Eating disorders and impulse control disorders are pathological conditions characterized by difficulties regulating behaviors related to food, stealing, fire-setting, hair-pulling, and gambling. Anorexia nervosa involves refusal to maintain a healthy body weight due to fear of gaining weight. It often begins in adolescence and can have severe medical complications if untreated. Impulse control disorders like kleptomania and trichotillomania involve recurrent failure to resist urges to steal or pull out one's hair despite negative consequences. Selective serotonin reuptake inhibitors and cognitive behavioral therapy may help treat eating disorders and impulse control disorders.

1. EATING
DISORDERS
MR. KULTHE VIKRANT

2. Introduction
• Do you think your weight is right for you?
• Have you felt like dieting or losing weight?
• Do others around you think you are obsessed about
what you eat and how much you eat?
• If you think you have eaten too much do you have an
urge to vomit or exercise a lot?
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3. • Though these questions are simple, a
lot of us are in some degree or not,
worried about them and they must
have crossed our minds at some stage
in our life.
• Leading a healthy life and preventing
future health problems is partly
responsible for us considering these
aspects of ourselves.
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4. • A lot of us also try various methods (dieting,
exercising) at some stage, to try and achieve some of
our goals to become healthier.
• But in some individuals this reaches a pathological
level and they develop what we call as eating
disorders.
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5. Anorexia nervosa
Diagnostic criteria
• Refusal to gain or maintain body weight leading to
the persons weight being less than 85% of expected
body weight.
• Thus if the expected body weight is 60 kg for that
individual. The person will weigh less than 85% of
that i.e., less than 51 kg.
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6. Anorexia nervosa
Diagnostic criteria
• 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.
• Denial of the seriousness of the current
low body weight.
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7. Anorexia nervosa
Diagnostic criteria
• Undue influence of body weight or shape on self-
evaluation. That is inability to maintain weight or
lose gained weight leading to negative evaluation of
self.
• Leads to no menstrual periods in females.
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8. Anorexia nervosa
Diagnostic criteria
• Specific types:
– Restricting type - main method to control weight
is restricting food intake and/or exercise.
– Binge –eating type – The person engages in self
induced vomiting, or using laxatives, diuretics,
enemas, etc. to reduce weight.
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9. Epidemiology
• More in developed countries and in females
• Affects 1 in 100 in females
• The mean age at onset is approximately 17 years
• Often an associated life event, such as moving away
from home, precedes the first episode of anorexia
nervosa
• Incidence and prevalence have increased greatly over
the last few decades
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10. Aetiologies
• Many theories
• None of them causative on their own
• Many factors contribute to development
of the disorder
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11. Some of the causes
• Overemphasis on a slim female figure
• Media depiction of this slim figure as being
ideal and beautiful
• Disturbances in neurotransmitter levels in
brain
• More risk when there is family history of
eating disorder or mood disorder
• Associated with poor self image, self esteem
and depression
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12. Clinical picture
• BMI less than 18.5
• BMI is Body mass index
• It is calculated as
• BMI= Weight in Kg
(Height in metres) * (Height in metres)
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13. B.M.I Categories
• Underweight = <18.5
• Normal weight = 18.5–24.9
• Overweight = 25–29.9
• Obesity = BMI of 30 or greater
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14. • Weight loss is frequently accomplished by
reduction in total food intake
• exclusion of highly caloric foods
• extremely restricted diet
• Patients may lose weight by purging (via
either self-induced vomiting or misuse of
laxatives and diuretics) or by exercising
excessively
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15. • patient's fear of becoming fat increases, in spite
of losing weight
• Disturbed self image and body image
• Self-esteem in patients with anorexia nervosa is
overly dependent on body shape and weight
• Losing weight is judged to be an admirable
achievement of unusual self-discipline, whereas
weight gain is regarded as an unacceptable
failure
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16. • May also have fears of eating in public
• Signs of starvation account for most of the
physical findings in anorexia nervosa
• Patients who frequently engage in purging
behaviours, many do not binge-eat.
Instead they regularly vomit after
consuming small meals.
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17. Complications
• Common, especially if the disease has been present for 5
years or more
• Anaemia – severe in some cases
• Impaired renal and liver function, can progress to failure
• Electrolyte imbalance
• Cardiovascular complications – arrhythmias and hypotension
• Osteoporosis, fractures, falls
• Depression
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18. Differential diagnosis
• General medical conditions causing weight loss
• Depression
• The problem is both the above, can also be
secondary to the anorexia and may be a part of the
complications.
• The main differentiating factor is fear and reluctance
to gain weight is present in anorexia nervosa.
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19. Investigations
• Leukopenia, anaemia
• Reduced hormonal levels especially
low T3 and T4
• Reduced potassium levels
• Increased Urea levels
• Increased LFTs and Cholesterol
• Sinus bradycardia on ECG
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20. Treatment
• Patients do not seek help on their own
• Rarely complain about weight loss but may need to
present with complications of starvation, such as:
– cold intolerance
– muscle weakness
– loss of stamina
– constipation
– abdominal pain
– depression
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21. • Patients deny the core problem, and the history
obtained from such patients is unreliable, better to
get information from family about weight loss
• Patients may require acute intensive medical
intervention to correct fluid and electrolyte
imbalances, cardiac problems, and organ failure
• Weight restoration should be a central goal for the
seriously underweight patient
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22. • Most of these patients will require in-patient
management
• Patients are encouraged to consume increased
numbers of calories (to be increased in a phased
manner) in order to earn specific privileges
• Patients must be engaged in individual and family
therapy
• Treatment of depression and other complications as
needed
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23. Prognosis & Course of Illness
• 45% of patients have an overall good outcome,
• 30% have an intermediate outcome (i.e. still having
considerable difficulty with the symptoms of the
illness)
• 25% have poor outcome and rarely achieve a normal
weight.
