Eating Disorders
Eating as a
behviour:-
The eating behaviour is controlled by hunger and
appetite that are regulated by the hypothalamic satiety and hunger centers.
Change in appetite can be traced back to many physical and psychological
conditions. In depression there is a change in appetite which possibly
indicates a link with the serotonin brain system. The serotonin system is implicated in sleep, appetite,
aggression, sex and mood. Two psychiatric conditions has attracted a
considerable interest for many years, one involve food avoidance and the other
food indulgence, i.e. Anorexia Nervosa and Bulimia Nervosa.
Anorexia Nervosa
Sir William Gull and Charles Laseque were the first
to describe anorexia nervosa and recognize its psychogenic aetiology.
The
diagnostic criteria involve a significant weight loss or failure of weight
gain, which is self-induced. The person usually a young adult or a teenager and
mostly a female avoid fattening foods, induce vomiting, use laxatives in purging, or use
excessive exercise ; appetite
suppressants or diuretics to lose weight.
Psychopathology is mainly a fear of fatness
and change in body image as the person perceive his body as fat and ugly.
There is a widespread endocrine disorder in
anorexia nervosa. There is amenorrhoea in majority of cases. There is also a raised growth
hormone, raised cortisol and reduced T3.
A useful measure
of body weight is Quetelet’s body-mass index
which expresses body weight in relation to the height. BMI= Weight (in
kgs) / divided by (Height (in square
metres2))
The Diagnostic
criteria of Anorexia Nervosa are:
1. Refusal to maintain
normal minimal weight (15% below expected)
2. Fear of
weight gain or fatness even though underweight
3. Abnormal perception of
weight, size or shape
4. Amenorrhoea
(minimum 3 cycles)
Additional psychiatric Disorders
(1) Depression: 70% of anorexia patients are
depressed.
(2) Obsessional symptoms,
particulary centred around food and eating are found in 30% of anorexic
patients.
(3) Personality difficulties : 50% of cases fall within the avoidant,
anankastic and emotionally unstable
domains of personality.
Average incidence
(1) Mayo clinic 7/ 100,000
(2) Aberdeen 4/100,000
(3) Holland 5/100.000
Prevalence
15-year old Swedish school
children (Rastam et al 1989) found 700 cases per 100,000 in schoolgirls and 90
per 100,000 school boys. The estimated prevalence in Rochester, USA 200/100,000
females.
Aetiology.
(1) Sociocultural changes:
Modern Society glamorize slim female body and the model female body has seen
changes over decades with increasing reduction in the ideal female body weight.
(2) Family interaction: Minuchin described
pathological family interaction in Anorexia. Rigidity of roles and
relationships, enmeshment between mother and daughter, conflict avoidance and
overprotection play an important part in pathogenesis (Minuchin 1978).
(3) Developmental: Bruch
(1970) suggested that early parenting experiences
give poor sense of identity, uncertainty about the relevance and meaning of
internal states and an overwhelming sense of ineffectiveness.
(4) Personality: low
self-esteem and perfectionism characterize the personality of many patients
suffering with anorexia.
(5) Conflict relating to
sexual maturity. Some studies stressed the avoidance of mature adult sexuality
though it is reported that some anorexic patients have been abused sexually
(Sexual abuse 30%).
(6) Hypothalamus :Excess
5-HT; corticotrophin-releasing hormone
(Morley & Blundell 1969).
(7)Genetic factors:
concordance between monozygotic twins > dizygotic twins (Holland et al
1966).
Medical
complications
1. Reproductive function
(Loss of menstruation,
fertility and pregnancy difficulties)
2. Musculo-skeletal
(Myopathy-particularly of the limb girdle muscles, Pathological fractures,
Teeth)
3.Cardiovascular
(Palpitations and syncope).
4.Renal (Nocturia. Renal
stones)
5.Skin and Hair (Loss of
head hair increase in body
hair, acrocyanosis, chilblains)
6.Metabolic (Hypoglycaemia.
Liver dysfunction, high cholesterol)
7.Gastrointestinal
(Constipation)
6.Central
Nervous system (Poor concentration,
difficulty in undertaking complex thought)
9.Psychological
Symptoms
(Depression,
obsessive-compulsive behaviour)
Weight Control Methods, i.e. Abuse of Laxatives, Induction of Vomiting
and Diuretics may lead to the following complications:-
1.Gastrointestinal Tract
(Teeth, salivary gland
hypertrophy, upper and lower gastrointestinal tract bleeding, abdominal
distension, constipation)
2.Renal (Oedema1 dehydration, stones,
failure).
