Eating Disorders, An Overview:  Signs (mental and physical) how to address them

“To lose confidence in one’s body is to lose confidence in oneself.”
― Simone de Beauvoir

A common misconception about eating disorders is that they are a lifestyle choice. Nothing could be farther from the truth. Eating disorders can be deadly and are seen as a common morbidity in adolescent and young adult females. Too often, diagnosis in men goes overlooked and treatment may be neglected.  

Emotions, health, and the ability to function in life are all negatively impacted by eating disorders. Unhealthy eating habits tend to develop, which are caused by a range of psychological conditions that stem from obsessions with food, body weight and or body image disturbances. It is estimated that 20 million women and 10 million men in the United States Of America will have or have had an eating disorder at some point in their life. Sexual abuse plays a large role in eating disorders with 30% of patients having had a positive history. 

Anorexia: Fear Of Losing Self Control

Anorexia has a slightly higher morbidity than any eating disorder. Onset of anorexia in teenage girls is seen at age 15, 80-90% of patients with anorexia are female. Roughly 25 % of men are diagnosed with anorexia nervosa. 

The cause of anorexia can be many. Some patients may have a genetic predisposition to the disease process. While in others, it can be seen as a coping mechanism, precipitated as a coping mechanism against developmental challenges, transitions, family conflicts, and academic pressures. Sexual abuse may precipitate anorexia as well. 

A person with an eating disorder may believe “If you can control what you eat, you can control your life.” It’s a struggle between physical body image and mental health distortions. Persons who fall victim to anorexia may be in life situations where they feel they have no control, are trapped and under pressure to succeed. They become fixated and gain control over the amount of food that they take into their bodies which buys them control over their bodies. 

Common Signs of Anorexia:

-Over exercise and over activity

-Depressed mood

-Obsessive compulsive disorder related to food

-Family history of anorexia nervosa or affective disorder

-Emaciation

-Hypotension

-Heart arrhythmia

-Constipation

-If anorexia occurs before puberty, puberty can be delayed

-Loss of sexual interest in men

-Amenorrhea

-Cold intolerance

-Dry skin

-Dental enamel erosions

Common Issues To Consider For Men With Anorexia 

Men who are diagnosed with anorexia, may have been mildly to moderately obese at one point in their lives. Sexual abuse may have gone un-reported due to shame and stigmatization. Sexual orientation is another factor to consider since most men who have body image issues are straight. Although, symptoms of eating disorders are said to increase by 10% in gay men.

Laboratory Findings In Both Men And Women

May include leukopenia and mild anemia, elevated BUN, hypercholesterolemia, elevated LFTs, metabolic acidosis, decreased thyroid levels, low estrogen in females, low testosterone in males, EKG sinus bradycardia, dysrhythmia, hypotension, and syncope. 

Treatment

Often focusses on strict behavioral goals which include reducing control overeating, weight, and shape. A main focus of treatment is on healthy eating behaviors. Comprehensive in-patient treatment with NG (Naso Gastric Feedings) or IV (Intravenous) feedings, may be needed as well as psychotherapy and nutritional counseling. Treatment with SSRI’s (Selective serotonin reuptake inhibitors) after weight gain. Family therapy and cognitive behavioral therapy are also suggested treatment regimens. 

Bulimia Nervosa: The Urge To Eat 

Bulimia Nervosa typically shows signs in adolescence or early adulthood. It is described as objectively eating large amounts of food (binging) with a loss of self-control and compensatory behavior which involve self-induced vomiting (purging). “I can’t stop,” describes one patients account of the binge and purge cycle. 

The causal factors underpinning eating disorders have been clarified by understanding about the central control of appetite. Cultural, social, and interpersonal elements can trigger onset, and changes in neural networks can sustain the illness. Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery.

Binging and vomiting occur in 80-90% of people with bulimia. Binge-eating and purging behaviors can lead to a range of medical complications, such as electrolyte imbalance, which can lead to arrhythmia or death, esophageal tears, gastric disruption, problems with fertility, and dental decay. People suffering from BN typically have a normal weight or are slightly overweight. They are extremely critical of themselves and have a depressed mood. Adolescents suffering from BN often have a high risk for suicidal behavior. 

Physical Findings

-Diarrhea (laxatives)

-Erosion of enamel noted at the back of their teeth

-Dental carries

-Esophagus tears 

-Menstrual irregularities or amenorrhea 

-Mood disturbances

-Family history of obesity

Labs

May show fluid and electrolyte imbalances which include hypokalemia, hypochloremia, and metabolic acidosis. 

Treatment

Includes comprehensive medical care and monitoring, psychotherapy and nutritional counseling. The focus is on establishing a pattern of regular eating without purging. Healthy exercise SSRI’s for depression, individual, family therapy and cognitive behavioral therapy. 

Men may go under diagnosed since they may feel that they do not have a problem and they feel fine. They also may have a misconception that eating disorders contribute to other health issues. This denial behavior is common in men with bulimia. 

Binge Eating Disorder, Most Common In Americans

Binge eating disorder is the most common disorder affecting 3% of American adults. Typically, people experience a lack of control and consume large amounts of food than the average person would. It emerges in adolescence and early adulthood and can continue on in midlife. In the beginning, a person can eat a little more or little less food than usual. The urge to eat more becomes compelling until it consumes the persons whole life. 

