EATING DISORDERS

Introduction
Eating disorders are serious medical illnesses marked by severe disturbances to a person’s eating
behaviours. Obsessions with food, body weight, and shape may be signs of an eating disorder. These
disorders can affect a person’s physical and mental health; in some cases, they can be life-
threatening. But eating disorders can be treated.

Who is at risk for eating disorders?

Eating disorders can affect people of all ages, racial/ethnic backgrounds, body weights, and genders.
Although eating disorders often appear during the teen years or young adulthood, they may also
develop during childhood or later in life (40 years and older).

People with eating disorders may appear healthy, yet be extremely ill.

The exact cause of eating disorders is not fully understood, but research suggests a combination of
genetic, biological, psychological, and social factors can raise a person’s risk.

The two most important eating disorders are:

• Anorexia nervosa, and

• Bulimia nervosa

A third category is “eating disorders not otherwise specified (EDNOS),” which includes several
variations of eating disorders. Most of these disorders are similar to anorexia or bulimia but with
slightly different characteristics. Binge eating disorder, which has received increasing research and
media attention in recent years, is one type of EDNOS.

Anorexia Nervosa
Anorexia nervosa is a clinical syndrome in which the person has a morbid fear of obesity. It is
characterized by the individual’s gross distortion of body image, preoccupation with food, and
refusal to eat. The disorder occurs predominantly in females 12 to 30 years of age. Without
intervention, death from starvation can occur.

Anorexia nervosa is characterized by highly specific behavioral and psychopathological symptoms

and significant somatic signs. Majority are females and the onset is during adolescence. The core
psychopathological feature is the dread off at ness, weight phobia and a drive for thinness.

Aetiology

a. Genetic causes: Among female siblings of patients with established anorexia nervosa, 6-10 per
cent suffer from the condition compared to the 1-2 percent found in the general population of the
same age (Strober, 1995).

b. A disturbance in hypothalamic function.

c. Social factors: There is a high prevalence of anorexia nervosa among female students and in
occupational groups particularly concerned with weight (for example, dancers). Influence of mass
media, beauty contests are other important social causes.

d. Individual psychological factors: A disturbance of body image, a struggle for control and a sense of
identity are important factors in the causation of anorexia nervosa. Traits of low self-esteem and
perfectionism are often found.

e. Causes within the family: Disturbance in family relationships, over-protection, family members
having an unusual interest in food and physical appearance.

There are two subtypes of anorexia nervosa: a restrictive subtype and binge-purge subtype.

Restrictive: People with the restrictive subtype of anorexia nervosa place severe restrictions on the
amount and type of food they consume.

Binge-Purge: People with the binge-purge subtype of anorexia nervosa also place severe restrictions
on the amount and type of food they consume. In addition, they may have binge eating and purging
behaviours (such as vomiting, use of laxatives and diuretics, etc.).

Symptomatology (Subjective and Objective Data)

1. Morbid fear of obesity. Preoccupied with body size. Reports “feeling fat” even when in an
emaciated condition.

2. Refusal to eat. Reports “not being hungry,” although it is thought that the actual feelings of
hunger do not cease until late in the disorder.

3. Preoccupation with food. Thinks and talks about food at great length. Prepares enormous
amounts of food for friends and family members but refuses to eat any of it.

4. Amenorrhea is common, often appearing even before noticeable weight loss has occurred.

5. Delayed psychosexual development.

6. Compulsive behavior, such as excessive hand washing, may be present.

7. Extensive exercising is common.

8. Feelings of depression and anxiety often accompany this disorder.

9. May engage in the binge-and-purge syndrome from time to time

Clinical Features

• There is an intense fear of becoming obese. This fear does not decrease even if the person loses
weight grossly and becomes very thin.

• The body weight is 15 per cent below the standard weight.

• There is a body image disturbance. The patient is unable to perceive the body size accurately.
• The pursuit of thinness may take several forms. Patients generally eat little and set themselves
daily calorie limits (often between 600 and 1000 calories). Some try to achieve weight loss by
inducing vomiting, excessive exercise, and misusing laxatives.

