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Eating Disorder(EDO)
Classification and external resources
ICD-10 F50.
ICD-9 307.5
MeSH D001068

An eating disorder is any psychological condition characterized by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individuals physical and emotional health. Eating disorders are estimated to affect 5-10 million females and 1 million males in the United States.[1] Although not yet classified as separate disorder, binge eating disorder[2] is the most common eating disorder in the United States affecting 3.5% of females and 2% of males according to a study by Harvard affiliated McLean Hospital. Bulimia nervosa was the second most common followed by Anorexia nervosa.[3]

Contents

[edit] Statistics-Facts

 This article is in a list format that may be better presented using prose. You can help by converting this article to prose, if appropriate. Editing help is available. (December 2009)
  • Eating disorders affect all socio-economic levels.[4]
  • 40% of 9- and 10-year-old girls are already trying to lose weight.[5]
  • Binge eating is the most common eating disorder in the United States affecting 3.5% of females and 2% of males, followed by bulimia nervosa then anorexia nervosa.[6]
  • Females with anorexia nervosa have a higher suicide rate than those with any other mental health disorder and the general population[7] up to 60 times higher according to one study[8]
  • Anorexia nervosa has the highest mortality rate of any psychiatric disorder.[9]
  • Anorexia nervosa although usually reported in white adolescent females affects all races and ages groups[10][11]
  • The mortality rate for anorexia nervosa is 4.0%, bulimia nervosa is 3.9% and 'eating disorder not otherwise specified' (EDNOS) which includes binge eating disorder is placed at 5.2%[12]
  • Males account for 5%-10% of anorexia nervosa cases[13] and 10%-15% of bulimia nervosa cases.[14]
  • An optimum healthy weight is calculated using the Body Mass Index

[edit] Causes

It is not known with certainty what causes eating disorders. It can be due to a combination of biological, psychological or environmental causes.

[edit] Biological

DNA, the molecular basis for inheritance.
  • Genetic: Numerous studies have been undertaken that show a possible genetic predisposition toward eating disorders.[15][16][17]
  • Biochemical:Eating behavior is a complex process controlled by the neuroendocrine system of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component.Dysregulation of the HPA-axis has been associated with eating disorders,[18][19] such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones[20] or neuropeptides[21].
  • leptin and ghrelin; leptin is a hormone produced primarily by the fat cells in the body it has a inhibitory effect on appetite by inducing a feeling of saiety. Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine. Circulating levels of both hormones are an important factor in weight control. While often associated with obesity both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.[31]
  • immune system:studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response. There may be a direct correlation between autoantibody levels and associated psychological traits.[32]
    3D view of the four "true" lobes of the cerebral cortex : frontal (blue), parietal (green), temporal (yellow), occipital (red).
  • infection:PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. Children with PANDAS "have Obsessive Compulsive Disorder (OCD) and/or tic disorders such as Tourette's Syndrome, and in whom symptoms worsen following strep. infections such as "Strep throat" and Scarlet Fever." (NIMH) There is a possibility that PANDAS may be a precipitating factor in the development of Anorexia nervosa in some cases, (PANDAS AN).[33]
  • lesions:studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder[34][35][36]
  • tumors:tumors in various regions of the brain have been implicated in the development of abnormal eating patterns.[37][38][39][40][41]
  • brain calcification: a study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.[42]
  • Obstetric complications. There have been studies done which show obstetric and perinatal complications such as maternal anemia, very pre-term birth (32<wks.), being born small for gestational age and sustaining a cephalhematoma at birth increase the risk factor for developing either anorexia nervosa or bulimia nervosa.[43][44][45]

