Eating disorder in Adolescents jo.pptx

1. EATING DISORDERS IN ADOLESCENCE
Dr Jo Martin Kuncheria
JR, Pediatrics

2. Eating disorders
• Eating disorders (EDs) are a group of behavioral conditions
characterized by insufficient, excessive or peculiar patterns of
food intake
• Body dissatisfaction related to overvaluation of a thin body as
ideal
• Associated with dysfunctional patterns of cognition and weight
control behaviors
• Result in significant biologic, psychological and social
complications
• Mainly affect white adolescent females, also affect males

3. Eating disorders classification
• Anorexia nervosa
• Bulimia nervosa
• Restrictive food intake disorder
• Binge eating disorder
• Eating disorder not otherwise specified

4. Eating disorders definition
• Anorexia nervosa
Overestimation of body size and shape with a
relentless pursuit of thinness
- restrictive sub type :- typically combines
excessive dieting and compulsive exercising
-Binge-purge subtype:- Intermittently over
eat and then vomit or take laxatives

5. Bulimia nervosa
• Episodes of eating large amounts of food in a
brief period followed by compensatory
vomiting , laxative use, exercise or fasting
• This is to rid the body of the effects of
overeating in an effort to avoid obesity

6. Avoidant restrictive food intake
disorder
• Food intake restricted/avoided because of
adverse feeding/eating experiences/sensory
qualities of food
• Results in unintended weight loss / nutritional
deficiencies /problems with social interactions

7. Binge eating disorder
• Binge eating not followed by compensatory
behaviors like vomiting/ laxatives
• Shares many features of obesity
Eating disorder not otherwise specified
• Called disordered eating can worsen into full
syndrome eating disorder

8. Anorexia nervosa - Epidemiology
• Commonly affects young females between the ages of 10 years and
30 years.
• The lifetime prevalence of AN in young females is around 0.9%.
Varies widely (0.1–5.7%)
• AN is 10–20 times more common in females than in males
• More frequent in specific risk groups like fashion models, ballet
dancers, gymnasts and those involved in wrestling sports.
• The prevalence of AN in India is unknown

9. Anorexia nervosa - Etiology
• Dysfunction in the neurotransmitters involved in regulating eating
behavior; namely: serotonin, dopamine and norepinephrine are
commonly reported in studies.
• Endogenous opioids may play a role in denial of hunger by anorexic
patients
• The dopamine receptor D4 (DRD4) gene abnormalities were associated
with the binge/ purge subtype of AN.
• Positron emission tomography (PET) studies report an increase in
caudate nucleus metabolism.
• Family studies report a concordance rate of 55% in monozygotic twins as
compared to only 5% in dizygotic twins, suggesting strong genetic loading.
• Psychological factors implicated in etiology of AN include having a lifetime
of generalized anxiety and obsessive-compulsive traits, a lack of the sense
of autonomy and selfhood, poor selfesteem and low optimism.

10. Anorexia nervosa- clinical features & diagnosis
• Anorexia nervosa patients eat significantly less, harbor a normal
appetite and indeed are often excessively preoccupied with food.
• Various food fads like cutting food on plate in multiple small
pieces rather than eating it, arranging food obsessively, and
hiding food in bags or at home are often present in sufferers.
• Inability to maintain the anorexic control results in sudden bouts
of excessive eating, which is then followed by purging, commonly
by self-induced vomiting.
• Other compensatory behaviors of AN include abuse of laxatives,
diuretics, insulin, thyroid hormones or excessive jogging and
strenuous exercising.

11. Anorexia nervosa- clinical features & diagnosis
• Individuals with AN fail to maintain a body weight that is appropriate
for age, sex and developmental trajectory.
• In severe cases, features of starvation like abnormal reproductive
hormone functioning, amenorrhea, hypothermia, bradycardia,
orthostasis, dependent edema, hypotension and lanugo hair appear.
• Adolescents with AN might suffer from delayed puberty, and adults
generally also show an aversion to sex while anorexic.
• Patients of AN often report additional obsessive-compulsive behavior,
depression or anxiety symptoms.
• Major depressive disorder or dysthymia is the commonest comorbid
diagnosis and may be present in up to 50% of patients with AN.
• About half of AN patients develop symptoms of bulimia sometimes
during the illness

