Podcast
Questions and Answers
What is considered a hallmark symptom of anorexia nervosa that distinguishes it from other psychiatric syndromes?
Which of the following factors is NOT included in the diagnostic criteria for anorexia nervosa?
What is the recommended first step in the treatment of severe anorexia nervosa when weight loss has been critical?
Why is anorexia nervosa considered to have the highest mortality rate among psychiatric disorders?
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Which of the following statements regarding the epidemiology of eating disorders is accurate?
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What characteristic behavior is commonly associated with individuals suffering from anorexia nervosa?
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What is the typical BMI threshold for diagnosing significantly low body weight in anorexia nervosa for adults?
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Which treatment approach is recommended for children and adolescents with anorexia nervosa?
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Which of the following is a common consequence of dehydration in individuals with anorexia nervosa?
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What behavior might an individual with bulimia nervosa typically exhibit following a binge-eating episode?
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Which of the following is NOT a characteristic of bulimia nervosa?
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Which treatment is recognized as the most effective for binge-eating disorder?
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What is a distinguishing feature of avoidant/restrictive food intake disorder (ARFID) compared to anorexia nervosa (AN)?
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What is a common manifestation of purging disorder?
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In binge-eating disorder, individuals report a sense of loss of control over their eating. Which additional criteria must they meet?
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How does body dysmorphic disorder (BDD) differ from typical concerns about appearance?
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Which of the following statements about PICA is incorrect?
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What is a primary reason for addressing findings from physical exams with individuals suspected of bulimia nervosa?
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Which of the following is the most effective treatment for avoidant/restrictive food intake disorder (ARFID)?
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What does the diagnosis of rumination disorder require?
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Which of the following is NOT a common complication associated with PICA?
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What is the most commonly reported symptom in individuals with binge-eating disorder?
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Which of the following is a significant risk factor for developing body dysmorphic disorder?
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Study Notes
Eating Disorders
- Complex psychiatric illness with disturbances in body image, impacting body function, and causing significant distress
- Individuals with eating disorders frequently experience medical concern including cardiovascular, pulmonary, gastrointestinal, and electrolyte issues
- Most medical and psychiatric practitioners lack competence in the treatment of eating disorders
- Pharmacological interventions have less empirical support, though they may enhance the effects of psychotherapy
- Referral to a specialist is recommended due to the complexity of management.
Eating Disorder Epidemiology
- ~30 million individuals are affected by an eating disorder in their lifetime
- Prevalence is higher in women than men
- Prevalence is higher in gay men and transgender individuals
- Some research suggests that prevalence is lower in lesbian women compared to heterosexual women
- ~1/3 of those with an eating disorder never receive treatment
- ~1 in 5 individuals with an eating disorder require hospitalization
- Eating disorders have the highest mortality rate of any psychiatric disorder due to high suicide rates, especially in AN patients
Screening Tool: SCOFF
- Assesses for the presence of an eating disorder
Anorexia Nervosa (AN)
- Characterized by persistent dietary restriction that leads to significantly low body weight, intense fear of gaining weight or becoming fat, and body image disturbance.
- Develop "food rules" related to both quantity and type of food
- Exhibit obsessive preoccupation with food, eating, dieting, weight, and body shape
- Frequently engage in ritualistic eating behaviors
- Have difficulty eating in settings that are not highly controlled environments
- Frequently engage in exercise that is driven and compulsive.
- Binge eating and purging behaviors can be present in the binge/purge subtype of AN
- Hallmark fear of becoming fat and relentless pursuit of thinness is absent in other psychiatric syndromes
Anorexia Nervosa Clinical Manifestations
- Dehydration, dizziness, headaches
- Fainting, fatigue
- Low blood pressure, low body temperature
- Osteoporosis, electrolyte imbalances
- Low BMI, extreme weight loss, and thinness
- Irregular menstruation or absence of menstruation
- Delayed puberty or slow growth
- Brittle nails, bruising, depression
- Dry hair, skin, sensitivity to cold, slow heart rate
Anorexia Nervosa Diagnosis Criteria
- Restriction of food intake → significantly low body weight
- Fear of excessive weight gain or obesity
- Body image disturbance or denial of the seriousness of illness
- In adults, a BMI of < 17 kg/m² is considered significantly low
- A BMI of 17 to < 18.5 kg/m² may also be significantly low depending on the patient’s initial weight.
Additional Considerations for Anorexia Nervosa
- Individuals with AN have significantly distorted views of their body (often see themselves as fat)
- Weight or shape has an undue influence on their self-evaluation
- If the patient does not have a distorted view of their body or exhibit a preoccupation with their weight or shape, a diagnosis can be made if there is a persistent lack of recognition of the seriousness of the current low body weight
- Individuals who meet the above criteria but have a BMI within the average or above-average range despite significant weight loss are classified as having atypical AN
Anorexia Nervosa Treatment and Management
- Nutrition supplementation
- Psychotherapy (ie., cognitive behavioral therapy)
- For children and adolescents, family-based treatment is recommended
- When weight loss has been severe, rapid, or when weight has fallen below ~75% of the recommended weight, prompt restoration of weight becomes critical, and hospitalization should be considered.