Warning Signs Of Binge Eaters

-Eats at discreet times

-Uncomfortable eating around others

-Fear of eating in public

-Frequently diets

-Withdraws from friends

-Shows extreme concern with body weight and shape 

-Eating large amounts of food when not feeling physically hungry

-Eating much more rapidly than normal

-Feeling disgusted with oneself

-Stomach cramps (constipation, acid reflux)

-Noticeable fluctuations in weight

-Difficulties concentrating

Health Consequences Related To Binge Eating

Obesity, weight stigma and weight stigma are all serious concerns that can arise from BED. These can lead to more serious health concerns and comorbidities such as diabetes, heart disease, and several others. Although, most people will present at a normal weight. 

Pica, The Eating Of Non-Nutritive Foods

Pica is described as eating non-nutritive non-food substances of the period of one month. The term ‘pica’ comes from the Latin word meaning magpie bird, because of the birds tendency to gather various objects for consumption out of sheer curiosity. Most commonly seen in children, pica can also be a disorder seen in mentally impaired adults. In women it is seen during pregnancy.

People suffering from pica have a tendency to eat earth, raw starches, ice, charcoal, ash, paper, chalk, cloth, baby powder, coffee grounds, and eggshells. It can be an isolated disorder but at times can also manifest with schizophrenia, trichotillomania, and OCD. 

Risk Factors Related To Pica

-Stress

-Cultural issues

-Nutritional deficiencies

-Pregnancy

-Epilepsy

-Family Psychopathology

-Child neglect

-Underlying mental health disorder

-Learned behavior

Assessment Of Pica

Exams can be normal but healthcare professionals need to be on the alert for signs of poisoning. Certain objects that are ingested can cause toxicity as well as complications that can lead to obstruction and bezoar formation, along with ulceration and perforation. Lead poisoning can also occur which can further cause seizures, headaches, lethargy, and cranial nerve palsy.

Labs And GI Studies

Iron studies, lead levels, and zinc studies should be considered in all people suspected of having Pica. Metabolic studies are especially important when a person has been ingesting clay since it can cause metabolic disturbances and hypokalemia. Plain abdominal x-rays, barium studies, and endoscopy. In many cases, serial studies are needed to ensure that the substance has passed.

Pica is not a life-threatening disease and is categorized as being benign. In pregnant women and in children, the disease can spontaneously resolve. It some people suffering from pica, it can persist for years. If a person is having symptoms of pica, close attention should be placed, as to avoid further complications due to possible bowel obstruction and ulcers that can happen.

Rumination Disorder

Rumination disorder is the repeated regurgitation of food after chewing and swallowing without the use of medication ingestion. Spitting out of the regurgitated material can also be placed in this category. Due to being under reported RD is difficult to diagnose and treat. RD does not occur in conjunction to Anorexia, bulimia, binge eating or avoidant restrictive disorders. 

A physical cause for RD must be ruled out. Treatment includes diaphragmatic breathing exercises and habit reversal. The person experiencing RD is taught the signs and situations along with how to reverse them. Deep breathing techniques replace the rumination habit. 

Avoidant And Restrictive Food Disorder

Avoidant and restrictive food disorder was first introduced in 2013. It’s a complex eating disorder that stems from genetic, psychological and social ramifications that affects mostly children and adolescents. It is further categorized as a persistent failure to meet appropriate nutritional and energy needs. Typical patients with ARFD present as having significant weight loss or nutritional deficiency, dependence on enteral feeding or nutritional supplements, and or a marked interference in psychosocial functioning.

Major Signs Presenting In ARFD

-Fear of negative consequences of eating

-Low appetite of disinterest in food

-Avoidant of food based sensory characteristics

-Falling off growth curve in the pediatric population

Treatment

The focus of treatment is on weight gain and family-based therapy. Family-based therapy focuses on lifting blame, raising the family’s anxiety about the dangers of low weight and malnutrition in young people, and empowering parents to take charge of nutrition and to focus on the goal of weight gain. Cognitive behavioral therapy may lift anxiety as well. 

Almost anyone can suffer form an eating disorder. Eating disorders occur more frequently in affluent countries. Although, it does not mean that people suffering from this disease process are all well off financially. Pressures from mainstream media and social media contribute to current day body image issues in both males and females. 

Special attention needs to be placed by healthcare professionals on the psychosocial aspects of eating disorders. Specifically, on repeated behaviors that cause cyclic incidences. Clinicians should put focus on empowering their patients who are suffering from eating disorders which will increase their self-esteem. Accepting yourself for who you truly are is true recovery. 

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853853/

https://pubmed.ncbi.nlm.nih.gov/12573387/

https://www.psychologytoday.com/us/blog/hunger-artist/201508/taking-losing-and-letting-go-control-in-anorexia

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757497/

http://www.scienceofeds.org/2012/11/23/self-denial-secrecy-and-deliberate-lying-in-eating-disorders/

https://americanaddictioncenters.org/male-eating-disorders/bulimia

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637727/

https://www.nationaleatingdisorders.org/learn/by-eating-disorder/bed

https://www.ncbi.nlm.nih.gov/books/NBK532242/

https://www.ncbi.nlm.nih.gov/books/NBK532242/

https://pubmed.ncbi.nlm.nih.gov/30789419/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492032/

https://www.nationaleatingdisorders.org/learn/by-eating-disorder/other/rumination-disorder

https://www.psychiatrictimes.com/view/understanding-and-treating-avoidant-restrictive-food-intake-disorder-children-and-adolescents

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