t
Troubled interpersonal or family relationships.
t
Treatment is usually as an outpatient but hospitalisation
t
Being ridiculed because of size or weight.
Culture
Cultures that place a high value on being thin and consequent
media messages/adverts encouraging dieting may contribute.
Anorexia nervosa
t
There are restrictive (minimal food intake and exercise) and
bulimic (episodic binge-eating with laxative use and induced
vomiting) subtypes.
t
Diagnosis (ICD-10/DSM-5) requires:
t
a morbid fear of fatness;
t
deliberate weight loss;
t
distorted body image;
t
Body Mass Index (BMI, weight [kg]/ht [m]2) <17.5;
t
amenorrhoea (primary prepubertally, or secondary; oral
contraceptive pill may still cause vaginal bleeds);
t
loss of sexual interest and potency in men; in prepubertal
boys development will be arrested.
t
Associated clinical features include:
t
preoccupation with food (dieting, preparation of elaborate
meals for others);
t
self-consciousness about eating in public, socially isolating
behavior;
t
vigorous exercise;
t
constipation;
t
cold intolerance;
t
depressive and obsessivecompulsive symptoms.
t
Physical signs/complications include:
t
emaciation: often disguised by make-up/clothes;
t
dry and yellow skin;
t
fine lanugo hair on the face and trunk;
t
bradycardia and hypotension;
t
anaemia and leucopenia;
t
consequences of repeated vomiting, including hypokalae-
mia, alkalosis, pitted teeth, parotid swelling and scarring of the
dorsum of the hand (Russells sign).
t
Differential diagnosis
t
Organic causes of low weight (e.g. diabetes mellitus), which
are not usually associated with abnormal attitudes to weight or
eating. Diabetes may, however, coexist with anorexia.
t
Psychiatric causes of low weight include depression (which
may also coexist with anorexia), psychotic disorders with delu-
sions concerning food, and substance or alcohol abuse.
t
Management
t
Patients value their emaciated state and are usually ambiva-
lent about treatment. Good therapeutic rapport and motiva-
tional counselling are important.
t
Exclude other diagnoses and monitor physical health.
t
For adolescents, family interventions are first line.
t
For adults, effective psychological therapies include cogni-
tive behavioural therapy (CBT), interpersonal psychother-
apy (IPT), focal psychodynamic therapy and family therapy
(Chapter 33).
t
Specialist inpatient programmes typically provide a struc-
tured, symptom-focused treatment regime to achieve weight
restoration. In very severe cases, nasogastric feeding may be
instigated without the patients consent under the Mental
Health Act.
t
Coexistent depression should improve with weight gain,
even without antidepressants.
29
may be needed because of:
severe or rapid weight loss, or BMI <13.5, because of high
Chapter 13 Eating Disorders
risk of fatal arrhythmia or hypoglycaemia
significant suicide risk
physical sequelae of starvation or purging.
t
Prognosis
t
Anorexia has the highest death rate of any psychiatric disor-
der (see Figure 13.1 for prognosis).
t
Osteoporosis is a long-term complication.
Bulimia nervosa
t
Diagnosis (ICD-10/DSM-5) requires the presence of:
t
a morbid fear of fatness;
t
craving for food and binge-eating (of large amounts in a
short time (e.g. >2000 kcal in a session));
t
recurrent behaviours to prevent weight gain (e.g. self-
induced vomiting; misuse of laxatives, diuretics, enemas;
omitting insulin; if diabetic; fasting or excessive exercise);
t
preoccupation with body weight and shape.
t
episodes are not exclusively during episodes of anorexia ner-
vosa.
t
Associated clinical features include:
t
normal or excessive weight (which often fluctuates);
t
loss of control or in a trance-like state during bingeing;
t
intense self-loathing and associated depression;
t
in multi-impulsive bulimia, alcohol and drug misuse, delib-
erate self-harm, stealing and/or sexual disinhibition coexist;
poor impulse control is the common pathology.
t
Physical signs/complications include:
t
amenorrhoea, which occurs in 50% (despite normal weight);
t
hypokalaemia, which may cause dysrhythmias or renal damage;
t
signs of excessive vomiting; acute oesophageal tears can
occur during forced vomiting.
t
Differential diagnosis
t
Consider anorexia nervosa, affective disorder and obesity.
t
Rare causes of overeating include KleineLevin and Klver
Bucy syndromes (see Glossary).
t
Management involves:
t
medical stabilisation;
t
psychotherapy (usually CBT or IPT) to establish a regular
eating programme, re-establish control of diet and address
underlying abnormal cognitions;
t
antidepressants; these are effective, best established for
fluoxetine (60 mg) but less effective than CBT.
t
Prognosis
t
With CBT or IPT, 3040% achieve remission, gains which
are typically maintained.
Binge-eating disorder and obesity
t
This involves binge-eating with associated subjective loss of
control and distress, without purging, and typically leads to obe-
sity (BMI >30).
t
Aetiological factors of obesity include:
t
weight-controlling genes
t
family and cultural influences
t
high availability of cheap calorific foods
t
a sedentary lifestyle.
t
Management involves CBT, exercise and educational pro-
grammes. Anti-obesity medications such as orlistat (reduces
absorption of dietary fat) are of short-term benefit. Surgery (e.g.
gastric banding or bypass surgery) is indicated in severe cases.