Eating disorders in women

Abstract

Eating disorders, especially anorexia nervosa and bulimia nervosa have been classically described in young females in Western population. Recent research shows that they are also seen in developing countries including India. The classification of eating disorders has been expanded to include recently described conditions like binge eating disorder. Eating disorders have a multifactorial etiology. Genetic factor appear to play a major role. Recent advances in neurobiology have improved our understanding of these conditions and may possibly help us develop more effective treatments in future. Premorbid personality appears to play an important role, with differential predisposition for individual disorders. The role of cultural factors in the etiology of these conditions is debated. Culture may have a pathoplastic effect leading to non-conforming presentations like the non fat-phobic form of anorexia nervosa, which are commonly reported in developing countries. With rapid cultural transformation, the classical forms of these conditions are being described throughout the world. Diagnostic criteria have been modified to accommodate for these myriad presentations. Treatment of eating disorders can be quite challenging, given the dearth of established treatments and poor motivation/insight in these conditions. Nutritional rehabilitation and psychotherapy remains the mainstay of treatment, while pharmacotherapy may be helpful in specific situations.

INTRODUCTION

Eating disorders are disorders of eating behaviors, associated thoughts, attitudes and emotions, and their resulting physiological impairments.[1] Eating disorders are associated with a significant burden on patients[2] and their family members[3] and have among the highest mortality rate one of psychiatric disorders.[4]

The eating disorders, especially anorexia nervosa and bulimia nervosa, have been classically described to occur in young females. Although recent research has shown that the prevalence in males was previously underestimated, these disorders do have a clear female preponderance.[1] Various reasons have been ascribed for this finding, most of them being psychosocial. The overvaluation of slimness, which is commonly seen in Western females, is considered to be an important contributory factor in the pathogenesis of eating disorders. These disorders were found to be more common in “Western nations” and have been hypothesized to be slowly spreading to “non-Western nations” as a result of the cultural transformation.

In this chapter, some of the recent research findings in eating disorder are discussed, with emphasis on Indian studies. As the amount of research in this area in our country is relatively sparse, it is augmented with data from other developing countries. The contribution of research from developing countries in understanding the concept of these disorders and the lacunae in current research are discussed.

HISTORY

Cases of emaciation without medical causation were first reported in the late 17^th century. The term anorexia nervosa was introduced by William Gull in 1874 to describe four cases of adolescent girls with deliberate weight loss.[1] Weight phobia, which is considered central to the concept of eating disorders was described as a feature of eating disorders, only in the 1930s.[5,6] Hence, some (but not all[7]) authors suggest that weight concerns may be an artifact produced by cultural changes in the 1930s, and may not be a core feature of the disorder.

Bulimia nervosa was first described by Russell in 1979[8] as an “ominous variant of anorexia nervosa.” Later descriptions have characterized bulimia nervosa as an independent disorder, with pathological eating behavior at a normal weight. Some authors[5] have hypothesized that bulimia nervosa was nonexistent before recent times, and changes in the cultural and economic conditions, such as the rising prosperity and surplus of food, has led to the onset of disorder. Others[9] have presented historical cases with probable bulimia nervosa to suggest that the disorder may have existed but may not have been identified in earlier times. However, Keel and Klump,[10] who reviewed the historical cases systematically, suggest that these were closer to binge eating disorder (BED); and that bulimia nervosa is probably a culture-bound syndrome of recent origin.

In the developing countries, anorexia nervosa was rarely reported till the 1970s and 1980s.[11,12,13] But later studies have confirmed the presence of eating disorders; some of these studies suggest that the prevalence of eating disorders may be similar to that in the Western nations.[10] However, in non-Western nations, patients often present without prominent weight concerns.[10]

NOSOLOGY

Based on similarities in psychopathology and high comorbidity, many authors have tried to classify eating disorders as subtypes of mood, obsessive-compulsive, or psychotic disorders, etc. However, eating disorders “breed true,” and do not evolve into a mood or other disorders.[1] In the International Classification of Disease 10 (ICD 10),[14] eating disorders are considered independently and classified under the broad category of “behavioral syndromes associated with physiological disturbances and physical factors.”

