1. FEEDING AND EATING DISORDER
BY: FARAHANA NASIR MAHFUZAH MAT JUNOS
10th NOVEMBER 2015

2. TIMELINE Introduction DSM-4 vs DSM-5 Pica and rumination
Avoidant/restrictive food intake disorder
Anorexia Nervosa
Bulimia Nervosa
Binge-eating disorder

3. INTRODUCTION
Feeding disorder commonly in infancy or early childhood, a child's refusal to eat certain food groups, textures, solids or liquids for a period of at least one month, which causes them to not gain enough weight or grow naturally.
Eating disorder is a group of condition by abnormal eating habit to detriment of an individual’s physical and mental health
Insufficient food intake
Excessive food intake

4. DSM-4 vs DSM-5 Anorexia nervosa Bulimia nervosa
Eating disorder not otherwise specific
PICA
Rumination
Avoidance & Restrictive food intake disorder
Binge-eating disorder
Among the most substantial changes are recognition of binge eating disorder, revisions to the diagnostic criteria for anorexia nervosa and bulimia nervosa, and inclusion of pica, rumination and avoidant/restrictive food intake disorder. DSM-IV listed the latter three among Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, a chapter that will not exist in DSM-5.
In recent years, clinicians and researchers have realized that a significant number of individuals with eating disorders did not fit into the DSM-IV categories of anorexia nervosa and bulimia nervosa. By default, many received a diagnosis of “eating disorder not otherwise specified.” Studies have suggested that a significant portion of individuals in that “not otherwise specified” category may actually have binge eating disorder

5. Pica (DSM-5)
Persistent eating of non-nutritive substances for a period of at least one month.
The eating of non-nutritive substances is inappropriate to the developmental level of the individual.
The eating behaviour is not part of a culturally supported or socially normative practice.
If occurring in the presence of another mental disorder (e.g. autistic spectrum disorder), or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention.
Note:
Pica often occurs with other mental health disorders associated with impaired functioning
* Eg non-nutritive substance, paper, clay, metal, chalk, soil, glass, sand * can lead to 1) toxixity 2) anemia / malnutrition 3) surgical emergency

6. RUMINATION DISORDER (DSM-5)
Repeated regurgitation of food for a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition).
The behaviour does not occur exclusively in the course of Anorexia Nervosa, Bulimia Nervosa, BED, or Avoidant/Restrictive Food Intake disorder.
If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.
Rumination vs binge-eating disorder vs purging - rumination, repeated regurgitation - binge-eating, excessive food intake - purging, induce vomite, laxative, want to take the food out again

7. AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (DSM-5)
1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional supplements.
Marked interference with psychosocial functioning.
2. The disturbance is not better explained by lack of available food or by an associated culturally practice.
3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced [body image].
4. The eating disturbance is not due to current medical condition or not better explained by another mental disorder. When it’s occur in the context of another condition or disorder, it warrants additional clinical attention.

8. ANOREXIA NERVOSA
distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat
2 subdivision - Restrictive type: Eat little and exercise vigorously. More often with obsessive-compulsive traits. - Binge eating/purging type: Eat in binges followed by induced vomiting, laxatives, excessive exercise or diuretics. More with major depression and substance abuse.
Female > male
Common in thin figure profesional (ballet, cheerleader, figure skating, modelling, etc)

9. DSM-V DIAGNOSTIC CRITERIA
Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or becoming fat, even though underweight. 
Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self- evaluation, or denial of the seriousness of the current low body weight.
The criteria cant be use in male or female using OCP

10. PHYSICAL FINDING AND COMPLICATION
Amenorrea
Lanugo (fine body hair)
Melanosis coli (laxative abuse)
Leukopenia
Osteoporosis
Hypochloremic hyperkalemic alkalosis
Hypercholesterolemia
Arrhythmias
Cardiac arrest

11. Variable (complete, fluctuate, deteriorate) Mortality 10% due to:
DDX
Major depression
Bulimia
Somatization
Schizophrenia
COURSE AND PROGNOSIS
Variable (complete, fluctuate, deteriorate)
Mortality 10% due to:
Starvation
Suicide
Electrolye disturbance
Cardiac failure