3.Cardiovascular
(Dysrhythmias, postural hypotension)
4.Central Nervous System
(Tetany, fits)
5.Metabolic (Dehydration,
hypokalaemia, hyponatraemia)
Endocrine system
(1) The hypothalamic-pituitary-gonadal axis
regresses to a LH-prepuberty
state. Oestrogen and FSH progesterone levels are
undetectable and pelvic and
ultrasonography reveals ovaries diminished in size but with a multifollicular
appearance and a small uterus.
(2) All of the
hormonal components of the hypothalamic-pituitary-adrenal axis are
increased and this is thought to reflect increased hypothalamic secretion of
CRH and the dexamethasone suppression test is abnormal.
(3)Thyroxine and T3 are reduced and reverse T3 is
increased. The TSH response to TRH is delayed.
Metabolism
(1) Hypoglycaemia
(2) Raised
liver function tests
(3) Cholesterol
high
Salt and Electrolyte Balance
(1) Potassium levels
occasionally fall below 3mmol/l.
The ECG may show
prolonged QT intervals and U waves.
Fatal dysrhythmias occur without warning.
(2) Sodium, magnesium and
phosphate are also sometimes reduced. Avoid too rapid a correction of these
abnormalities which can tip the patient into an acute confusional state.
(3) Oedema is only rarely caused by heart failure, the most usual cause
is the rehydration after laxative abuse and vomiting or so-called
"refeeding oedema". Weight gain in these cases can be as much as 15
kgs in a week.
Haematology
Marrow suppression:
haemoglobin reduced to 9 gm/100ml
White cell counts of less than 4,000 are common.
Platelet suppression is
rare
ESR is low.
Gastro-intestinal System
Gastric emptying is delayed
Central Nervous system
Concentration is impaired
Cerebral atrophy associated with ventricular dilatation and widening may
be related to vomiting or raised cortisol.
Long Term Health
Problems:
Osteoporosis which becomes more severe with length and severity of
illness and severity of weight loss.
Pathological fractures may appear after ten years of amenorrhoea.
Outcome
The combined mortality and morbidity rate from anorexia nervosa
approximates to 5%
The mortality rate rises to 20% after 20 years of illness. The
chance of recovery after 15 years of illness are minimal and active treatment
should be implemented within the first ten years of illness.
Prognostic factors
1.Long duration
resistant to treatment
2.Lower minimum
weight
3.Premorbid Adjustment:
3 Personality
difficulties
4.Social
difficulties
5.Poor
relationship with family
Bulimia Nervosa
History
The syndrome of bulimia nervosa was first described
by Russell in 1979.
Clinical
A history of weight loss.
Loss of control of eating
Binging 1000kcal or more.
Definition
1. Episodes of overeating : Recurrent episodes of binge eating
Feeling
of lack of control of eating during binge
Minimum
average of 2 binges a week in 3 months
2. Methods
to counteract weight gain
a) vomiting
b) laxatives
c) fasting/Strict Diet
d) appetite suppressants
e) metabolic stimulants
f) diuretics
h) vigorous exercise
3. Morbid
fear of fatness with a sharply defined
weight threshold, Persistent overconcern with shape or weight
4. Often
a history of anorexia nervosa
(1) Depressive symptoms
predominate.
(2) Impulsive
behaviour such as alcohol abuse, self harm, shoplifting - borderline
personality disorder.
Epidemiology
Incidence of bulimia
nervosa 9.9/100,000 population (Hoek 1991)
Point Prevalence 20/100,000
poulation (Hoek 1991)
Prevalence of 1% amongst young women (Johnson-Sabine, 1989; Bushnell et al,
1990).
The aetiology of bulimia nervosa is often subsumed under the broader
category of "eating disorders". This followed Russell’s original
observation that bulimia nervosa was a variant of anorexia nervosa. Russell (1985) later argued that bulimia
nervosa was an example of
pathoplasticity within psychiatry. Bulimia nervosa is thus the contemporary
mode of presentation of a neurosis or personality disorder.