Anorexia nervosa and bulimia nervosa are the major eating disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition, Text Revision (DSM-IV-TR).[15] In addition, ICD 10[14] includes “vomiting associated with other psychological disturbances,” “atypical anorexia nervosa,” “atypical bulimia nervosa” and “overeating associated with other psychological disturbances” under eating disorders. In DSM-IV-TR, anorexia nervosa is further subtyped into binge eating/purging type and restricting type. Bulimia nervosa is subtyped into purging and nonpurging type. In DSM-IV-TR, BED has been included in the appendix as a condition worthy of further study.

Studies have shown that the majority of the patients with eating disorders fit into the redundant category of eating disorder not otherwise specified (EDNOS).[16,17] The validity of this category as a single diagnostic entity has been questioned; as it includes subsyndromal forms of anorexia nervosa, bulimia nervosa as well as other disorders which do not fit into these categories. ICD 10 partly circumvents this problem by including subsyndromal forms of the disorders as atypical anorexia nervosa and atypical bulimia nervosa. Recent research is geared towards finding clinically useful and nosologically valid entities within the EDNOS group; e.g., BED, night eating syndrome, purging syndrome, etc. Purging disorder is seen in individuals of normal weight who self-induce vomiting or purge by laxatives in the absence of binge eating. Night eating syndrome is characterized by eating large quantities of food in the night time associated with sleeplessness and morning anorexia.

Innovations in the nosology of eating disorders are expected from the future classificatory systems.

INCLUSION OF NEW CATEGORIES

The inclusion of BED and obesity is under active consideration of the DSM-V work group.[18] But, the current evidence suggests that obesity is a condition of heterogeneous etiology. Indeed, there is scant evidence that obesity, in general, is caused by mental dysfunction.[19]

REVISIONS IN CORE DEFINING FEATURES

Amenorrhea

The inclusion of amenorrhea as a criterion for anorexia nervosa has been debated. It is considered useful because it is clear and objective. Further, the presence of amenorrhea may also reflect important biological abnormalities that provide information about the etiology of the illness and/or might inform the development of biological treatments. But studies have reported that there are many patients who meet all clinical criteria for anorexia nervosa except for that of amenorrhea. Most of the differences between patients with and without amenorrhea seem to reflect the nutritional status of the patient, rather than any core pathology. So, various authors have advocated for the removal of amenorrhea as an essential criteria for the diagnosis of anorexia nervosa.[20]

FAT PHOBIA/WEIGHT CONCERNS

Reports from non-Western countries have shown that patients with symptoms suggestive of anorexia nervosa present with various rationales for food refusal, apart from weight concerns.[21,22,23] Lee is credited with characterizing this phenomenological variant of anorexia nervosa.[24] Lee et al.[21] investigated the symptomatology of 70 Chinese patients with anorexia nervosa in Hong Kong. Less than one-half of the patients were found to report fat phobia at any time during their illness. Instead, weight loss was primarily attributed to stomach bloating, loss of appetite, fear of food, or simply eating less. The authors concluded that “fat phobia, cross-culturally speaking, is not the raison d’être for all cases of morbid self-starvation” and proposed “that the identity of anorexia nervosa should be conceptualized without invoking the explanatory construct of fat phobia exclusively.” A series of five cases without weight concern has also been reported in India.[22] Such patients with diminished weight concerns are also seen in around 15–20% of eating disorders in the Western nations.[25,26,27] It has also been seen that South Asians living in Western countries present less frequently with fat phobia when compared with the white English population.[28] However, studies conducted to differentiate patients with and without weight concerns using the “Drive for Thinness” subscale of Eating Disorders Inventory suggest that patients who score low on “Drive for Thinness” have less severe eating disorder pathology[24] and general psychopathology[29] compared to patients with high scores. Furthermore, endorsement of a fat phobia can emerge during treatment.[30] Hence, while several theorists have advocated for a removal of the “weight concern” criterion for diagnosing anorexia nervosa;[31,32,33] others suggested that weight phobia is the sine quo non of anorexia nervosa and should be retained in the future diagnostic systems.[7] Based on a systematic review, Becker et al.[24] state that nonfat phobic anorexia nervosa does not meet the Robins and Guze's criteria[34] for diagnostic validity, as a subtype of anorexia nervosa. However, due to its frequent presentation in various countries, they suggest its inclusion as a common presentation of EDNOS to enhance its clinical detection.

