Eating Disorders and Related Conditions
I.
How Eating Patterns and Eating
Problems Develop
A.
Continuum of eating pathology
hypotheses
B.
Problem eating in childhood ->
overweight/obese during middle childhood
+ peer teasing/rejection -> drive for thinness in adolescence ->
weight preoccupation ->negative
body image, dieting, weight concerns + other risk factors = clinically
significant eating disorder
II.
Eating Disorders and Eating Problems
in Children and Adolescents:
A. Feeding Disorder
B. Failure to Thrive
C. Pica
D. Other Eating Disturbances in Childhood:
a. Food avoidance emotional disorder
(FAED)
b. Selective eating
c. Restrictive eating
d. Food refusal
e. Specific fear or phobia leading to avoidance
of eating
f. Pervasive refusal syndrome
E. Obesity
F. Anorexia nervosa (and atypical or
subclinical forms)
G. Bulimia nervosa (and atypical or
subclinical forms)
H. Binge Eating Disorder*
I. Provisional Criteria
A.
Feeding Disorder
Sudden or marked deceleration
in weight gain
Affects up to 1/3 of young children
Disproportionately affects children from impoverished
environments
Equally common among males and females
Onset during the first 2 years of life can lead to
malnutrition and have serious impact on development
Relationship with maternal eating disorders
B.
Failure to thrive
Characterized
by: weight below the 5th percentile for age and/or deceleration in
the rate of weight gain from birth to the present of at least two standard
deviations
Associated
with insensitive parenting, parental psychopathology, insecure attachments with
primary caregivers, and lack of stimulation
Normalization
can occur with proper intervention
C.
Pica
What
Is Pica?
The name "pica" comes from the Latin word for magpie, a bird known
for its large and indiscriminate appetite.
Persons
with pica most frequently crave and consume non-food items such as dirt, clay,
paint chips, plaster, chalk, cornstarch, laundry starch, baking soda, coffee
grounds, cigarette ashes, burnt match heads, cigarette butts, and rust. Glue,
hair, buttons, paper, sand, toothpaste, soap, oyster shells, and broken
crockery also have been cited in pica cases.
Affects
mostly very young children, institutionalized children and those with mental
retardation
Disorder
usually remits on its own or in conjunction with added infant stimulation and
improved environmental conditions; formal treatment emphasizes operant
conditioning
Pica
in childhood constitutes a risk factor for bulimia in adolescence
D. Other Eating Disturbances in
Childhood:
a. Food avoidance emotional disorder
(FAED)
i.
A history of food avoidance or difficulties for
at least 1 month
ii.
Low weight & growth impairment common
iii.
No issues with body image
b. Selective eating
i.
Narrow range of preferred foods for at least 2
years
ii.
Normal
growth, eat appropriate number of calories
iii.
More common in males than females
iv.
No concerns with weight and shape
c. Restrictive eating
i.
Eat
little, no enjoyment or interest on eating, small appetite?
ii.
Small
and light, may present may present with weight loss around puberty or failure
to gain weight
iii.
No body
image distortion
d. Food refusal
i.
Common
in younger children, but becomes a problem in older children
ii.
Normal
growth and weight gain
iii.
No body image issues
e. Specific fear or phobia leading to avoidance
of eating
i.
Fear
of swallowing or chocking, associated with specific texture/type of foods
ii.
Usually
precipitating event
iii.
No
weight or shape concerns
iv.
If
pervasive, may impact growth and pubertal development
f. Pervasive refusal syndrome
i.
Profound
and pervasive refusal to eat, drink, walk, talk, or care for self
ii.
Often
thought of as extreme form of PTSD
iii.
Results
in extreme dehydration, malnutrition, and weight loss
iv.
Invariable
requires hospital admission
E.
Childhood Obesity
Definition:
BMI above the 95th percentile, based on norms for child’s age and
sex
Dramatic
increase in prevalence of overweight over last few decades:
Ages
1988-1994
Today
2-5
7.2%
10.4%
6-11
11.3%
15.3%
12-19
10.5%
15.5%
Obesity rate for
boys age 7-13 nearly tripled between the early 1980s and the mid-1990s
Obesity
rate for girls during this time more than doubled
Increase
in minority groups is double that of white children
Concomitant
phenomenon for adults: 64.5% of adults in US are either overweight or obese,
and this number is rising
Risk
Factors
Heredity:
by age 17, a child of two obese parents has 3x the chance of being obese as a
child of lean parents
Environment:
food choices and physical activity both heavily influenced by parental modeling
Onc study found that,
on average, children only spend 12-13 minutes daily engaged in vigorous
physical activity, compared with 10 hours per day in sedentary activities
Ronald
McDonald is the second most recognized figure in the world, topped only by
Santa Claus
One
fourth of all vegetables eaten in the
10-15%
of all calories consumed by
Consequences:
Physical
Hypertension
Type
II diabetes
Increased
risk for health problems as an adult
Psychological
Teasing
Lowered
self-esteem
Body
image distress
Main
Considerations for Treatment:
Mainly
family-based, behavioral treatments have been found to be effective for helping
children lose and manage their weight. This includes the adoption of
healthier eating habits (as a family), setting more limits on food, engaging in
more physical activity and educating children about body weight and health
issues in general.