Specific antecedents and predisposing
conditions
Weight loss is always
present
History of anorexia nervosa.
Dieting increases the risk~8-fold (Patton et
al, 1990; Marchi and Cohen, 1990).
Overeating with weight loss
Normal homeostatic response: (weight-loss alters
central 5 HT function which in turn weaken normal satiety response) or
psychological explanation -counter regulation.
No consistent pathophysiological features: Interest has focused on chalecystokinin,
noradrenaline, 5 HT, peptide
YY and neuropeptide Y
Non specific nervosa
(1) Affective
disorders, alcoholism and eating disorders.
(2) Family
disturbance with multiple care arrangements, a lack of
warmth, high levels of control
and physical and sexual abuse.
The diagnosis of anorexia nervosa rarely
poses difficulties but a crucial step at the first assessment interview is to
engage the patient into treatment. Often the patient is unforthcoming and angry
at being coerced into seeing a doctor by concerned relatives and friends. A
structured style of interviewing which questions how the disorder has affected
health and psychological functions, career or social life can overcome this
resistance, reassuring the patient that her problem can be understood.
It is important to enquire about symptoms
associated with bulimia nervosa as these may terrify the patient and reinforce
her need to have rigid control over her diet. Direct questioning may lead to
denial. It is better to normalise the behaviour with probes such as "It is
a common occurrence when people are as underweight as you are that they have
episodes when their eating seems excessive or out of control, has this ever
happened to you? At times like this people experience discomfort and may even
vomit has this happened to you? Have you ever had to make yourself sick to give
you some relief. "Often people who
are underweight suffer badly from constipation, has this ever happened to you?
Sometimes people with this illness are driven to be active, does this apply to you?" "Many
people with this problem use other methods to control their weight, health shop
preparations, street drugs etc, perhaps you have had to do this?
The relationship between eating and life
circumstances and context is established with a weight history. A weight,
physical and psychiatric history of all family members is pertinent.
The formulation should detail the
constitutional risk factors, patterns of interaction and behaviour,
precipitating events and factors (which often lie within the family) that
perpetuate the illness
Questions for the assessment of the Medical Sequelae of Eating Disodrers
(1) When
was your last period?
(2) Do
you feel the cold badly, how does it effect your ?.
(3) Have
you noticed any changes in your body hair, head hair, skin or nails?
(4) Have
you noticed any 'weakness in your muscles? What about climbing stairs or
brushing your hair?
(5) Are
you troubled by aches in your bones or have you had fractures?
(6)
What is your sleep like? Do you have to wake to go to the toilet?
(7) Have
you fainted or had dizzy spells?
(8) Have
you noticed palpitations?
(9) Have you had any trouble with your teeth, what
about denture sensitivity? Do you attend to mouth hygiene after you have
vomited?
(10) Have
you vomited blood or lost blood from your back passage?
(11) Do you suffer from bloating or
abdominal pain?
(11) Have you noticed that glands on your
face have become swollen?
The classical treatment advocated by Gull
was to remove the sufferer from her home environment to a nursing home,
where moral 'management' would he applied.
There has been a marked change away from
this approach over the last 20 years during which new specific
psychotherapeutic treatments have been developed. A recent study has produced
the remarkable finding that specialist outpatient treatment can lead to an
outcome that is as good if not better than inpatient treatment. Furthermore,
patient compliance is improved (Crisp et al 1991). This replicates the findings
from Bristol (Morgan et al), which it was found that an early outpatient
intervention was effective.
A consensus is
gradually emerging that a stepped care approach towards treatment is
appropriate. Early or mild cases can be treated within the community by
suitably trained general practitioners or community psychiatric nurses and
supported by the self help associations
In all cases apart from medical emergencies,
which need acute management, outpatient treatment is the first line of
treatment. Weight gain should be a focus of treatment for two reasons. Firstly,
starvation leads to a cascade of secondary disabilities, medical, psychological
and social, and these perpetuate the disorder (see above). Secondly it is a
widely held clinical impression that the disease runs a chronic course unless
weight is restored to a healthy level. Weight should be graphed at regular
intervals. A target range of weight (which spans over 5kg) should be plotted.
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Excessive Dieting Education
(nutritional, weight, General
Practitioner
clinical) Community
Psychiatric Nurse.