CLINICAL FEATURES

The clinical features of eating disorders are varied and usually involve multiple body systems, though the key symptoms relate to eating, body weight and shape.[35]

ANOREXIA NERVOSA

Numerous criteria have been proposed for the diagnosis of anorexia nervosa. Most of the criteria share the following essential features:

• Weight loss/lack of weight gain and behaviors that are designed to produce such weight loss

• A psychopathology characterized by the relentless drive for thinness and/or a morbid fear of fatness. The essential psychopathology seems tightly linked to overvalued beliefs, primarily the overvaluation of thinness. The drive for thinness as a psychopathological motif has been emphasized more by Americans, beginning with Hilde Bruch, whereas the morbid fear of fatness, the phobic avoidance of normal weight, has been emphasized more by the British[1]

• The medical consequences of starvation: For example endocrine dysfunction manifested as amenorrhea in women and loss of sexual potency in men, hypothermia, bradycardia, orthostasis and severely reduced body fat stores, etc

• Anorexia nervosa is often, but not always, associated with disturbances of body image, the perception that one is distressingly large despite obvious medical starvation. The distortion of body image is disturbing when present, but not pathognomonic, invariable, or required for diagnosis.[1]

The ICD 10[14] enlists the following criteria for the diagnosis of anorexia nervosa:

• There is weight loss or, in children, a lack of weight gain, leading to a body weight at least 15% below the normal or expected weight for age and height

• The weight loss is self-induced by avoidance of “fattening foods”

• There is self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold

• A widespread endocrine disorder involving the hypothalamic-pituitary-gonadal axis is manifested in women as amenorrhea and in men as a loss of sexual interest and potency (an apparent exception is the persistence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill)

• The disorder does not meet the criteria A and B for bulimia nervosa.

Bulimia nervosa

The ICD 10[14] enlists the following criteria for bulimia nervosa:

• There are recurrent episodes of overeating (at least twice a week over a period of 3-month) in which large amounts of food are consumed in short periods

• There is a persistent preoccupation with eating and strong desire or a sense of compulsion to eat (craving)

• The patient attempts to counteract the “fattening” effects of food by one or more of the following:

  • Self-induced vomiting
  • Self-induced purging
  • Alternating periods of starvation
  • Use of drugs such as appetite suppressants, thyroid preparations, or diuretics; when bulimia occurs in diabetic patients, they may choose to neglect their insulin treatment.

• There is self-perception of being too fat, with an intrusive dread of fatness (usually leading to underweight).

Patients with bulimia nervosa have a powerful and intractable urge to overeat and have a feeling of lack of control over the episodes of binge eating. There are controversies as regard to the criteria for what constitutes a binge. Some focus on the quantity of food taken, some on the subjective state of the person and others on the rapid rate of eating. The DSM-IV[15] gives the criterion “eating, in a discrete period of time (e.g., within a 2-h period), an amount larger than most people would eat during a similar period and similar circumstances” and a sense of lack of control. The clinical features of bulimia nervosa are similar to that of binge eating/purging type of anorexia nervosa. These disorders can be differentiated by the presence of large amount of weight loss seen in patients of anorexia nervosa.

BINGE EATING DISORDER

BED is characterized by recurrent episodes of binge eating in the absence of regular compensatory behavior such as vomiting or laxative abuse. Related features include eating until uncomfortably full, eating when not physically hungry, eating alone and feelings of depression or guilt. Although it is not limited to obese individuals, it is most common in this group and those who seek help do so for treatment of overweight rather than for binge eating. The prevalence of BED is reported to be 2–5% in community samples, and 30% in individuals who seek weight control treatment. It has a more equal gender ratio than bulimia nervosa.[36] BED eating disorder is associated with increased psychopathology including depression and personality disorders.

