Feeding and eating disorder

FEEDING AND EATING DISORDER
MODERATOR: DR. VISHAL SINHA
PRESENTATOR: DR. RAMASHANKAR MADDESHIYA

Definition
 A persistent disturbance of eating or eating-related behavior that results in
the altered consumption or absorption of food and that significantly impairs
physical health or psychosocial functioning.
(Source : DSM-5 pg. 329)
 E.g. pica, rumination disorder, avoidant/restrictive food intake
disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder

Classification system and eating disorder
DSM-5 ICD-10
307.1 Anorexia Nervosa
Specify whether:
Restricting type
Binge-eating/purging type
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
307.51 Bulimia Nervosa F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
307.51 Binge-Eating Disorder F50.8 Other eating disorders (pica of nonorganic origin
in adults and psychogenic loss of appetite)
F98.3 Pica In children
307.59 Avoidant/Restrictive Food Intake Disorder
307.52 Pica
In children
In adults

DSM-5 ICD-10
307.53 Rumination Disorder F98.21 Rumination Disorder
F50.4 Overeating associated with other psychological
disturbances
F50.5 Vomiting associated with other psychological
disturbances
307.59 Other Specified Feeding or Eating Disorder
e.g.-
o Atypical anorexia nervosa
o Bulimia nervosa (of low frequency and/or limited
duration)
o Binge-eating disorder (of low frequency and/or
limited duration)
o Purging disorder
o Night eating syndrome
307.50 Unspecified Feeding or Eating Disorder F50.9 Eating disorder, unspecified
Classification system and eating disorder

ANOREXIA NERVOSA
 The term anorexia nervosa is derived from the Greek term for
"loss of appetite"
 characterized by three essential criteria
 The first is a self-induced starvation to a significant degree a behaviour
 The second is a relentless drive for thinness or a morbid fear of fatness-a
psychopathology.
 The third criterion is the presence of medical signs and symptoms resulting
from starvation-a physiological symptomatology.
 It is the oldest recognized feeding or eating disorder

Epidemiology
 Life time prevalence 2-4%
 The most common age of onset is between 14 and 18 years
 10 to 20 times more often in females than in males
 Most frequent in developed counties
 It may be seen with greatest frequency among young women in professions
that require thinness, such as modelling and ballet.
 Mortality rate 6:1 as compared to general population (20% death due to suicide) (CTP-10th ed.)
Etiology
 Higher concordance rates in monozygotic twins than in dizygotic twins.
 Sisters of patients with anorexia nervosa are likely to be afflicted, but this
association may reflect social influences more than genetic factors
 Diminished norepinephrine, serotonine turnover

BIOLOGICAL FACTORS
 Increase secretion of endogenous opioids
 Thyroid function suppression
 lowered hormonal levels (luteinizing, follicle-stimulating, and gonadotropin-
releasing hormones).
 Several CT studies reveal enlarged CSF spaces (enlarged sulci and ventricles)
 Caudate nucleus metabolism was higher in the anorectic state (PET)
 Hypothalamic-pituitary axis (neuroendocrine) dysfunction

SOCIAL FACTORS
 Support for their practices in society's emphasis on thinness and exercise
 Troubled, relationships with their parents
 Vocational ad avocational interests interact with other vulnerability factors
to increase the probability

PSYCHOLOGICAL AND PSYCHODYNAMIC FACTORS
 Critical challenges at this time of life include the need to establish
independence, a well-defined personal identity, fulfilling relationships, and
clear values and principles to govern one’s life. Family struggles, conﬂicts
regarding sexuality
 Certain personality traits including high levels of perfectionism, self-
discipline, harm-avoidance, and self-criticism are common in individuals with
the illness
 Bruch (1973, 1982) suggested that anorexia nervosa stems from failures in
early attachment, attempts to cope with underlying feelings of
ineffectiveness and inadequacy, and an inability to meet the demands of
adolescence and young adulthood.

DSM-5 Criteria
A. Restriction of energy intake relative to requirements, leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally
normal or, for children or adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that
interferes with weight gain, even though at a significantly low weight.
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 persistent lack of
recognition of the seriousness of the current low body weight.