• Other signs and symptoms are secondary to starvation and include sensitivity to cold, delayed
gastric emptying, constipation, low blood pressure, bradycardia, hypothermia and amenorrhea in
females.

• Vomiting and abuse of laxatives may lead to a variety of electrolyte disturbances, the most serious
being hypokalaemia.

• Hormonal abnormalities also may be seen.

Course and Prognosis

Anorexia nervosa often runs a fluctuating course with periods of exacerbations and partial
remissions. Outcome is very variable.

According to some studies, people with anorexia are up to ten times more likely to die as a result of
their illness compared to those without the disorder. The most common complications that lead to
death are cardiac arrest, and electrolyte and fluid imbalances. Suicide also can result.

Many people with anorexia also have coexisting psychiatric and physical illnesses, including
depression, anxiety, obsessive behavior, substance abuse, cardiovascular and neurological
complications, and impaired physical development.

Diagnostic criteria for anorexia nervosa

A. 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).

B. Intense fear of gaining weight or becoming fat, even though underweight.

C. 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.

D. In post menarche 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,
e.g., Oestrogen, administration.)

Treating anorexia involves three components:

1. restoring the person to a healthy weight;

2. treating the psychological issues related to the eating disorder; and

3. reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing
relapse.

Treatment

Pharmacotherapy

• Neuroleptics

• Appetite stimulants

• Antidepressants

Psychological therapies

• Individual psychotherapy

• Behavioral therapy

• Cognitive behavior therapy

• Family therapy

Nursing Interventions

• Short-term management is focused on ensuring weight gain and correcting nutritional deficiencies.
Maintaining normal weight and preventing relapses are long-term goals to be achieved.

• Hospitalization is usually required and successful treatment depends on good nursing care, with
clear aims and understanding on the part of the patient as well as the nurse.

• Eating must be supervised by the nurse and a balanced diet of at least 3000 calories should be
provided in 24 hours.

• In the early stages of treatment, it is best for the patient to remain in bed in a single room while
the nurse maintains close observation. The goal should be to achieve a weight gain of 0.5 to 1kg per
week.

• Weight should be checked regularly. Monitor serum electrolyte levels and signs and symptoms like
amenorrhea, constipation, hypoglycemia, hypotension, etc. Control vomiting by making the
bathroom inaccessible for at least 2 hours after food.

• In extreme cases when the patient refuses to eat and comply with the treatment, gavage feedings
may need to be instituted.
Bulimia Nervosa
Bulimia is from a Greek word meaning “ox hunger.” This disorder involves episodes of rapid
consumption of a large amount of food, followed by compensatory behavior, such as vomiting,
fasting, or excessive exercise to prevent weight gain.

Defined

Bulimia nervosa is an eating disorder (commonly called “the binge-and-purge syndrome”)

characterized by extreme overeating, followed by self-induced vomiting and abuse of laxatives and
diuretics. The disorder occurs predominantly in females and begins in adolescence or early adult life.

The DSM defines a BINGE as eating an excessive amount of food within less than 2 hours.
Bulimia nervosa is described as repeated bouts of overeating and a preoccupation with control of
weight that leads to self-induced vomiting.

People with bulimia often have coexisting psychological illnesses, such as depression, anxiety and/or
substance abuse problems. Many physical conditions result from the purging aspect of the illness,
including electrolyte imbalances, gastrointestinal problems, and oral and tooth-related problems.

Symptomatology (Subjective and Objective Data)

1. Binges are usually solitary and secret, and the individual may consume thousands of calories in
one episode.

2. After the binge has begun, there is often a feeling of loss of control or inability to stop eating.

3. Following the binge, the individual engages in inappropriate compensatory measures to avoid
gaining weight (e.g., self-induced vomiting; excessive use of laxatives, diuretics, or enemas; fasting;
and extreme exercising).

4. Eating binges may be viewed as pleasurable but are followed by intense self-criticism and
depressed mood.

5. Individuals with bulimia are usually within normal weight range, some a few pounds underweight,
some a few pounds overweight.

6. Obsession with body image and appearance is a predominant feature of this disorder. Individuals
with bulimia display undue concern with sexual attractiveness and how they will appear to others.

