be addressed (Mehler, 1996).

• Oral:
  • Cheliosis (cracking on side of lips due to stomach acid)
  • Dental Caries
  • Pharyngeal soreness (sore throat)
  • Sialadenosis (inflammation of salivary glands)
• Pulmonary:
  • Aspiration pneumonia (food gets into lungs causing pneumonia)
• Mediastinal:
  • Arrhythmias
  • Diet pill toxicity
    • Hypertension
    • Intracerebral hemorrhage
    • Palpitations
  • Hypotension
  • Syrup of Ipecac toxicity
    • Cardiomyopathy (disease of heart muscles)
    • Heart failure
    • Ventricular arrhythmias
  • Mitral valve prolapse
• Gastroesophageal:
  • Barrett’s esophagus (precancerous cells due to stomach acid being in esophagus)
  • Dyspepsia (acid reflux)
  • Dysphagia (pain or difficulty swallowing)
  • Esophageal rupture
  • Esophageal ulcer
  • Esophagitis (inflammation, a precursor to Barrett’s esophagus)
  • Hematamesis (throwing up blood)
  • Mallory-Weiss tears (dry heaves tear lining of esophagus, light blood in vomit)
  • Sore throat
• Gastrointestinal:
  • Cathartic colon (irritable bowel)
  • Constipation
  • Diarrhea
  • Hematochezia (blood in the stool)
  • Pancreatitis (inflammation of pancreas)
• Endocrine:
  • Diabetic complications
  • Hypoglycemia
  • Irregular menses
  • Mineralocorticoid excess (excessive adrenal-made steroid causes diabetes and increased blood pressure)
• Reproductive:
  • Low birth-weight infant
  • Spontaneous abortion
• Neuromuscular:
  • Diet pill toxicity
    • Seizures
  • Syrup of Ipecac toxicity
    • Neuromyopathy (disease of the muscular system)
• Fluid, Electrolyte, and Acid-Base (Electrolyte Imbalances):
  • Dehydration
  • Hyperamylasemia (make too much pancreatic enzyme that breaks down sugar)
  • Hypochloremia (low chloride)
  • Hypokalemia (low potassium)
  • Hypomagnesaemia (low magnesium)
  • Hyponatremia (low salt)
  • Idiopathic edema (swelling of hands, feet, face)
  • Metabolic acidosis (blood becomes acidic)
  • Metabolic alkalosis (blood become alkaline)
  • Pseudo-Bartter’s syndrome (condition of low electrolytes)
  • Russell’s sign- skin lesions on the hand consisting of abrasions, small lacerations, and callosities on the joints caused by repeated contact of the teeth to the skin when inducing vomiting (Daluiski et al., 1997).

In addition to the symptoms above, other complications include:

• Malnutrition
• Muscle weakness
• Depression
• Anxiety

Prevalence and Comorbidity Statistics:

• 1%-3% of general population (American Psychiatric Association, 1994)
• 50%-75% have major depression or dysthymia (American Psychiatric Association, 2000)
• 43% report anxiety (American Psychiatric Association, 1993)
• 30%-37% report substance abuse (American Psychiatric Association, 2000)
• 13% have bipolar disorder (American Psychiatric Association, 2000)
• 20%-50% report sexual abuse (rates similar to other psychiatric populations). (American Psychiatric Association, 2000)
• 25% of bulimics were originally anorexic (Mehler, 1996)
• An average of 60% of bulimics and recovered bulimics had narcissistic traits (Lehoux et al., 1999)
• Personality Disorders, 42%-75% of individuals (American Psychiatric Association, 2000):
  • Borderline
  • Avoidant
  • Histrionic
  • Dependent

Recovery Rates (Mehler, 1996):

• 80% of patients recover
• 25% of “recovered” patients retain some abnormal eating

Relapse for Anorexia Nervosa and Bulimia Nervosa (Keel et al., 2005)

• 35% of women with anorexia nervosa
• 35% of women with bulimia nervosa
• Greater body image disturbance contributed to relapse in both disorders with worse psychosocial function increasing risk for relapse in bulimia nervosa