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Eating Disorders | Dr. William Winter is a child and adolescent psychiatrist.
Will Winter, MD, FAAP
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Eating is a behavior. When someone chooses to overeat or under eat, problems specific to each can follow. Also, when someone manipulates the digestive process by inducing emesis (vomiting) or induces defecation, this will lead to specific and predictable problems.

Binging

Vignette 1
A 16 year-old female is under pressure at school. She has SATs this year and has a number of other big exams that, in total, will have a huge impact on where she will be accepted to college next year. She has a history of "obsessing" over schoolwork. She is an "overachiever", participating in many different extra- curricular activities, i.e. seasonal sports teams, clubs and the school play. On top of this, she has social pressures as she is in the popular social circle at school and it takes a lot of effort to maintain that status.

She is about 5'3" and has gained about 30 pounds over the past year. She is overweight in appearance. When asked, she reports that she tends to eat when she is nervous, particularly at night when she is by herself and thinking about all of her responsibilities and worries about the future. The amount of food she eats at these times is more than she eats all day.

Discussion
The description above describes binge eating. When she is alone and stressed out, she is self-medicating with food. The pleasure of tasting certain foods and, more importantly, the feeling of satiety by having her stomach filled (stretched) can distract her from the unpleasant feeling of stress that she had prior to eating. By overeating, she effectively, albeit temporarily, treats her anxiety chemically in her brain.


Bulimia Nervosa

Vignette 2
We will refer back to the same 16 year-old from the first vignette as a starting point. But instead of simply over eating, in this example, immediately after over eating, she goes to the bathroom and purges (she makes herself vomit). She does this every night.

On appearance, her weight is unremarkable. Along with the eating and purging behavior, she feels very badly. She has low self-esteem. She is disappointed in herself- both for binging and for purging. In both instances, she feels a sudden loss of control.

Discussion
Diagnostically, this describes Bulimia Nervosa. The disorder is often associated with mood symptoms, i.e. depression as well as anxiety. There can also be concerning medical sequelae.


Anorexia Nervosa

Vignette 3
In this case, instead of overeating at night, this adolescent is handling the stress by doing the opposite- restricting her food intake. She reports that she only feels in control when she is restricting. As a result, she is 30 pounds underweight. She almost fainted in school. That was why her mother brought her in for an evaluation.

Appearance
She generally wears layers of clothing even when it is warm outside. Today she is not and we see that her arms and legs are noticeably very thin. It seems like her knees and elbows are too big and are sticking out. Her upper ribs are noticeable near the clavicles. Her neck is thin and her head looks disproportionately large for her thin body.

She thinks that she is fat. She can't stop thinking about food- and this bothers her to no end because she is afraid to gain weight.

Also, while taking a history, she reports that her period has stopped.

Discussion
This presentation best fits a diagnosis of Anorexia Nervosa.

- She is substantially underweight, (if measured in this vignette, she would be less than 85% of her ideal body weight to meet criteria).
- Fear of weight gain
- She has a body image issue (believes she is fat)
- Amenorrhea

As opposed to the example of binging above, the person in this vignette is apparently handling her anxiety by taking control of something that she has full control over- her choice to eat. Unfortunately, the imbalance is not resolved. Instead of it being imbalance in the direction of food intake, it is imbalance in the direction of food restriction. There are serious health risks to both.

Anorexia carries with it an alarmingly high mortality rate: between 5% to 20% (from cardiac arrest or suicide). Cardiac arrest can result from electrolyte abnormalities from malnutrition.

If the age of onset of Anorexia is prior to puberty, the child's growth can be permanently arrested.

Treatment for Eating Disorders:
Treatment for Anorexia Nervosa, Bulimia Nervosa or Binge eating requires a team approach.

- Talk therapy, i.e. individual, group, and family therapy are recommended. Depending upon the severity of the problem this may be an intensive process. CBT can be useful.
- Psychiatric medication may be useful if clinically indicated.
- Medical follow-up by Pediatrician/ Internist/ appropriate specialist
- A nutritionist is an essential part of the team.

Possible Medical Complications caused by eating disorders

Obesity
Hyperlipidemia
Diabetes mellitus
Sleep apnea
Hypertension
Cardiac and respiratory disorders

Purging
Cardiac arrhythmia (due to electrolyte abnormalities)
Cardiac myopathies (weakening of the cardiac muscle)
Dehydration
Dental caries (cavities from repeated exposure to stomach acid)
Reflux - can result in esophageal cancer or need to surgically remove lower esophagus
Parotid gland enlargement (results in a widened face)
Secondary Renal failure (kidney failure)

Weight loss
Amenorrhea (loss of period)
Bradycardia (slow heart rate)
Cold intolerance
Constipation
Hypoglycemia
Low albumin (important protein in blood)
Orthostatic hypotension (from dehydration with lack of food intake)
Osteoporosis and osteopenia with associated stress fractures
Structural and functional brain changes
Thyroid dysfunction