Eating disorders : Classification, Causes and Comorbid

Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual’s physical and mental health. Bulimia nervosa and anorexia nervosa are the most common specific forms in the United States. Though primarily thought of as affecting females (an estimated 5–10 million being affected in the U.S.), eating disorders affect males as well (an estimated 1 million U.S. males being affected). Although eating disorders are increasing all over the world among both men and women, there is evidence to suggest that it is women in the Western world who are at the highest risk of developing them and the degree of westernization increases the risk.

The precise cause of eating disorders is not entirely understood, although, it there is evidence that it may be linked to other medical conditions and situations. One study showed that girls with ADHD have a greater chance of getting an eating disorder than those not affected by ADHD. One study showed that foster girls are more likely to develop bulimia nervosa. Some also think that peer pressure and idealized body-types seen in the media are also a significant factor. However, research shows that for some people there is a genetic reason why they may be prone to developing an eating disorder.

While proper treatment can be highly effective for many of the specific types of eating disorder, the consequences of eating disorders can be severe, including death (whether from direct medical effects of disturbed eating habits or from comorbid conditions such as suicidal thinking).

Classification

  • Anorexia nervosa (AN), characterized by refusal to maintain a healthy body weight, an obsessive fear of gaining weight, and an unrealistic perception of current body weight. Anorexia can cause menstruation to stop, and often leads to bone loss, loss of skin integrity, etc. It greatly stresses the heart, increasing the risk of heart attacks and related heart problems. The risk of death is greatly increased in individuals with this disease
  • Bulimia nervosa (BN), characterized by recurrent binge eating followed by compensatory behaviors such as purging (self-induced vomiting, excessive use of laxatives/diuretics, or excessive exercise) Bulimics may also fast for a certain amount of time following a binge.
  • Binge eating disorder (BED) or compulsive overeating, characterized by binge eating, without compensatory behavior.
  • Compulsive overeating, COE
  • Purging disorder, characterized by recurrent purging to control weight or shape in the absence of binge eating episodes.
  • Rumination, characterized by involving the repeated painless regurgitation of food following a meal which is then either re-chewed and re-swallowed, or discarded.
  • Diabulimia, characterized by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
  • Food maintenance, characterized by a set of aberrant eating behaviors of children in foster care.
  • Eating disorders not otherwise specified (EDNOS) can refer to a number of disorders. It can refer to a female individual who suffers from anorexia but still has her period, someone who may be at a “healthy weight”, but who has anorexic thought patterns and behaviors, it can mean the sufferer equally participates in some anorexic as well as bulimic behaviors (sometimes referred to as purge-type anorexia), or to any combination of Eating Disorder behaviors which do not directly put them in a separate category.
  • Pica, characterized by a compulsive craving for eating, chewing or licking non-food items or foods containing no nutrition. These can include such things as chalk, paper, plaster, paint chips, baking soda, starch, glue, rust, ice, coffee grounds, and cigarette ashes. These individuals cannot distinguish a difference between food and non food items.
  • Night Eating Syndrome, characterized by morning anorexia, evening polyphagia (abnormally increased appetite for consumption of food (frequently associated with insomnia, and injury to the hypothalamus).
  • Orthorexia nervosa, a term used by Steven Bratman to characterize an obsession with a “pure” diet, where it interferes with a person’s life.

Several of the above mentioned disorders, such as diabulimia, food maintenance syndrome and orthorexia nervosa, are not currently recognized as mental disorders in any of the medical manuals, such as the ICD-10 or the DSM-IV.

Causes

The exact cause of Eating Disorders is unknown. However, it is believed to be due to a combination of biological, psychological and/or environmental abnormalities. A common belief is that “Genetics loads the gun, environment pulls the trigger.”[citation needed] This would mean that some people are born with a predisposition to it, which can be brought to the surface pending on environment and reactions to it. Many people with eating disorders suffer also from body dysmorphic disorder, altering the way a person sees themselves.