7. Binges usually alternate with periods of normal eating and fasting.

8. Excessive vomiting may lead to problems with dehydration and electrolyte imbalance.

9. Gastric acid in the vomitus may contribute to the erosion of tooth enamel.
Predisposing Factors to Anorexia Nervosa and Bulimia Nervosa

1. Physiological Factors

a. Genetics: A hereditary predisposition to eating disorders has been hypothesized on the basis
of family histories and an apparent association with other disorders for which the likelihood
of genetic influences exist. Anorexia nervosa is more common among sisters and mothers of
those with the disorder than among the general population. Several studies have reported a
higher than expected frequency of mood disorders among first-degree biological relatives of
people with anorexia nervosa and bulimia nervosa and of substance abuse and dependence in
relatives of individuals with bulimia nervosa (APA, 2000).
b. Neuroendocrine Abnormalities: Some speculation has occurred regarding a primary
hypothalamic dysfunction in anorexia nervosa. Studies consistent with this theory have
revealed elevated cerebrospinal fluid cortisol levels and a possible impairment of
dopaminergic regulation in individuals with anorexia (Halmi, 2008).
c. Neurochemical Influences: Neurochemical influences in bulimia may be associated with the
neurotransmitters serotonin and norepinephrine. This hypothesis has been supported by the
positive response these individuals have shown to therapy with the selective serotonin
reuptake inhibitors (SSRIs). Some studies have found high levels of endogenous opioids in
the spinal fluid of clients with anorexia, promoting the speculation that these chemicals may
contribute to denial of hunger (Sadock & Sadock, 2007). Some of these individuals have been
shown to gain weight when given naloxone, an opioid antagonist.

2. Psychosocial Factors

a. Psychodynamic Theory: The psychodynamic theory suggests that behaviors associated with
eating disorders reflect a developmental arrest in the very early years of childhood caused by
disturbances in mother-infant interactions. The tasks of trust, autonomy, and separation-
individuation go unfulfilled, and the individual remains in the dependent position. Ego
development is retarded. The problem is compounded when the mother responds to the child’s
physical and emotional needs with food. Manifestations include a disturbance in body identity and
a distortion in body image. When events occur that threaten the vulnerable ego, feelings emerge
of lack of control over one’s body (self). Behaviors associated with food and eating provide
feelings of control over one’s life.

b. Family Dynamics: This theory proposes that the issue of control becomes the overriding factor
in the family of the individual with an eating disorder. These families often consist of a passive
father, a domineering mother, and an overly dependent child. A high value is placed on
perfectionism in this family, and the child feels he or she must satisfy these standards. Parental
criticism promotes an increase in obsessive and perfectionistic behavior on the part of the child,
who continues to seek love, approval, and recognition. The child eventually begins to feel
helpless and ambivalent toward the parents. In adolescence, these distorted eating patterns may
represent a rebellion against the parents, viewed by the child as a means of gaining and remaining
in control. The symptoms are often triggered by a stressor that the adolescent perceives as a loss
of control in some aspect of his or her life.

Clinical Features
• An irresistible craving for food: There are episodes of overeating in which large amount of food are
consumed within short periods of time (eating binges)

• Attempt to counteract the effects of over eating by self-induced vomiting

• There is usually no significant weight loss

Other symptoms include:

• Chronically inflamed and sore throat

• Swollen glands in the neck and below the jaw

• worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to
stomach acids

• Gastroesophageal reflux disorder

• Intestinal distress and irritation from laxative abuse

• Kidney problems from diuretic abuse

• Severe dehydration from purging of fluids

Diagnostic Criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
(1) eating, in a discrete period of time (e.g., within any 2-hour period). an amount of food that is
definitely larger than most people would eat during a similar period of time and under similar
circumstances
(2) a sense of lack of (control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating)

B. 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.

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least
twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur
exclusively during episodes of Anorexia Nervosa.