[edit] Differential Diagnosis

  • achalasia; There have been cases where achalasia, a disorder of the esophagus which affects peristalsis has been misdiagnosed as various eating disorders including anorexia nervosa, bulimia nervosa, compulsive eating disorder and obesity related problems. It has been reported in cases where there is sub-clinical manifestation of anorexia nervosa and also in cases where the full diagnostic criteria AN has been met.[46]
  • superior mesenteric artery syndrome: (SMA)syndrome;"is a gastrointestinal disorder characterized by the compression of the third or transverse portion of the duodenum against the aorta by the superior mesenteric artery resulting in chronic partial, incomplete, acute or intermittent duodenal obstruction". It may occur as a complication of AN or as a differential diagnosis. There have been reported cases of a tentative diagnosis of AN, where upon treatment for SMA syndrome the patient is asymptomatic.[47][48]
  • Lyme Disease: is known as the "great imitator," as it may present as a variety of psychiatric or neurologic disorders including anorexia nervosa. "A 12 year old boy with confirmed Lyme arthritis treated with oral antibiotics subsequently became depressed and anorectic. After being admitted to a psychiatric hospital with the diagnosis of anorexia nervosa, he was noted to have positive serologic tests for Borrelia burgdorferi. Treatment with a 14 day course of intravenous antibiotics led to a resolution of his depression and anorexia; this improvement was sustained on 3 year follow-up."[49][50] Serologic testing can be helpful but should not be the sole basis for diagnosis. The Centers for Disease Control (CDC) issued a cautionary statement (MMWR 54;125) regarding the use of several commercial tests. Clinical diagnostic criteria has been issued by the CDC (CDC, MMWR 1997; 46: 531-535).
  • Toxoplasma seropositivity even in the abscence of symptomatic toxoplasmosis has been linked to changes in human behavior and psychiatric disorders including those comorbid with eating disorders such as depression. In reported case studies the response to antidepressant treatment improved only after adequate treatment for toxoplasma.[51]
  • Addison's Disease; is a disorder of the adrenal cortex which results in decreased hormonal production. Addison's disease, even in subclinical form may mimick many of the symptoms of anorexia nervosa.[52]

[edit] Psychological

Eating disorders are classified as Axis I[53] disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV). Published by The American Psychiatric Association. There are various other psychological issues that may factor into eating disorders, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters", A,B and C.The causality between personality disorders and eating disorders has yet to be fully established.[54] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder.[55][56][57] Some develop them afterwards.[58] The severity and type of eating disorder symptoms have been shown to affect comorbidity.[59]

[edit] Personality Traits

There are various childhood personality traits associated with the development of eating disorders.[74] During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. The onset of disordered eating causes various neurobiological changes that increase and reinforce these personality traits and their negative effect on eating behavior thus setting in motion a vicious circle. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain[75] such as the amygdala[76][77] and the prefrontal cortex[78] Some traits such as rigidity are part of the executive functions which also originate in the frontal lobe. Disorders in the prefrontal cortex and the executive functioning system have have been shown to effect eating behavior.[79]

[edit] Environmental

William-Adolphe Bouguereau (1825-1905) - The Difficult Lesson (1884).jpg
[edit] Child Maltreatment

Child maltreatment which encompasses physical, psychological and sexual abuse, as well as neglect has been shown by innumerable studies to be a precipitating factor in a wide variety of psychiatric disorders including eating disorders.Children who are subjugated to abuse may develop a disordered eating pattern in an effort to gain some sense of control or for a sense of comfort.Or they may be in an environment where the diet is unhealthful or insufficient.

Child abuse and neglect can cause profound changes in both the physiological structure and the neurochemistry of the developing brain. Children who as wards of the state were placed in orphanages or foster homes are especially susceptible to developing a disordered eating pattern. In a study done in New Zealand 25% of the study subjects in foster care exhibited an eating disorder.(Tarren-Sweeney M. 2006) A unstable home environment is detrimental to the emotional well-being of children, even in the absence of blatant abuse or neglect the stress of an unstable home can contribute to the development of an eating disorder.[101][102][103] [104][105][106][107][108][109]

[edit] Social Isolation

Social isolation has been shown to have a deleterious effect on an individuals' physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, this has been especially noted in cases of coronary heart disease. "The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors." ( Brummett et al.)

Social isolation can be inherently stressful, depressing and anxiety provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.[110][111][112][113]

[edit] Parental Influence

Parental influence has been shown to be an intrinsic component in developing the eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment.It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been proven between obesity and parental pressure to eat more.

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child's eating behavior. Affection and attention have been shown to effect the degree of a childs' finicalness and their acceptance of a more varied diet.[114] [115] [116][117][118][119]

[edit] Peer pressure

In various studies such as one conducted by The Mcnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior," says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. "Those are really important."

Dieting among adolescents was also reported to being influenced by peer behavior. With many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.[120] [121] [122][123]

[edit] Cultural Pressure

There is a cultural emphasis on thinness which is especially pervasive in western society. There is an unrealistic stereotype of what constitutes beauty and the ideal body type as portrayed by the media, fashion and entertainment industries."The cultural pressure on women to be thin is an important predisposing factor for the development of eating disorders" (Bryan Lask,PhD) [124] [125]

