Patients with depressive disorder generally do not have an intense fear of obesity or body image disturbance. Depressed patients usually have a decreased appetite, whereas anorexia nervosa patients often claim to have a normal appetite and to feel hungry. Patients with somatization disorder do not generally express a morbid fear of obesity. Severe weight loss and amenorrhea longer than 3 months are unusual in somatization disorder. Schizophrenic patients might have delusions about food being poisoned but rarely are they concerned with caloric content.
They also do not express a fear of gaining weight. Other eating disorders may share similar features to anorexia nervosa, but may not meet all diagnostic criteria. Patients with bulimia nervosa do not have an abnormally low body weight.
Patients who meet some but not all of the diagnostic criteria for anorexia nervosa set out by the DSM—5 may be given a diagnosis of other specified feeding or eating disorder. General medical conditions of central nervous system pathology, such as brain tumors, can simulate the binging and compensatory behaviors seen in bulimia nervosa. Klein—Levin syndrome, also rare, is more common in men and consists of hyperphagia and periodic hypersomnia. Patients with the binge—purge subtype of anorexia nervosa fail to maintain their weight within a normal range.
Patients with borderline personality disorder sometimes exhibit binge—eating but do not have other criteria for bulimia nervosa. Patients with binge—eating disorder do not exhibit compensatory behaviors such as purging, excessive exercise, or diet pill, diuretic, or laxative use. Other psychiatric disorders may present similarly to bulimia nervosa.
Overeating is common in major depressive disorder with atypical features, but individuals with this disorder will not exhibit the compensatory behaviors or excessive concern with body shape and weight present in bulimia nervosa.
Patients with borderline personality disorder may engage in binge—eating behavior as an impulsive act, but will exhibit other personality changes and will not be excessively concerned with body weight or shape. Differential diagnosis for binge—eating disorder includes bulimia nervosa, obesity, and other psychiatric conditions such as bipolar and depressive disorders and borderline personality disorder. Binge—eating disorder differs from bulimia nervosa in that binge—eating disorder is not associated with compensatory weight loss behaviors that are present in bulimia nervosa.
While binge—eating disorder is associated with overweight and obesity, key features of binge—eating disorder include higher levels of overvaluation of body weight shape, increased rates of psychiatric comorbidity, and successful outcomes with evidence—based psychotherapy. Bipolar and depressive disorders include features of increases in appetite and weight gain, but episodes of overeating may not be associated with a loss of control.
Similarly, patients with borderline personality disorder may exhibit binge—eating but will not meet all criteria for binge—eating disorder, although the two conditions can exist simultaneously. Differential diagnosis includes anorexia nervosa, factitious disorder and non—suicidal self—injury. In patients with anorexia nervosa, the eating of nonnutritive substances is done as an attempt to control the appetite.
In factitious disorders, patients will ingest non—food substances as a means to create physical symptoms. In the patients with non—suicidal self—injury, the patients will swallow objects that could be potentially harmful, in the context of getting more attention, or negative coping.
Rumination disorder can certainly occur in the context of other medical conditions or other psychiatric disorders especially in the anxiety category. If that is the case, the diagnosis is appropriate when the severity of the symptom requires additional attention.
Loss of appetite is a very nonspecific symptom that can be seen in a number of medical gastrointestinal disorders, food allergies, intolerances, cancer as well as psychiatric disorders reactive attachment disorder, autism spectrum disorder, any of the anxiety disorders, anorexia, obsessive—compulsive disorder, major depressive disorder, schizophrenia, factitious disorder.
The most frequent comorbidity is anxiety disorders. Children with certain neurological neuromuscular disorders might have some feeding difficulties associated with the problems in the innervation of the oropharyngeal muscles or in patients with hypotonia or problems swallowing. A comprehensive treatment plan including a combination of nutritional rehabilitation, medical monitoring, psychotherapy, and medication is recommended Figure 1.
Treatment guidelines are well documented by the American Psychiatric Association in its practice guideline for treating eating disorders.
Based on information from references 9 and Expected rates of controlled weight gain should be 2 to 3 pounds per week for inpatients and 0. New studies suggest that starting at higher caloric levels up to 1, calories may promote faster weight gain with no additional risk of refeeding syndrome.
Daily morning weights, vital signs including orthostatic vital signs, fluid intake, and urine output should be measured. Frequent physical examinations should be performed to detect circulatory overload, refeeding edema, and bloating. Monitor serum electrolyte levels low potassium or phosphorus , and get an electrocardiogram if needed. During the initial stages of the treatment, daily weights might be stressful for the patient.
The patient can be given the choice to be informed of changes in daily weight or not be informed, especially if it causes anxiety, frustration, or distress. Stool softeners, not laxatives, should be used to treat constipation.
The diet should be supplemented with vitamins and minerals as micronutrient deficiencies are common. Patients should be given positive reinforcement praise and negative reinforcement restrictions of exercise and purging. They should be closely supervised, and access to bathrooms should be restricted for at least 2 hours after meals. After weight restoration has progressed, stretching can begin, followed by gradual reintroduction of aerobic exercise.
Psychosocial treatments are required during hospitalization as well as after discharge. Research data more strongly support the efficacy of cognitive-behavioral and interpersonal therapies, although there are high rates of non—response to treatment. Newer treatment models such as the Maudsley Model of Treatment for Adults with Anorexia Nervosa is aimed at addressing rigidity, cognitive distortions about the utility of anorexia nervosa, socio—emotional impairment, and interpersonal relationships, are currently under investigation to evaluate long—term efficacy.
Group therapy, support groups, and step programs like Overeaters Anonymous may be useful as adjunct treatment and for relapse prevention.
