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.     

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.     

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.     

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.     

Hormonal and biochemical abnormalities in women suffering from eating disorders

This study reports the results of a biochemical investigation of 80 eating disorder patients and results of an endocrinological investigation of 20 subjects. Of the 80 subjects studied, 22 suffered from anorexia nervosa and 51 were diagnosed as having bulimia. These patient's results were compared to those of 30 control subjects. The eating disorder patients had significantly higher levels of total CO2 calcium, alanine aminotransferase and cholesterol, and significantly lower levels of potassium, chloride and phosphate in the plasma. Hypokalaemia was strongly associated with self-induced vomiting and laxative abuse. Hypercholesterolaemia occurred most commonly in anorexia nervosa patients. Preliminary endocrinological results suggest decreased gonadotrophin levels are associated with binge eating and self-induced vomiting and laxative abuse, as well as with low weight. We feel eating disorder patients should be interviewed and examined by a physician with an interest in this area. Appropriate investigations should be ordered. The physician should also undertake counseling about the short- and long-term sequelae of disordered eating.     

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.     

An epidemiological study of anorectic and bulimic symptoms in adolescent girls: implications for pediatricians.

Our findings suggest that most cases of anorexia nervosa among high school girls are eventually recognized and treated. However, it is worrisome that a large number of girls suffering from early anorexia nervosa and an even greater number suffering from bulimia do not seek treatment for their disorder. In addition, it is clear that girls who do not meet criteria for the full syndromes may nonetheless be engaging in the cardinal behaviors associated with these disorders. Therefore, the pediatrician must actively inquire about weight control practices and binge-purge behavior during the course of routine examinations. These behaviors are sufficiently common that such inquiry should be incorporated into the routine evaluation of every girl, even when there is no obvious reason to be concerned. The vast majority of girls will express dissatisfaction with their weight and report that they have attempted to control their weight in some manner, most often with dieting, in the past year. Normative data from a cross-sectional study such as the one described provide some guidelines as to when such behavior is likely to be associated with other types of problems, such as depressive symptoms or amenorrhea. For example, our data suggest that weight loss of 10 lbs or more in the past year and fasting are more likely to be associated with depressive symptoms and menstrual irregularity than less severe forms of caloric restriction. Our findings also suggest that purging behavior (self-induced vomiting and laxative use), particularly in combination with binge eating, is associated with very high rates of both depressive symptoms and menstrual irregularity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Breastfeeding practice in mothers with eating disorders

The purpose of this study was to compare the prevalence of breastfeeding in women with anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorders not otherwise specified – purging subtype, with mothers with no eating disorders during the first 6 months after birth. The study is based on the Norwegian Mother and Child Cohort Study conducted at the Norwegian Institute of Public Health. Questionnaire‐based information on eating disorder diagnoses and breastfeeding in 39 355 women was used to estimate the risk of cessation of breastfeeding with Cox proportional hazards regression. Almost all women (98%) initially breastfeed their infants, with no statistically significant difference between the eating disorders subgroups and women with no eating disorders. However, the risk of early cessation before 6 months post‐partum increased for all subgroups of mothers with eating disorders, compared with mothers with no eating disorders. After adjusting for maternal body mass index, age, education, birthweight and pre‐term birth, only mothers with anorexia nervosa [hazard ratios (HR), 2.35; 95% confidence interval (CI) 1.22–4.53] and eating disorder not otherwise specified‐purging subtype (HR, 1.95; 95% CI 1.08–3.53) had increased risk for cessation of breastfeeding There were no differences in the risk of cessation of exclusive breastfeeding. These results show that some eating disorders may influence mothers' early feeding practices and indicate that additional support may be necessary to assist women with anorexia nervosa in maintaining breastfeeding.     

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.     

Prevalence of eating disorders and psychiatric comorbidity among children and adolescents

There are no prevalence or co-morbidity studies on eating disorders in India. This retrospective chart review studied the prevalence and psychiatric co-morbidity among juveniles with eating disorders. Forty-one cases with ICD 10 diagnosis of eating disorders were identified and analyzed. The prevalence of eating disorders was 1.25% Psychogenic vomiting was the commonest eating disorders and anorexia nervosa the emerging eating disorder. The most common co-morbidities were depression, intellectual disability, and dissociative disorder.     

Bulimia nervosa: an update and treatment recommendations.

Bulimia nervosa is a common eating disorder in adolescent women. Biological, psychological, and social factors are implicated in onset and important in treatment. Diagnosis of the syndrome, but not its subtypes, can be made well using the DSM-IV system. Screening tools, laboratory findings, and physical findings can be helpful in making the diagnosis. Comorbid disorders include affective disorders, addictive disorders, anxiety disorders, personality disorders, and anorexia nervosa. The etiology of bulimia nervosa is complex, with biologic, psychological, social, and family factors, which likely differ somewhat from patient to patient. Treatment, accordingly, should be comprehensive, individualized, and multifaceted. Many patients respond well to the use of an antidepressant, and cognitive-behavioral therapy is a useful approach for many patients. Combining these two treatments seems to be a good strategy. Environmental and family issues also need to be addressed. Many patients are treated insufficiently. More research on bulimia nervosa specific to adolescence is needed.     

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.     

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.     

Bulimia nervosa

Although there is a lot of information coming up to explain the pathogenesis of anorexia nervosa, yet little is know about bulimia nervosa in Indian literature. This case report highlights the typical presentation of a case of bulimia nervosa in an adolescent girl, where bulimia symptoms were preceded by anorexic behavior. Our case showed clinical similarity with the diagnostic criteria of the available classification system. The absence of self-evaluation for body weight and shape in this case be explained on the basis of cultural factors. To some extent, initial anorexic behavior could have played a role in etiopathogenesis of bulimia nervosa.     

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.     

Organic diseases mimicking atypical eating disorders

The authors present three case studies of patients referred to Children's Hospital and Medical Center, Seattle, Washington, for evaluation of possible eating disorders. The atypical manifestations of the cases warranted further investigation, which revealed an organic basis for their weight loss. The authors summarize the typical findings of bulimia and anorexia nervosa and discuss the clues from the case studies that mandated further evaluation.     

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.     

Transplacental metabolic alkalosis

We present a newborn with hypochloraemic metabolic alkalosis due to severe metabolic alkalosis of his mother. Hypoventilation as a leading symptom resolved quickly with treatment but may be life-threatening if not detected. In this case, the mother had a probable eating disorder. Little is known about transplacentally acquired electrolyte disorders in this setting. In the absence of symptoms, most of the cases might be undetected. The usual neonatal outcome of anorexia and/or bulimia nervosa in pregnancy is a lower birthweight and a lower risk for instrumental delivery.     

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.