Eating disorders

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behaviour. Anorexia nervosa has been well documented in pre-pubertal children. Eating disorders are most prevalent in the Western cultures where food is in abundance and for females attractiveness is equated with thinness. Eating disorders are rare in countries like India. As Western socioculturel ideals become more widespread one may expect to see an increase in number of cases of eating disorders in non-Western societies. Etiological theories suggest a complex interaction among psychological, sociocultural, and biological factors. Patients with anorexia nervosa manifest weight loss, fear of becoming fat, and disturbances in how they experience their body weight and shape. Patients with bulimia nervosa present with recurrent episodes of binge eating and inappropriate methods of weight control such as selfinduced vomiting, and abuse of diuretics and laxatives. Major complications of eating disorders include severe fluid and electrolyte disturbances and cardiac arrhythmias. The most common cause of death in anorexia nervosa is suicide. Management requires a team approach in which different professionals work together. Individual and family psychotherapy are effective in patients with anorexia nervosa and cognitivebehavioral therapy is effective in bulimia nervosa. Pharmacotherapy is not universally effective, by itself. Patients with eating disorders suffer a chronic course of illness. The pediatrician plays important role in early diagnosis, management of medical complications, and psychological support to the patient and the family.     

Eating disorders in adolescent girls*

Eating disorders are common in contemporary society. New information is emerging on the pathogenesis of anorexia nervosa and bulimia nervosa and includes psychologic, biologic, family, environmental, genetic and social factors. The physician providing care to adolescents is challenged to carry out a careful evaluation and monitor the patient for complications, especially loss of bone mass. Treatment requires a multidisciplinary team.     

Differential diagnosis and pathogenesis of anorexia nervosa

Anorexia nervosa is a disease of increasing frequency with serious medical and psychological consequences. The presentation is one of significant weight loss. The initial assessment of such a patient must differentiate between an underlying systemic medical illness and an eating disorder. This paper will review the more common medical conditions causing weight loss and their distinguishing characteristics, including malignancy, inflammatory bowel disease, infections and metabolic disorders. Once an organic disease is ruled out, anorexia nervosa must then be differentiated from other eating disorders such as bulimia or other psychological diseases such as depression, schizophrenia, drug abuse, conduct disorders, and anxiety reactions. The pathogenesis of anorexia nervosa includes complex societal, family, and individual factors which require evaluation in the treatment process.     

Les crises de boulimie à l’adolescence

Binge eating, bulimia nervosa, binge eating disorder, anorexia-bulimia are terms often used without really knowing what precisely one is referring to. Otherwise, there are many articles concerning anorexia nervosa in medical literature, a disease, which can be seen and fascinates. These eating disorders are frequent in today's society; medical, psychological and social consequences are important.     

Management of child and adolescent eating disorders: the current evidence base and future directions

Although eating disorders in children and adolescents remain a serious cause of morbidity and mortality, the evidence base for effective interventions is surprisingly weak. The adult literature is growing steadily, but this is mainly with regard to psychological therapies for bulimia nervosa and to some extent in the field of pharmacotherapy. This review summarises the recent research literature covering management in three areas, namely physical management, psychological therapies, and service issues, and identifies prognostic variables. Findings from the adult literature are presented where there is good reason to believe that these might be applied to younger patients. Evidence-based good practice recommendations from published clinical guidelines are also discussed. Suggestions for future research are made, focusing on 1) the need for trials of psychological therapies in anorexia nervosa, 2) applications of evidence-based treatments for adult bulimia nervosa to the treatment of adolescents, and 3) clarification of the benefits and costs of different service models.     

Family dynamics and treatment of anorexia nervosa and bulimia

This paper describes the nature of the family involvement typically observed in anorexia nervosa and bulimia and the role of family therapy in a comprehensive treatment approach. Both the patterns of family interaction observed by clinicians and researchers and the varieties of family treatment used to address these disorders are described. The different types of relationships observed between the eating-disordered patient and the family are also described.     