12. ICD -10 criteria for anorexia nervosa
• Body weight is maintained at least 15% below that
expected
Quetelet’s body mass index is 17.5 or less.
• A self perception of being too fat, with an intrusive dread of
fatness, which leads to a self-imposed low weight threshold
• The weight loss is self induced by avoidance of fattening foods.
self-induced vomiting ,self-induced purging ,excessive exercise , use of
appetite suppressants and/or diuretics
• A widespread endocrine disorder involving the hypothalamo
pituitary-gonadal axis is manifest in the female as amenorrhea and in the
male as a loss of sexual interest and potency.

13. Differential diagnosis of anorexia nervosa
• Medical illness that can account for the weight
loss
[Brain tumor, cancer cachexia, hyperthyroidism ,human immunodeficiency virus (HIV) ,
tuberculosis (TB) or other chronic wasting disorders]
• Psychiatric disorders, depression may mimic AN,
with loss of appetite and weight loss
Depressive patients however are lethargic and complain of tiredness, whereas AN
patients often are overly active.
Anxiety patients too may have decreased food intake and suffer from rapid weight loss,
although they do not suffer from body image misperceptions.
Multiple gastrointestinal and eating-related problems may occur in somatoform
disorder but recurrent treatment seeking differentiates them from AN

14. Management of anorexia nervosa
• Involving family members into the treatment plan is necessary for success.
• Primary consideration during hospitalization is to correct patients’
dehydration, electrolyte imbalances and nutritional state; as these can seriously
compromise health or lead to death.
• Constipation often occurs in AN due to the minimal food intake and is usually
relieved when patients begin to eat normally.
• Stool softeners may occasionally be given, but never laxatives.
• Realimentation should be started slowly because of the rare complication of
stomach dilation and the possibility of circulatory overload .
• Multiple small feeds (about six) throughout the day or liquid food supplement
may be better accepted by patients.

15. Management of anorexia nervosa cont
Psychotherapy is preferred over pharmacotherapy.
Cognitive and behavioral approaches have the most evidence base and include teaching patients to monitor
their food intake, their binging and purging behaviors, and their problems in interpersonal relationships.
Family therapy, stressing on family relationships may also help.
In pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) have had some success in causing
weight gain and in reducing symptoms anxiety or depression, and fluoxetine at dosage at or above
20 mg/day has shown some promise in preventing relapse.
Of the antipsychotics, olanzapine may help reduce anxiety, agitation, and improve weight; particularly in
patients with binge-purge subtype of AN.
Cyproheptadine, amitriptyline, clomipramine and pimozide have also been tried with mixed success.
Programs which combine pharmacotherapy with prominent behavioral therapy approaches show the best
outcome.

16. Course and outcome of anorexia nervosa
• Mortality caused by complications of starvation ranges
from 5% to 18%.
• Only 25% of patients improve completely from all
symptoms with treatment.
• Binge eating-purging type patients show better recovery
than restrictive subtype.
• Patients with childhood neuroticism, parental conflict,
vomiting, laxative abuse and other comorbid psychiatric
symptoms have the poorest outcome.

17. Bulimia nervosa - Epidemiology
• Bulimia is more common than anorexia
• Lifetime prevalence of BN is estimated to be around
2–4% in young women.
• BN is ten times more common in women than in
men
• Onset in early adulthood, generally later than the
onset of AN.
• Prevalence of BN in India is not known

18. Bulimia nervosa- Etiology
• Neurotransmitters related to satiety, serotonin and
norepinephrine, are also associated with BN.
• Raised plasma endorphin levels in BN patients
• Genetic predisposition is lesser than AN.
• Socially, patients of BN tend to be high achievers and
respond to social and cultural pressures for slimness.
• Patients often suffer from other impulse control
problems like alcohol abuse, shoplifting etc

19. Bulimia nervosa- Clinical features
Bulimia nervosa is essentially characterized by three cardinal features:
(1) Binges
(2) Purges
(3) Body image disturbances
Binges refer to periods of rapid consumption of food, accompanied by a sense of loss of
control overeating.
The commonest purging method involves self-induced vomiting by inserting finger into the
throat, although some patients vomit on will.
Body image disturbance. Bulimia patients suffer from a morbid fear of fatness, worry about
their body image and harbor concern about their sexual attractiveness.
Bulimia patients also generally maintain body weight within the normal weight range,
although some may be overweight or underweight.
Bulimia nervosa patients also suffer from high rates of comorbid mood disorders, impulse
control disorders, substance-related disorders and a variety of personality disorders.
Past history often reveals food fads, pica and sexual abuse in childhood.