COMORBIDITY

The diagnostic challenges of eating disorders are only partly addressed when a specific eating disorder is identified, because, in the large majority of cases, comorbid psychiatric disorders accompany the eating disorder.[1] Common co-occurring conditions include:

Mood/affective disorders

Affective disorders are commonly seen in patients with both anorexia and bulimia nervosa.[35] Recent studies have shown a high degree of comorbidity between bipolar affective disorders and eating disorders, especially between bulimia nervosa and bipolar II disorders.[37] This comorbidity becomes more apparent when subthreshold forms of the disorders are included.[38]

Anxiety disorders

The prevalence of anxiety disorders in general and obsessive compulsive disorder, in particular, is much higher in people with anorexia and bulimia nervosa. Anxiety disorders often have their onset in childhood before the onset of an eating disorder, supporting the possibility they are a vulnerability factor for developing anorexia nervosa or bulimia nervosa.[39]

Substance use disorders

Eating disorders are associated with increased risk of multiple substance use disorders, with the risk being more for bulimia nervosa and binge eating/purging subtype of anorexia nervosa.[40,41]

Personality traits and disorders

It has been suggested that anorexia nervosa may be associated with obsessional and perfectionistic forms of personality disturbances, bulimia nervosa with impulsive and unstable personality disorders, and BED with avoidant and anxious forms of personality disorders.[42] Cluster B and obsessive-compulsive personality disorders have been reported to predict a poorer course and/or outcome, and histrionic personality traits and self-directedness have been reported to predict a more favorable course and/or outcome. In the setting of an eating disorder, vulnerable personality traits may be amplified into what appear to be primary personality disorders but are actually secondary personality disturbances.

Other psychiatric disorders

There is a high comorbidity of anorexia nervosa with body dysmorphic disorder-estimated at 25–39% - in which patients additionally have obsessional preoccupations regarding specific body parts not related to weight or shape in particular.[1]

COMPLICATIONS AND MORTALITY

Medical complications in eating disorders results from (a) the amount and rate of starvation, (b) the means used to produce weight loss (dieting alone, with or without over exercising, self-induced vomiting, laxatives, diet pills, diuretics), and (c) binge eating.

In patients with anorexia nervosa, every major organ system can be involved, and the risk of mortality is substantial. Particular areas of concern include dermatologic changes (some of which evidently need acute intervention; e.g., purpura), endocrine abnormalities (including mismanagement of diabetes), gastrointestinal problems (including the risk of gastric dilatation), cardiovascular/pulmonary problems (including arrhythmias and pneumomediastinum), severe electrolyte abnormalities, and bone demineralization.[43]

Eating disorders are associated with one of the highest rates of mortality among psychiatric disorders up to 19% within 20 years of onset among those initially requiring hospitalization.[1] Eating disorder patients die from either the medical consequences of starvation (cardiac muscle loss and arrhythmia, sometimes related to hypokalemia) or suicide. In a meta-analysis conducted in 1995 of 42 published studies,[44] the crude mortality rate was 5.9%, translating into 0.56%/year or 5.6% per decade. In the studies specifying the cause of death, 54% of the patients died as a result of eating disorder complications, 27% committed suicide, and the remaining 19% died of unknown or other causes.[45] In a meta-analysis of standardized mortality rates (SMR) in 2001, the overall aggregate SMR of anorexia nervosa in studies with 6–12 years of follow-up was 9.6 and in studies with 20–40 years of follow-up 3.7.[46] Anorexia nervosa comorbid with alcohol dependence is associated with up to 50 times higher, and anorexia nervosa comorbid with insulin-dependent diabetes mellitus with up to 10 times higher mortality than each of these illnesses alone.[1]

