Eating disorders

Eating Disorders forms a relatively broad diagnostic spectrum. They are characterized by pathological eating behavior and self-perception, with many other somatic, psychological and social consequences. Multifactorial causes of the disease include risk factors:


 * 1) genetic;
 * 2) developmental;
 * 3) stressful;
 * 4) environmental.

Some are common to the entire diagnostic spectrum. The etiopathogenesis of the disease is not entirely known. In recent years, the awareness of experts and the entire population about the occurrence and clinical manifestations of eating disorders has increased significantly. The connection between eating disorders and the promotion of an extremely slim ideal of beauty (using computer-edited photographs) is most often discussed in the media. Goals to achieve unrealistic slenderness often lead to dissatisfaction with one's own appearance, even very young individuals of normal weight then display subsequent risky dietary behavior.

Epidemiology
The prevalence of anorexia nervosa (AN), bulimia nervosa (BN) and psychogenic overeating (PP) is 0.6, 1.0 and 2.8% with a risk several times higher (up to 10 times) in women. The median time of the disease is 18-21 years. Children under 12 represent about 5% of patients. As many as 40% of patients with eating disorders have been described with self-harm, especially in bulimic patients. In our population, it has been proven that at the age of 13, 35% of girls and 13% of boys are dissatisfied with their bodies, 50% of girls want to lose weight, 40% consciously limit themselves to food and 4% intentionally vomit. With the increase in obesity in children, we see eating disorders with premorbid obesity far more often.

Clinical picture
Patients usually first contact a general practitioner, pediatrician, internist, gastroenterologist, dermatologist, surgeon, neurologist, gynecologist, center of applied reproduction or dentist. They do not ask for help directly with an eating disorder. The most common complaints are fatigue, dizziness, lack of energy,  menstrual disorders, weight gain or loss, constipation, flatulence, abdominal pain, heartburn, sore throat, palpitations, polyuria, polydipsia, insomnia. Pathological eating behavior is likely to be concealed by patient. Even in the physical examination, there may not be a pathological finding at first. Therefore, it is necessary to think about the diagnosis, especially for adolescents and young women at risk (top athletes, dancers, models, actresses and students of these fields). And purposefully ask about problematic eating behavior. We inform the patient about the disease and its consequences, monitor the problems and if they persist and worsen to malnutrition, we send the patient for psychiatric examination. Early detection of the disease and adequate treatment are essential for the course of the disease. The biggest problem, however, is the fact that most patients and sometimes their parents often initially refuse adequate treatment. They hide problems that worsen the somatic condition and prognosis (abuse laxatives,  diuretics, manipulation  insulin, abuse antiobesity drugs and other substances) for a long time out of shame and fear of stigma. People with disabilities often seek different alternative approaches. They have unrealistic demands on the doctor, they want to be cured, but keep the weight very low. With children, diagnosis may be more difficult; adult criteria may not always be used (eg amenorrhea in prepubertal children). Poor nutrition can result in weight stagnation during growth. Children are also more likely to complain about somatic problems. In contrast to the restriction of their own food intake, they sometimes show conspicuously intererest in food theoretically, and even cook and controll the diet of members of the whole family. We often observe changes in taste, salting, seasoning, excessive drinking or insufficient fluid intake. When observing eating behavior, we find that they eat slowly, ceremoniously, "poke" at food and "morsel" between meals. Children may be affected by an eating disorder for a lifetime, e.g smaller stature and infertility. They lose weight more rapidly and dehydration, hypochloraemia and hypokalemia manifest in drowsiness, muscle weakness, bradycardia, arrhythmias and can lead to cardiac arrest. Puberty is delayed, osteoporosis occurs earlier, often in the second year of the disease. A SCOFF questionnaire was developed for rapid screening of both AN and BN (Morgana et al., 1999)


 * {| class="wikitable"

! colspan="2" |SCOFF
 * 1.||Do you ever feel uncomfortably full to madness?
 * 2.||Are you afraid of losing control over the amount of food you eat?
 * 3.||Have you recently lost more than 7 kilograms in 3 months?
 * 4.||Do you think you are fat when others think you are too slim?
 * 5.||Do you think that food controls your life?
 * }
 * 4.||Do you think you are fat when others think you are too slim?
 * 5.||Do you think that food controls your life?
 * }
 * 5.||Do you think that food controls your life?
 * }

The clinical features of the syndrome in a cooperating patient or family can be easily identified. Diagnosis is reliable when all diagnostic guidelines are followed.

