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ANOREXIA

INTRODUCTION
DERIVED FROM THE GREEK TERM,
LOSS OF APPETITE

COMMON IN:

FEMALE > MALE

MID TEENS (14 TO 18 YEARS OLD)
YOUNG WOMEN IN PROFESSIONS
THAT REQUIRE THINNESS

AETIOLOGY
BIOLOGICAL
Endogenous
opioids
Hypothalamicpituitary axis
dysfunction

SOCIAL
Societys emphasis
on thinness and
exercise
Hobby and
profession

PSYCHOLOGICAL
Substitute their
preoccupation of
eating with other
pursuits
Feel oral desires
are greedy and
unacceptable

THREE CRITERIA
Self induced starvation to a significant degree
Relentless drive for thinness / morbid fear of
fatness
Presence of medical signs and symptoms
resulting from starvation

DSM IV DIAGNOSTIC CRITERIA

REFUSAL TO MAINTAIN BODY WEIGHT AT OR ABOVE A MINIMALLY NORMAL

WEIGHT AT OR ABOVE A MINIMALLY NORMAL WEIGHT FOR AGE AND HEIGHT

INTENSE FEAR OF GAINING WEIGHT OR BECOMING WEIGHT OR BECOMING

FAT, EVEN THOUGH UNDERWEIGHT

DISTURBANCE IN THE WAY IN WHICH ONES BODY WEIGHT OR SHAPE IS

EXPERIENCED, UNDUE INFLUENCE OF BODY WEIGHT OR SHAPE ON SELFEVALUATION, OR DENIAL OF THE SERIOUSNESS OF THE CURRENT BODY
WEIGHT

IN POSTMENARCHAL FEMALES, AMENORRHEA, I.E., THE ABSENCE OF AT

LEAST THREE CONSECUTIVE MENSTRUAL CYCLES

DSM IV DIAGNOSTIC CRITERIA (SPECIFIC TYPE)

RESTRICTING TYPE
DURING THE EPISODE, THE PERSON HAS NOT

REGULARLY ENGAGED IN BINGE-EATING OR PURGING

BEHAVIOUR

BRINGE-EATING/PURGING TYPE
DURING THE EPISODE, THE PERSON HAS REGULARLY

ENGAGED IN BINGE-EATING OR PURGING BEHAVIOUR

CLINICAL FEATURES
1. VOLUNTARILY REDUCES AND MAINTAINS AN UNHEALTHY DEGREE OF WEIGHT
LOSS

2. FAILS TO GAIN WEIGHT PROPORTIONAL TO GROWTH

3. EXPERIENCES INTENSE FEAR OF BECOMING FAT
4. HAS RELENTLESS DRIVE FOR THINNESS DESPITE OBVIOUS MEDICAL
STARVATION, OR BOTH

5. EXPERIENCES SIGNIFICANT STARVATION-RELATED MEDICAL

SYMPTOMATOLOGY

6. BEHAVIOUR AND PSYCHOPATHOLOGY PRESENT FOR AT LEAST THREE MONTHS

PECULIAR BEHAVIOUR ABOUT FOOD

HIDE FOOD ALL OVER THE HOUSE
DISPOSE MEALS IN NAPKINS OR HIDE IN THE
POCKETS

CUT MEAT INTO VERY SMALL PIECES, SPEND A

LOT OF TIME REARRANGING PIECES ON PLATE

WHEN CONFRONTED, THEY DENIED THEIR

BEHAVIOUR IS UNUSUAL, OR FLATLY REFUSE

TO DISCUSS IT

WHEN PATIENT SEEK MEDICAL ATTENTION?

1. WEIGHT LOSS BECOMES APPARENT
2. SHOWED PHYSICAL SIGNS

(HYPOTHERMIA, DEPENDANT OEDEMA,

BRADYCARDIA, HYPOTENSION, LANUGO
APPEARANCE

3. FEMALE PATIENT MAY COME DUE TO

AMENORRHOEA

COMPLICATIONS RELATED TO WEIGHT LOSS

Cachexia
Loss of fat
Loss of muscle
mass
Reduced
thyroid
metabolism
Difficulty in
maintaining
core body
temperature

Cardiac

Gastrointestinal

Reproductive

Loss of cardiac
muscle
Small heart
Cardiac
arrhythmias
Prolonged QT
interval
Bradycardia
Ventricular
tachycardia

Delayed gastric
emptying
Bloating
Constipation
Abdominal pain

Amenorrhea
Low level of LH
and FSH

COMPLICATIONS RELATED TO WEIGHT LOSS

Dermatological
Lanugo
Oedema

Haematological
Leukopenia

Neuropsychiatric
Abnormal taste
sensation
Apathetic
depression
Mild cognitive
disorder

