Essay on the Types of Eating Disorders | Types | Disorders | Psychology

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Essay on the Types of Eating Disorders

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Essay Contents:

1. Essay on Obesity
2. Essay on Anorexia Nervosa
3. Essay on Failure to Thrive
4. Essay on Psychogenic Vomiting
5. Essay on Compulsive Water Drinking

1. Essay on Obesity:

By convention, obesity is said to be present when body weight exceeds by 20 percent in the standard weight used in the usual height-weight table.

Epidemiology:

Obesity is the most common nutritional disorder in affluent societies. The second National Health and Nutritional Examination survey found that 26 per­cent of American adults or about 34 million people aged between 20 to 75 years are overweight.

The factors which exert a powerful influence on the prevalence of obesity are:

(i) Socioeconomic status:

Obesity is 6 times more common among women of low status than among women of high status.

(ii) Age:

There is a three-fold increase in pre­valence between the ages of 20 and 50.

(iii) Sex:

Women show a higher prevalence of obesity than do men.

(iv) Occupation:

Some occupations predispose to obesity e.g. cooks, barmen and business­men, whilst fashion models, airline pilots and army personnel have to keep them­selves slim.

Determinants of Obesity:

The determinants of obesity can be classified as:

(i) Heredity:

Eighty percent of offspring of two obese parents are obese compared to forty percent of the offspring of one obese parent and only ten percent of the offspring of lean parents.

(ii) Developmental determinants:

Increased adipose tissue mass in obesity can result from either an increase in fat cell size hypertrophic obesity), an increase in fat cell number (hyperplastic obesity) or from an increase in both size and number (hyper­trophic hyperplastic obesity). The majority of persons whose obesity began in adult life suffer from hypertrophic obesity. Obesity beginning in childhood is more likely to be hyperplastic obesity.

(iii) Physical activity:

The marked decrease in physical activity in affluent societies is the major factor in the recent rise of obesity as a public health problem.

(iv) Brain damage:

Brain damage can lead to obesity, although it is a rare cause in humans. There are two broad anatomical systems mediating hunger and satiety; hunger with special representation in the lateral hypothalamus and satiety in the ventromedial hypothalamus.

(v) Endocrine factors:

Obesity frequently accompanies hypothyroidism, hypogona­dism, hypopituitarism, Frohlich’s syn­drome, Cushing’s syndrome and ‘Lesions in hypothalamus (e.g., due to encephalitis, meningoencephalitis, cerebral injuries, third ventricle tumors etc.).

(vi) Drugs:

The use of steroids, oral contra­ceptives, tricyclic antidepressants (Amitriptyline and not imipramine), lithium, phenothiazines, risperidone, olanzapine, insulin and alcohol.

(vii) Social determinants:

Social determinants (discussed under epidemiology).

(viii) Emotional determinants:

Of the various emotional disturbances, only three are spe­cifically related to obesity:

i. Overeating.

ii. Disparagement of Body-image.

iii. Complications of Dieting.

Clinical Features:

The most serious manifestation is caused by pressure on the thorax. This condition may progress to ‘Pickwickian syndromecharacterized by hypoventilation with consequent hypercapnia and hypoxia and finally somnolence.

Obesity may lead to a variety of orthopaedic dis­turbances and flat feet.

Mild degrees of obesity may be associated with amenorrhoea and other menstrual disturbances, ab­dominal and diaphragmatic hernias and varicose veins.

Hyperlipidaemia, gallstones, hyperuricemia, gout and non-insulin dependent diabetes mellitus are all common among the obese than in the general popu­lation. Hypertension, increased sweating leading to intertrigo, itching and skin disorders are common.

Overweight men have significantly higher mortality rates for colorectal and prostatic carcinoma. Overweight women have significantly higher rates of cancer of ovary, uterus, cervix and breast.

Diagnosis:

In most cases, the diagnosis will be apparent from the patient’s appearance but the degree of obesity should also be assessed, usually by measurement of height and weight and reference to the table where the weight of the patient can be compared with that of an ‘ideal’ subject of the same sex, height and frame.

In addition, the skin fold thickness over the triceps muscle can be measured by using special springboard calipers. Obesity is indicated by a reading above 20 mm in a man, and above 28 mm in a woman.

Management:

Obesity is a chronic condition, resistant to treatment and prone to relapse.

Weight reduction can be achieved only by reduc­ing energy intake or by increasing output, or by a combination of two. There are no ‘slimming foods’ or ‘slimming tablets’ which do not depend on a reduced energy intake.

(i) Behaviour therapy:

Treatment focuses upon altering the ABC’s of behaviour: the antecedents (events which prompt eating), the behaviour itself, and the consequences that follow eating.