20. ICD -10 criteria for Bulimia nervosa
Recurrent episodes of overeating in which large amounts of food are
consumed in short periods of time
Persistent preoccupation with eating and a strong desire or a sense of
compulsion to eat (craving)
The patient attempts to counteract the fattening effects of food by one
or more of the following: self-induced vomiting; self-induced purging, alternating
periods of starvation, use of drugs like appetite suppressants, thyroid preparations
Binge eating happens at least two times per week over a period of 3
months
A selfperception of being too fat, with an intrusive dread of fatness
There is often, but not always, a history of an earlier episode of
anorexia nervosa, the interval between the two disorders ranging from a few
months to several years.

21. Bulimia nervosa –Differential diagnosis
• Differentiating BN from AN can be difficult as both the disorders share several
core features and patients often have phases of AN and BN alternating during
the course of ED.
• Most diagnostic guidelines give preference to the diagnosis of AN when
symptoms of both are present and label the condition as AN binge-purge
subtype.
• Atypical depression mimics BN. Instead of lack of appetite, patients suffer from
overeating and excessive sleep with prominent increased libido.
• Organic conditions that may resemble BN include the Kluver-Bucy syndrome and
the Kleine-Levin syndrome.
• Kluver-Bucy syndrome, resulting from bilateral temporal lobe lesions, presents
with hyperphagia and hypersexuality mimicking BN but is differentiated by
additional presence of hyperorality and visual agnosia .
• Kleine-Levin syndrome is a sleep disorder characterized by persistent episodic
hypersomnia where patients may also experience hyperphagia and
hypersexuality.

22. Bulimia nervosa- Management
• Most patients of BN can be managed on outpatient
department (OPD) basis and hospitalizations are rarely
necessary
• Hospitalization for management of electrolyte imbalance or
gastric/esophageal tears.
• Pharmacotherapy includes tricyclic antidepressants and
SSRIs.
• Fluoxetine can reduce binge-purge episodes by 50%. A
higher dose (60 mg) has been found better than 20 mg.
• Sertraline and fluvoxamine are alternative drugs.

23. Bulimia nervosa- Management
• Cognitive behavioral therapy (CBT) has shown
robust evidence of effectiveness and many national
guidelines (NICE: UK) now suggest it as a first-line therapy
• CBT has more patient retention as compared to
pharmacotherapy alone and the benefits of CBT are
maintained even 12 months post-therapy.
• CBT aims to modify patient’s cognitive distortions
about food, weight and body image while behavior
alteration focusses on interrupting the cycle of binging and
dieting.
• Other psychotherapies which have shown promise in BN
include interpersonal therapy and dynamic therapy.

24. Bulimia nervosa – course and outcome
• The outcome of BN is better as compared to AN, with 40–
50% of treated patients showing complete remission.
• Untreated patients continue a chronic course with partial
remission and exacerbations over the years.
• A longer duration of the illness at presentation, past history
of AN, other comorbid disorders like depression and
substance use predict poorer outcome.
• Patients who resist purging generally show better outcome

25. To conclude
• Around 2–10% of young women of western countries suffer from EDs. AN has a
prevalence of 1% while BN has a prevalence of 2–4% in young women.
• Eating Disorder Examination Questionnaire is the most commonly used
tool to generate ED diagnoses.
• Disturbance in body image is considered as one of the core psychopathology of
ED and is seen in most EDs.
• AN additionally has significantly low body weight while BN patients generally
maintain body weight. Binges and purges may happen in both disorders.
• Anorexia nervosa has significant genetic loading while bulimia has more
environmental risk factors.
• Treatment of both AN and BN includes CBT and pharmacotherapy. SSRIs,
particularly fluoxetine has been found useful in treatment.

26. Thank you