Feeding and Eating disorders are one of the devastating disorders , Anorexia is a killer disease , very common in childhood and adolescent, mainly in girls more than boys. Bulimia is charecterize by binge eating followed by compulsive purging . Binge eating disorders and night eating syndrome are becoming very prevalent Feeding disorders as avoidant restrictive food intake disorder , rumination disorders and pica are the types of feeding disorders in infant and childhood period psychological rehabilitation, nutritional plan and medical therapy are the most effective lines of treatment foe eating Disorders

1. Heba Essawy , MD., CEDS.,
Professor of Psychiatry
Head Of Eating Disorders Clinics
Okasha Institute Of Psychiatry
Medical School
Ain Shams University

2. Roadmap
Anorexia Nervosa
Bulimia Nervosa
Binge-eating disorder
Rumination Disorder
Pica
Avoidant/Restricting
Food Intake Disorder
Obesity ????
Risk Factors
Diagnosis
Manegement
Clinical Sheet
applied in
Eating Disorder
clinics in
Institute Of
Psychiatry

3. Risk Factors for EDs
Achievement Oriented :
Perfectionists
Good students
Competitive careers
Early Puberty.
Failed attempts to lose weight.
Athletics.
Family history of eating disorder, substance abuse
or mood disorder.

4. Eating Disorders is alarming:
40-60% of primary school girls (ages 6-12) are concerned
about their weight . (Smolak, 2011)
Among high-school students, 44% of females and 15% of
males attempted to lose weight. (Serdula et al., 1993)
 Teenagers , one half girls and one third boys use
unhealthy weight control behaviors (ex, skipping meals,
fasting, smoking cigarettes, purging)
(Neumark-Sztainer, 2005)

6. Feeding and Eating Disorders
Etiology of Eating Disorders
Types of Feeding and Eating
Disorders
Clinical Picture
 Medical Complications
Different Lines of Treatment

7. Feeding and Eating Disorders
Etiology of Eating Disorders
Clinical Picture
 Medical Complications
Different Lines of Treatment

8. Feeding and Eating Disorders
Etiology of Eating Disorders
- Biological
- Psychological
- Social

9. Etiology
(kristinaschwerin
et.al.2010)

10.  Increased risk of anorexia nervosa among first-degree
biological relatives of individuals with the disorder
Twin studies
 concordant rates for monozygotic twins is significantly higher
than those for dizygotic twins.
Genetic Factors May Predispose to Eating
Disorders

11. Genetics Linked to Anorexia
 Records from 30,000 Swedish twins found
identical twins more likely to share an eating
problem than fraternal twins or non twin
siblings
 found that genes were responsible for 56%
of the cases.
 “People need to understand that they are fighting
their biology and not just a psychological need to be
thin”
By Dr. Cynthia Bulik of University of North Carolina
School of Medicine

12. Etiology
(kristinaschwerin
et.al.2010)

13. Personality Traits
Low self-esteem
Feelings of inadequacy or lack of
control in life
Fear of becoming fat
Depressed, anxious, angry, and lonely
feelings
Keep feelings to themselves

14. Etiology
(kristinaschwerin
et.al.2010)

15. Environmental Factors
 1-Interpersonal Factors
 Troubled family and personal relationships
 Difficulty expressing emotions and feelings
 History of being bullied based on weight
 History of trauma, sexual, physical and/or mental abuse
- 60-75% of all bulimia nervosa patients have a history of
physical and/or sexual abuse

16. Environmental Factors: Social
2- Social Factors (media, clutural and Family pressures)
 Cultural pressures that glorify "thinness" and place value
on obtaining the "perfect body”
 Mothers who are overly concerned about their
daughter’s weight and physical attractiveness might
cause increase risk for development of eating disorders
 Girls with eating disorders often have brothers and a
father who are overly critical of their weight.
 People pursing professions or activities that emphasize
thinness are more susceptible
 ie. Modeling, dancing, gymnastics, wresting

17. Feeding and Eating Disorders
Etiology of Eating Disorders
Types of Feeding and Eating
Disorders
Clinical Picture
 Medical Complications
Different Lines of Treatment

18. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

21. Diagnosis AN (DSM-5):
 Restriction of energy intake relative to
requirements leading to a significantly low
body weight in the context of age, sex.
 Intense fear of gaining weight or becoming
fat, or persistent behavior that interferes
with weight gain.
 Disturbance in one's body weight or shape ,
persistent lack of recognition of the
seriousness of low body weight
Specify:
 Restricting type
 Purging type/Binge Eating.