Non-professional Weight Reduction Groups or lay-led groups:

Prominent among these groups are TOPS (Take off Pounds Sensibly) and Weight Watchers (WW)—the largest commercial groups. Despite high dropout rates, these groups are important resources for control of mild obesity.

(ii) Psychoanalysis:

There is no evidence that uncovering unconscious causes of eating can alter the symptoms of obese people who overeat in response to stress.

(iii) Drugs:

Drugs e.g., appetite suppressants.

(iv) Diet:

Increasing intake of complex carbo­hydrates, fruits, vegetables, cereals, and decreasing intake of fats and concentrated carbohydrates.

A weight reducing diet should contain the daily allowance of l00 g of carbohydrate, 50g of protein, 40-45g fat, 300ml of skimmed milk, vitamins and iron. A weekly loss of 0.5 to 1 kg should be the general aim.

Therapeutic Starvation:

A period of several weeks of starvation in hospital with only water, non-caloric drinks and vitamin and mineral supplements being allowed, has been recommended for very obese patients who have failed to respond to orthodox treatment.

(v) Exercise:

It is useful as a supplement to dieting unless there is medical contraindi­cation. Regular daily exercise is much more valuable than episodic activity.

(vi) Surgery:

Surgery has become the treat­ment of choice for small percentage of obese persons who suffer from morbid obesity (a body weight in excess of 100% overweight). Currently the favoured opera­tion for morbid obesity is gastric reduc­tion, designed to radically reduce the amount of food that can be ingested at any time.

2. Essay on Anorexia Nervosa:

Anorexia nervosa is a disorder characterized by a pre­occupation with body weight and food: behaviour directed towards losing weight; peculiar patterns of handling food, weight loss; intense fear of gaining weight, disturbance of body image and in women, amenorrhoea.

History:

Simone Porta (1496-1554) gave the first description of anorexia nervosa. William Gull and Lasegue con­currently and independently recognized anorexia nervosa as a disorder sui genesis. Earlier William Gull called it “apepsia hystericus ” but six years later he renamed it ‘anorexia nervosa’. Lasegue, in 1873, named it ‘anorexia hysterique’.

Epidemiology:

In India, the exact incidence and prevalence of anor­exia nervosa is not known. Studies conducted in the West have shown different prevalence rates depend­ing on the age group, sex, race, profession and popu­lation studied.

Case register studies in hospitals have reported the prevalence rates per lac population as 0.2 to 10. It is approximately 1 in 250 girls at puberty. Ninety four to 96 per cent of anorexia nervosa patients are females. Onset is usually in the early teens. (13-19 years)

Etiology:

(a) Psychological theories:

Crisp, in 1967, postulated that anorexia nervosa constitutes a phobic avoidance response being caused by false learning experiences. Slade and Russell (1973) reported that anorectic tended to overestimate their body width when asked to judge the length of a line rela­tive to a part of their body, say their hips.

(b) Personal and family characteristics:

The writings of Hilde Brucha, in her book, ‘The Golden Cage’ see the anorexia as the victim of a circumstance which has moul­ded her and entraps her.

Various studies found high levels of neuroticism, introversion, anxiety, indepen­dence and obsessionality in the premorbid personality of anorectics and an increased rate of affective disorder in relatives and indeed in recovered anorectics.

(c) Biochemical hypothesis:

Mawsonin in 1974 suggested the role of norepinephrine and dopamine in the causation of anorexia nervosa.

(d) Genetic and chromosomal aberrations:

The frequency of HLA-A₂₆, BW₁₆ and B₅₁ was higher and B₈ was lower in anorectic patients than in normal controls.

(e) Endocrinal hypothesis:

Oestrogens, Progesterones, LH and FSH tend to present in lower than usual quantities in the circula­tion of anorexia subjects with low weight. The abnormalities in ACTH, a partial diabetes insipidus, poor glucose tolerance and a sustained insulin response and a low testosterone levels in male anorexics have also been reported.

(f) Life events:

The events like death or serious illness of a close relative, medical illness of the patient herself, failure at school or work, sexual conflicts, parental divorce or separation, stressful life situations, older maternal and paternal age, a premorbid per­sonality of perfectionism, compliance with the rules of the family and society and mildly overweight.

Clinical Features:

The term “anorexia nervosa” is a misnomer as the patient with this disorder may neither show “anorexia” (i.e., decreased appetite) nor be “nervous”.

(i) Behaviour:

It is expressed as drastic dyeing and food idiosyncrasies; eating binges, especially carbohydrase, followed by self- induced vomiting, Russel’s sign i.e., Abra­sions on the back of hand are due to skin rubbing against the teeth), laxatives, enemas or even diuretics to control weight, secretive actions such as hoarding, hiding, crumbling or disposing of food; preoccu­pation with body image as shown by much mirror gazing.

