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Wednesday, August 13, 2025

Eating disorders


Introduction

Eating disorders are serious psychiatric conditions characterized by persistent disturbances in eating behaviors, attitudes toward food, and body image, often resulting in significant physical and psychological morbidity. They involve a complex interplay of biological, psychological, and sociocultural factors and can be life-threatening if untreated.

The main clinically recognized eating disorders include:

  • Anorexia nervosa (AN)

  • Bulimia nervosa (BN)

  • Binge-eating disorder (BED)

  • Other specified feeding or eating disorder (OSFED)

  • Avoidant/restrictive food intake disorder (ARFID)

  • Pica and rumination disorder

Epidemiology

  • Prevalence:

    • AN: ~0.3–1% lifetime prevalence in women.

    • BN: ~1–1.5% in women, 0.1–0.5% in men.

    • BED: ~2–3% in adults, most common eating disorder in both sexes.

  • Gender: More common in females, but increasing recognition in males.

  • Age of onset: Typically adolescence to early adulthood; BED can occur later in life.

  • Mortality: Highest among psychiatric disorders (especially AN) due to medical complications and suicide.

Etiology and Risk Factors

Biological Factors

  • Genetic predisposition (heritability estimates 50–80% for AN and BN)

  • Dysregulation of neurotransmitters (serotonin, dopamine) affecting appetite and mood

  • Hormonal influences (e.g., leptin, ghrelin, sex hormones)

Psychological Factors

  • Perfectionism, obsessive-compulsive traits

  • Low self-esteem, body dissatisfaction

  • Poor coping mechanisms for stress or trauma

Sociocultural Factors

  • Cultural emphasis on thinness as ideal body type

  • Media influence and social comparison

  • Participation in weight-focused activities (modeling, gymnastics, dance)

Other Risks

  • Childhood obesity or early dieting

  • History of abuse or bullying

  • Comorbid psychiatric disorders (depression, anxiety, substance use disorders)

Major Types and Clinical Features

1. Anorexia Nervosa (AN)

  • Core features:

    • Restriction of energy intake leading to significantly low body weight

    • Intense fear of gaining weight or becoming fat

    • Distorted perception of body weight/shape or denial of seriousness of low weight

  • Subtypes:

    • Restricting type

    • Binge-eating/purging type

  • Physical signs:

    • Emaciation, bradycardia, hypotension, hypothermia

    • Lanugo hair, dry skin, hair loss

    • Amenorrhea (loss of menstruation)

  • Complications: Osteoporosis, electrolyte imbalance, cardiac arrhythmias, multi-organ failure

2. Bulimia Nervosa (BN)

  • Core features:

    • Recurrent binge eating episodes (eating large amounts of food in a discrete period with loss of control)

    • Recurrent inappropriate compensatory behaviors (self-induced vomiting, laxatives, diuretics, excessive exercise)

    • Episodes occur at least once a week for 3 months

  • Physical signs:

    • Normal or slightly overweight

    • Dental erosion (acid exposure), parotid gland enlargement

    • Calluses on knuckles (Russell’s sign) from induced vomiting

  • Complications: Electrolyte disturbances (hypokalemia), metabolic alkalosis, arrhythmias, esophageal tears

3. Binge-Eating Disorder (BED)

  • Core features:

    • Recurrent binge-eating episodes without compensatory behaviors

    • Associated with eating rapidly, until uncomfortably full, eating when not hungry, eating alone due to embarrassment, feelings of disgust/guilt afterward

  • Physical signs: Often overweight or obese

  • Complications: Obesity-related conditions (type 2 diabetes, hypertension, hyperlipidemia)

4. Other Specified Feeding or Eating Disorder (OSFED)

  • Clinically significant symptoms that cause distress/impairment but do not meet full criteria for AN, BN, or BED.

  • Examples: Atypical anorexia nervosa (all criteria met except low weight), purging disorder, night eating syndrome.

5. Avoidant/Restrictive Food Intake Disorder (ARFID)

  • Restrictive eating not driven by body image concerns but due to sensory issues, fear of choking/vomiting, or lack of interest in food.

  • Leads to nutritional deficiencies, weight loss, and psychosocial impairment.

6. Pica and Rumination Disorder

  • Pica: Persistent eating of non-nutritive substances (e.g., clay, paper).

  • Rumination disorder: Repeated regurgitation of food, re-chewing, or re-swallowing.

Diagnosis

Clinical Assessment

  • Comprehensive history (eating behaviors, weight history, body image perception, psychiatric history)

  • Physical examination (BMI, vital signs, signs of malnutrition or purging)

  • Laboratory evaluation (electrolytes, renal/liver function, CBC, thyroid function)

  • ECG (check for arrhythmias)

Screening Tools

  • SCOFF questionnaire (≥2 positive answers suggests risk)

  • Eating Disorder Examination Questionnaire (EDE-Q)

Management

A multidisciplinary approach is essential, involving medical, nutritional, and psychological interventions.

1. General Principles

  • Medical stabilization if acutely ill (especially in AN with severe malnutrition or electrolyte imbalance)

  • Correct nutritional deficiencies and refeed cautiously to avoid refeeding syndrome

  • Psychotherapy as mainstay of long-term treatment

  • Family involvement, especially in pediatric/adolescent cases

2. Psychotherapy

  • First-line:

    • Family-based therapy (FBT) – especially effective in adolescents with AN

    • Cognitive behavioral therapy (CBT-ED) – most effective for BN and BED

  • Other options: Interpersonal therapy (IPT), dialectical behavior therapy (DBT)

3. Nutritional Rehabilitation

  • Gradual increase in caloric intake to restore healthy weight (AN)

  • Balanced meal planning to reduce binge/purge cycles (BN, BED)

  • Work with a registered dietitian experienced in eating disorders

4. Pharmacotherapy

  • BN: Fluoxetine (SSRI) – 60 mg/day reduces binge-purge frequency

  • BED: Lisdexamfetamine – approved for moderate to severe BED

  • Comorbid depression/anxiety: SSRIs

  • No approved medications for AN, but adjunctive agents may help manage comorbidities

5. Hospitalization Criteria (especially in AN)

  • Weight <75% expected BMI

  • Rapid weight loss

  • Severe electrolyte abnormalities

  • Bradycardia (<40 bpm), hypotension, hypothermia

  • Suicidality or severe psychiatric comorbidity

Complications

Medical

  • Cardiac: arrhythmias, heart failure

  • Gastrointestinal: delayed gastric emptying, constipation, esophageal tears

  • Endocrine: amenorrhea, infertility, osteoporosis

  • Renal: dehydration, electrolyte disturbances

  • Neurological: cognitive impairment

Psychiatric

  • Depression, anxiety, obsessive-compulsive disorder, substance misuse

  • Increased suicide risk (especially in AN)

Prognosis

  • AN: ~50% full recovery, 30% partial recovery, 20% chronic course

  • BN/BED: Better prognosis with treatment; high relapse risk if untreated

  • Early detection and treatment improve outcomes significantly




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