Weight and menstrual function in patients with eating disorders and cystic fibrosis

Many patients with eating disorders have menstrual dysfunction. In patients with anorexia nervosa, amenorrhea has been linked to weight loss. However, many patients with bulimia nervosa, even those of average or greater than average weight, also experience menstrual abnormalities, including amenorrhea. It was hypothesized that low weight per se is not responsible for menstrual dysfunction in patients with eating disorders. First, 16 patients with bulimia nervosa of average weight and 29 patients with cystic fibrosis of below average weight of similar menstrual age were compared. Of the patients with bulimia nervosa, 11 (73%) had had secondary amenorrhea at some time compared with 8 (28%) of the patients with cystic fibrosis (P less than .01). At the time of study, 6 (40%) of the patients with bulimia nervosa and 21 (78%) of the patients with cystic fibrosis were having regular cycles (P less than .01). Next 18 patients with anorexia nervosa were compared with 18 patients with cystic fibrosis matched for weight and menstrual age. Although 18 (100%) of the patients with anorexia nervosa had had secondary amenorrhea, only 6 (33%) of the patients with cystic fibrosis had amenorrhea. Although only 1 (6%) of the anorexia nervosa group was currently having regular cycles, 14 (78%) of the patients with cystic fibrosis were (P less than .0001). Closer approximation to ideal body weight was associated with regular menses only in the cystic fibrosis group. Exercise did not appear related to regularity of menstruation in any group. Body weight is not the major factor responsible for menstrual abnormalities in patients with eating disorders.     

Bulimia nervosa in adolescence

Investigations of bulimia nervosa have focused primarily on adult samples, although bulimia nervosa commonly has its onset in adolescence. Pediatricians are often questioned about its etiology, course, and treatment. In an attempt to provide pediatricians with answers, we integrate findings from recent epidemiological and treatment studies with a clinical report of 18 women who developed bulimia nervosa during their teens and sought treatment at our eating disorders clinic.     

Management of eating disorders in children and adolescents

The eating disorders, anorexia nervosa, bulimia nervosa and their variants, typically develop in adolescence or early adulthood, mainly in females. Despite a long history, the evidence base for effective treatments is weak and existing clinical guidelines are based on consensus views rather than strong research. Effective coordinated management of physical and psychological aspects of the disorders is crucial, but outcomes remain very variable, with adverse outcomes commonly extending into adulthood. Anorexia nervosa carries a high morbidity and occasional mortality.     

Management of eating disorders in children and adolescents.

The eating disorders, anorexia nervosa, bulimia nervosa and their variants, typically develop in adolescence or early adulthood, mainly in females. Despite a long history, the evidence base for effective treatments is weak and existing clinical guidelines are based on consensus views rather than strong research. Effective coordinated management of physical and psychological aspects of the disorders is crucial, but outcomes remain very variable, with adverse outcomes commonly extending into adulthood. Anorexia nervosa carries a high morbidity and occasional mortality.     

Dental aspects of anorexia and bulimia nervosa

Anorexia nervosa and bulimia nervosa are both psychosocial pathological eating disorders. An intense preoccupation with food, weight and a distorted body image coupled with a morbid fear of becoming obese are common elements in both syndromes. Self-starvation with extreme weight loss is associated with anorexia nervosa. Bulimia nervosa is characterized by unrestrained eating sprees followed by purging, fasting or vomiting. Approximately 50% of anorexia nervosa patients also practice bulimia. The impact of eating disorders on the oral soft and hard tissues depends upon the diet as well as the duration and frequency of binge-purge behavior. Erosion of the teeth due to frequent regurgitation of highly acidic stomach contents is a common finding. Dental caries development is less predictable and appears to be diet- and oral hygiene-dependent. Painless enlargement of the parotid salivary glands is a common sequela of chronic vomiting but the pathophysiological cause has not been firmly established. The dehydration of the oral soft tissues due to salivary gland impairment in addition to dietary deficiencies and poor oral hygiene can adversely impact the health of the periodontal tissues and oral mucosa. Initial dental care is focused on discouraging behavior that is destructive to the oral tissues. Improved oral hygiene, the use of gastric acid-neutralizing antacid rinses and the daily application of topical fluorides can be useful in reducing enamel erosion. Extensive restorative oral rehabilitation should be postponed until the underlying psychiatric components of the disorder are stabilized.     