[edit] Eating Disorders in Men

There has been an increasing rate of males suffering from various eating disorders including anorexia nervosa. There is a stigma attached, as eating disorders are generally viewed as primarily affecting women. Among men the rates of eating disorders are higher in the gay and bi-sexual communities(Feldman & Meyer, 2007), yet it also affects heterosexual men. Despite the perceived stigma, some high profile male celebrities have publicised their struggles with eating disorders such as actor Dennis Quaid, who struggled with what he called "manorexia" for which he sought treatment. Quaid said his problems began when he went on a diet to lose forty pounds to play Doc Holliday in the movie "Wyatt Earp" in 1994. Billy Bob Thornton has also struggled with anorexia, once losing 59 lbs. Thomas Holbrook, M.D., is Clinical Director of the Eating Disorders Program at Rogers Memorial Hospital in Oconomowoc, Wisconsin despite being a psychiatrist he suffered from anorexia nervosa with compulsive exercising. At one time the 6-ft.-tall psychiatrist weighed just 135 lbs. "I was terrified," he says, "of being fat." His story has been chronicled in various publications including USA Today and People Magazine.

[edit] Signs

[edit] Anorexia-Bulimia

Anorexia nervosa (AN) is divided into two subtypes restrictive,which doesn't enage in purging behavior and purging type which does. Bulimia nervosa is divided into two subtypes purging and the less common; non purging. There is a tendency for diagnostic "crossover" in which symptoms change over time between the restricting and binge eating/purging anorexia nervosa subtypes and bulimia nervosa.[126][127]

[edit] Binge Eating

Both bulimics and those with binge eating disorder (BED) engage in binge eating. Those with BED do not engage in any compensatory behavior e.g. they do not purge, use laxatives or engage in compulsive exercise.

[edit] Other Eating Disorders

[edit] Rumination Syndrome

Rumination Syndrome, is an under-diagnosed eating disorder, characterized by the regurgitation of food which is then either re-chewed, re-swallowed or discarded.[130]

[edit] Diabulimia

Diabulimia; not currently a recognized medical condition, is the deliberate manipulation of insulin including witholding shots, by individuals with Type 1 diabetes in an effort to control their weight.[131] Insulin is an anabolic hormone[132] that is involved in the metabolism of carbohydrates and lipids (fats).[133] It helps the body maintain muscle mass, it also encourages fat retention.[134]

The effects of withholding insulin can lead to severe complications[135] such as diabetic ketoacidosis. The long term effects can lead to the acceleration of diabetes related complications such as diabetic vasculopathy which may lead to limb amputation.[136][137]

[edit] Food Maintenance Syndrome

Food Maintenance Syndrome is characterized by a set of aberrant eating behaviors of children in foster care it is "a pattern of excessive eating and food acquisition and maintenance behaviors without concurrent obesity", it resembles "the behavioral correlates of Hyperphagic Short Stature". (Tarren-Sweeney M. 2006)[138] It is hypothesised that this syndrome is triggered by the stress and maltreatment these children are subjected to.

[edit] Female Athlete Triad

Female Athlete Triad is a syndrome in which eating disorders/disordered eating behavior, amenorrhoea/oligomenorrhoea and decreased bone mineral density (osteoporosis and osteoenia) are present.[139][140]

[edit] Additional Eating Disorders

[edit] Symptoms-Complications

Symptoms and complications vary according to the nature and severity of the eating disorder[141]

[edit] Diagnosis

A diagnosis is made by a trained mental health or medical professional.

[edit] Medical

Illu thyroid parathyroid.jpg

A consultation with a reputable medical professional who specializes in eating disorders is an indispensible part of both the diagnostic process and treatment. A complete medical and psychosocial history should be provided. A rational and formulaic approach to the diagnosis should be used. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causitive or contributory factor in an eating disorder."Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders,we therefore recommend performing a cranial MRI in all patients with suspected eating disorders"(Trummer M et.al.2002)[149]

All possible organic causes should be taken into consideration, no matter how obscure. Insulinomas, (pancreatic tumors) have been implicated as the primary causative factor in cases of anorexia nervosa. A thyroid screen should be also conducted as hypothyroidism and hyperthyroidism may mimic some of the symptoms of, can occur concurrently with, be masked by or exacerbate an eating disorder. [150][151][152][153][154][155][156]

[edit] Psychological

A trained clinician conducts a clinical interview and may employ various psychometric tests some are general in nature others were devised specifically for use in the assessment of eating disorders.Some of the general tests that may be used are the Hamilton Depression Rating Scale[163] and the Beck Depression Inventory.[164] [165]

[edit] Treatment

Treatment varies according to type and severity of eating disorder. Usually more than one treatment option is utilized.[166] Some of the treatment methods are:

  • Cognitive Behavioral Therapy(CBT)[167][168][169] is an evidence based approach. The basic premise is that a person's thoughts cause their feelings and behaviors not external stimulus like other people, situations or events in a persons life. The rational is to change how a person thinks and reacts to a situation even if the situation itself does not change.CBT has been shown to be efficacious in the treatment of bulimia nervosa.
  • Family Therapy[171]
    • Maudsley Family Therapy; The Maudsley model of family-based treatment for anorexia nervosa, was developed in the 1980s (Dare, 1985), it utilizes a variety of family therapy models and is designed for use with adolescents 18 and under who are living with their families. It is an evidence based approach designed as an aggressive intervention at the onset of anorexia nervosa and bulimia nervosa.[172][173]
  • Behavioral Therapy;focuses on gaining control and changing unwanted behaviors.[174]
  • Interpersonal Psychotherapy (IPT); "The current treatment of IPT was developed by the late Gerald Klerman and Myrna Weissman in the 1980s as a means of operationalising the interpersonal approach to psychotherapy for a series of treatment studies in depression conducted in the United States. Since that time it has been modified for a variety of other indications including Dysthymia, Bulimia Nervosa, Substance Misuse ,Somatization and depression in a variety of clinical settings. Preliminary studies in Anorexia Nervosa, Bipolar Disorder, PTSD and some anxiety disorders are underway. In each adaptation the fundamentals of the treatment manual are adhered to, however different components are emphasized." (International Society for Interpersonal Psychotherapy)

[175]

  • Art Therapy;is the therapeutic use of art. The American Art Therapy Association describes art therapy "as a belief that individuals can resolve conflicts, develop interpersonal skills, and gain self-esteem and insight through the creative process of artistic self-expression".[176]
  • Nutrition counseling[177]
  • Medical Nutrition Therapy; Medical nutrition therapy (MNT) also referred to as Nutrition Therapy is the development and provision of a nutritional treatment or therapy based on a detailed assessment of a person's medical history, psychosocial history, physical examination, and dietary history.[178][179][180]
  • Medication;there are currently medications developed for use in obesity treatment such as Orlistat. To date there are none specifically designed for use in either anorexia or bulimia nervosa although olanzapine has shown promise in various studies for its' propensity to promote weight gain as well as the ability to ameliorate obsessional behaviors concerning weight gain.[181][182][183][184][185]
  • Self Help Groups; there are various support and self-help groups for eating disorders which may be helpful and can be used in conjunction with professional treatment. Both Eating Disorders Anonymous and Overeaters Anonymous are based on the traditional 12-step program pioneered in Alcoholics Anonymous.
  • Psychoanalysis is a non evidence based approach. While the psychoanalyst Hilde Bruch, the author of "The Golden Cage" helped bring anorexa nervosa to the public conciousness, the discipline has fallen into disrepute. "Alice Eagly, the chairwoman of the psychology department at Northwestern University, explained why: Psychoanalysis is “not the mainstream anymore” and so “we give it less weight.”". Psychoanalysis has been accused of having iatrogenic, i.e. harmful tendencies."Psychoanalysis is a great idea in personality, just as long as one is a male, who grew up in a two parent house, who had either a sister or female playmate at a very young age, with a great memory, and who has lots of money and no specific time frame in which one would like one's psychological problems cured." (Popkin, Nathan. NWU)[186]

[edit] Prognosis

Monarch Butterfly Pink Zinnia 1800px.jpg

There are varying estimates as to the prognosis of individual eating disorders as the criteria used to arrive at the respective conclusions vary. With increasing knowledge as to the causes of individual eating disorders and which treatment options prove to be the most efficacious, the remission rates and ultimately full recovery rates rise.

  • anorexia nervosa (AN);for AN the remission rate has been placed between 75%-83%, with varying estimates as to the full recovery rate. Dr. Walter Vandereycken a noted expert in the field chooses to be optimistic in his prognostic assessment and places the potential recovery rate at 70%.[187]
  • bulimia nervosa (BN); for BN the remission rate has been placed as high as 75%[188] In a 7.5 year follow-up study done by Herzog et al. at the Harvard Medical School the full recovery rate for BN was 74%, 99% of those with BN achieved at least partial recovery.[189]
  • binge eating disorder (BED); the outcomes of studies on BED treatment were predicated on the absence of binge eating episodes at 6mo. and 12mo. followup, the rate in this study was 51.7%. The reduction of binge eating episodes was 88.3%.[190]

[edit] See also

[edit] References

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  • Waniek C; Prohovnik I; Kaufman MA; Dwork AJ Rapidly progressive frontal-type dementia associated with Lyme disease. New York State Psychiatric Institute, NY 10032, USA.J Neuropsychiatry Clin Neurosci 1995 Summer;7(3):345-7 Abstract
  • William Sheehan, Steven Thurber. Anorexia Nervosa: A Suggestion for an Altruistic Paradigm from an Evolutionary Perspective. Article

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