- If any doubt, patients should be hospitalized.
Bulimia Nervosa (BN)
- Characterized by recurrent episodes of binge eating accompanied by feelings of loss of control followed by recurrent inappropriate compensatory behaviors to prevent weight gain
- These behaviors occur at least once a week for 3 months
- Compensatory behaviors include self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, and/or excessive exercise
- Key feature of BN is the centrality of body image in self-evaluation and extreme dissatisfaction with body weight/shape
- Individuals with BN often experience symptoms as distressing
Bulimia Nervosa Clinical Manifestations
- Gastritis, esophagitis, dehydration, and or electrolyte disturbances
- Tooth enamel decay and parotid gland enlargement due to recurrent vomiting
- Scars on the back of the hand
- Discussing findings from physical exam and laboratory values with individuals may prompt exploration of self-induced vomiting, use of diuretics or laxatives, and disordered eating patterns even when an individual does not initially bring forward these concerns
Bulimia Nervosa Diagnosis Criteria
- Recurrent episodes of binge eating accompanied by feelings of loss of control overeating
- Occurs, on average, at least once a week for 3 months
- Recurrent inappropriate compensatory behavior to influence body weight
- Self-evaluation that is unduly influenced by body shape and weight concerns
Bulimia Nervosa Treatment and Management
- Cognitive behavioral therapy (CBT) is the treatment of choice
- Interpersonal psychotherapy
- Selective serotonin reuptake inhibitors (SSRIs)
Binge Eating Disorder (BED)
- Characterized by recurrent episodes of binge eating, associated with significant distress, and occurs, on average, at least once a week for 3 months
- Most commonly among people overweight or obese
- Contributes to excessive caloric intake
- Compared with people with AN or BN, those with binge-eating disorder are older and more likely to be male
Binge-Eating Disorder Epidemiology
- Affects ~3.5% of women and 2% of men in the general population during their lifetime
- May be present in ≥ 30% of patients in some weight-reduction programs
- Among those seeking bariatric surgery, approximately 1/3 have BED
- BED can emerge in adolescence but typically in early adulthood onset
Binge Eating Disorder Clinical Manifestations
- Characterized by eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not hungry, eating alone because of embarrassment, and/or feeling disgusted with oneself, depressed, or guilty afterward
- Unlike BN, binge eating is not followed by recurrent compensatory behaviors
- Associated with a sense of loss of control.
Binge Eating Disorder Diagnosis Criteria
- Binge eating episodes occur, on average, at least once a week for 3 months
- Patients have a sense of lack of control over overeating
- Also, ≥ 3 of the following must be present:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of embarrassment
- Feeling disgusted, depressed, or guilty after overeating
Binge Eating Disorder Treatment and Management
- Cognitive behavioral therapy (CBT) is the most studied and best-supported treatment for BED
- Sometimes interpersonal psychotherapy appears equally effective
- Consideration of drug therapy, usually selective serotonin reuptake inhibitors (SSRIs) or lisdexamfetamine (Vyvanse)
- Both result in remission rates of ≥ 60%, and improvement is usually well-maintained over the long term
Avoidant/Restrictive Food Intake Disorder (ARFID)
- Characterized by restrictive eating patterns in the absence of body image concerns
- Avoid food for reasons unrelated to body image disturbance
- Three types of ARFID are specified in the DSM-5:
- Aversion to the sensory characteristics of food (ie., textures, smells, and visual appearance)
- Lack of interest in food or limited appetite
- Fear of negative consequences of eating, (ie., vomiting, choking, gastrointestinal pain), often related to specific trauma around eating
Avoidant/Restrictive Food Intake Disorder Epidemiology
- May first appear in adulthood or persist from childhood into adulthood
- Usually presents in infancy or early childhood
- Affects males greater than seen in AN or BN disorders
- Between 13%-29% of children and adolescents meet the criteria for ARFID upon initial presentation to eating disorder services
- Other eating disorders such as AN, BN, and BED most typically occur in early-late adolescence after a period of normative eating
- Individuals with ARFID may have long-standing difficulties with eating
Avoidant/Restrictive Food Intake Disorder Diagnosis Criteria
- Food restriction leads to significant weight loss, failure to thrive or grow as expected in children, significant nutritional deficiency, dependence on nutritional support, and or marked disturbance of psychosocial functioning
- Food restriction is not caused by the unavailability of food, a cultural practice, physical illness, medical treatment, or another eating disorder
- No evidence of a disturbed perception of body weight or shape
Avoidant/Restrictive Food Intake Disorder Additional Considerations
- AN can emerge out of restrictive eating and malnourishment associated with an earlier ARFID presentation
- Gathering a detailed history of eating and feeding behaviors, including longstanding food preferences, and other behaviors that may indicate concern about weight/shape is critical
Avoidant/Restrictive Food Intake Disorder Treatment/Management
- Cognitive behavioral therapy (CBT)
Purging Disorder