Anorexia und Bulimia nervosa im Kindes- und Jugendalter

Eating disorders are among the most common chronic illnesses in female adolescents and for some patients these psychiatric disorders are potentially fatal. This article defines anorexia and bulimia nervosa and goes on to describe the epidemiology, etiology, pathogenesis, comorbidities and differential diagnosis of these disorders. Details concerning eating disorder symptoms, hyperactivity, psychiatric symptoms, such as distorted self-image and obsessive fear of gaining weight are given, as well as somatic complications. A plan of treatment of eating disorders is provided in a multimodal therapy approach consisting of somatic rehabilitation, psycho-education, individual psychotherapy, involvement of family members and medication. Finally, recommendations for pediatricians, often the first to be notified by patients and their families and therefore fulfilling an important role in the initial diagnosis and referral to other specialists, are provided.     

Evidence-based treatment of eating disorders

Anorexia nervosa and bulimia nervosa are common problems facing adolescents and young adults. Treatment of these disorders poses a challenge to health care providers given the general paucity of clinical trials to guide management. There is evidence to support the use of CBT as well as psychopharmacotherapy to decrease binge and purge behaviors in bulimia nervosa. Significantly fewer trials have examined the efficacy of such therapies for anorexia nervosa. Short-term trials appear promising regarding potential treatments for bone loss in anorexia nervosa. The role of exercise in the management of anorexia nervosa remains controversial and begs future investigative efforts.     

Eating disorders in children and adolescents

Anorexia nervosa and bulimia nervosa are common disorders in the pediatric population. This article is designed to help the clinician develop a detailed understanding of these disorders as they affect children and adolescents. The etiology, diagnosis, complications, and treatment of these eating disorders are discussed. The special circumstances of diabetes mellitus, athletics, and the interface with the obese patient also are covered. The need to correctly identify a patient with the disorder, perform the appropriate testing, and organize the most appropriate treatment is required from virtually every primary care practitioner.     

A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up

BACKGROUND: There is growing evidence that family therapy is an effective treatment for adolescent anorexia nervosa. This study aimed to ascertain the long-term impact of two forms of outpatient family intervention previously evaluated in a randomised controlled trial (RCT). METHOD: A five-year follow-up was conducted on a cohort of 40 patients who had received either 'conjoint family therapy' (CFT) or 'separated family therapy' (SFT). All patients were traced and 38 agreed to be reassessed (29 interviewed in person, 3 completed telephone interviews, 6 completed questionnaires and/or agreed for parents/GP to be interviewed). RESULTS: Overall there was little to distinguish the two treatments at 5 years, with more than 75% of subjects having no eating disorder symptoms. There were no deaths in the cohort and only 8% of those who had achieved a healthy weight by the end of treatment reported any kind of relapse. Three patients developed bulimic symptoms but only one to a degree warranting a diagnosis of bulimia nervosa. The one difference between the treatments was in patients from families with raised levels of maternal criticism. This group of patients had done less well at the end of treatment if they had been offered conjoint family meetings. At follow-up this difference was still evident, as shown in the relative lack of weight gain since the end of outpatient treatment. CONCLUSIONS: This study confirms the efficacy of family therapy for adolescent anorexia nervosa, showing that those who respond well to outpatient family intervention generally stay well. The study provides further support for avoiding the use of conjoint family meetings at least early on in treatment when raised levels of parental criticism are evident.     