 Specify whether:
Restricting type: During the last 3 months, the individual has not engaged in
recurrent episodes of binge eating or purging behaviour
Binge-eating/ purging type: During the last 3 months, the individual has
engaged in recurrent episodes of binge eating or purging behavior
 Specify if:
In partial remission:
In full remission:
 Specify current severity:
Mild: BMI >1 7 kglm2
Moderate: BMI 1 6-1 6.99 kglm2
Severe: BMI 1 5-1 5.99 kglm2
Extreme: BMI <1 5kglm

 SUBTYPES:
o 1) Restricting type
o 2) Binge-eating/ purging type
 Both types may be socially isolated and have depressive disorder symptoms
and diminished sexual interest. Over exercising and perfectionistic traits are
also common in both types.
 The suicide rate is higher in persons with the binge eating-purging type*
 Patients are often secretive, deny their symptoms, and resist treatment
* Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and
other eating disorders: a meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731

ANOREXIA NERVOSA BULIMIA NERVOSA
GENERAL ► Low weight
► Loss of body fat
► Muscle Atrophy
► Hypothermia
► Weight within normal
overweight/obese range
SKIN ► Lanugo (fine hair growth on body)
► Hair loss or thinning
► Carotenemia (yellowing of skin)
► Russell’s sign: Calluses on hands
from teeth scraping during self
induced vomiting (not extremely
common)
CARDIO-VASCULAR ► Arrhythmias
► Bradycardia
► Hypotension
► Orthostasis
► Prolonged QTc
► Peripheral edema
► Prolonged QTc
► Myocardial toxicity from emetine
(ipecac)

GASTROINTESTINAL ► Delayed gastric emptying
► Constipation
► Gastric distention
► Swollen parotid and salivary glands
► Elevated serum amylase levels
► Erosion of dental enamel, multiple
caries
ELECTROLYTE/METABOLIC ► Hypokalemia
► Hyponatremia
► Hypochloremia
► Alkalosis
►Hypercholesterolemia
► Hypoglycemia
► Elevated liver enzymes
► Hypokalemia
► Hyponatremia
► Hypochloremia
► Alkalosis

ENDOCRINE ► Low luteinizing
hormone
► Low follicle stimulating hormone
► Low estrogen or testosterone
► Low thyroxine
► Elevated cortisol
► Amenorrhea
► Decreased bone mineral density (can
lead to osteopenia or osteoporosis)
► Oligomenorrhea or
amenorrhea
HAEMATOLOGICAL ► Leukopenia
► Anaemia

D/d
 ORGANIC PATHOLOGY (gastrointestinal disease, hyperthyroidism, malignancy, AIDS)
 Depressive disorder
 OCD
 Schizophrenia
 Bulimia nervosa
 Substance induced disorder
 Avoidant/restrictive food intake disorder
Course And Prognosis
 Varies spontaneous recovery without treatment, recovery after a variety of
treatments, or a gradually deteriorating course resulting in death caused by
complications of starvation.

 30-50% full recovery
 10-20% remain chronically ill
 Reminder have improved but continue to struggle with certain disordered behaviors
 Restricting-type seemed less likely to recover than those of the binge/purging
 Favourable outcome if admission of hunger, lessening of denial and immaturity,
and improved self-esteem.
 Childhood neuroticism, parental conﬂict, bulimia nervosa, vomiting, laxative
abuse, and various behavioural manifestations (e.g., obsessive-compulsive,
hysterical, depressive, psychosomatic, neurotic, and denial symptoms) have been
related to poor outcome
 Depression is a common comorbid diagnosis, with rates of up to 63 per cent in
some studies (Herzog et al., 1992), while obsessive-compulsive disorder (OCD) has been
found to be present in 35 per cent of patients with anorexia nervosa (Rastam, 1992).

Managements
TREATMENT GOAL:
 1) To disrupt disordered behaviors, specifically, problematic pattern of
feeding and eating
 2) Altering the problematic cognitions , attitude and beliefs
 3) To address associated psychiatric comorbidity
OPTIONS FOR MANAGEMENT
 Hospitalization
 Psychological intervention
 Pharmacotherapy

Algorithm for guiding choice of initial treatment of anorexia nervosa.

 HOSPITALIZATION
• Stabilize all complication
• Target weight gain : 0.9-2.5 kg / week
• In-patient care for anorexia nervosa is not a predictor of better outcomes
than treatment in less intensive settings and is substantially more expensive
(Madden S, Hay P, Touyz S: Systematic review of evidence for different treatment settings in anorexia nervosa.
World J Psychiatry. 2015;5(1):147–153. )
 PSYCHOLOGICAL INTERVENTION
 Different forms of self-help and group treatments are less effective than
face-to-face individual therapy
• Electronic media (e.g., smartphone apps) for delivering therapy has little
robust evidence that this is an effective approach (Loucas CE, Fairburn CG, Whittington C, et al.
: E-therapy in the treatment and prevention of eating disorders: A systematic review and meta-analysis. Behav Res Ther.
2014;63C:122–131.