- Characterized by recurrent purging behavior intended to influence weight or shape in the absence of binge eating
- Absence of low weight, significant weight loss, or binge episodes
Purging Disorder Clinical Manifestations
- Tooth/enamel decay
- Irregular heartbeat, dizziness, fainting
- Scarred hands
- Pregnancy complications
- Digestive issues or constipation
- Dehydration, Nutritional deficiencies, Electrolyte imbalances
Purging Disorder Treatment and Management
- Inpatient treatment is more common in cases that require medical monitoring or daily assessments
- Outpatient treatment might include psychotherapy and nutrition counseling
- Medications aren’t used to treat purging disorder but are prescribed to treat concurrent mood disorders that may be causing additional stress or making it harder to cope with recovery
Pica
- Diagnosed when the individual, aged >2 years, eats one or more non-nutritive, non-food substances for a month or more → and requires medical attention as a result
- No specific aversion to food in general but a preferential choice to ingest substances such as clay, starch, soap, paper, or ash
- Onset is most common in childhood
- Can occur in association with other major psychiatric conditions in adults
- An association with pregnancy has been observed
- Only diagnosed when medical risks are increased by behavior
- More common among pregnant African American women and institutionalized individuals with intellectual disability
- The cause is not known, but an association with iron deficiency has been reported
- No known genetic factors specifically associated with pica
- The proper treatment of pica is unclear
- Proper supervision of young children and behavioral techniques for older children are recommended
Pica Complications
- Laboratory studies are needed to rule out lead poisoning
- Pica can also lead to excessive weight gain, malnutrition, intestinal blockage, intestinal perforation, and malabsorption
- Other complications such as poisoning, intestinal obstruction, intestinal perforation, and infections may occur from ingesting feces or dirt
Rumination Disorder
- Individuals have no demonstrable associated gastrointestinal or other medical condition but repeatedly regurgitate their food after eating and either rechew or swallow it or spit it out
- Typically occurs daily and must persist for at least 1 month
- Weight loss and malnutrition are common sequelae
- In infancy, the onset is typically between 3 and 12 months of age
- Exact cause unknown
- For some children, the act of chewing is comforting
- Infants who are neglected, abused, or ill may develop this behavior → , which may be a way child to gain attention
Rumination Disorder Manifestations
- Repeatedly bringing up food from the throat or stomach and re-chewing
- Weight loss
- Bad breath and tooth decay
- Repeated stomach aches and indigestion
- Raw and chapped lips
Rumination Disorder TREATMENT AND MANAGEMENT
- Mainly focuses on changing a child's behavior
- Changing a child's posture during and right after eating
- Giving children more attention
- Making feeding time relaxing and pleasant
- Distracting your child when he or she starts the rumination behavior
Body Dysmorphic Disorder (BDD)
- Involves individuals having an irrational preoccupation with what they believe to be a defect or a flaw in their physical appearance
- Flaws or defects are not noticed by others, or concerns are disproportionate to what others perceive
- Common areas include the skin (eg, acne, scars, wrinkles), hair (eg, thinning hair or unwanted body or facial hair), and nose
- However, the preoccupation can focus on any part of the body
Body Dysmorphic Disorder (BDD) MANIFESTATIONS
- Preoccupations are unwanted, difficult for the individual to control, and often very time-consuming
- Engage in repetitive behaviors or thoughts at some point during their disorder
- Excessive mirror checking
- Excessive grooming
- Repeatedly applying makeup
- Seeking reassurance from peers
- Comparing him- or herself to others
Body Dysmorphic Disorder (BDD) ADDITIONAL CONSIDERATIONS
- Individuals with body dysmorphic disorder often receive cosmetic treatment such as dermatologic treatment or cosmetic surgery to try to fix their perceived flaws
- However, cosmetic treatment rarely relieves the symptoms of body dysmorphic disorder and may instead worsen the severity of the preoccupation
- The majority of individuals have an onset in adolescence, with two-thirds of individuals with the disorder having onset before the age of 18 years
Body Dysmorphic Disorder (BDD) TREATMENT AND MANAGEMENT
- Cognitive-behavioral therapy (CBT) to be the most effective treatment
- CBT is consistently effective in treating a range of somatic symptoms and related disorders, including somatic symptom disorder, conversion disorder, illness anxiety disorder, and body dysmorphic disorder
- Pharmacologic treatments (eg, antidepressants, antiepileptic drugs, and antipsychotics) have been proposed for somatic symptom disorders → however, research indicates they generally are not effective
- SSRI BENEFICIAL FOR BODY DYSMORPHIC DISORDERS
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Description
Explore the complex nature of eating disorders, which are psychiatric illnesses that disrupt body image and function. This quiz covers key statistics on prevalence and treatment challenges, highlighting the need for specialized care. Understand the diverse impact of eating disorders across different populations and gender identities.
