Eating

Disorder
Abdah , Qistina , Daniel , Aqil
 Learning Outcomes

1. Anorexia Nervosa
2. Bulimia Nervosa
3. Binge Eating Disorder
4. Obesity
5. Pica
6. Rumination Disorder
7. Avoidant/selective food intake
8. Other specified feeding/eating disorder
ANOREXIA NERVOSA
BULIMIA NERVOSA
Binge Eating
Disorder
Qistina Adilah
Defined as recurring episode of eating significantly more food in short
period of time than most people would eat under similar
circumstances, with episodes marked by feelings of lack of control.

- Occur in private generally include foods of dense caloric content

- During the binge, do not compensate in any way after binge episode
(laxative use)
 DIFFERENTIAL DIAGNOSIS

BULIMIA NERVOSA ANOREXIA NERVOSA

No recurrent compensatory Not exhibit an excessive drive for

behavior such as thinners
- Vomiting Normal weight/obese
- Laxative abuse
- Excessive dieting
 EPIDEMIOLOGY
● The most common eating disorder
● Common in Female (4%) > Male (2%)
● Prevalence is higher in overweight population
- Have greater caloric intake during binging and non-binging episodes
- Greater eating disorder pathology (more emotional during eating, chaotic
eating habits)
- Higher rates of comorbid psychiatric disorders.

● 25% – > seek medical care for obesity

● 50% to 70% → developed severe obesity (BMI> 40)
 ETIOLOGY
Cause is unknown

● Linked to other psychological disorder

- Feeling of anger, stress, sadness, anxiety may trigger Binge Episode Disorder
- Impulsive behavior and extroverted personality are linked to the disorder

● Biological factor
- Abnormal functioning of chemical messages to the brain
- Hormone that regulate appetite (Leptin, Neuropeptide Y and Ghrelin)

● Obese may be associated with

- Insomnia ,Early menarche, neck/shoulder/lower back pain, Chronic muscle pain and
Metabolic disorder
 Based on DSM-5 Diagnostic Criteria for Binge
Eating Disorder
A. Recurrent episodes of binge eating. An episode is characterized by BOTH of the following:

1. Eating in discrete period of time (within 2 hour of period) , in an amount of food that is definitely larger
than what most people would eat in a similar period of time under similar circumstance.

2. A sense of lack of control over eating during the episode,

B. The binge-eating episodes are associated with 3 or more of the following

1. Eating much more rapidly than normal

2. Eating until feeling uncomfortably full

3. Eating large amounts of food when not feeling physically hungry

4. Eating alone because of embarrassed feeling by how much one is eating.

5. Feeling disgusted with oneself, depressed, or very guilty afterward

C. Marked distress regarding binge eating is present

D. The binge eating occurs, on average, at least once a week for 3 months

E. The binge eating is not associated with the recurrent use of inappropriate compensatory
behavior such as in bulimia nervosa and does not occur exclusively during the source of
bulimia nervosa or anorexia nervosa.

Level of severity based on the frequency of episodes

● Mild: 1-3 binge eating episodes/week

● Moderate: 4-7 binge-eating episodes/week
● Severe: 8-13 binge-eating episodes/week
● Extreme: 14 or more binge-eating episodes/week
 MANAGEMENT
1. PSYCHOTHERAPY: Cognitive-behavioral therapy (CBT) is the most effective
- Shown lead to decrease in binge eating and associated problem (eg: depression)
- But no shown marked weight loss
- Show better result when combined with antidepressants drugs, SSRI

2.Self-Help Groups: Overeaters Anonymous (OA)

- Proven to be helpful in binge eating disorder patients.

- For moderate obesity → Weight Watchers organization can be helpful

3. Pharmacotherapy: Selective Serotonin Reuptake Inhibitors (SSRI)

- Improvement in mood as well as binge eating disorder

- Examples of drugs: FLuvoxamine, Citalopram, Sertraline
- Some studies showed high dose SSRI
- Fluoxetine at 60-100mg often resulted in weight loss
- However only initially for short lived, weight always return once the medication was
discontinued.
4.OBESITY
Qistina Adilah
Obesity is defined as chronic illness manifested by an excess of body fat. Excess of body fat
results from a greater amounts of calories consumed than are burnt off.