Younger cases
 family-based treatment (FBT) have a good recovery rate
 cognitive-behavioural therapy (CBT).
 FBT has the more immediate benefit when compared directly with CBT for adolescents
Adult cases
 Fairburn’s enhanced form of CBT (CBT-E) has more promising results
 CBT-E is more effective than interpersonal psychotherapy (IPT) and psychodynamic therapy
 Specialist supportive clinical management (SSCM) (lower recovery rate than for CBT-E)
 The Maudsley model of anorexia nervosa treatment for adults (MANTRA)
(less effective than CBT-E)
 Dialectical behaviour therapy (DBT) focusing on the compulsive pathology
of such cases.

 ATYPICAL ANTIPSYCHOTIC:
 Olanzapine has some better results.(Powers et al., 2002, Barbarich et al.,
2004, Attia et al., 2011)
 No improvement seen with quetiapine (Powers et al., 2012, Court et al., 2010,
Bosanac et al., 2007) or risperidone (Hagman et al., 2011).

BULIMIA NERVOSA
 The term bulimia nervosa derives from the terms for "ox hunger" in Geek
(1) Episodes of binge eating
(2) Compensatory behaviors are practiced after binge eating to prevent weight
gain, primarily self-induced vomiting, laxative abuse, diuretics, enemas, abuse
of emetics and, less commonly, severe dieting and strenuous exercise
(3) Weight is not severely lowered as in anorexia nervosa;
(4) The patient has a morbid fear of fatness, a relentless drive for thinness, or
both and a disproportionate amount of self-evaluation that depends on body
weight and shape.
 Physical discomfort-for example, abdominal pain or nausea terminates the binge eating, which is
often followed by feelings of guilt, depression, or self-disgust.

Epidemiology
 BN more common than AN
 Prevalence 1-4% in young women
 F> M 10:1
 Onset is often later in adolescence than that of anorexia nervosa

Etiology
BIOLOGICAL FACTORS
 ↑ endorphin level, ↓ serotonin and norepinephrine
 ↑ frequency of BN is found in first-degree relatives
 Exaggerated perception of hunger signals related to sweet taste mediated
by the right anterior insula area of the brain. (MRI)
SOCIAL FACTORS
The families of patients with bulimia nervosa ae generally less close and more
conﬂictual than the families of those with anorexia nervosa.

PSYCHOLOGICAL FACTORS
 Patients with BN are more outgoing, angry, and impulsive than those with
AN.
 Patients with BN lack superego control and the ego strength of their
counterparts with AN.
 The struggle for separation from a maternal figure is played out in the
ambivalence toward food; eating may represent a wish to fuse with the
caretaker, and regurgitating may unconsciously express a wish for
separation

DSM-5 Criteria
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 time period), an amount of food
that is definitely larger than what most individuals would eat in a similar period of
time under similar circumstances.
2 . A sense of lack of control over eating during episode (e.g., a feeling that one cannot stop eating
or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight
gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or
excessive exercise.
C. Atleast once 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.

Mild: An average of 1 -3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
Severe: An average of 8-1 3 episodes of inappropriate compensatory behaviors per week.
Extreme: An average of 1 4 or more episodes of inappropriate compensatory behaviors per
week.

D/d:
 Anorexia nervosa, binge eating-purging type
 Neurological disease, such as epileptic-equivalent seizures, central nervous
system tumours, Kliver-Bucy syndrome, or Kleine-Levin syndrome.
Atypical depression
 Impulse control disorder
 Substance induced disorder
 Bulimia nervosa is characterized by higher rates of partial and
full recovery compared with anorexia nervosa

Treatment
Medically or
psychologically
unstable (e.g.,
suicidal)?
•Hospitalization, Day
Program or Intensive
Outpatient Program
Therapist
experienced in
CBT available?
•Course of
individual
CBT
Course of
SSRI
treatment
(e.g.,
fluoxetine, 60
mg/day)Algorithm for guiding choice of initial
treatment of bulimia nervosa.
Tasman 4th ed.
Walsh BT & Devlin MJ (1995) Eating disorders. Child and Adolescent Psychiatric Clinics
of North America, 4, 343–357.

BINGE EATING DISORDER
 Eat an abnormally large amount of food over a short time without any
compensatory act
 It is the most common eating disorder. 2-6%
 F: M 1.75: 1
 Appears in approximately 25 percent of patients who seek medical care for
obesity
 50 to 75 percent of those with severe obesity (body mass index [BMI]
greater than 40).
 Impulsive and extroverted personality styles
 It may be used to reduce anxiety, stress or depressive moods.

DSM-5 Criteria
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 what most people would eat in a similar period of time 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. The binge-eating episodes are associated with
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 feeling embarrassed 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. at least once a week for 3 months.
E. the binge eating is not associated with recurrent use of inappropriate
compensatory behaviour
Mild: 1 -3 binge eating episodes per week.
Moderate: 4-7 binge-eating episodes per week.
Severe: 8-1 3 binge-eating episodes per week.
Extreme: 1 4 or more binge-eating episodes per week.