EPIDEMIOLOGY

Western countries

Incidence

Most incidence studies of eating disorders have used psychiatric case registers or medical records of hospitals in circumscribed areas. Hence they underestimate the incidence in the community. The reported incidence rates of anorexia nervosa and bulimia nervosa are up to 8/100,000 persons/year and 13/100,000 persons/year, respectively.[45] Studies, including meta-analysis in Western cultures suggest that the incidence of anorexia nervosa increased up to the 1970s when it reached a plateau.[47,48] On the other hand, the incidence rate of bulimia nervosa is increasing.[10] Eating disorders seem to have become more common among younger females during the latter half of the 20^th century in Western cultures, during a period when icons of beauty (e.g., contestants at beauty contests) became thinner and women's magazines published significantly more articles on methods for weight loss.[49,50,51,52]

Prevalence

Based on the National Comorbidity Survey replication, lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and BED are 0.9%, 1.5%, and 3.5%, respectively, in women, and 0.3%, 0.5%, and 2.0% in men.[53] Other researches suggest that only about 15% of individuals have no preoccupation with dieting, weight or shape; hence, subthreshold disorders of eating behaviors may be more prevalent. Eating disorders are among the most gender-divergent disorders in psychiatry, but the divergence is substantially narrower than previously believed. Previous estimates of the ratio of men to women for eating disorders were typically 1 in 20–1 in 10. Recent community-based epidemiological studies, however, found ratios of approximately 3 to 1 for both anorexia nervosa and bulimia nervosa.[1]

Non-Western countries

Earlier studies suggested that anorexia nervosa was rare in non-Western countries, including India.[54,55,56] Epidemiological studies in Korea have shown a prevalence rate of 0.02–0.03%.[57,58] Nakamura et al.[59] found a prevalence of 0.003% of general population, and 0.005% of female population had anorexia nervosa; and 1.02/100000 females had bulimia nervosa in a circumscribed area in Japan. Kuboki et al.[60] found a prevalence of 2.9–3.7/100,000 for eating disorders in 1985 and 3.6–4.5/100,000 for anorexia nervosa and 1.3–2.5/100,000 for bulimia nervosa in 1992 in Japan. Azuma and Henmi[61] found a rural/urban difference with 0.2% prevalence in urban areas and 0.05% in rural areas. Chen et al.[62] found a prevalence of 0.03% in Hong Kong. Nobakht and Dezhkam[63] reported a prevalence of 0.9% for anorexia nervosa and 3.2% for bulimia nervosa among high school students in Iran. Surveys among high school students found a prevalence of 0.9% in Egypt[64] and 0.002% in Pakistan for bulimia nervosa.[65] Further, authors have noted an increasing prevalence of eating disorders associated with body dissatisfaction in non-Western countries, which is hypothesized to be the effect of Westernization.[66] Studies in Western countries show that eating disorders occur more frequently among ethnic minorities.[67,68]

Keel and Klump[10] in their review of studies in non-Western countries, comment that “excluding the criterion of weight concerns, anorexia nervosa appears to represent a similar proportion of the general and psychiatric populations in several Western and non-Western nations.” Another interesting finding reported was the relatively lower difference in prevalence of bulimia nervosa and anorexia nervosa in non-Western countries compared to Western countries. The authors hypothesize that bulimia is more culturally dependent than anorexia nervosa.

ETIOLOGY AND RISK FACTORS

Currently, eating disorders are considered to be complex disorders with multifactorial etiology, involving biological,[69] psychological, and environmental factors, like most other psychiatric syndromes.[1]

BIOLOGICAL FACTORS

Biological theories for eating disorders have been in vogue since late 19^th century when eating disorders were considered to result from postpartum pituitary necrosis. Although this theory was soon disproved, a variety of subsequent theories have been advanced focusing on putative biological underpinnings - for example, the hypothesis that some predisposing hypothalamic abnormality exists, evidenced by amenorrhea. However, recent evidence suggests that the endocrine abnormalities occur as a consequence of starvation.[1] The current biological hypothesis suggests that eating disorders represent a distortion and overriding of the normal neurobiologically regulated eating behaviors in response to the continued drive for thinness and a fear conditioning about normal weight.

