Case 6: Laila Nair - Eating Disorders

Eating Disorders (ED): Description

Mental condition causing disordered eating + weight control behaviours

ED Types

Anorexia nervosa (AN)

Bulimia nervosa (BN)

Binge eating disorder (BED)

AN

Low body weight from self-imposed dietary restriction + weight loss behaviours

• Restricting Type: Excessive dieting, exercise, fasting

• Binge Eating/Purging Type: Recurrent binge eating + purging

  • Vomiting

  • Diuretic, laxative, enema misuse

BN

Repeated binge eating episodes + compensatory weight loss behaviours

• Self-induced vomiting

• Laxative misuse

• Starvation

BED

Repeated binge eating episodes WITHOUT compensatory weight loss behaviours

ED: Epidemiology

More common in women

BED: Most common ED in adults

ED: Etiology

Genetics

Neurobiological factors

• Abnormal reward processing

• Serotonin dysfunction

Psychiatric comorbidities

• OCD

• Anxiety

Childhood factors

• Obesity (BN)

• Early puberty

• Trauma

Psychosocial factors

• Social idealization of thinness (social media)

• Athletes: RED-S

  • Prioritize leanness + low weight

• Food insecurity

• Poor self-image

• Stress

Family dynamics

• Culture

  • Stigma

  • Idealization of thinness

• Parental weight talk

• Poor family function

• Strict diet

AN: Pathophysiology

1. Altered serotonin + dopamine receptor binding

2. Decreased eating = Emotional relief + low mood (malnutrition) + decreased reward sensitivity (eating)

3. Chronic undereating = Adapt to starvation

• Increased ghrelin (insensitivity)

• Decreased leptin

• Increased cortisol

BN: Pathophysiology

1. Decreased serotonin + dopamine levels

2. Impair satiety + reward system = Uncontrolled eating

BED: Pathophysiology

Binge episode = Increase dopamine + endogenous opioid = Activate reward pathway = Reinforcement

Decreased serotonin receptors = Impaired satiety + emotional dysregulation

ED: Clinical Presentation

Body dissatisfaction + preoccupation with weight/food

Secretive eating

Mood disorders

AN (Restricting): Clinical Presentation

Yellow palms

Malnutrition

• Bradycardia

• Amenorrhea

• Secondary osteoporosis

• Muscle weakness

• Lanugo body hair: Short, light-coloured fuzz

BN + AN (Purging): Clinical Presentation

Arrhythmias

Gastritis

Bilateral parotid gland swelling

Russel Sign: Calluses on knuckles

• Self-induced vomiting = Knuckle contact on incisors

Teeth caries

Amenorrhea

BED: Clinical Presentation

Overweight or normal weight

AN: Diagnostic Criteria

DSM-5

All of…

1. Energy intake restriction → Underweight

2. ≥ 1 of:

• Fear of weight gain

• Persistent behaviours preventing weight gain

  • Purging

  • Excessive exercise

3. ≥ 1 of:

• Body image disturbance

• Disproportionate impact of weight/body shape on self-value

• Unaware of seriousness of low weight

BN: Diagnostic Criteria

DSM-5

All of…

1. Recurrent binge eating episodes

2. Recurrent weight compensatory behaviours

• Self-induced vomiting

• Drug misuse (laxative, diuretic)

• Starvation periods

• Excessive exercise

3. ≥ 1 time/week over 3 months

4. Disproportionate impact of weight/body shape on self-worth

5. Behaviours NOT during AN episodes

BED: Diagnostic Criteria

DSM-5

All of…

1. Recurrent binge eating episodes

• Excessive food consumed in short period

• Lack of control

2. ≥ 3 of…

• Faster eating

• Uncomfortably full

• Eating when not hungry

• Eating alone → Embarrassment

• Feelings of disgust, depression, guilt

3. Distress

4. Binge eating ≥ 1 time/week over 3 months

5. No purging + behaviours NOT during AN/BN episodes

ED: BMI

AN: Underweight

• < 18.5

BN: Normal

• ≥ 18.5

BED: Overweight/obese OR normal

• ≥ 25

ED: Investigations

Blood tests

• Electrolytes (low K+, Na+, Cl-, Ca2+)

• ABG/VBG (metabolic disturbances)

• Glucose: Hypoglycemia

ECG

Extreme ED

AN: BMI < 15

BN + BED: ≥ 14 episodes/week

ED: Treatment/Management

Acute

Nonpharmacological

Pharmacological

ED: Acute Treatment

Hospitalization

• Extreme ED + rapid weight loss

• SI

• Dehydration

• Unstable vitals

  • Low BP

  • Orthostatic hypotension

• Abnormal HR

  • Brady/tachycardia

  • Arrhythmia

• Electrolyte imbalances

  • Low Na+, K+, Mg2+, phosphate

Family counselling

ED Management: Nonpharmacological

Psychotherapy: First-line

• CBT/CBT-E (enhanced): Adults

• Family-based therapy: Adolescents + young adults

Nutritional education + promote healthy eating habits

• Dietician referral

• Monitor weight gain

Encourage physical activity

• Healthy lifestyle

• Normal weight reached = Sports + weight training for bone health

AN Management: Pharmacological

Treat comorbidities

Atypical antipsychotics: Olanzapine

• Increase weight

BN Management: Pharmacological

SSRIs: Fluoxetine

• Decrease binge + purging

BED Management: Pharmacological

Antidepressants: Reduce binge impulse

• SSRIs

  • Ex: Citalopram, fluoxetine, sertraline

• SNRIs

  • Ex: Duloxetine

• Norepinephrine dopamine reuptake inhibitors (NDRIs)

  • Ex: Bupropion

Lisdexamfetamine (Vyvanse)

• MOA: Block dopamine + norepinephrine reuptake and increase dopamine + norepinephrine release = Modulate mesolimbic reward system + improve impulse control

• Indications: Moderate to severe BED

ED: Complications

ASCVD

• Hyperlipidemia

• Metabolic syndrome

• CVD

• T2DM

Other psych conditions

• Depression

• SUD

Menstrual dysfunction