ANOREXIA NERVOSA AND RELATED EATING
DISORDERS
DIAGNOSTIC
CRITERIA OF CLASSICAL ANOREXIA NERVOSA
1. Considerable weight losss which is
self induced by
(a)avoidance of "fattening
foods"
(b) self-induced vomiting
(c) self-induced purging
(d) excessive exercise
2. A Specific psychopathology
An (over-valued idea - a dread of fatness
A self-imposed low weight threshold
3. A specific endocrine disorder
In the
female: early amenorrhoea
In the
male: loss
of sexual interest and potency
OVARIAN AND HORMONAL CHANGES ACCORDING TO PATIENTS'
WEIGHT
amorphous multi- dormant
follicular follicle
-----------------------------------------------------------------------------
% of Average Body
Weight (ABW) 73 85 98
FSH ++ ++
LH +
oestradiol + +
ovarian volume + ++
uterine area + ++ ++
ANOREXIA
NERVOSA:
Physical Complications
|
Amenorhea/loss of libido |
Gastric dilatation |
|
Hypothermia |
Myopathy and neuropathy |
|
Peripheral oedema |
Impaired liver function |
|
Congestive heart failure |
Delayed puberty |
|
Hypokalaeinia |
(if early onset) |
|
Bone marrow hypoplasia |
Osteoporosis |
ANOREXIA
NERVOSA: Multidiinensional
Causation
1.Vulnerable
personality
2.Psychological
conflicts - individual
- family
3.Socio-cultural
factors -cult of thinness
-hazardous
dieting
-social
class
-race
4. Genetic and constitutional factors : ? disturbed
hypothalamic
regulation
TABLE 2:
THE PREVALENCE OF ANOREXIA NERVOSA IN
VULNERABLE FEMALE POPULATIONS
|
AREA |
SUBJECTS |
AGE PREVALENCE |
RATE |
|
|
(years: mean or range) |
||||
|
Ballet students |
Toronto1 Canada1 |
18.6 + 0.3 |
|
|
|
|
South-East. England2 |
15.6 + 1.6 |
|
|
|
|
|
|||
|
Modelling students |
Toronto, Canada1 |
21.4 + 0.3 |
|
|
|
Dieticians |
United Kingdom3 |
20 - 39 |
|
|
|
|
London - |
16+ |
|
|
|
|
private schools |
16 - 18 |
1.1 |
|
|
|
London - |
16+ |
0.2 |
|
|
|
state schools4 |
16 - 18 |
0.14 |
|
|
Schoolgirls |
London - state schools6 |
15 |
0 |
|
|
|
|
|||
|
|
Rome, Italy8 |
13- 20 |
0.8 |
|
|
|
South Australia9 |
12- 18 |
0.1 |
|
DIAGNOSTIC
CRITERIA OF BULIMIA NERVOSA
1. Eating
disorder
Preoccupation with food -> episodic gorging
2. Attempts to counter the
"fattening" effects of food
By inducing vomiting or abusing purgatives or
alternating starvation or diuretics or other methods less often
3. A
specific psychopathology
An over-valued idea - a dread of fatness
A self-imposed weight threshold below the patient's
"healthy weight"
BULIMIA
NERVOSA: Physical
Com~lications
Cardiac arrhythmias
Renal impairment from hypokalaemia
Muscular paralysis
Urinary infection Epileptic seizures
Tetany from
hypokalaemic alkalosis
Swollen salivary glands
Eroded dental enamel
Injury to myenteric plexuses of large bowel
ANOREXIA NERVOSA (AN) and BULIMIA NERVOSA (BN)
Clinical Features
|
|
AN |
BN |
|
Food avoidance |
Constant |
Intermittent |
|
Overeating Self-induced vomiting |
- |
+++ |
|
or purging |
+ |
+++ |
|
Weight loss |
+++ |
+ |
|
Amenorrhoea |
+ |
+ |
|
Dread of weight
gain |
++ |
+++ |
DIAGNOSTIC
CRITERIA OF ANOREXIA NERVOSA IN THE YOUNG
1. Weight loss
or failure to pain weight
Self-induced by avoidance of "fattening"
foods
2. A specific psychopathology
An over-valued idea - a dread of fatness
3. A delayed puberty
A delay in the sequence of pubertal events -
especially a late menarche
PREDICTORS OF POOR OUTCOME
IN ANOREXIA NERVOSA
1. “Late”
age of onset (late teens or older)
2.
Already continuously ill for several years
3.
Disturbed relationship between the patient and other ~ of the family
4.
Poor adjustment at school and other personality problems before onset of
illness
? 5. Very
low body weight on admission.
PRINCIPAL
AIMS OF TREATMENT
Anorexia
Nervosa: Return
to a normal weight
Bulimia
Nervosa: Restore
control over eating
MAIN PSYCHOLOGICAL COMPONENTS OF
IN-PATIENT TREATMENT IN ANOREXIA NERVOSA
1. It
is a nursing therapy
2. It
provides structure and supervision
3. It
aims at a trusting relationship between nurse and patient
4. Other
psychological treatments are adjuncts only:
(i) behaviour therapy
(ii) group therapy
(iii) family meetings
(iv) cognitive therapy
(v) education, etc.
DAY HOSPITAL
V. IN-PATIENT TRIAL
1. Weight
gain : In-patient slightly better
2. General
outcome : Favoured day-patients
(M-R
Scores)
3. Day
programme : More acceptable to patients
advantages and
GFS
Encouraged
patient autonomy
OUT-PATIENT
FAMILY TREATMENTS
FAMILY THERAPY FAMILY
COUNSELLING
1. Whole
family seen Parents
seen together
patient
seen separately:
interactions
observed no such
observations
interventions
made or
interventions
2. Parents
encouraged to take control of daughter's eating
"We
have no evidence that families produce anorexics.
"Family therapy is hindered if families believe
that they are taken to be 'the cause' of the problem."
DRUG TREATMENT
(i) Anorexia Nervosa - no place
(ii) Bulimia
Nervosa - some benefit from 5HT uptake inhibitors -usually short-term only.
COMPONENTS OF COGNITIVE-BEHAVIOURAL THERAPY
Presenting a cognitive view of the disorder
Cognitive restructuring
Self-monitoring (thoughts and behaviour)
Education
Self-control measures aimed at regular eating
Introducing "avoided foods" in the diet
PSYCHOLOGICAL TREATMENTS IN
BULIMIA: CONCLUSIONS
All effective: Cognitive-behavioural therapy
Behaviour
therapy
Interpersonal
psychotherapy
Group
therapy
But we need: More specific therapies
PSYCHOLOGICAL TREATMENTS IN
ANOREXIA AND BULIMIA NERVOSA CONCLUSIONS
1. Nursing
treatment is the most effective method of ensuring weight gain in anorexia
nervosa (in-patients (in the short term)
2. Out-patient
family therapy is the treatment of choice in younger patients with anorexia nervosa
(in the long-term).
3. Several
out-patient psychological treatments are effective in bulimia nervosa:
cognitive-behavioural therapy behavioural therapy
inter-personal
psychotherapy
group
therapy
But we need: more specific therapies