Prospective 10-year follow-up in adolescent anorexia nervosa--course, outcome, psychiatric comorbidity, and psychosocial adaptation

The aim of the present study was to follow up the long-term course of adolescent-onset anorexia nervosa by repeated assessment, to analyze the association between the course of the eating disorder and psychiatric comorbidity, and to evaluate psychosocial outcome. The sample consisted of 39 inpatients who were reinvestigated 3, 7, and 10 years after discharge. The patients and 39 controls matched for age, gender, and occupational status were assessed with structured interviews on DSM-III-R eating disorders, additional axis I and axis II psychiatric disorders, and psychosocial functioning. Results showed that 69 % of the original subjects met the criteria for full recovery at the 10-year follow-up. One patient (3%) still exhibited the full syndrome of restrictive anorexia nervosa, two patients (5%) the full syndrome of bulimia nervosa. None of the patients had died. Of the subjects, 51% currently had an axis I psychiatric disorder and 23% met the full criteria for a personality disorder. Apart from the eating disorder, anxiety disorders and avoidant-dependent and obsessive-compulsive personality disorders were the most common psychiatric diagnoses. There was a significant association between psychiatric comorbidity and the outcome of the eating disorder and between outcome and psychosocial adaptation. With regard to psychiatric morbidity and psychosocial functioning, long-term recovered patients did not differ significantly from normal controls. It is concluded that in most patients adolescent anorexia nervosa takes a prolonged course, although it seems to be more favorable than in adult-onset forms. Those who achieve complete recovery from the eating disorder have a good chance of overcoming other psychiatric disorders and to adapt to social requirements.     

Perplexities and provocations of eating disorders

Background:  Etiological hypotheses of eating disorders, anorexia nervosa and bulimia nervosa have not produced informative research for predictably effective treatment.
Methods:  The rationale for applying a model of allostasis, a dysregulation of reward circuits with activation of brain and hormonal stress responses to maintain apparent stability, is developed for eating disorders.
Results:  The neurotransmitter systems involved in the allostatic state of a reward system in anorexia nervosa and bulimia nervosa may be similar to those present in drug addiction.
Conclusion:  The biological vulnerabilities underlying the unique features of eating disorders should be intensively investigated with the advancing techniques in genetics and neuroimaging. Preventing chronicity with early diagnosis and adequate treatment before age 18 is necessary.     

Bulimia nervosa in adolescence

Although eating disorders of the bulimic type have been known for a long time, "bulimia nervosa" as a special and specific type of eating disorder was described only during the last decade. Clinical evidence has shown an increase in bulimic disturbances during the last few years. About 30% of the bulimic disturbances begin between the 14th and 18th year of age. About 50% of patients with bulimia nervosa have been anorexic before. A group of 30 patients with anorexia nervosa and a group of 11 patients with bulimia nervosa were compared by means of the dexamethasone suppression test and two depression scales at the beginning of inpatient treatment, after 8-12 weeks of inpatient treatment and at discharge. Patients with anorexia nervosa revealed significantly higher cortisol levels at the beginning of inpatient treatment as compared with the bulimic group. Cortisol levels were normalized with weight gain. Therapeutic measures in bulimia nervosa comprise medical and psychotherapeutic methods.     

What is the evidence basis for existing treatments of eating disorders?

Most existing treatments of eating disorders (ED) produce a period of remission that is short lived and expressed in fewer than 50% of the patients. Antidepressants (eg, selective serotonin reuptake inhibitors [SSRI]) have a small effect in bulimia nervosa and they are not recommended in anorexia nervosa (AN) because serotonin inhibits food intake. In a randomized, controlled trial, training of eating behavior and satiety, supply of warmth, reduction of physical hyperactivity, and restoration of social activities brought 75% of patients with ED into remission, and 93% remained in remission during follow-up. Further randomized, controlled trials comparing presently used interventions will provide the evidence needed to improve the treatment of ED.     

Eating disorders in college

Anorexia nervosa and bulimia nervosa are serious chronic psychiatric disorders that can result in significant medical and psychologic outcomes. These multifaceted disorders affect the emotions, thinking, behavior, and physical health of afflicted individuals. Symptoms often peak during the years many youth are attending college. The intersection of issues of emancipation, individuation, intimacy, and eating disorders may be part of the reason that researchers report a high incidence of eating disorders in this specialized population. This article presents an overview of eating disorders in the college population and covers psychologic and psychopharmacologic treatment.