Anorexia nervosa
Anorexia nervosa (ICD-10: ) according to ICD-10 criteria characterizes:


 * 1) Body weight maintained at least 15% below the expected weight (whether reduced or never reached) or Quetelet Body Mass Index (BMI): weight (kg) / height (m2) is 17.5 or less. Prepubertal patients do not meet the expected weight gain during growth.
 * 2) The patient loses weight on her own, through diets, provoked vomiting, taking diuretics, anorexics, laxatives or excessive exercise.
 * 3) Specific psychopathology is represented by fear of obesity persisting even under severe underweight, distorted perceptionof one's own body, and intrusive, controlling thoughts of maintaining underweight, sometimes eating rituals.
 * 4) Extensive endocrine disorder, hypothalamic-pituitary-gonadal axis, in women amenorrhoea, (often covered by HRT), in men loss of sexual interest.
 * 5) Beginning before puberty, delays or stops further development (growth, breast development, primary amenorrhea, pediatric genitalia in boys). After recovery, puberty will be completed, but menarché may be delayed. Bulimia nervosa begins later and often develops from AN or its subclinical form.

Bulimia nervosa
Bulimia nervosa (ICD-10: ) according to ICD-10 we characterize:
 * 1) Constant dealing with food, irresistible desire for food with bouts of overeating.
 * 2) Trying to get rid of calories from food consumed in one (or more) ways: provoked vomiting, abuse  laxatives, starvation, anorectics,  diuretics, thyroid preparations, laxatives, in diabetic patients manipulations  insulin therapy. Restrictive and bulimic subtypes may alternate.
 * 3) Specific psychopathology is based primarily on morbid fears of obesity. The patient considers her target weight to be less than the optimal or healthy premorbid weight. Binge eating attacks correspond to consuming too much food (usually one that he normally refuses for dietary reasons - such as sweets) in a short time.

Overeating associated with other mental disorders
Overeating associated with other mental disorders (F50.4) includes:


 * Overeating, which can be a reaction to stress (sexual trauma, loss of a loved one or exercise).
 * It leads to weight gain due to psychological factors and eating disorders.
 * Subsequent obesity can gradually lead to a decrease in self-esteem, mood disorders, anxiety, insecurity in personal relationships, social isolation and the development of another somatoform disorder. It can also be induced by long-term psychopharmacotherapy.
 * Involvement in various dietary measures often leads to a vicious circle of significant weight fluctuations, affective lability and depressive disorders.

Atypical forms of anorexia nervosa and bulimia nervosa
Atypical forms of anorexia nervosa (F50.1) and bulimia nervosa (F50.3) do not meet all the criteria for classification, but otherwise show a typical clinical picture and especially the treatment is the same. They occur more frequently in primary care. The disease can be considered atypical when patients hide some symptoms. We do not argue with patients about the symptoms so as not to deepen their resistance to treatment. Family information is especially important for young patients. At present, experts are paying more attention to psychogenic overeating, which, especially with the individual's predisposition, leads to obesity and has a comparable impact on health and quality of life with other eating disorders. The diagnostic subtypes of the spectrum of eating disorders often overlap, but their treatment, course and prognosis vary.

Treatment
Psychiatric and psychological examination should lead to communication of diagnosis, psychoeducation, design and motivation for further treatment. If the first contact is a self-help group, the prognosis and course of the disease depend on its organization and the way patients are referred for further treatment (effectiveness has been demonstrated in BN programs with the participation of experts).

The treatment of eating disorders is very demanding, working with ambivalence for treatment requires considerable skills and patience. We emphasize interdisciplinary cooperation, cooperation with the family, ev. with school, with sports coaches. Without improved motivation to change eating behavior and adjust weight, even highly sophisticated medical approaches remain ineffective and experts clueless. The pediatrician or general practitioner plays a crucial role in the first contact with the patient and his family, especially in early diagnosis and psychoeducation and in the persistence of the problem in the recommendation of further appropriate professional care. Nutritional therapists are increasingly involved in the treatment of eating disorders, mostly members of the therapeutic team. Clear definition of professional competencies and adherence to clear rules and boundaries are important for good team cooperation, as eating disorders can be very manipulative in nature. Psychotherapeutic and counseling interventions require psychotherapeutic training and supervision and considerable communication skills.

Realimentation
Hospitalization at intermediate care unit occurs in patients without insight and motivation for treatment only when there is a serious threat to somatic status: at weight below 85% of standard weight, pulse below 40 beats per minute, blood pressure below 90/60 mmHg in adults and 80/50 mmHg in children, dehydration, hypothermia, hypokalemia, hypoglycemia, electrolytic imbalance and threat renal, cardiac or liver failure. The indication for hospitalization of a child is clearly weight loss of more than 25%, dehydration, signs of circulatory failure (bradycardia, hypotension), persistent vomiting, severe depression or suicidal behavior. Hospitalization often requires gavage and parenteral nutrition. Partial oral food intake should be started as soon as possible. The side effect of realimentation is refeeding syndrome, uncommon but life-threatening. Malnutrition leads to a reduction in intracellular phosphate supply, at normal serum concentrations. The sudden realimentation of carbohydrates, which increases the secretion of insulin and cellular uptake of phosphates, leads to  hypophosphatemia. Clinical signs include rhabdomyolysis, muscle weakness, leukocyte changes, respiratory, cardiac failure, hypotension, cardiac arrhythmias, seizures, ataxia, encephalopathy, coma and sudden death. Early non-specific manifestations may remain unrecognized. Rapid changes in serum osmolarity, rapid correction of hyponatraemia or hypokalaemia may also lead to central pontine myelinolysis.