Weight
Monitoring School
counsellor
Specialised
voluntary organizations
Clinical Anorexia Nervosa Specific psychotherapy GeneraI or Child
Psychiatrist
(educational,
behavioural,
cognitive,
problem solving)
Anorexia Nervosa
> 1 year Specific
outpatient Psychotherapy Specialised
Eating Disorder Unit
duration Family
or cognitive analytical)
Anorexia Nervosa with life Inpatient or Day Patient
Treatment Specialised Eating Disorder Unit
threatening complications or
treatment resistant to
outpatient care
Outpatient Treatment
(A) Individual Therapy
(1) The Therapeutic Alliance
Whatever mode of therapy used the
relationship should be collaborative and a kind, firm and consistent approach
used to tackle the anorexic behaviour. The therapist should be knowledgeable
about eating disorders and nutrition. The first phase of treatment is to
engender motivation to recover from the illness. The goal of treatment is to
produce a balanced eating pattern. The issues of power, control and trust
within the therapeutic relationship need to be recognised as they can lead to
coercion or frustration. Mutual trust is essential as it is futile to the
therapist or carers to insist on goals, which are unattainable. Women with
anorexia nervosa may try to placate the therapist and lie about vomiting,
laxative abuse or food intake.
Another component of therapy is to foster
alternative strategies to weight loss. A focus upon low self-esteem, lack of
appropriate assertiveness and the binds of perfectionism and over control is
required. Hilda Bruch a psychoanalyst with a wide experience in the treatment
of eating disorders advised against traditional psychoanalytical therapy for
eating disorders, for example interpretations made by the therapist may be
experienced by the sufferer as a repetition of a pattern in which they have
been told what they think and feel by significant others. A style of therapy in
which there is active participation with homework tasks such as reading, diary
keeping and problem solving is successful.
It is probably essential to set a limit on
therapy although follow-up "booster" sessions are recommended for up
to five years as the trust and support engendered by treatment need to be
continued.
(2) Education
Education about the sequences of the
disorder and its treatment and correction of mistaken assumptions particularly
about aetiology is crucial. Women with anorexia nervosa consistently state that
there is nothing wrong with them, they consider themselves to be "frauds,
wasting medical time". It is important to counter these arguments by
providing information about the condition, for example to warn that without
treatment less than a half may make a full recovery, and that severe life
threatening physical problems may arise. The best recovery possible is obtained
by joint work.
A supplement of approximately 7,000 kcals is
required to gain 1 kg. So a calorie intake of 3,000 k/cal per day is necessary
to gain weight at a rate of 1 kg per week. Inpatient treatment has to balance
the difficulties of rapid weight gain with the dangers of institutionalisatlon.
This dilemma is not there with outpatient treatment and weight gain can proceed
more slowly, although goals should be clear. Overactivity at low weight can be
dangerous and this should be discouraged.
Information, and judicial investigation of
the medical consequences are an important component of treatment. A screen of
haematology, urea and electrolytes, liver function tests and cholesterol is
useful for those who are severely underweight. Pelvic ultrasonography and bone
density measurement are at times relevant. Bulimia nervosa follows anorexia
nervosa in a quarter of cases and the fear of this complication is often
present. It is therefore helpful to stress this topic and develop strategies to
minimise its occurrence, this includes developing a regular pattern of eating
with a mixed diet and to warn of the dangers of vomiting or laxative abuse.
Hunger frequently increases when the dietary
restrictions are lifted, this combined with the difficulty in monitoring
fatness lead to feelings of lack of control. Reassurance can be given that this
is a normal and transient phase. Although in the long term weight gain will
lead to tangible benefits, in the short term it can lead to severe distress.
Anxiety and despair are common and the struggle to accept weight gain and to
continue to increase the diet becomes harder. It is helpful to forewarn the
patient and relatives about this and that "anorexic attitudes about
weight, shape and eating may last for several years even after a patient
recovery of weight and menstrual function.
(3) Support
It is useful to engage the family or other
carers in treatment although active control over eating is less appropriate and
successful for older patients. Relatives can get information and support from
the self help organisation, The Eating Disorders Association. These and other
specialist centres often run parents groups.