(ii) Thinking process:

Gross distortion of body image; preoccupation with slimness; denial of illness; struggle to curb intense hunger initially but loss of appetite later.

(iii) Perception:

The anorexia patients have distorted body image as shown by belief that looks well even when cachectic.

(iv) Emotional:

Morbid fear; depressive symp­toms such as sleep disturbances, crying spells, sad mood etc. have been found in many patients.

(v) Physiological functioning:

Amenorrhea; constipation, dry skin, hypotension, hypo­thermia, bradycardia and dependent edema as manifestations of cachexia, high energy despite cachexia, decreased BMR, poor sexual adjustment because of decreased interest in sex, languo hair, flat glucose tol­erance curve and atrophic vaginal mucosa. Anorexia tardive. The term is used to de­scribe anorexia nervosa in older patients beginning after the age of 30.

Diagnosis:

The DSM-IV (1992) requires the following criteria for the diagnosis of anorexia nervosa:

(i) Refusal to maintain weight over a minimal normal weight for age and height.

(ii) Intense fear of gaining weight or becom­ing fat, even when underweight.

(iii) Disturbance in the way in which one’s body weight, size or shape is experienced. (Body- image disturbance)

Significant loss of weight (>25% of original heights). Final weight is 15% less than minimum limit of normal weight (for age, sex and height) or Quetelet body mass index of 17.5 or less (Quetelet Index is weight (Kg.) divided by Height (in metres).

(iv) In females, absence of at least 3 menstrual cycles when otherwise expected to occur (primary or secondary amenorrhoea).

Differential Diagnosis:

It includes:

(i) Depressive disorder

(ii) Somatization disorder

(iii) Delusion of food in schizophrenias

(iv) Bulimia

(v) Medical illnesses along with anorexia nervosa.

Management:

The immediate aim of treatment is to restore the patient’s nutritional state to normal:

(a) Behavioural therapy:

Behavioural therapy is most effective in the medical manage­ment and nutritional rehabilitation of the patient. Most behaviour therapy programmes follow an operant condition­ing, with positive reinforcement, negative reinforcement or response prevention tech­nique is applied.

(b) Drug treatment:

Antidepressants (Newer & Classical) are also frequently been used in the treatment. Lithium is contraindicated in patients who vomit or abuse laxatives. Corticotropin and L-Dopa have also been found useful.

(c) Family therapy:

Parental conflicts in one third to one half of anorectic families re­quire appropriate attention.

(d) Individual psychotherapy:

Individual psy­chotherapy should focus on making the patients aware of their behaviour and the effect it has on maintaining their illness.

(e) Electroconvulsive therapy:

ECT is preferred as a life saving measure, when a patient is grossly emaciated and often dehydrated, and adamantly refuses to eat or drink, or persistently vomits back every­thing she ingests. ECT is given to lift depression and improve the patient’s emo­tional state.  

3. Essay on Failure to Thrive:

The term is used to describe infants and children who demonstrate a failure of physical growth, malnutri­tion, and retardation of social and motor develop­ment. Infants may present with a clinical picture of marasmus, with body wasting, or they may present with edema.

This syndrome has also been labelled by various terms such as hospitalism, institutional syndrome, anaclitic depression, reactive attachment disorder of infancy (RADI) etc.

Epidemiology:

There are no specific data on prevalence, sex ratio or familial patterns.

Etiology:

(a) Contribution of the infant:

These infants are labelled as ‘difficult’ babies—for instance, those with irregular rhythmicity of biological functions, negative with­drawal responses to new stimuli, very lethargic, hypoactive child, infants with se­rious sensory or physical impairments.

(b) Deficient or defective bonding:

Deficient or defective bonding e.g., a pro­longed period of infant in an incubator fol­lowing premature birth.

(c) Contribution of the caretaker:

i. Maternal illness.

ii. Psychodynamic factors e.g., the mother’s avoidance of her baby because it reminds her of someone she hates.

(d) Lack of parenting skills:

Mothering skills may be deficient.

(e) Lack of primary caretaker:

Institutional­ization or prolonged hospitalization.

Clinical Picture:

These children usually present with absent, delayed or distorted emotional and social development and failure to thrive.

Hypokinesis, dullness, sleepiness, listlessness or apathy with a poverty of spontaneous activity—an appearance of watchfulness or ‘radar-like’ gaze, infantile postures. Weight is markedly below normal. Poor muscle tones. The skin may be colder and more pale or mottled than normal child’s.

There is lack of developmentally appropriate signs of social responsively and age-appropriate beha­viours.