12. TREATMENT
- Food - hospitalization - behavioral, family (Maudsley approach), supervise wt-gained program
- SSRI (paroxetine: help the comorbid depression) - low dose 2nd gen. antipsychotic - benzodiazepam
*refeeding syndrome
Food. The caloric intake, 1st to stabilize wt, then wt gain
Hospitalization : if the wt more than 20% below ideal body wt or if there’s serious medical/psychiatric complication.
Maudsley approach :
SSRI show unaffective due to inadequate dietary intake for trypton (serotonin precursor)
Refeeding syndrome: cardiovascular collapse, starvation-induced hypophosphatemia, and dangerous fluctuations in potassium, sodium, and magnesium levels

13. PREPARED BY : MAHFUZAH BINTI MD JUNOS

14. BULIMIA NERVOSA
An eating disorder which is characterized by recurrent binge eating, followed by compensatory behaviors such as - vomiting - use of laxatives,enemas,diuretics - excessive exercise
Patients are embarrassed of their binge eating and overly concern with body weight however they usually maintain a normal weight or even overweight
There are two subcategories of bulimia : - PURGING TYPE : involve vomiting,enemas ,diuretics - NON PURGING TYPE : involve excessive exercise or fasting

15. DIAGNOSIS ( DSM – 5 ) Recurrent episodes of binge eating.
Recurrent inappropriate attempts to compensate for overeating and prevent weight gain
These behaviors occur at least once a week for 3 months.
Perception of self-worth is excessively influenced by body weight and shape.

16. PHYSICAL FINDINGS AND COMPLICATIONS :
Dental enamel erosion
Salivary glands hypertrophy (sialadenosis )
Calloused
Aspiration
Electrolyte imbalance (hypochloremic hypokalemic alkalosis)
Laxative dependence ( metabolic acidosis )

18. COMORBID PSYCHIATRY DISORDER
Mood disorders
Anxiety disorder
Personality disorders
Substance abuse

19. EPIDEMIOLOGY Lifetime prevalence : 1-4% > common in female
Onset in late adolescence or early adulthood
More common in developed countries
High incidence associated with other psychiatric disorder

20. COURSE AND PROGNOSIS Chronic and relapsing illness
Better prognosis than anorexia nervosa
Symptoms exacerbated by stressful conditions
Half patients recover fully with treatment
Half patients have chronic course with fluctuating symptoms

21. TREATMENT :
1. PHARMACOTHERAPY : - SSRIs are first line treatment ( Fluoxetine ) - TCAs THERAPY - Cognitive behavior therapy - Interpersonal psychotherapy - Group therapy - Family therapy

23. BINGE- EATING DISORDER
An eating disorder characterized by periods of extreme over-eating, but here they DO NOT try to control their weight by purging or restricting calories as do anorexics or bulimics,so they usually are obese
Patients with this disorder suffer emotional distress over their binge eating.
BINGE-EATING : defined as excessive food intake within a 2-hour period accompanied by a sense of lack of control

24. DIAGNOSIS ( DSM – 5 ) Recurrent episodes of binge eating
Severe distress over binge eating
Binge eating occur at least once weekly for the last 3months and is not associated with compensatory behavior
Three of followings are present : Eating very rapidly - Eating until uncomfortably full - Eating large amount when not hungry - Eating alone due to embarrassment over eating habit - Feeling disgusted , depressed, guilty after overeating

25. WHAT TRIGGER BINGE EATING :
Dysphoric mood
Interpersonal stressors
Intense hunger after dietary restrain

26. TREATMENT :
Individual psychotherapy and behavioral therapy with strict diet and exercise program.
Comorbid mood disorders or anxiety disorders should be treated.
Pharmacotherapy: used adjunctively to promote weight loss. Include:
-Stimulants: phentramine and amphetamine. (suppress appetite)
-Orlistat : Xenical ( inhibit pancreatic lipase – decrease amount of fat absorbed )
-Sibutramine : Meridia ( inhibit reuptake of norepinephrine ,serotonin and dopamine