EATING/ELIMINATION DISORDERS

Anorexia nervosa (AN) and bulimia nervosa (BN) are similar disorders that are often challenging to the clinician.When the two conditions are present in the same individual it is called bulimorexia.It is often difficult to understand the motivation for self-induced starvation or vomiting.The caregiver, as well as the parents, may feel frustrated because there appears to be simple and logical solution to the problem but it is rarely easy to manage.One of major differences between AN and BN is that individuals with BN tend to be outgoing and they are aware that the behavior is abnormal so that they are self-conscious about it.There appears to be increased depression and addiction in both conditions.

Anorexia Nervosa

Anorexia nervosa (AN) is often characterized as an intense fear of becoming obese that does not diminish even when weight is lost.Body image is distorted so that the patient may complain of being overweight despite obvious emaciation.It is important to exclude medical conditions such as diabetes or thyrotoxicosis associated with weight loss.The DSM-III required a weight loss of 25 percent of original body weight or for a growing child, weight that less than 25 percent of expected.The DSM-III-R modified the weight loss to 15 percent to allow for earlier diagnosis.Absence of 3 menstrual cycles in children expected to be menstruating was also added.

The current (DSM) diagnostic criteria are shown in Table 5-1.There are now two types of AN called binge-eating/purging –who lose weight as a result of laxatives, diuretics or self-induced vomiting, and restricting.The restricting subtype is associated with weight loss resulting from severe calorie restriction and/or exercise.The prevalence appears to be about 0.5-1 percent of adolescents between 12 and 18 ears of age.Only 5-10 percent of those diagnosed are male.The disorder is considered to be multifactorial with psychological being only a part.There are contribution from cultural issues that are more common in Western societies that embrace the slim and trim body.There are develpomental and family factors so that picky eaters and young children with digestive disorders are more likely to have symptoms of AN.There is also an association with major depression.

                The approach to management of AN involves refeeding and psychotherapy.Initial treatment involves weight gain and, in the early phases, psychotherapy is postponed until weight gain is established.Before managed care, patients were often admitted to psychiatric hospital but now they are admitted to medical or pediatric wards.The psychotheraphy phase is then conducted as an outpatent.The insurance companies are apt to deny admission for the initial weight gain maintaining that it can be achieved as an outpatient.A team approach to management in a supervised enviroment is more likely to be successful than out-patient care.

                Electrolyte abnormalities are common in severe cases.Refeeding may be difficult and small gains should be sought with goals for weight gain that are realistic.It is reasonable to start with 250 cal above the previous intake and gradual increase as tolerated.A low but significant (0-5 percent) mortality has been reported.