Psychotherapy
When patients manage their ambivalence with the disease and treatment, they usually accept the help of a specialist. The procedure of treatment and psychotherapy is then selected according to motivation (for younger and family cooperation), stage of the disease and its duration and changes that the patient is currently able to (mere weight adjustment, change of attitudes in eating behavior, solving relationship problems, relapse prevention). The attitude and personality of the therapist and the availability of other qualified care also play a role. But in the acute phase of the disease (with severe malnutrition), the effectiveness of psychotherapy is questionable, as most patients have difficulty concentrating on psychotherapeutic work, working to improve insight and understanding the context in which pathological eating behavior occurs and is maintained. In the case of children, the younger and more mentally immature a child is, the worse his cooperation and treatment is and the more responsibility lies with the child's surroundings.

Cognitive-behavioral therapy
Of the psychotherapeutic approaches, Cognitive-Behavioral Therapy (CBT) is the most commonly used. It helps to change unwanted eating behaviors (overeating, vomiting and overuse of diuretics, laxatives, food restriction, avoidant behavior) and to establish a normal eating regime. At the same time, he works to change his thinking (influencing the negative perception of his own body, reduced self-esteem and perfectionist demands on himself and his surroundings).

Interpersonal psychotherapy
Interpersonal psychotherapy (IPT) focuses on relationship problems. We include it mainly in the relapse prevention program (which occurs in up to 50% of cases).

Psychodynamic psychotherapy
Psychodynamic (psychoanalytic) psychotherapy requires a modified approach with knowledge of the specific symptoms of eating disorders, already described by Hilde Bruch (1973). It is usually indicated when short-term interventions fail and / or comorbidity of eating disorders with personality problems, in individuals with a history of psychotraumatization, sexual abuse and / or post-traumatic stress disorder.

Family therapy
For adolescents diagnosed with AN, European treatment standards primarily recommend family therapy. A new approach for adolescent patients and their families brings "multi-family programs," intensive psychotherapeutic programs designed for a group of four to six families of patients with AN. An adapted CBT program with family participation is recommended for adolescents with BN.

Psychoeducation
Intensified work with families is supported by the current trend in the care of the mentally ill, including psychoeducation and support for individuals who care for the chronically (mentally ill), because their attitudes can fundamentally influence the course of the disease. New technologies are increasingly involved in new forms of prevention and treatment: sending support SMS, internet counseling, chat psychotherapy and clubs for parents. From the Internet, families can obtain basic information about the somatic and psychological consequences of the disease, normal eating habits and weight, and inappropriate dietary and purgative methods. Psychoeducation available on the Internet brings recommended diets, scales to assess the severity of the disease and disorders of self-perception and contacts (eg www.idealni.cz).

In recent years, new concepts of therapy have been developed, such as "mentalization," (improving the ability to understand oneself and others) or cognitive remediation (focusing on specific cognitive issues of PPP).

Psychopharmacotherapy
In eating disorders, antidepressants, but also antipsychotics and appetite stimulants and others have been tested. No substance is clearly effective in completely outweighing the risk of side effects. Their risk in individuals with severe malnutrition can be significantly increased. The effect of antidepressants in the prevention of relapse of AN has been described in AN, in BN in the reduction of the frequency of overeating and vomiting (even in the absence of depression). However, antidepressants are used mainly in the current depressive, anxious and obsessive symptoms, in the failure of psychotherapy and psychosocial approaches or in those who refuse psychotherapy.

Efficacy has been demonstrated in comorbid psychiatric disorders ( Alcohol and Drug Addiction, Self-Harm, Kleptomania, Sexual Disinhibition, and  OCD). At the same time, a comprehensive (specialized) program is needed in treatment.

Treatment by virtual reality
In a virtual environment, the patient performs tasks that allow him to learn from the consequences of his behavior. So, for example, what happens to the patient's figure if he eats more or less. The patient is allowed to compare the actual body shape with the avatar created using his body perception. This is a more illustrative approach than simply explaining the effects of self-destructive behavior.

Forecast
PPP mortality in childhood is reported at 3%. The onset of the disease in prepubertal age has a worse prognosis. AN is a mental illness with the highest mortality, sometimes as high as 10-20%. Deaths are often caused by suicide, a third of deaths are attributed to heart failure. Other causes are pneumonia, liver failure, myocardial degeneration. However, mortality and serious somatic consequences cannot be underestimated for BN and PP either, even if we do not have reliable epidemiological data. Estimates of the outcome of the disease indicate that up to 50% of individuals with AN will recover, 20% will remain very thin, 25% will be very lean and 5 to 10% will die from malnutrition. 52-70% of patients achieve full or partial remission of BN, the others suffer from chronic problems and frequent relapses.

Related Articles

 * Obesity

Source

 * PAPEŽOVÁ, Hana. Poruchy příjmu potravy [online]. [cit. 2012-03-13]. .