Body mass index (BMI) → Weight(kg)/ Height(m) x Height(m)

For adults, WHO defines overweight and obesity as follows:

•overweight is a BMI greater than or equal to 25
•obesity is a BMI greater than or equal to 30.
EPIDEMIOLOGY
Based on National health & Morbidity Survey :

- Highest prevalence age : 55-59 years old

- Females (33.6%) > Males (27.8%)
- Race: Indians (43.5%) > Malays (35.4%) > Chinese (21.9%)

•The worldwide prevalence of

obesity nearly tripled between
1975 and 2016
 ETIOLOGY

Satiety: Feeling result when hunger is satisfied (Increase in appetite, decrease in

satiety)

Metabolic signals derived from food has been absorbed, carried by blood to
brain, signal activate the receptor cell (hypothalamus) to produce satiety.
Dysfunction in serotonin, dopamine,norepinephrine involvement in regulating
eating behavior.
Habitual eating patterns → impaired satiety cause inability to stop eating if
food is available. They are susceptible to all kinds of external stimuli to eating
but unresponsive to usual internal signal of hunger.
2. Genetic Factors: about 80% of patients who are obese have family history of
obese

- Identical twin studies raised apart can both be obese, that suggests a
hereditary role.
- Factors affecting body weight

LEPTIN → Highly expressed in areas of hypothalamus to control feeding,

hunger and energy expenditure.

NEUROPEPTIDE Y → Synthesized in many areas of brain, potent stimulator of

feeding

Leptin suppress the feeding by inhibit expression of Neuropeptide Y.

GHRELIN → secreted in stomach and circulate in blood. It will activate

neuropeptide Y neurone in hypothalamic, thereby stimulating food intake.
ETIOLOGY
 MANAGEMENT

● DIETARY THERAPY
- Low Calorie Diet
- Lower-fat Diet
- High Protein Low Carbohydrate Diet
- Dietary Education

● Exercise
● Lifestyle change
● Pharmacotherapy
 Pharmacotherapy
Considered in patient:

- BMI >30kg/m2

- BMI >27kg/m2 with weight related comorbidities

1 Orlistat (Xenical) (120mg, there times/day) combination with low-calorie diet, induce
Selective gastric and pancreatic lipase inhibitor losses 10% initial weight first 6 monthsI

To reduce the absorption of dietary fat (which then excreted in stool)

2. Sibutramine
Inhibit the reuptake of serotonin and norepinephrine and enhance post-ingestive satiety

3. Phentermine
Amphetamine derivative that suppress appetite.
SURGICAL TREATMENT/BARIATRIC SURGERY
Considered in patient:
BMI > 40kg/m2
BMI >35 kg/m2 with weight related comorbidities

1. Gastroplasty (Vertical banded gastroplasty)

- Putting inflatable band around the upper portion of stomach, creating small pouch
above the band
- Stomach stoma is reduce so that the passage of food slows.

2. Gastric Bypass (Roux-en-Y)

- Making the stomach smaller and bypassing part of small intestine

3. Biliopancreatic bypass procedure, which involve transection of stomach

- Remove 80% of stomach

- Connect the end portion of intestine to end of duodenum
 Psychotherapy
Behaviour Therapy

1. Counselling for lifestyle changes

2. Self-monitoring encouraged to keep daily records of physical activity, food intake
and problem
3. Portion control to gauge size portions eaten
4. Stimulus control to identify and avoid enviromental cues associated with unhealthy
eating and sedentary lifestyle
5. Contingency management include use of rewards for positive lifestyle changes
6. Stress management - meditation, relaxation techniques and regular physical
activity
7. Cognitive-behavioural strategies - change patients attitudes and belief about
unrealistic expectations
05
PICA
 About the Disease

Venus has a Mercury is the Jupiter is the Despite being red,

beautiful name smallest planet biggest planet Mars is a cold place

Mercury is the closest planet to the Sun, but does its name have
anything to do with the liquid metal?
 PICA

Repeated ingestion of a non-nutritive for at least 1 month.

- The behaviour must be developmentally inappropriate, not culturally

sanctioned and sufficiently severe to merit clinical attention

- May be benign or may have life threatening consequences

 EPIDEMIOLOGY
- Affects both sexes equally

- Occurs in up to 15% of those with severe mental retardation

- Age of onset: between 2 to 4 years old

Commonly seen in:

- Children

- MR

- Chronic schizophrenia

- Prisoners trying to avoid court case

 AETIOLOGY

- Not exactly known, but in some cases, pica is reported to be associated with

- Severe child maltreatment in the form of parental neglect and

deprivation

- Developmental and speech delays

- Nutritional deficiencies such as zinc or iron

- However, these cases are very rare

 CLINICAL FEATURES
● Lead poisoning

- From lead based paint

● Intestinal parasite

- From ingestion of soil or feces

- Anemia and zinc deficiency

- Ingestion of clay

- Severe iron deficiencies

- Ingestion of large quantities of starch

- Intestinal obstruction

- Hairball, stones or gravel

 DSM V CRITERIA
A. Persistent eating of nonnutritive, non food substances over a period of at least 1 month.