Skeletal
Osteoporosis

COMPLICATIONS RELATED TO PURGING

Medical

Gastrointestinal

Hypokalemic
Hypochloremic
alkalosis
Hypomagnesemia

Salivary gland
and pancreatic
inflammation
Elevated serum
amylase
Oesophageal and
gastric erosion
Dysfunctional
bowel with
haustral dilation

Dental
Dental enamel
erosion
Dental decay

Neuropsychiatric
Seizures
Mild
neuropathies
Fatigue and
weakness
Mild cognitive
disorder

PATHOLOGY AND LAB EXAMINATION

COMPLETE FULL BLOOD COUNT

REVEALS LEUKOPLAKIA WITH RELATIVE

LYMPHOCYTOSIS.
IF BINGE EATING/ PURGING PRESENT, SERUM
ELECTROLYTE REVEALS HYPOKALEMIC
ALKALOSIS.

FASTING SERUM GLUCOSE CONCENTRATION.

SERUM SALIVARY AMYLASE CONCENTRATIONELEVATED IF THE PATIENT IS VOMITING.

ECG
BP - HYPOTENSION

DIFFERENTIAL DIAGNOSIS
BULIMIA NERVOSA
MEDICAL CONDITIONS AND
SUBSTANCE USE DISORDER

DEPRESSIVE DISORDER
SOMATIZATION DISORDER
SCHIZOPHRENIA

TREATMENT
HOSPITALIZATION

FIRST CONSIDERATION IN THE TREATMENT OF AN

IS TO RESTORE PATIENTS NUTRITIONAL STATE.

PATIENTS WHO ARE BELOW 20% OF THEIR EXPECTED
BMI, ARE RECOMMENDED FOR INPATIENT PROGRAM.
PATIENTS WHO ARE BELOW 30% OF THEIR EXPECTED
BMI, REQUIRE PSYCHIATRIC HOSPITALIZATION FOR
2 TO 6 MONTHS

TREATMENT
PSYCHOTHERAPY
1.

2.
3.

COGNITIVE-BEHAVIORAL
THERAPY (CBT)
DYNAMIC PSYCHOTHERAPY
FAMILY THERAPY

PHARMACOTHERAPY

.CYPROHEPTADINE (PERIACTIN)
.AMITRIPTYLINE (ELAVIL)

Bulimia Nervosa

Definition (DSM-IV-TR)
Binge eating combined with
inappropriate ways of stopping
weight gain
Binge eating: Eating more food than
most
persons in similar circumstances & in a
similar
period of time, accompanied by a
strong sense

Epidemiology

More prevalent than anorexia nervosa

1-3 % of young women
Men: Women = 1: 10
Late adolescence @ early adulthood
Often in normal-weight person with history of
obesity
1st degree of family history

Etiology
Biological
Factors

Social Factors Psychological

Factors
serotonin & High achievers: Self-perceptions
aboutbody
norepinephrin: societal
pressures to be image(size,
food intake
slender
shape & weight
(binge eating)
endorphin:
feeling of wellbeing after
vomiting

Depression,
anxiety, anger
& self-loathing
Obsessive traits

binge eating
social
interruption/physical
discomfort (abdominal
pain, nausea)
stop eating
guilt, depression (postbinge anguish), selfdisgust
recurrent
compensatory
behavior
purging: self-induced
vomiting, repeated
laxatives, enemas or
diuretic uses

non-purging: fasting,
excessive exercise

Warning Signs
Physical Signs
Frequent changes in weight (loss @ gains)
Signs of damage due to vomiting: swelling
around the cheeks or jaw, calluses on
knuckles, damage to teeth & bad breath
Feeling bloated, constipated or
developing intolerances to food
Loss of or disturbance of menstrual
periods in females
Fainting or dizziness
Tired

Psychological Signs
Preoccupation with eating, food, body shape
and weight
Sensitive to comments relating to food,
weight, body shape or exercise
Low self esteem and feelings of shame, self
loathing or guilt, particularly after eating
Having a distorted body image (e.g. seeing
themselves as fat even if they are in a healthy
weight range for their age and height)
Obsession with food & need for control
Depression, anxiety or irritability

Behavioral Signs
Evidence of binge eating
Vomiting or using laxatives, enemas or
diuretics
Compulsive or excessive exercising (e.g.
including exercising in bad weather, in spite of
sickness, injury or social events &
experiencing distress if exercise is not
possible)
Repetitive or obsessive behaviors relating to
body shape & weight (e.g. weighing
themselves repeatedly, looking in the mirror
obsessively and pinching waist or wrists)

DSM-IV-TR Diagnostic Criteria for

Bulimia Nervosa

Subtypes
Purging

More body-image disturbance

More anxiety concerning eating
Normal/under-weight
Risk for medical complications
- Dehydration
- Hypokalemia (muscle
weakness, cardiac
arrythmias, renal
impairment)
- Hypomagnesemia
- Hypochloremic alkalosis
- Hyperamylasemia
- Gastric tear
- Esophageal tear
- Dental erosion (upper front
teeth)
- Hypotension
- Bradycardia

