aneroxia nervosa, bulemia nervosa , binge eating , diet, overeating , obesity , treatment psychotherapy .

1. Heba Essawy , MD
Professor of Psychiatry
Ain Shams University

2. Roadmap
Anorexia Nervosa
Bulemia Nervosa
Binge-eating disorder
Obesity
Diagnosis
Epidemiology
Medical risks
Etiology
Treatment
prognosis

3. Risk Factors for EDs
 Perfectionism for AN
 Early Puberty
 Failed attempts to lose weight
 Athletics
 Beginning a diet
 Family history of eating disorder, substance abuse or
mood disorder

4. Diagnosis of Anorexia Nervosa
DSM IV
Refusal to maintain 85% of ideal body weight
Intense fear of becoming fat
Body image distortion; undue influence of weight
on self evaluation; denial of risks of low weight
Amenorrhea (in post-menarchal females)
Purging-type
Restricting-type

5. Proposed DSM V changes
“less than minimally expected” instead of 85% ideal
body weight
Remove “refusal” (pejorative)
Add “behavior” to avoid weight gain, since many
patients deny fear of gaining weight
Remove amenorrhea
Subtyping be for current episode

6. 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.

7. 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

8. 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.

9. 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

10. Etiology
(kristinaschwerin
et.al.2010)

11. 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

12. Anorexia Nervosa: Treatment
 Determine inpatient vs. day treatment vs. outpatient
 Multidisciplinary teams are ESSENTIAL!
 Primary care provider
 Psychiatrist
 Individual therapist
 Family therapist
 Nutritionist
 1st
: weight restoration
 2nd
: psychological
 3rd
: maintinance (long-term)

13. Medical Admission Criteria
 <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
 Acute medical complication
 Severe depression/suicidality– Psychiatric
admit
 Refractory to outpatient treatment

14. Anorexia Nervosa: 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.

15. 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

16. ANOREXIA NERVOSA
Prognosis:
 40% → recover.
 30% → continue with milder course.
 30% → chronic cases.
Risk of death
 Suicide
Cardiac arrest
Malnutrition
 > 3 years of illness: prognosis is poor

17. Bulemia Nervosa – DSM IV
Recurrent episodes of binge-eating (eating larger
amounts of food than others would eat in a
discrete- 2 hour- period of time, with a sense of lack
of control)
recurrent inappropriate compensatory behavior
(vomitting, laxatives, excessive exercise, etc)
Both occur at least 2x/wk for 3 months
Self-evaluation is unduly influenced by body
shape or weight
(purging type, non-purging type)

18. Proposed DSM V changes
Change frequency of compensatory behaviors from
2x/week to 1x/week
Deletion of non-purging subtype, because it more
closely resembles binge-eating disorder

19. 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.

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

21. Bulemia: Etiology
Media factors
Individual
Temperament
(ie. impulsive)
biological
Family dynamics
Societal, cultural

22. 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

23. Bulemia: Treatment
 Multidisciplinary team
Primary care provider
Psychiatrist
Family therapist
Nutritionist
 Evidence based : CBT + Antidepressant (SSRI)

24. Bulemia: Treatment (Therapy)
Family therapy is a good option if patient is young
and still lives at home (But not as much evidence as
for Anorexia)
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)
Nutrition plan, exercise, physical activity

25. 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

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

27. Binge Eating Disorder – DSM IV (only in
appendix)
Episodic intakes of larger than typical amounts of
food
Episodes occur in brief (<2 hrs) periods of time
Subjectively, sense of loss of control while eating
At least 2 days/week for 6 months

28. Binge Eating Disorder- Diagnosis
Also needs 3 of the following:
Eating much more rapidly than normal
Getting uncomfortably full
Large amounts of food when not physically
hungry
Eating alone because embarrassed about how
much one is eating
Feeling disgusted with oneself, depressed, or
guilty when over-eating

29. Proposed DSM-V changes
That binge eating disorder should become a free-
standing diagnosis, rather than only in the appendix
Less Frequency: once a week for 3 months

30. 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

31. 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

32. Binge Eating Disorder:
Epidemiology
Most common eating disorder
Lifetime prevalence:
3.5% women
2% men

33. Binge Eating Disorder:
Medical Risks
Less acute risk than with restrictive eating patterns
Long-term risks significant: the many organ systems
affected by obesity, shortened life-span, etc

34. Binge Eating Disorder: Etiology
Media factors
genetic
Individual
Temperament
(ie. impulsive)
biological
Family dynamics
Societal, cultural

35. 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

36. Binge Eating Disorder:
Treatment (Therapy)
Therapies either prioritize…
Weight loss
Binge-reduction
Neither (ie. relationships, depression etc)
Group psychotherapy
There is little evidence that obese individuals who
binge should receive different therapy than obese
individuals who do not binge

37. Binge Eating Disorder:
Psychosocial Support
Family need help with co-dependency
Weight loss programs
Weight watchers, Jenny Craig, etc.
12-step Self help groups
Food Addicts in Recovery Anonymous
Overeaters Anonymous

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