Biologica

  • Genetic: Numerous studies have been undertaken that show a possible genetic predisposition toward eating disorders as a result of Mendelian inheritance.
  • Epigenetics: Epigenetic mechanisms are means by which environmental effects alter gene expression via methods such as DNA methylation; these are independent of and do not alter the underlying DNA sequence. They are heritable, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission due to epigenetic mechanisms has been implicated in various eating disorders. “We conclude that epigenetic mechanisms may contribute to the known alterations of ANP homeostasis in women with eating disorders.”
  • Biochemical: Eating behavior is a complex process controlled by the neuroendocrine system of which the Hypothalamus-pituitary-adrenal-axis (HPA axis) is a major component. Dysregulation of the HPA axis has been associated with eating disorders, such as irregularities in the manufacture, amount or transmission of certain neurotransmitters, hormones[24] or neuropeptides and amino acids such as homocysteine, elevated levels of which are found in AN and BN as well as depression.
  • serotonin: a neurotransmitter involved in depression also has an inhibitory effect on eating behavior.
  • norepinephrine is both a neurotransmitter and a hormone; abnormalities in either capacity may affect eating behavior.
  • dopamine: which in addition to being a precursor of norepinephrine and epinephrine is also a neurotransmitter which regulates the rewarding property of food.
  • leptin and ghrelin: leptin is a hormone produced primarily by the fat cells in the body; it has an inhibitory effect on appetite by inducing a feeling of saiety. Ghrelin is an appetite inducing hormone produced in the stomach and the upper portion of the small intestine. Circulating levels of both hormones are an important factor in weight control. While often associated with obesity, both hormones and their respective effects have been implicated in the pathophysiology of anorexia nervosa and bulimia nervosa.
  • immune system: studies have shown that a majority of patients with anorexia and bulimia nervosa have elevated levels of autoantibodies that affect hormones and neuropeptides that regulate appetite control and the stress response. There may be a direct correlation between autoantibody levels and associated psychological traits.
  • infection: PANDAS, is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. Children with PANDAS “have obsessive-compulsive disorder (OCD) and/or tic disorders such as Tourette syndrome, and in whom symptoms worsen following infections such as “strep throat” and scarlet fever.” (NIMH) There is a possibility that PANDAS may be a precipitating factor in the development of anorexia nervosa in some cases, (PANDAS AN).
  • lesions: studies have shown that lesions to the right frontal lobe or temporal lobe can cause the pathological symptoms of an eating disorder.
  • tumors: tumors in various regions of the brain have been implicated in the development of abnormal eating patterns.
  • brain calcification: a study highlights a case in which prior calcification of the right thalumus may have contributed to development of anorexia nervosa.
  • somatosensory homunculus: is the representation of the body located in the somatosensory cortex, first described by renowned neurosurgeon Wilder Penfield. The illustration was originally termed “Penfield’s Homunculus”, homunculus meaning little man. “In normal development this representation should adapt as the body goes through its pubertal growth spurt. However, in AN it is hypothesized that there is a lack of plasticity in this area, which may result in impairments of sensory processing and distortion of body image”. (Bryan Lask, also proposed by VS Ramachandran)
  • Obstetric complications: There have been studies done which show maternal smoking, obstetric and perinatal complications such as maternal anemia, very pre-term birth (32

Psychological

Eating disorders are classified as Axis I disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) published by the American Psychiatric Association. There are various other psychological issues that may factor into eating disorders, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 “clusters”, A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Some people have a previous disorder which may increase their vulnerability to developing an eating disorder. Some develop them afterwards. The severity and type of eating disorder symptoms have been shown to affect comorbidity.[66] The DSM-IV should not be used by laypersons to diagnose themselves, even when used by professionals there has been considerable controversy over the diagnostic criteria used for various diagnoses, including eating disorders. There has been controversy over various editions of the DSM including the latest edition, DSM-V, due in May 2013.

Comorbid Disorders

  • depression
  • obsessive compulsive personality disorder
  • substance abuse, alcoholism
  • borderline personality disorder
  • anxiety disorders
  • narcissistic personality disorder
  • obsessive compulsive disorder
  • histrionic personality disorder
  • Attention-deficit hyperactivity disorder
  • avoidant personality disorder
  • Personality traits

There are various childhood personality traits associated with the development of eating disorders. During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson’s disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or viral infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain such as the amygdala and the prefrontal cortex Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behavior.

