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PROBLEM 1Part 1 Learning Goals
- What are eating disorders, their prevalence and risk factors?
- DSM for pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia
nervosa, bulimia nervosa, binge eating disorder, other specified feeding or eating
disorder, unspecified feeding or eating disorder
- What personality traits predict ED? (Cassin)
DSM 5
- Pica:
o persistent eating of nonnutritive, nonfood substances for at least 1 month
o inappropriate to the developmental level of the person, behavior is not
socially normative
- Rumination disorder:
o repeated regurgitation of food for at least 1 month (bringing swallowed food
again to the mouth, could be re-chewed, re-swallowed or spit out)
o does not occur during the course of anorexia, bulimia, binge eating or
avoidant/restrictive food intake disorders
- Avoidant/restrictive food intake disorder
o persistent failure to meet nutritional or energy needs (bc of lack of interest in
eating or food, avoidance based on the sensory characteristics of food,
concern about aversive consequences of eating etc.)
o associated with:
o significant weight loss
o significant nutritional deficiency
o dependence on enteral feeding or oral nutritional supplements
o marked interference with psychosocial functioning
o no evidence of a disturbance in the way in which one’s body weight or shape
is experiences (anorexia or bulimia)
- ANOREXIA NERVOSA:
o a) restriction of energy intake leading to significantly low body weight (less
than minimally normal)
o b) intense fear of gaining weight or becoming fat, persistent behavior that
interferes with weight gain
o c) disturbance in which one’s body weight or shape is experienced, excessive
influence of body weight or shape on self-evaluation (distorted image),
persistent lack of recognition of the seriousness of the current low body
weight
o 2 types:
restrictive type:
during the last 3 months, the person has not engaged in binge
eating or purging
the person achieves weight loss through dieting, fasting or
excessive exercise
binge-eating/purging type:
, during the last 3 months, the person has episodes of binge
eating or purging (self-induced vomiting or misuse or laxatives)
o Mild (BMI > 17), Moderate (BMI 16-16.99), Severe (BMI 15-15.99), Extreme
(BMI < 15), 18.5 is the normal limit
o for children, determining a BMI-for-age percentile is useful
o partial remission: criteria A is not met, patient is normal weight, but criteria B
or C is still met
o associated features in supporting diagnosis:
semi starvation can cause life-threatening medical conditions
physiological disturbances such as amenorrhea (missing periods) and
vital sign abnormalities are common
depressive features are common
OCD features, related or unrelated to food are prominent
concerns about eating in public, feelings of ineffectiveness, strong
desire to control one’s environment, inflexible thinking, limited social
spontaneity, overly restrained emotional expression
binge-eating/purging type have higher rates of impulsivity and more
likely to abuse alcohol and other drugs
excessive levels of physical activity
o prevalence: 12-month prevalence is young females in 0.4%, female to male
ratio is 10:1, most prevalent in post-industrialized high-income countries
o development: usually begins during adolescence or young adulthood
o course: hospitalization may be required to restore weight, crude mortality
rate is 5%
o risk factors:
temperamental: anxiety disorder or obsessional traits in childhood
environmental: cultures or occupations in which thinness is valued
genetic: higher risk among first-degree relatives of people with the
disorder
o diagnostic markers: low white blood cells, dehydration, high cholesterol, low
levels of magnesium, zinc and phosphate, low bone mineral density,
amenorrhea, constipation, abdominal pain, cold intolerance, lethargy (lack of
energy), emaciation (abnormally weak), low blood pressure, yellowing of the
skin, enlarged salivary glands, dental enamel erosion
o suicide risk: 12 per 100.000 per year
o differential diagnosis:
social phobia: social fears unrelated to eating behaviors should also be
present
OCD: obsessions unrelated to food are also present
body dysmorphic disorder: distortion is unrelated to body shape or
size (e.g. nose)
MDD, SCZ, SUD, A/R food intake: don’t have fear of weight gain even if
they lose weight nor body image disturbances
Bulimia: they maintain body weight above a normal level
o comorbidity: bipolar, depressive and anxiety disorders, OCD (especially in
restricting type), alcohol use or substance use (especially in
binge-eating/purging type)
, - BULIMIA NERVOSA:
o a) recurrent episodes of binge eating
binge eating characterized by: 1. eating an amount of food that’s
larger than what most people would eat in a short period of time (less
than 2 hours) 2. sense of lack of control over eating during the episode
o b) recurrent inappropriate compensatory behavior to prevent weight gain aka
purging behavior (self-induced vomiting, misuse of laxatives diuretics or other
medication, fasting, excessive exercise)
o c) binge eating and purging both occur at least once a week for 3 months
o d) self-evaluation is excessively influenced bod shape and weight
o doesn’t occur during episodes of anorexia
o Mild (1-3 episodes per week), Moderate (4-7 episodes per week), Severe (8-
13 episodes per week), Extreme (14 or more episodes per week)
o partial remission: not all criteria is met
o features supporting diagnosis:
they usually eat food they would otherwise avoid
they’re typically ashamed of the behavior and try to hide it
binge-eating occurs in secrecy
most common trigger is negative affect, other include interpersonal
stressors, dietary restraint and boredom
people with BN are typically within the normal or overweight range
(BMI > 18.5. and 30 < in adults)
menstrual irregularity or amenorrhea, fluid or electrolyte disturbances
from purging, cardiac and skeletal myopathies, gastrointestinal
symptoms
o prevalence: 12-month prevalence in young females in 1-1.5%, female to male
ratio is 10:1, more frequent in industrialized countries
o development and course: peaks in older adolescence and young adulthood,
binge eating frequently begins during or after an episode of dieting or
multiple stressful life events, crude mortality rate is 2%, diagnostic crossover
from AN can occur
o risk factors:
temperamental: weight concerns, low self-esteem, depressive
symptoms, social anxiety disorder, and overanxious disorder in
childhood
environmental: internalization of thin body ideal, CSA
genetic: childhood obesity and early pubertal maturation
o diagnostic markers:
no specific diagnostic tests, physical examination is not useful
abnormalities due to purging, loss of dental enamel, enlarged salivary
glands, scars on hand etc.
o differential diagnosis:
AN binge-eating purging type: underweight
binge eating: no compensatory behavior
atypical MDD, borderline: usually don’t show concern for body image
and purging behavior
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