22. Subtypes AN (DSM-5):
Restricting Type: during last 3months, the person has
not engaged in recurrent episodes of binge eating or
purging behavior
Binge-Eating/Purging Type: during last 3 months, the
person engaged in
recurrent episodes of binge eating or purging behavior

23. Epidemiology:
 Life time prevalence 0.5- 3.7%
 Girls from 14- 18ys 0.5- 1%
 AN and BN 30 - 50%
 Death 3-8%
 Age: 10-30years.
 Risk : Sp. After stress
 M:F ratio 1: 20
 In professions modeling –
ballet dancers.

24. Anorexia Nervosa
*onset and course
 mean age at onset is 17 years
 bi-modal peaks at ages 14 and 18
 course and outcome are highly variable
 30 % recover after a single episode
 30 % fluctuation pattern of weight gain followed by
relapse
 30% chronic deteriorating course of the illness over many
years
 > 3 years of illness: prognosis is poor

25. Feeding and Eating Disorders
Etiology of Eating Disorders
Types of Feeding and Eating
Disorders
Clinical Picture
 Medical Complications
Different Lines of Treatment

26. Medical Complication
 Death (hypokalemia , starvation, sudden cardiac death)
 Hypometabolic state (bradycardia, hypotension, hypothermia)
 Dehydration
 Arrhythmia, heart failure.
 Bone loss
 Peripheral edema
 Delayed sexual maturity
 Hair loss, brittle hair, Lanugo.
 On recovery: Re-feeding syndrome

28. Feeding and Eating Disorders
Etiology of Eating Disorders
Types of Feeding and Eating
Disorders
Clinical Picture
 Medical Complications
Different Lines of Treatment

29. Anorexia Nervosa: Treatment
 Determine inpatient vs. day treatment vs. outpatient
 Multidisciplinary teams are ESSENTIAL!
 Family Doctors
 Certified Psychiatrist
 Certified Nurse
 Certified Psychologist
 Nutritionist
 1st: weight restoration : Nutritional Management.
 2nd: psychological : Distortion of body image, low self-
esteem, and interpersonal conflicts
 3rd: maintinance :Achieving long-term remission and
rehabilitation.

30. Anorexia Nervosa : Hospitalization
 Indication :
 <75% ideal body weight
 Hypothermia T<36
 Bradycardia HR<50 while awake, <45 asleep
 Orthostasis-drop in sbp >10, increase in HR>35
 Dehydration
 Severe hypokalemia (<2-3 mmol/L) or other
electrolyte abnormality
 Severe depression/suicidality– Psychiatric
admit
 Refractory to outpatient treatment

31. Weight Restoration : Nutritional
Manegement
 Oral Or Intavenous Feeding
-Intravenous feeding is used for patients who refuse to eat or the
amount of weight loss has become life threatening
 Physician strictly sets the rate of weight gain
 Usually from half to one kg per week
 In the beginning 1,000 calories are given per day
 Calorie intake may eventually go up to 3,500 calories per day
 Dietitian is often used to develop strategies for planning
meals and to educate the patient and parents
 Useful for achieving long-term remission

32. Anorexia Nervosa:
Psychological Therapy
 Best evidence is for family-based treatment (Maudsley
approach)
 Who: younger patients who live at home, intact family
 Philosophy: no-blame, family did not cause anorexia; family
is the best resource to help her get better
 Elevate family’s anxiety about the gravity of the illness.
Empower parents to do whatever they need to do to get the
anorexic to eat. Align siblings with the patient for support.
Externalize the anorexia.
 “Family Meal”
 Once weight-restored: explore the family dynamics and
psychological issues.

33. Anorexia Nervosa: Medications
 No approved medication treatments for Anorexia Nervosa
 Prozac (or other SSRI) for co-morbid depression or anxiety
 Low-dose Atypical Antipsychotics off-label for near-
psychotic thinking that is characteristic of anorexia,
Zyprexa may help with weight gain
- problem: informed consent for risks of weight gain

34. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

37. Diagnostic Criteria for Bulemia Nervosa DSM-5
 A. Recurrent episodes of binge eating:
(1) Eating large amount in a discrete period of time
(2) lack of control over eating
B. Recurrent compensatory behavior in order to prevent
weight gain.
C. Binge eating and inappropriate compensatory
behaviors is at least once a week for 3 months.