Environmental

  • Child maltreatment
  • Child abuse which encompasses physical, psychological and sexual abuse, as well as neglect has been shown by innumerable studies to be a precipitating factor in a wide variety of psychiatric disorders, including eating disorders. Children who are subjugated to abuse may develop a disordered eating in an effort to gain some sense of control or for a sense of comfort. Or they may be in an environment where the diet is unhealthy or insufficient. Child abuse and neglect can cause profound changes in both the physiological structure and the neurochemistry of the developing brain. Children who, as wards of the state, were placed in orphanages or foster homes are especially susceptible to developing a disordered eating pattern. In a study done in New Zealand 25% of the study subjects in foster care exhibited an eating disorder (Tarren-Sweeney M. 2006). An unstable home environment is detrimental to the emotional well-being of children, even in the absence of blatant abuse or neglect the stress of an unstable home can contribute to the development of an eating disorder.
  • Social isolation Social isolation has been shown to have a deleterious effect on an individuals’ physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. “The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors.”  Social isolation can be inherently stressful, depressing and anxiety provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.
  • Parental influence Parental influence has been shown to be an intrinsic component in developing the eating behaviors of children. This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents’ own body shape and eating patterns, the degree of involvement and expectations of their children’s eating behavior as well as the interpersonal relationship of parent and child. This is in addition to the general psychosocial climate of the home and the presence or absence of a nurturing stable environment. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more. Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child’s eating behavior. Affection and attention have been shown to affect the degree of a childs’ finickiness and their acceptance of a more varied diet.
  • Peer pressure In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties. Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. “Teen girls’ concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior,” says psychologist Eleanor Mackey of the Children’s National Medical Center in Washington and lead author of the study. “Those are really important.” According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight Such dieting is reported to being influenced by peer behavior, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.
  • Cultural pressure  There is a cultural emphasis on thinness which is especially pervasive in western society. There is an unrealistic stereotype of what constitutes beauty and the ideal body type as portrayed by the media, fashion and entertainment industries. “The cultural pressure on men and women to be “[perfect]” is an important predisposing factor for the development of eating disorders” (Prof. Bryan Lask).
  • In men It is estimated that 8 million people in the United States are suffering from an Eating Disorder, and of that number 10% are men. Professionals suggest that the percentage suffering that are men is much higher, but because of the old fashioned idea that this illness strikes only women, few men come forward to find the help they deserve. To date, the evidence suggests that the gender bias of clinicians means that diagnosing either bulimia or anorexia in men is less likely despite identical behavior. Men are more likely to be diagnosed as suffering depression with associated appetite changes than receive a primary diagnosis of an eating disorder.
  • In addition, there may often be shrouds of secrecy because of the lack of therapy groups and treatment centers offering groups specifically designed for men. They may feel very alone at the thought of having to sit in a group of women, to be part of a program designed for women, and even at the prospect that a treatment facility will turn them down because of their sex.
  • Men who participate in low-weight oriented sports such as jockeys, wrestlers and runners are at an increased risk of developing an Eating Disorder such as Anorexia or Bulimia. The pressure to succeed, to be the best, to be competitive and to win at all costs, combined with any non-athletic pressures in their lives (relationship issues, family problems, abuse, etc.) can help to contribute the onset of their disordered eating.
  • It is not uncommon for men suffering with an Eating Disorder also to suffer with alcohol abuse and/or substance abuse simultaneously (though many women also suffer both disordered eating and substance abuse problems, combined). This may be due to the addictive nature of their psychological health, combined with the strong images put out by society of men’s overindulgence in alcohol.
  • There may also be a link between ADHD, with male sufferers of Anorexia, Bulimia, and self-injury. More research is still needing to be done in this area.
  • For all those who suffer, men and women alike, there are many possible co-existing psychological illnesses that can be present, including depression, anxiety, PTSD, self-injury behaviors, substance abuse, OCD, borderline personality disorder, and Multiple Personality Disorders.
  • It is important to remember that most of the underlying psychological factors that lead to an Eating Disorder are the same for both men and women; low self-esteem, a need to be accepted, depression, anxiety, an inability to cope with emotions & personal issues, and other existing psychological illnesses. All of the physical dangers and complications associated with being the sufferer of an Eating Disorder are the same. A great number of the causes are the same or very similar (family problems, relationship issues, alcoholic/addictive parent, abuse, societal pressure).

Symptoms-complications

Symptoms and complications vary according to the nature and severity of the eating disorder:

Possible Symptoms and Complications of Eating Disorders
acne
xerosis
amenorrhoea
tooth loss, cavities
constipation
diarrhea
water retention and/or edema
lanugo
telogen effluvium
cardiac arrest
hypokalemia
death
osteoporosis
electrolyte imbalance
hyponatremia
brain atrophy
pellagra
scurvy
kidney failure
suicide

  • Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behavior.

Diagnosis

The initial diagnosis should be made by a competent medical professional. “The medical history is the most powerful tool for diagnosing eating disorders”(American Family Physician). There are many medical disorders that mimic eating disorders and comorbid psychiatric disorders. All organic causes should be ruled out prior to a diagnosis of an eating disorder or any other psychiatric disorder is made.

  • Medical The diagnostic workup typically includes complete medical and psychosocial history and follows a rational and formulaic approach to the diagnosis. Neuroimaging using fMRI, MRI, PET and SPECT scans have been used to detect cases in which a lesion, tumor or other organic condition has been either the sole causative or contributory factor in an eating disorder. “Right frontal intracerebral lesions with their close relationship to the limbic system could be causative for eating disorders, we therefore recommend performing a cranial MRI in all patients with suspected eating disorders” (Trummer M et al. 2002), “intracranial pathology should also be considered however certain is the diagnosis of early-onset anorexia nervosa. Second, neuroimaging plays an important part in diagnosing early-onset anorexia nervosa, both from a clinical and a research prospective”.(O’Brien et al. 2001).

Psychological

Eating Disorder Specific Psychometric Test
Eating Attitudes Test
SCOFF questionnaire
Body Attitudes Test
Body Attitudes Questionnaire
Eating Disorder Inventory
Eating Disorder Examination Interview

After ruling out organic causes and the initial diagnosis of an eating disorder being made by a medical professional, a trained mental health professional aids in the assessment and treatment of the underlying psychological components of the eating disorder and any comorbid psychological conditions. The clinician conducts a clinical interview and may employ various psychometric tests. Some are general in nature while others were devised specifically for use in the assessment of eating disorders. Some of the general tests that may be used are the Hamilton Depression Rating Scale] and the Beck Depression Inventory

Source : wikipedia

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