Non-purging
Less body-image disturbance
Less anxiety concerning eating
Obese

Investigations

FBC
BUSE
Amylase test: hyperamylasemia
Urinalysis: high urine specific gravity (dehydration)
RPT
ECG
Endoscopy

Differential Diagnosis
Anorexia nervosa
Binge eating purging eating

Course & Prognosis

Prognosis depends on severity of
vomiting sequelae
Better prognosis than anorexia
nervosa
50 % improve with treatment
Outpatients
Improvement lasts 5
years with waxing &
waning courses

Inpatients
< 1/3: doing well at 3year follow-up
1/3: symptoms
improve
1/3: poor outcome with
chronic symptoms

Management
Psychotherapy
CBT
1st line treatment
Aim:
- Interrupt the self-maintaining
behavioral cycle of bingeing & dieting
- Alter their dysfunctional cognitions:
beliefs about food, weight, body
image & overall self-concept

Dynamic psychotherapy
Insight-oriented therapy
Aim:
- Clients self-awareness
- Understanding of the influence of
the past
on present behavior

Pharmacotherapy
Antidepressant (comorbid of
depressive
disorders)
SSRI: fluoxetine ( binge eating &
purging)
TCA: imipramine
Anti-convulsants (comorbid of bipolar I
disorder)
Carbamazepine

Eating Disorder Not

Otherwise Specified (DSM-IV)
Residual category used for eating
disorder that do not meet the criteria for
a specific eating disorder

OBESITY

 Obesity is a complex, multifactorial condition

characterized by excess body fat.
The WHO definition is:
a BMI greater than or equal to 25 is overweight in
men
a BMI greater than or equal to 30 is obesity in
women

BMI

Body Mass Index (BMI) is the best currently

accepted measure
BMI = kg/m

Classificati BMI
on
(kg/m)
Underweight <18.5
Normal
range
Overweight
Pre-obese
Obese I
Obese II

18.5- 22.9
23
23.0- 27.4
27.5- 34.9
35.0- 39.9

Risk of co-morbidities
Low (but increased risk of
other clinical problems
Increasing but acceptable
risk
Increased
High
Very high

WAIST CIRCUMFERENCE (WC)

Waist Circumference (WC) measurement is simple,
reliable, and correlates well with abdominal fat
content irrespective of the BMI.
Based on current evidence, the following wc is
associated with an increased risk of co-morbidities
Men 90cm
Women 80

EPIDEMIOLOGY

The National Health and Morbidity Survey revealed that

the rate of obesity in Malaysia had increased by almost
three and a half times, from 4.4% in 1996 to 15.1% in
2011.
This puts the number of obese Malaysians at around 2.5

FACTORS THAT CONTRIBUTE TO OBESITY

Genetic factors
About 80%of patients who are obese have a family
history of obesity

Developmental factors
Obesity that begins early in life characterized by
adipose tissue with an increase number of adipocytes
(fat cells) of increased size.
Obesity in adult life, the size of the adipocytes are
increased.

 Physical activity
Decrease in physical activity cause major factor in the
rise of obesity

Brain-damage factor
Rare

COURSE & PROGNOSIS

Effects on health
Obesity has adverse effect on health and is associated
with broad range of illnesses
Eg: hypertension, hypercholesterolemia, diabetes

Longevity
The more overweight a person is, the higher that
persons risk for death is

 Prognosis
The prognosis for weight reduction is poor. Of patients
who lose significant amounts of weight, 90% regain it
eventually

TREATMENT
Diet
The basis of weight reduction is simplereduce caloric intake by take low-calorie
diet

 Exercise
Increased physical activity is an important part of a
weight-reduction regimen

 Pharmacotherapy
Drug may suppress appetite, but tolerance to this
effect may develop after several weeks of use
One weight-loss medication approved by the Food
and Drug Administration (FDA) for long term use is
orlistat (Xenical)
Which is selective gastric and pancreatic lipase inhibitor
that reduces the absorption of dietary fat

Sibutramine (Meridia): is a -phenylethylamine that

inhibits the reuptake of serotonin and
norepinephrine.
It was approved by FDA for weight loss and maintenance
of weight loss

Rimonabant: it is a selective cannabinoid-1 receptor

blocker
Reduce body weight and improve cardiovascular risk
factors in obese patients

 Surgery
Surgical methods that cause malabsorption of food or
reduce gastric volume have been used in persons who
are markedly obese
Gastric bypass: stomach is made smaller by transecting
or stapling one of the curvature
In gastroplasty, the size of the stomach stoma is reduced
so that the passage of food slows. Results are successful
although vomiting, electrolyte imbalance and obstruction
may occur

Gastric bypass

Gastroplasty