• 5% -10% of patients with anorexia nervosa die as a
result of complications
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24. • Most commonly death results from the
consequences of starvation, suicide, or
electrolyte imbalance
• It is very important to be aware of this
syndrome and diagnose and treat it in early
stage to prevent the morbidity and mortality
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25. Impulse control disorders
• Types:
– Intermittent explosive disorder
– Kleptomania
– Pyromania
– Trichotillomania
– Pathological gambling
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26. Intermittent Explosive Disorder
• Several discrete episodes of failure to resist
aggressive impulses that result in serious assaultive
acts or destruction of property
• The degree of aggressiveness expressed during the
episodes is grossly out of proportion to any
precipitating psychosocial stressors.
• Absence of any other underlying disorder i.e.,
medical or psychiatric.
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27. Intermittent Explosive Disorder
• Aetiological theories:
– Limbic discharges
– Inter – ictal phenomena
– Childhood abuse
– Association with Narcissistic
personality
– High rates of mood and substance
use disorders in family
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28. Intermittent Explosive Disorder
• Signs & Symptoms
– Aggressive outbursts occur in discrete episodes
and are grossly out of proportion to any
precipitating event.
– lack of rational motivation or clear-cut gain
– patient expresses embarrassment, guilt, and
remorse after the act
– Some patients have described periods of
exhaustion and sleepiness immediately after these
acts of violence
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29. Intermittent Explosive Disorder
• Psychological Test
– minor cognitive difficulties
– developmental difficulties such as
delayed speech or poor coordination.
– history of febrile seizures in
childhood, episodes of
unconsciousness, or head injury may
be reported.
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30. Intermittent Explosive Disorder
• Differential Diagnosis
– The clinician must decide whether the
aggressive or erratic behaviour would
be better explained as a result of a
specific personality disorder or
conduct disorder.
– Purposeful behaviour with subsequent
attempts to malinger must be
distinguished from intermittent
explosive disorder.
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31. Intermittent Explosive Disorder
• Treatment
– Current scientific data are insufficient and
inconclusive regarding treatment of the
disorder
– Clinicians must proceed with individualized
treatment plans based on their best clinical
judgment
– Antipsychotics, anxiolytics, mood stabilizers
and antidepressants have all been used on
their own or in combination
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32. Intermittent Explosive Disorder
• Complications
– Intermittent explosive disorder can be complicated by legal
difficulties, job loss, difficulties with interpersonal
relationships, and divorce.
• Prognosis & Course of Illness
– Intermittent explosive disorder is thought to have its onset
in adolescence or young adulthood and to run its course by
the end of the third decade of life.
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33. Kleptomania
– Recurrent failure to resist impulses to steal objects that are
not needed for personal use or for their monetary value.
– Increasing sense of tension immediately before committing
the theft.
– Pleasure, gratification, or relief at the time of committing
the theft.
– The stealing is not committed to express anger or
vengeance and is not accounted for by any other medical
or psychiatric condition especially anti-social personality
disorder.
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34. Kleptomania
• The theft usually occurs in retail stores or work locations or
from family members.
• Some patients report feeling high or euphoric while stealing.
• Most feel guilty after the act and may donate stolen items to
charity, return items to the location from which they were
stolen, or pay for the stolen items
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35. Kleptomania
• The aetiology of kleptomania is unknown. It may
represent a symptom rather than a disorder
• More common in women than in men
• Because most shoplifters steal for profit, fewer than
5% of shoplifters meet criteria for kleptomania
• Family studies have demonstrated high rates of
mood, substance use, and anxiety disorders in first-
degree relatives
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36. Kleptomania
• Treatment:
• Psychotherapy and pharmacotherapy have been
useful in single reports.
• Selective serotonin reuptake inhibitors (SSRIs) and
lithium are the agents used most frequently to treat
kleptomania.
• Kleptomania is thought to begin in adolescence and
can continue into the third or fourth decades of life
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37. Pyromania
– Deliberate and purposeful fire setting on more than one
occasion.
– Tension or affective arousal before the act.
– Fascination with, interest in, curiosity about, or attraction to
fire and its situational contexts (e.g. paraphernalia, uses,
consequences).
– Pleasure, gratification, or relief when setting fires, or when
witnessing or participating in their aftermath.
– Not for any gain and not accounted for by any other
medical or psychiatric disorder
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38. Pyromania
• Little is known about this disorder and needs to be
differentiated from other causes for setting fire
• Complications mainly legal, harm to self or others due
to this behaviour
• Treatments used are again more individualistic and
results vary
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39. Trichotillomania
– Recurrent pulling out of one's hair resulting in noticeable
hair loss.
– An increasing sense of tension immediately before pulling
out the hair or when attempting to resist the behavior.
– Pleasure, gratification, or relief when puling out the hair.
– Not accounted for by another mental disorder or medical
condition (eg, skin disorder)
– The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
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40. Trichotillomania
– Prevalence rates 0.6%
– More common in females
– Genetic predisposition
– Patients frequently deny that they pull their hair
intentionally
– Many patients do not feel pain when the hair is pulled;
some patients report that it feels good.
– Some may indulge in swallowing the hair to hide the
behaviour causing complications (trichobezar leading to
intestinal obstruction)
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41. Trichotillomania
• SSRI are helpful
• CBT and family therapy may be useful
• Patients with a later age at onset tend to have
more severe symptoms that run a chronic course
• Treat co morbid depression and anxiety disorders
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42. Any Questions?
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