38. Bulemia: Epidemiology
Lifetime Prevalence
1.5% women
0.5% men
Prevalence of binge-purge behaviors:
13% girls
7% boys

39. Medical Complication
 Electrolyte abnormalities
 Dental – loss of enamel, chipped teeth, cavities
 Parotid enlargement
 Conjunctival hemorrhages
 Calluses on dorsal side of hand (Russel’s sign)
 Esophagitis
 hematemesis
 Latxative-dependent: cathartic colon, melena, rectal
prolapse

42. Bulemia: Treatment
 Multidisciplinary team
 Family Doctors
 Certified Psychiatrist
 Certified Nurse
 Certified Psychologist
 Nutritionist
Treatment Approches :
Evidence based Treatment :
Cognetive Behavior Therapy + Antidepressant
(SSRI)

43. Bulimia Treatment
 Primary Goal
 Cut down or eliminate binging and purging
 Patients establish patterns of regular eating
 Treatment Involves:
 Psychological support
 Focuses on improvement of attitudes related to E.D.
 Encourages healthy but not excessive exercise
 Deals with mood or anxiety disorders
 Nutritional Counseling
 Teaches the nutritional value of food
 Dietician is used to help in meal planning strategies
 Medication management
 Antidepressants (SSRI’s) are effective to treat patients who also
have depression, anxiety, or who do not respond to therapy alone
 May help prevent relapse

44. Bulemia: Individual Therapies
Interpersonal therapy (IPT) (short-term treatment
focused on life transitions)
Psychodynamic Psychotherapy (good for long-term
results in people with chronic depressive and
personality symptoms)
Family therapy is a good option if patient is young and
still lives at home (But not as much evidence as for
Anorexia)

45. Psychological Treatment
 2- Group Therapy
 Provides a supportive network
 Members have similar issues
 Can address many issues, including:
 Alternative coping strategies
 Exploration of underlying issues
 Ways to change behaviors
 Long-term goals

46. Bulemia: Medicaions
 High-dose Fluoxetine/Prozac (SSRI) – very good
evidence!
 Sertraline/Zoloft (SSRI) – some good evidence
 Buproprion/Wellbutrin (other antidepressant) –
contraindicated! (risk of seizures if history of
purging)
 Topiramate/Topomax (mood stabalizer, promotes
weight loss) – some good evidence, but use with
caution esp if low-weight

47. Nutritional Counseling

48. Bulemia: Prognosis
33% remit every year
But another 33% relapse into full criteria
Adolescent-onset better prognosis than adult-onset
Death-rate = 1%

49. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

50. DSM-5 Diagnostic Criteria for Binge Eating
Disorder
 Eating, in a discrete period of time , large amount
 Lack of control over eating during the episode
 Binge eating occurs, on average, at least once a week
for three month

51. Binge Eating Disorders
Characterized by recurrent binge eating without
the regular use of compensatory measures to
counter the binge eating.
Symptoms include:
-Indications that the binge eating is out of control,
such as eating when not hungry,
-Eating to the point of discomfort,
-Eating alone because of shame about the
behavior
-Feelings of strong shame or guilt regarding the
binge eating

52. DSM-5 Diagnostic Criteria for Binge Eating
Disorder
 BE 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
hungry
4. feeling disgusted with oneself, depressed, or very
guilty afterwards

53. Types Of Binge Eating
 1- Night Nocturnal Eating .
 2-Depreviation Binge.
 3- Opportunity Binge.
 4- Pleasure Binge.
 5- Vengeful Binge.

54. Night Nocturnal
Eating

55. Night eating syndrome (NES) : Diagnosis
 Evening hyperphagia (consumption of 25% or more of the total daily
calories after the evening meal) and/or nocturnal awakening and
ingestion of food two or more times per week.
 Three of five associated symptoms
- lack of appetite in the morning, urges to eat in the
evening/at night, belief that one must eat in order
to fall back to sleep at night, and/or difficulty
sleeping

56. Night Eating Syndrome : Statistics
Prevalence : in 1 and 2% of the general population, and
approximately 10% of obese individuals.
Sex Ratio : NES affects both men and women
Age of onset : in early adulthood (spanning from late
teenage years to late twenties) and is often long-
lasting, children rarely reporting NES.

57. Complication Of BED
Obesity
-Increase Risk of Type II DM
-- Cardiovascular Disease
-- Breathing problem
-- Physical aliments (joint/
muscle)
Without obesity
-Sleep Problem .
-- Anxiety / Depression .
-- Irritable bowel Syndrome.
-- Early Menstruation.

58. Binge Eating Disorder:
Treatment (Medication)
 SSRI
 high dose reduces binge behavior short-term
 but doesn’t help weight loss
 Topomax, Zonisamide (anticonvulsants, mild
mood stabalizer)
 Helps binge reduction
 Helps weight loss
 Caution for adverse effects, high discontinuation rates

59. Binge Eating Disorder:
Treatment (Therapy)
 Therapies either prioritize…
 Weight loss
 Binge-reduction
 Neither (ie. relationships, depression etc)
 Group psychotherapy
Family need help with co-dependency
12-step Self help groups
Food Addicts in Recovery Anonymous

60. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

61. Pica

62. Pica
 Persistent eating of non-nutritive substances for a
period of at least one month.
 The eating of non-nutritive substances is
inappropriate to the developmental level of the
individual.
 The eating behaviour is not part of a culturally
supported or socially normative practice.
 Not occurring in the presence of another mental
disorder (e.g. autistic ), or during a medical condition
(e.g. pregnancy).

63. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

65. What is ARFID?
ARFID characterized by :
 food avoidance or restriction that fails to meet an
individual’s nutritional or energy needs
 Related to sensory concerns
 Fear of unpleasant experiences such as choking or
vomiting
 Not related to body image concerns.
 Other psychiatric disorders including ASD , OCD
and ADHD may increase an individual’s risk for
ARFID.

66. Feeding and Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Binge Eating Disorder (BED)
Avoidant/Restrictive Food Intake
Disorder (ARFID)
Pica
Rumination Disorder

67. Rumination Disorder
 Repeated regurgitation of food for a period of at least
one month Regurgitated food may be re-chewed, re-
swallowed, or spit out.
 Not preceeded by nausea or vomoting
 The repeated regurgitation is not due to a medication
condition (e.g. gastrointestinal condition).
 The behaviour does not occur exclusively in the course
of Anorexia Nervosa, Bulimia Nervosa, BED, or
Avoidant/Restrictive Food Intake disorder.

68. What should an Assessment include?
 Specific interview that goes into more detail about
symptoms
 A full physical exam
 Nutritional assessment/evaluation
 History of body weight
 History of dieting
 Eating behaviors
 All weight-loss related behaviors
 Past and present stressors
 Body image perception and dissatisfaction

69. Heba Essawy
Website
www. Hebaessawy.com
Facebook Dr.heba essawy
Email
essawi_h@yahoo.com

70. WHAT IS ARFID ?

71. What is ARFID?
ARFID characterized by :
 food avoidance or restriction that fails to meet an
individual’s nutritional or energy needs
 Related to sensory concerns
 Fear of unpleasant experiences such as choking or
vomiting
 Not related to body image concerns.
 Other psychiatric disorders including ASD , OCD
and ADHD may increase an individual’s risk for
ARFID.

72. Types of ARFID include:
 Avoidant: Patients who only accept a limited diet in relation to
sensory features (sensory sensitivity); sensory aversion; sensory over-
stimulation
 Aversive: Individuals whose food refusal is related to aversive or fear-
based experiences (phobic avoidance) including choking, nausea,
vomiting, pain and/or swallowing
 Restrictive: Individuals who do not eat enough and show little interest
in feeding or eating (low appetite); extreme pickiness; distractible and
forgetful
 ARFID “Plus”: Individuals with avoidant, aversive, or restrictive
types of ARFID presentations who begin to develop features of
anorexia nervosa, including concerns about body weight and size, fear
of weight gain, negativity about fatness, negative body image without
body image distortion and preference for less calorically-dense foods
 Adult ARFID: Individuals with avoidant, aversive, or restrictive types
of ARFID presentations beyond childhood; may have had similar
symptoms since childhood including selective or extremely picky
eating, food peculiarities, texture, color or taste aversions related to
food.
ARFID: Facts and Fictions

74. What should an Assessment include?
 Specific interview that goes into more detail about
symptoms
 A full physical exam
 Nutritional assessment/evaluation
 History of body weight
 History of dieting
 Eating behaviors
 All weight-loss related behaviors
 Past and present stressors
 Body image perception and dissatisfaction

75. Assessment Tools
 There are numerous tests that can be used to assess
eating disorders
 EAT, EDI-2, PBIS, FRS, and SCOFF are some of the
more popular tests

76. EAT (Eating Attitudes Test)
 26 item self-report questionnaire broken down
into 3 subscales
 Dieting
 Bulimia & food preoccupation
 Oral control
 Designed to distinguish patients with anorexia
from weight-preoccupied, but healthy, female
college students
 Has advantages & limitations
 Subjects are not always honest when self-reporting
 Has been useful in detecting cases of anorexia nervosa

77. Eating Disorder Inventory (EDI)
 The EDI is a 64 item, self-report for the
assessment of psychological and behavioral traits
common in anorexia nervosa (AN) and bulimia.
 EDI consists of eight sub-scales measuring: 1)
Drive for Thinness, 2) Bulimia, 3) Body
Dissatisfaction, 4) Ineffectiveness, 5)
Perfectionism, 6) Interpersonal Distrust, 7)
Interoceptive Awareness ,8) Maturity Fears

78. Heba Essawy
Website
www. Hebaessawy.com
Facebook Dr.heba essawy
Email
essawi_h@yahoo.com

79. Any questions?
Heba Essawy
Website www. Hebaessawy.com
Facebook Dr.heba essawy
Email essawi_h@yahoo.com