 Better prognosis than BN and AN
T/t
 Psychotherapy
 SSRI
 Self-help groups
 Psychopharmacology
 Pharmacological approach to address weight loss , such as topiramate and
orlistat, may able to address both binge eating and weight loss.

PICA
 Pica is defined as persistent eating of non-nutritive substances.
 More frequent in the context of autism spectrum disorder or intellectual
disability
 A minimum of 2 years of age is required for making ∆ (DSM-5)
 Specific cravings (e.g. chalk or ice) commonly reported during pregnancy
 Equal prevalence in male and female
 Commonly associated with nutritive deficiency, poisoning, intestinal
obstruction, perforation, infections

DSM-5 Criteria
A. Persistent eating of non-nutritive, non-food substances over a period of at least 1
month.
B. The eating is inappropriate to the developmental level
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

T/t
 Should be differentiated with anorexia nervosa, factitious disorder, non-
suicidal self-injury as in personality disorder
 Prognosis is good.
 Pica generally remits spontaneously within several months in normal
intellectual function
 In pregnant women, pica is usually limited till pregnancy
No definitive treatment exists for pica per se; most treatment is aimed at
education and behavior modification.

RUMINATION DISORDER
 Derived from the Latin word ruminare, which means, "to chew the cud."
 It is an eﬀortless and painless regurgitation of partially digested food into
the mouth soon after a meal, which is either swallowed or spit out.
 It can occur in infancy, childhood, or adolescence.
 In infants, it typically occurs between 3 months -12 months of age
RISK FACTOR: Psychosocial problems such as lack of stimulation,
neglect, stressful life situations, and problems in the parent-child
relationship

DSM-5 Criteria
 A. Repeated regurgitation of food over a period of at least 1 month.
Regurgitated food may be re-chewed, re-swallowed, or spit out.
 B. The repeated regurgitation is not attributable to an associated
gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).
 C. The eating disturbance does not occur exclusively during the course of
anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/
restrictive food intake disorder.
 D. If the symptoms occur in the context of another mental disorder (e.g.,
intellectual disability [Intellectual developmental disorder] or another
neurodevelopmental disorder), they are sufficiently severe to warrant
additional clinical attention.

 Spontaneous remissions are common
 Secondary complications can develop, such as progressive malnutrition,
dehydration, and lowered resistance to disease. Failure to thrive, with
absence of growth and developmental delays in all areas, can occur in the
most severe cases.
T/t
 Improvement in Mother child relationship
 Improvement in child’s psychosocial environment
 Must evaluate surgical cause

AVOIDANT/RESTRICTIVE FOOD INTAKE
DISORDER
 Formerly known as feeding disorder of infancy or early childhood
 In DSM-5 it also include adolescents and adults
 Characterized by a lack of interest in food, or its avoidance based on the
sensory features of the food or the perceived consequences of eating.
 Manifested by a persistent failure to meet nutritional or energy needs
 e.g.: significant weight loss or failure to achieve expected weight, nutritional
deficiency, dependence on enteral feedings or nutritional supplements, or
marked interference with psychosocial functioning.

D/d
 Other medical conditions (e.g., gastrointestinal disease, food allergies and Intolerances,
occult malignancies)
 Specific neurological/neuromuscular, structural, or congenital disorders and conditions
associated with feeding difficulties.
 Reactive attachment disorder
 Autism spectrum disorder.
 Specific phobia, social anxiety disorder (social phobia), and other anxiety disorders.
 Anorexia nervosa
 Obsessive-compulsive disorder
 Major depressive disorder
 Schizophrenia spectrum disorders
 Factitious disorder

Algorithm for diagnosis of eating disorders.
Tasman 4th ed.

NIGHT EATING SYNDROME
 Night eating syndrome is characterized by the consumption of large
amounts of food after the evening meal.
 Individuals generally have little appetite during the day and suﬀer from
insomnia.
 Prevalence – 2%
 Five times more likely to have a first-degree relative with NES
 Nocturnal eating tends to occur during non-rapid eye movement (REM)
sleep and is usually short in duration
 Patients believe that they can only sleep if they eat

PURGING DISORDER
 Recurrent purging behavior after consuming a small amount of food in
persons of normal weight who have a distorted view of their weight or body
image.
 Purging behavior includes self-induced vomiting, laxative abuse, enemas,
and diuretics
 Purging disorder is diﬀerentiated from bulimia nervosa because purging
behavior occurs after eating small quantities of food or drink and does not
occur as a result of a binge episode.

Feeding and eating disorder

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