B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the
individual.

C. The eating behavior is not part of a culturally supported or socially normative practice.

D. If the eating behavior occurs in the context of another mental disorder (e.g.,

intellectual disability [intellectual developmental disorder], autism spectrum

disorder, schizophrenia) or medical condition (including pregnancy), it is sufficiently

severe to warrant additional clinical attention.

 DEVELOPMENT AND COURSE
- In adults, pica usually happens in the context of intellectual disability or other mental
disorders

- Pica may also manifest during pregnancy, when specific cravings (e.g. chalk or ice)
might occur

- The diagnosis of pica in pregnancy is only appropriate if such cravings lead to ingestion
of non-nutritive, nonfood substances to the extent that eating these substances cause
potential medical risks

- Pica can be fatal, depending on the substance ingested

 INVESTIGATION
•Review of person's eating habits

•Blood tests

● Lead concentrations

● Anemia

● Toxins and other substances

● Infections

● Iron and zinc level

•Imaging studies (Abdominal radiography (X-rays) , Upper and lower GI barium examinations, Upper GI
endoscopy)

•Evaluate other disorder (mental retardation, developmental disabilities, obsessive-compulsive disorder)

 MANAGEMENT
•Family guidance approaches

a) Keep away the abnormal items of diet

b) Fix parental neglect, maltreatment, stressful circumstances

•Environmental

a) Eliminate exposure to toxic substances and closed monitoring (lead)

Psychosocial Interventions

a)Behavioral

-antecedent manipulation

-mild aversion therapy (punishment)

-- positive reinforcement - overcorrection

b) Nutritional, dietary and oral health care approaches

 06
RUMINATION
DISORDER
 RUMINATION DISORDER
-Rumination is an effortless and painless regurgitation of partially digested food into the mouth soon after a
meal, which is either swallowed or spit out.

- In most cases, the re-chewed food is then swallowed again, occasionally, the child will spit it out.

- Rumination can be observed in developmentally normal infants who put their thumb or hand in the mouth,
suck their tongue rhythmically, and arch their

back to initiate regurgitation.

- This behavior pattern is observed in infants who don’t receive adequate emotional interactions and have
learned to soothe and stimulate through rumination.
 EPIDEMIOLOGY
- A rare disorder

- Seems to be more common among male infants

- Emerges between 3 months and 1 year of age

- It persists more frequently among children, adolescents and adult with

intellectual disability.

- Adults with rumination usually maintain a normal weight

 ETIOLOGY
- For some, the rumination behaviour is self soothing or produces a a sense of relief

- Leads to a continuation of the behaviour to bring it about

- Serve as self-stimulatory behaviour

- In youth with autism spectrum disorder or intellectual disability

- Overstimulation and tension might cause rumination as well

 RUMINATION VS VOMITTING
- Painless and purposeful movement.

- Characteristic position of straining and arching of the back, head held back.

- Sucking movements with tongue.

- Impression of enjoying/ gaining satisfaction towards the activity.

- No retching.

- Infant is usually hungry and irritable on between episodes of rumination.

- Weight loss and failure to make expected weight gains are common features in infants

- Malnutrition, particularly when the regurgitation is accompanied by restriction of intake.

 DSM V CRITERIA
A.Repeated regurgitation of food for a period of at least one month. Regurgitated food may be re-chewed,
re-swallowed, or spit out.

B.The repeated regurgitation is not due to GI or other medical condition (e.g. gastroesophageal reflux, pyloric
stenosis).

C.The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or
Avoidant/Restrictive Food Intake disorder.

D.If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe
enough to warrant independent clinical attention.

–Specify if:

in remission: After full criteria for rumination disorder were previously met, none of the criteria have been meet
or a sustained period of time
 COURSE AND PROGNOSIS
- Have a high rate of spontaneous remission

- Many cases goes undiagnosed and remits

- Course may also induce:

- Malnutrition

- Failure to thrive

- Death

Behavioral interventions using habit-reversal techniques may significantly lead to improved prognosis
 MANAGEMENT
1. Evaluation of mother-child relationship

- Reveals deficits that can be influenced by offering guidance to the mother

2. Behavioral intervention

- Habit reversal

- Reinforce an alternate behaviour that becomes more compelling than the behaviours leading to regurgitation

- Aversive behavioral interventions

- Squirting lemon juice into the infant's mouth when rumination occurs
3. In the case of child maltreatment or neglect