(4) Problem Solving
Once an atmosphere of trust has been
established, it is possible to focus on the difficulties which were blocked off
once the anorexia nervosa developed. These may involve difficulties in
developing an adult relationship with the parents or involve deeply held
attitudes and beliefs such as the need to be perfect or to be in control.
5) Family Therapy
In the 1970's there were enthusiastic
reports of the efficacy of family therapy in the treatment of anorexia nervosa.
A randomised control trial which compared family therapy with individual
treatment indicated that family therapy was more effective at preventing
relapse following inpatient treatment in the subgroup whose illness had begun
before the age of 15 and was of short duration
(Russell et al 1987). These reseach findings thus support clinical
pragmatism, in that it is helpful to involve the family of a young adolescent
who lives at home.
It remains unclear what specific components
of family therapy are of value although recent research suggests that parental
counselling combined with individual treatment may be more effective and
acceptable than a more formal family approach.
As in individual therapy education is an
important component of treatment. The family should be informed about the
medical, psychological and social ramifications of anorexia nervosa. It is
helpful to dispel the mistaken beliefs about aetiology, for example that it is
caused by stubbornness and naughtiness on the part of the sufferer or that the
behaviour of the family is causal. Such mistaken attitudes merely perpetuate guilt, recrimination and
criticism and make treatment difficult. The parents are helped to find 'ways in
which they can encourage their daughter to eat, this may entail direct
supervision with firm limit setting. Parents are encouraged to take control
over their daughters health and welfare, this requires them to negotiate a
consistent plan of management.
There are possible contra-indications to
family therapy. If the parents are divorced or separated, including the
parental couple in therapy together may fuel the fantasy of reuniting the
family. It is also inappropriate to entrust treatment to parents with severe
psychopathology, or who have physically and sexually abused their child. This
is relevant for approximately a third of cases and may be difficult to detect.
Also a previous attempt at family therapy which has failed leaves parents
hostile and angry. In such cases parents support groups can be of help.
6) Day Patient Treatment
Several specialised centres now offer day
patient treatment for anorexia nervosa. The prorotocols that have been devised
use a multidiscipimary team approach and use many components outlined above.
7) Inpatient Treatment
Inpatient treatment is required if the
patients physical or mental state is dangerous or there are contraindications
to outpatient treatment. An outline of some of the physical complications which
signal the need for urgent 'Treatment and other clinical factors is given
below.
A. Medical
Grounds for admission
I. Body
mass index below 13.5kg/m2 (rapid rate of fall)
2. Syncope
3. Proximal
myopathy
4 Hypoglycaemia
5. Electrolyte lmbalance
6 Petichael rash & platelet
suppression
B. Clinical Grounds for admission
1 risk
of suicide
2 Chronicity
>5 year's
3 Comorbidity
with impulsive behaviour
4 Intolerable
family situation.
5 Extreme
social isolation
5 Failure
of outpatient treatment
The aim in the inpatient unit is for the
nurses to take over control away from the patient in the initial stages. Food
is gradually reintroduced to obtain a steady rate of weight gain with snacks
and light meals.
Strict behavioral regimes
in which all privileges are taken away and total bed rest is prescribed are no
more effective than lenient regimes, and may increase the risk of developing
bulimia nervosa. Nevertheless it is
important that clear limits are set and that there is effective anticipation of
the patients difficulties.
The advantage of the
specialist unit is that patients can be treated in a group which means that
there are sufficient resources to ensure that nursing care is given during the
meal which is shared with other patients with anorexia nervosa. The nurse aims
to facilitate mutual support amongst the group. This may involve a patient at
the end of treatment reassuring and sympathizing with the novice but on other
occasions the aim will be to remove the focus on food. The expectation is that
all of the food will be finished and that it is the group’s task to ensure that
this is done. Often the counter transference can be intense and the nurse
should be sensitive to this and use it for example" I am sitting here
feeling frustrated and angry. I wonder if that is what some of you are also
feeling" It is necessary to continue supervision after meals to prevent
habitual vomiting. Similarly it is
essential to guard against the use of other methods of weight control, such as
laxative abuse and addictive exercising.
Nurses working with
patients with eating disorders have to work as a team, anticipate splitting,
set limits without excessive coercion and cope with the intense counter
transference. Such nursing skills are more effective than any drug treatment so
far tried.