Treatment

• Antidepressants, carbamazepine and lithium for patients with co-morbid mood disorders

• Group therapy

• Family therapy
• Cognitive behavior therapy

BINGE-EATING DISORDER
Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person
feels a loss of control over his or her eating. Unlike bulimia, binge-eating episodes are not followed
by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are
overweight or obese. They also experience guilt, shame and/or distress about the binge eating,
which can lead to more binge-eating.

Obese people with binge-eating disorder often have coexisting psychological illnesses including
anxiety, depression, and personality disorders. In addition, links between obesity and cardiovascular
disease and hypertension are well documented.

Two types of Bulimia Nervosa

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

Non-purging Type: during the current episode of Bulimia Nervosa, the person has used other
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

The DSM diagnosis of bulimia nervosa requires that the episodes of binging and purging
occur at least twice a week for 3 months.

Treatment

Treatment options for binge-eating disorder are similar to those used to treat bulimia.

Fluoxetine and other antidepressants may reduce binge-eating episodes and help alleviate
depression in some patients.

Patients with binge-eating disorder also may be prescribed appetite suppressants.

Psychotherapy, especially CBT, is also used to treat the underlying psychological issues associated
with binge-eating, in an individual or group environment

Preventive interventions for eating disorders

Psychoeducational Approaches -The focus is on educating children and adolescents about eating
disorders to prevent them from developing the symptoms;
De-emphasizing Sociocultural Influences -The focus here is on helping children and adolescents resist
or reject sociocultural pressures to be thin;
Society’s Preoccupation with Thinness -After winning Miss Universe (1996), she gained a few
pounds, some people became outraged and suggested she give up her crown.
Risk Factor Approach -The focus here is on identifying individuals with known risk factors for
developing eating disorders (e.g., weight and body concern, dietary restraint) and intervening to
alter these factors.
Eating Disorder Not Otherwise Specified

The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the
criteria for any specific Eating Disorder.
1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular
menses.
2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the
individual's current weight is in the normal range.

3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less
than 3 months.
4. The regular use of inappropriate compensatory behavior by an individual of normal body weight
after eating small amounts of food (e.g., self-induced vomiting after the consumption of two
cookies).
5.Repeatedly chewing and spitting out, but not swallowing, large amounts of food.

6.Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of
inappropriate compensatory behaviors characteristic of Bulimia Nervosa.

Obesity

The following formula is used to determine the degree of obesity in an individual:

Body mass index (BMI) = weight (kg)

height (m)2

The BMI range for normal weight is 20 to 24.9.

Studies by the National Center for Health Statistics indicate that overweight is defined as a
BMI of 25.0 to 29.9 (based on U.S. Dietary Guidelines for Americans).

Based on criteria of the World Health Organization, obesity is defined as a BMI of 30.0 or
greater. These guidelines, which were released by the National Heart, Lung, and Blood
Institute in July 1998, markedly increased the number of Americans considered to be
overweight. The average American woman has a BMI of 26, and fashion models typically
have BMIs of 18 (Priesnitz, 2005).

Obesity is known to contribute to a number of health problems, including hyperlipidemia,

diabetes mellitus, osteoarthritis, and increased workload on the heart and lungs.

Predisposing Factors to Obesity

1. Physiological Factors
a. Genetics: Genetics have been implicated in the development of obesity in that 80% of
offspring of two obese parents are obese (Halmi, 2008). This hypothesis has also been
supported by studies of twins reared by normal and overweight parents.

b. Physical Factors: Overeating and/or obesity has also been associated with lesions in the
appetite and satiety centers of the hypothalamus, hypothyroidism, decreased insulin
production in diabetes mellitus, and increased cortisone production in Cushing’s disease.

c. Lifestyle Factors: On a more basic level, obesity can be viewed as the ingestion of a
greater number of calories than are expended. Weight gain occurs when caloric intake
exceeds caloric output in terms of basal metabolism and physical activity. Many overweight
individuals lead sedentary lifestyles, making it very difficult to burn off calories.

2. Psychosocial Factors

a. Psychoanalytical Theory: This theory suggests that obesity is the result of unresolved
dependency needs, with the individual being fixed in the oral stage of psychosexual
development. The symptoms of obesity are viewed as depressive equivalents, attempts to
regain “lost” or frustrated nurturance and care.