- Improvement of the child’s psychosocial environment

- Increase tender loving care from the mother or caretakers

- Psychotherapy for the mother or both parents

5. Anatomical abnormalities

- E.g. hiatal hernia is not uncommon

- Must be evaluated which may lead to surgical repair

6. Severe case of malnutrition and weight loss

- Place a jejunal tube may need to be inserted before other treatments can be utilised

7. Pharmacotherapy

- Metoclopramide, cimetidine and even antipsychotics such as haloperidol have been cited to be helpful
 AVOIDANT/
RESTRICTIVE FOOD
INTAKE DISORDER
 It is characterized by
-lack of interest in food
-avoidance based on the sensory features of the food
-perceived consequences of eating

The person does not eat enough and not able to meet nutritional or energy needs
which results in failure to gain weight or to grow.

Epidemiology

➢ Occurs in 1.5% of infants

➢ 3% with failure to thrive
➢ 50% with feeding disorder
➢ Onset age is before 6 years old
TYPES OF EATING DISORDER

➔ Difficulty to digest certain foods

➔ Avoid certain colors/texture of
food
➔ Eating only small portions
➔ No appetite
➔ Afraid to eat after a frightening
episode of choking/vomiting
 DSM V CRITERIA
A.An eating or feeding disturbance as manifested by persistent failure to meet
appropriate nutritional and/or energy needs associated with one (or more) of
the following:
1.Significant weight loss (or failure to achieve expected weight gain or
faltering growth in children).
2.Significant nutritional deficiency.
3.Dependence on enteral feeding or oral nutritional supplements.
4.Marked interference with psychosocial functioning.

B.The disturbance is not better explained by lack of available food or by an

associated culturally sanctioned practice.
C.The eating disturbance does not occur exclusively during the course of
anorexia nervosa or bulimia nervosa, and there is no evidence of a
disturbance in the way in which one’s body weight or shape is experienced.

D.The eating disturbance is not attributable to a concurrent medical condition

or not better explained by another mental disorder. When the eating
disturbance occurs in the context of another condition or disorder, the severity
of eating disturbance exceeds that routinely associated with the condition of
disorder and warrants additional clinical attention.

Specify if:
–In remission: After full criteria for avoidant/restrictive food intake disorder
were previously met, the criteria have not been met for a sustained period of
time.
 COURSE & PROGNOSIS
❖ Most commonly develops in infancy or early childhood and may
persist in adulthood
❖ If identified within 1 year old: good prognosis (failure to thrive,
malnutrition or growth delay can be prevented)
❖ If late onset like 2 to 3 years old:
➢ Malnutrition
➢ Growth delay
➢ Failure to thrive
❖ Older children/adolescents: interfere with social functioning
 TREATMENT
Transactional model of intervention

❏ Education for the parents regarding the temperamental traits

of the infant
❏ Optimizing the interaction between the mother and infant
during feedings
❏ Train parents to deliver praise to the infant for any
self-feeding efforts
❏ Limit any distracting stimulation during meals
❏ Give attention and praise to positive eating behaviors
❏ Behavioral modification such as expanding the variety of foods
consumed
❏ Cognitive behavioral therapy (CBT) can be employed to help
ARFID, patients change the thought patterns that underlie their
eating disturbance
❏ Exposure therapy may also help patients tolerate
anxiety-provoking foods or the physical process of consuming
feared foods

Such psychological interventions coupled with nutritional education

and medical monitoring can help eliminate avoidant and restrictive
behaviors and promote recovery from ARFID
OTHER SPECIFIED
FEEDING OR
EATING DIORDER
Atypical anorexia nervosa:
All of the criteria for anorexia nervosa are met except that despite significant
weight loss, the individual’s weight is within or above the normal range

Bulimia nervosa (of low frequency and/or limited duration):

All of the criteria for bulimia nervosa are met, except that the binge eating
and inappropriate compensatory behaviors occur, on average, less than
once a week and/or for less than 3 months

Binge-eating disorder (of low frequency and/or limited duration):

All of the criteria for binge-eating disorder are met, except that the binge
eating occurs, on average, less than once a week and/or for less than 3
months
Purging disorder:
Recurrent purging behavior to influence weight or shape like self- induced
vomiting, misuse of laxatives, diuretics, or other medications. It also
happened in the absence of binge eating

Night eating disorder:

Recurrent episodes of night eating manifested by:
-Eating after awakening from sleep during the night
-Excessive food consumption after evening meal

There is awareness and recall of the eating

Not better explained by external influences such as:
-Individual’s sleep-wake cycle
-Local social norms

Causes significant distress and/or impairment in

functioning

Not better explained by binge-eating disorder or mental

disorder, including substance use

Not due to another medical disorder/ effect of medication.