Care
must be taken to not introduce body weight or food preoccupation that could
predispose a child to develop an eating disorder.
Eating Disorders in Adolescence
F.
Anorexia Nervosa
DSM-IVTR criteria:
Refusal
to maintain minimum body weight (85% of expected weight for height and build)
Intense
fear of gaining weight or becoming fat even though underweight
Body
image disturbance, undue influence of body weight or shape on self-evaluation,
or denial of seriousness of low body weight
Amenorrhea
Restricting
type and Binge/Purge type Anorexia Nervosa
Prevalence
.5%
among females (of all ages)
Subthreshold
Anorexia is more common
90% of
cases of Anorexia occur in women
Incidence
of Anorexia appears to have increased in recent decades
Risk Factors
Family
history
Participation in certain activities (e.g. dance, gymnastics,
modeling, etc.)
Certain
“closed” environments (e.g. all-girl boarding schools, dormitories, etc.)
Being
a member of the middle-upper middle class
Family
enmeshment
Personality
characteristics (rigidity)
Dieting
and/or body image distress
Familial
modeling of food/weight preoccupation
Symptoms or features:
Significant
and unexplained weight loss
Preoccupation
with food/calories/body or body parts
Excessive
exercise
Wearing
baggy clothes
Eating
noticeably less food/being secretive about food
Chronic
dieting
Depression
or lethargy
Physical consequences:
Osteoporosis
(thinning of bones)
Electrolyte
imbalance leading to heart failure
Hypotension
(dangerously low blood pressure)
Bradycarida (low
heart rate)
Hair
loss
Cold
intolerance
Amenorrhea
(loss of period)
Constipation
Lethargy
Dryness
of skin
Prognosis and Treatment
About
1/3 of people with Anorexia will fully recover, another 1/3 will partially
recover but continue to suffer from some symptoms, and the last 1/3 will become
chronically Anorexic. Twenty percent of patients with Anorexia Nervosa
will die.
Most
common forms of treatment for Anorexia include psychotherapy, inpatient
treatment that combines behavior therapy with medical monitoring, psychopharmacology, and family therapy.
Bulimia Nervosa
DSM-IVTR
criteria:
Recurrent
episodes of binge eating
Eating
in a discrete period of time more than other people would
Experiencing
a loss of control over eating
Recurrent
inappropriate compensatory behavior to prevent weight gain
Self-induced
vomiting; misuse of laxatives, diuretics or other medications; fasting; or
excessive exercise
Binge
eating and compensatory behavior both occur, on average, at least twice a week
for 3 months
Self-evaluation
is unduly influenced by body shape and weight
Disturbance
does not occur exclusively during episodes of Anorexia Nervosa
Purging
type and Nonpurging type Bulimia Nervosa
Prevalence:
Lifetime
prevalence in females is approximately 1-3%
Occurrence
of this disorder in males is approximately 1/10th that of females
Some
studies have found the prevalence rate of bulimia to be much higher than 1-3%,
especially in college populations, where it has been reported to be as high as
15-20%
Risk factors
Chaotic
family environment and/or substance abuse
Certain
“closed” environments where bingeing and purging behaviors are normalized (e.g.
sororities)
Body
image distress
Dieting
(thought by some researchers to lead to bingeing)
Personality
characteristics (impulsivity)
Familial
modeling of food/weight preoccupation
Symptoms or features
Being
secretive about food and eating
Trips
to the bathroom after meals
Strange
eating habits/rituals
Swollen
salivary glands
Marks
on backs of hands/fingers
Erosion
of enamel on teeth
Bingeing
or compulsive eating
Physical consequences:
Electrolyte
imbalances (e.g. low potassium) that can lead to heart failure
Tearing
of the esophagus lining
Erosion
of enamel on teeth
Dependence
on laxatives and/or diuretics
Mineral
deficiencies
Prognosis and Treatment
Disturbed
eating patterns persist for at least several years in high percentage of cases.
Course may be chronic or intermittent. Over longer term follow-up the
symptoms of many individuals appear to diminish. Periods of remission
longer than 1 year are associated with better long-term outcomes.
First-line
treatment is Cognitive-Behavioral Treatment, once person is medically stable.
Subclinical
Eating Disorders & EDNOS
Eating
Disorder Not Otherwise Specified is term used to describe patients with
symptoms that are severe but do not meet diagnostic criteria for either AN or
BN
Chronic
dieting
Compulsive
exercisers
“Fat
talk”