Management:

Psychosocial deprivation has to be differentiated from organic conditions (like congenital anomalies, infec­tions etc.) resulting in failure to thrive.

Possible interventions include:

i. Psychosocial support services like home- makers, adequate housing, improving the financial status of the family and decreas­ing the isolation.

ii. Psychotherapeutic interventions including individual, marital or family therapies and use of psychotropic medications.

iii. Educational counselling services including mother-infant groups, counselling to increase awareness and understanding of child’s needs and to increase parental skills.

iv. Provisions for close monitoring the progres­sion of the infant’s physical and emotional well-being.

v. Options for placement with relatives, foster care, or adoption if it becomes a necessary alternative.

Intensive sensory and emotional stimulation have been shown to be the sine qua non for inducing psy­chological recovery.

Outcome:

Prognosis and outcome are highly dependent on the severity of the inadequacy in caretaking, the length of time spent in the inimical environment, and the adequacy of corrective measures if the infant remains in or returns home or the adequacy of the new envi­ronment and caretaker(s) if the infant is placed else­where.

Infants and young children who remain with or return to their original families, however, are at risk for physical, psychiatric and educational disorders.

4. Essay on Compulsive Water Drinking (CWD):

It is a relatively uncommon syndrome characterized by drinking an excessive amount of fluids, far above their daily requirements, secondary to psychological rather than documented physical pathology. It results in water intoxication, produced by an expansion of intra cellular fluid (ICF) volume and hyponatremia. The progressive signs and symptoms of water intoxi­cation include lethargy, confusion, psychosis, seizures and coma.

Etiology:

Little is known about incidence familial aspects, eti­ology and course of the disorder.

Some reports indi­cate its association with psychological disturbances:

As an example:

a. Anxiety neurosis

b. Delusional hypochondriasis

c. Munchausen syndrome

d. Personality disorder

e. Chronic schizophrenia

f. Hysterical conversion

g. Depression

h. Compulsive eating

i. Mental retardation

Its age of onset corresponds roughly to adoles­cence or menopause. About 80% of the recorded cases are females.

There is a tendency toward large fluctuations in the amount of water consumed on an hourly, daily or weekly basis.

Differential Diagnosis:

It (CWD) has to be differentiated from disorders char­acterized by polyuria and polydipsia.

(i) Diabetes Insipidus:

The important differ­ences are given in Table 26.3

(ii) Other Disorders:

Other Disorders e.g., Diabetes mellitus, elevated BUN, insensitivity to vasopressin in renal disease, characteristic electrolyte disturbances with hypoglycemia, hypercal­cemia or intake of diuretics.

(iii) Intake of Psychotropic Drugs:

Intake of Psychotropic Drugs e.g., anti­cholinergics, phenothiazines, tricyclic antidepressants, lithium (nephrogenic diabetes insipidus) etc.

(iv) Syndrome of Inappropriate Secretion of ADH:

Syndrome of Inappropriate Secretion of ADH (SIADH) characterized by hy­ponatremia and renal salt loss (hyperosomotic urine) in the absence of renal or a adrenal disease may result in polydipsia and consequent polyuria. This is associated with a wide range of malig­nancies and forms of brain damage.

Management:

(i) Correct identification and treatment of underlying psychiatric condition is the best treatment.

(ii) Hypertonic saline (intravenously) brings about rapid symptomatic improvement.

Scales Used For Assessing Eating Disorders:

1. Feeding Disorders Checklist (FDC):

It is a simple daily catalogue of items concerned with eating, related to behaviour. It has 21 items related to bingeing, vomiting and purging.

2. Eating Disorder Inventory (EDI):

Developed by Garner, Olmsted and Polivy (1953), it has 64- item multiple choice questionnaire that covers eight aspects of primarily an emotional character drive for thinness, bulimia, body dissatis­faction, ineffectiveness, perfectionism, interper­sonal distrust, lack of interoceptive awareness and maturity fears. 3 subscales assess attitudes related to eating and body shape and 5 measure traits related to anorexia nervosa.

3. Eating Attitudes Test (EAT):

It is a 40-item self-rating scale to evaluate a broad range of behaviours and attitudes typical of eating dis­orders.

4. The Morgan-Russell Assessment Schedule:

(Morgan and Hoyvard, 1988). It consists of 5 scales measuring food intake (3 subscales), men­strual state (one subscale), psychosexual state (4 subscales), mental state (1 subscale) and socio­economic state (5 subscales). Final total score is divided by 5 to calculate average score.

5. Bulimic Investigatory Test, Edinburgh (BITE):

Bulimic Investigatory Test, Edinburgh (BITE) (By Henderson and Freeman, 1987). It is a 33 items self-report measure to identify symptoms of bulimia. It has symptoms and severity subscales.