Family therapy and marital therapy are helpful in cases of dysfunctional family patterns and interpersonal distress. Guided self—help manuals can reduce the number of binge—purge episodes in at least some patients with bulimia nervosa. In fact, a manual—driven self—help approach incorporating cognitive—behavioral principles combined with keeping contact with a general practice physician in one study did as well as specialist—based treatment in reducing bulimic episodes.
Computer—based health education can improve knowledge and attitudes as a patient—friendly adjunct to therapy. This might help explain why manual—driven self—help and psychoeducational programs that emphasize improvement of self—esteem and reassessment of body image have achieved some success. For children and adolescents with eating disorders, Maudsley family—based therapy has been shown to be the most effective treatment for weight restoration and cognitive function in anorexia nervosa, and is suggested to be efficacious in bulimia nervosa.
Elementary school—age children with behavioral problems, disordered eating, and obesity may benefit from a behavioral family—based therapy. Children and parents were examined and tested before and after the intervention and all lost weight.
Although eating disorders did not resolve, other behavioral problems did. There was less parental dissatisfaction as children developed better awareness and behavior patterns.
Treatment for pica should follow a psychoeducational treatment approach. Parents might need increased social support. Additionally, parents may need concurrent treatment for anxiety and depression of their own in some cases.
Reports about behavioral treatments, environmental enrichment, with group or individual therapy have shown varying benefits. Treating the nutritional insufficiencies is key. Very limited research is available regarding the treatment of this feeding disorder. Potentially progressive exposure to new foods is important, behavioral therapy or feeding clinics may also be helpful. The evidence for significant efficacy of psychotropic medication is lacking, with very few methodologically sound studies.
Randomized controlled trials of antidepressants, most notably selective serotonin reuptake inhibitors SSRIs , have not shown these medications to be effective in the treatment of anorexia nervosa or in the treatment of women with anorexia nervosa and comorbid depression, SSRIs eg, fluoxetine are commonly considered for patients with anorexia nervosa who have depressive, anxiety, or obsessive—compulsive symptoms that persist in spite of or in the absence of weight gain. However, SSRIs are associated with serious side effects for patients with eating disorders, including bone loss and increased risk of fracture.
Tricyclic antidepressants and monoamine oxidase inhibitors have shown modest benefits in decreasing anorexic symptoms and increasing weight. However, they should be used with caution, because they have greater risks of cardiac complications, including arrhythmias and hypotension, and psychotic symptoms.
Limited research has suggested that second generation antipsychotics may be useful in patients with severe, unremitting resistance to gaining weight, severe obsessional thinking, and severe denial reaching delusional states. Low doses of older antipsychotics may be used for marked agitation and psychotic thinking prior to meals. Antianxiety medications, such as benzodiazepines, may be used for extreme anticipatory anxiety concerning eating or before morning weight measures.
Estrogen replacement alone does not generally appear to reverse osteoporosis or osteopenia, and unless there is weight gain, it does not prevent further bone loss. In addition, return of menses is an important marker of recovery that cannot be evaluated if estrogen replacement is implemented. Promotility agents such as metoclopramide are commonly used for bloating and abdominal pains due to gastroparesis and premature satiety, but they require monitoring for drug—related extrapyramidal side effects.
Antidepressants are used primarily to reduce the frequency of disturbed eating and treat comorbid depression, anxiety, obsessions, and certain impulse—disorder symptoms and are shown to be efficacious in conjunction with psychotherapy. The only medication approved by the U.
Several studies have demonstrated efficacy of other SSRIs including sertraline Zoloft , paroxetine Paxil , and citalopram Celexa ; tricyclic antidepressants including imipramine Tofranil , nortriptyline Pamelor , and desipramine Norpramin ; and monoamine oxidase inhibitors including tranylcypromine Parnate.
Other psychotropic drugs are sometimes used. Lithium continues to be used occasionally as an adjunct for comorbid disorders. Various anticonvulsants have successfully reduced binge eating for some patients, but they can also increase appetite.
Topiramate lowers appetite but has been associated with cognitive side effects. Sibutramine has also been used to reduce appetite in bulimia nervosa and binge—eating disorder. Antidepressant medications, particularly SSRIs, have been shown to reduce binge—eating behavior, although it is unclear if this is a long—term effect. To be effective, the medication dosage is generally at the high end of the recommended range.
SSRIs, however, are not associated with substantial weight loss. Another medication option is the appetite—suppressant sibutramine, which is associated with at least a short—term reduction in binge eating, and is also associated with significant weight loss. Other medications used in binge—eating disorder include zonisamide and topiramate, which may be effective for binge reduction and weight loss, but have significant side effects that may limit their utility.
Prevention programs in schools for both females and males or in organizations like the Girl Scouts have been successful in reducing risk factors for eating disorders.
Often focusing on media literacy and interactive discussion, there are increasing reports of short—term and longer—term benefits in body satisfaction and acceptance of normal growth.
Eating Disorders Kathleen N. Franco, MD Erin H. Definition and Etiology Eating disorders are syndromes characterized by severe disturbances in eating behavior and by distress or ex-cessive concern about body shape or weight and often occur with severe medical or psychiatric comorbidities. Swallowing Disorders Swallowing disorders, also called dysphagia dis-FAY-juh , can occur at different stages in the swallowing process:.
Feeding Disorders Feeding disorders are conditions in which an infant or child is unable or refuses to eat or has difficulty eating, resulting in weight loss, malnutrition, lethargy, impaired intellectual and social-emotional development and growth retardation. Behaviors in Feeding Issues:. Our Services:. Contact Info. Lakewood Oh Esther A. Verbovszky M. At this time we are offering online therapy for speech, swallowing and voicing. Contact us today to find out more info!
Stopping Gag Reflex Problems March 11,
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