Chapter 27
Eating Disorders
232
, Chapter 27: Eating Disorders
Important conditions
1. Anorexia nervosa.
2. Bulimia nervosa.
3. Obesity.
4. Other notable conditions
A. Pica.
B. Binge eating disorder.
C. Kleine Levin syndrome.
D. Kluver Bucy syndrome.
1. Anorexia nervosa
A 14 year old girl presents with a two year history of progressive weight loss. She has had amenorrhoea
for the past six months. She eats small quantities of fruit and vegetables, refusing to eat a range of foods which include
biscuits, bread and chips because they are “fattening”. She runs 10km in the mornings and spends two hours in the
evenings doing sit-ups. Her parents are concerned that she is very underweight despite the fact that she says that her
hips, abdomen and thighs are “huge”. Her goal is to have the figure of a catwalk model.
ICD-10 criteria
Body weight at least 15% below expected, or body mass index (BMI) 17.5 or less. Pre-pubertal patients may
show failure to make the expected weight gain during the period of growth.
The weight loss is self-induced by avoidance of “fattening foods”, and one or more of the following may
also be present: self-induced vomiting, self-induced purging, excessive exercise, use of appetite suppressants
and/or diuretics.
There is body image distortion in the form of a specific psychopathology whereby a dread of fatness persists
as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.
A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as
amenorrhoea and in men as a loss of sexual interest and potency.
If onset is pre-pubertal, the sequence of pubertal events is delayed or even arrested (growth ceases, in girls the
breasts do not develop and there is a primary amenorrhoea, in boys the genitals remain juvenile). With recovery,
puberty is often completed normally, but the menarche is late.
Note: people with anorexia nervosa tend to gauge the size of other people and inanimate objects correctly but
tend to over-estimate their own size (body image distortion).
Note: anorexia nervosa is associated with an over-valued idea (not a delusion) regarding a body image
distortion.
Note: in atypical anorexia nervosa, one/more of the key features of anorexia such as amenorrhoea or significant
weight loss are absent but otherwise there is a fairly typical clinical picture.
Body mass index (BMI)
Weight in kilograms divided by height in metres squared [Weight (kg)/height (m)2].
o Underweight: < 18.5.
o Healthy weight: 18.5 to 24.9.
o Overweight: 25 to 29.9.
o Obesity: > 30.
Examples of methods for assessing body image distortion
Ask the person to:
o Draw their perceived body size on a sheet of paper attached to a wall.
o Adjust the distance between two lights (or adjust the width of a light beam projected onto a wall) to match
their perceived shape.
o Select a silhouette card that best represents themselves from a series of silhouettes varying from a very
thin body figure to a very obese body figure.
o View a real life image and adjust its size until it matches the patient’s view of their body size.
Computer techniques involving body part and whole body distortions can also be used to assess body image
distortion.
Restricting and binge eating/purging type of anorexia nervosa
DSM-V but not ICD-10, recognises two types of anorexia nervosa.
o Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in
binge eating or purging behaviour (e.g. self-induced vomiting or the misuse of laxatives, diuretics or
enemas).
233
Eating Disorders
232
, Chapter 27: Eating Disorders
Important conditions
1. Anorexia nervosa.
2. Bulimia nervosa.
3. Obesity.
4. Other notable conditions
A. Pica.
B. Binge eating disorder.
C. Kleine Levin syndrome.
D. Kluver Bucy syndrome.
1. Anorexia nervosa
A 14 year old girl presents with a two year history of progressive weight loss. She has had amenorrhoea
for the past six months. She eats small quantities of fruit and vegetables, refusing to eat a range of foods which include
biscuits, bread and chips because they are “fattening”. She runs 10km in the mornings and spends two hours in the
evenings doing sit-ups. Her parents are concerned that she is very underweight despite the fact that she says that her
hips, abdomen and thighs are “huge”. Her goal is to have the figure of a catwalk model.
ICD-10 criteria
Body weight at least 15% below expected, or body mass index (BMI) 17.5 or less. Pre-pubertal patients may
show failure to make the expected weight gain during the period of growth.
The weight loss is self-induced by avoidance of “fattening foods”, and one or more of the following may
also be present: self-induced vomiting, self-induced purging, excessive exercise, use of appetite suppressants
and/or diuretics.
There is body image distortion in the form of a specific psychopathology whereby a dread of fatness persists
as an intrusive, overvalued idea and the patient imposes a low weight threshold on himself or herself.
A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifest in women as
amenorrhoea and in men as a loss of sexual interest and potency.
If onset is pre-pubertal, the sequence of pubertal events is delayed or even arrested (growth ceases, in girls the
breasts do not develop and there is a primary amenorrhoea, in boys the genitals remain juvenile). With recovery,
puberty is often completed normally, but the menarche is late.
Note: people with anorexia nervosa tend to gauge the size of other people and inanimate objects correctly but
tend to over-estimate their own size (body image distortion).
Note: anorexia nervosa is associated with an over-valued idea (not a delusion) regarding a body image
distortion.
Note: in atypical anorexia nervosa, one/more of the key features of anorexia such as amenorrhoea or significant
weight loss are absent but otherwise there is a fairly typical clinical picture.
Body mass index (BMI)
Weight in kilograms divided by height in metres squared [Weight (kg)/height (m)2].
o Underweight: < 18.5.
o Healthy weight: 18.5 to 24.9.
o Overweight: 25 to 29.9.
o Obesity: > 30.
Examples of methods for assessing body image distortion
Ask the person to:
o Draw their perceived body size on a sheet of paper attached to a wall.
o Adjust the distance between two lights (or adjust the width of a light beam projected onto a wall) to match
their perceived shape.
o Select a silhouette card that best represents themselves from a series of silhouettes varying from a very
thin body figure to a very obese body figure.
o View a real life image and adjust its size until it matches the patient’s view of their body size.
Computer techniques involving body part and whole body distortions can also be used to assess body image
distortion.
Restricting and binge eating/purging type of anorexia nervosa
DSM-V but not ICD-10, recognises two types of anorexia nervosa.
o Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in
binge eating or purging behaviour (e.g. self-induced vomiting or the misuse of laxatives, diuretics or
enemas).
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