Recent evidence has shown a strong genetic contribution to the etiology of eating disorders. Twin studies demonstrate a 3 times higher concordance in monozygotic twins compared to dizygotic twins. Genetic factors may contribute more than 50% to the appearance of anorexia nervosa and bulimia nervosa. Large studies have shown consistent (but not specific) linkage between polymorphic variants of 5-HT(2A) receptor gene and the BDNF gene and anorexia nervosa restricting subtype.[70] Andersen and Yager[1] suggest that genetic factors probably contribute by increasing the presence and strength of risk factors, such as persevering, perfectionistic, sensitive, fearful, or impulsive personality traits, or through biological vulnerabilities that more easily lead to disrupted regulation of serotoninergic mechanisms when dieting occurs.

Contemporary theories have pointed to putative serotonin mechanisms, based on observations that individuals with anorexia nervosa have abnormal cerebrospinal fluid serotonin levels when ill, that may not completely reverse on partial weight gain.[71] Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from anorexia nervosa and bulimia nervosa.[72] It is postulated that that a trait-related disturbance of 5-HT neuronal modulation predates the onset of anorexia nervosa and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition.[72] Other neuromodulators such as disturbed corticotropin releasing hormone, opioids, cholecystokinin, neuropeptide Y, peptide YY, leptin, ghrelin, etc., have also been implicated in the etiology of eating disorders.

Neuroimaging studies suggest that white matter and gray matter volume losses occur in eating disorders, but these remit with recovery. Studies have implicated cingulate, frontal, temporal, and parietal regions in anorexia nervosa. Functional studies suggest that challenges such as food and body image distortions may activate some of these regions. These disturbances persist after recovery from anorexia nervosa, raising the possibility that these traits may be a part of the vulnerability to develop an eating disorder.[73]

PSYCHOLOGICAL FACTORS

In the first half of the 20^th century, psychodynamic formulations of eating disorders predominated. Early formulations were centered on fear of oral impregnation: However, they were replaced by formulations emphasizing maturational and existential fears; with restricting type anorexia nervosa being hypothesized as providing an escape from onrushing negative visions of the emerging sexuality and other biological and social challenges of adolescence.

Presence in childhood of traits such as perfectionism, rigidity, and being rule-bound each increase the risk of subsequently developing anorexia nervosa by a factor of nearly seven. Trauma during childhood or adolescence contributes to the likelihood of later psychiatric disorders, in general, not specifically an eating disorder.

Investigators are beginning to identify endophenotypes have like poor set shifting and weak central coherence the help of family studies.[74,75,76] These might help in unraveling the psychobiology of eating disorders.

ENVIRONMENTAL FACTORS

Keel and Klump[10] have commented that culture seems to have a pathoplastic effect in anorexia nervosa with regards to weight concern while bulimia nervosa seems to be a culture-bound syndrome. Many of the cases from non-Western countries have been found to lack weight concerns.

The view that eating disorders are etiologically related to the internalization of the social pressure resulting from the standards of female beauty of the modern industrial society or Western culture holds a dominant position in the current discourse around etiology of eating disorders.[77] Environmental factors like enrollment to ballet schools, teasing by family and friends, and comments and directives from authority figures (doctors, nurses, teachers, coaches) regarding need to change weight play a role in the pathogenesis of eating disorders.

Lee[78] suggests that admiration of thinness is not inherent to non-Western cultures. Kayano et al.[79] compared the body dissatisfaction and eating attitudes among students from Indian (residing in Muscat, Oman), Omani, Filipino, Japanese and Euro-American backgrounds. Subjects from India, Oman and the Philippines demonstrated eating attitudes that were similar to or worse than subjects from Western countries and Japan, but their desire for thinness was not as strong. The study showed that although non-Western cultures have disordered eating behavior, it may be motivated by reasons other than body dissatisfaction. However globalization and exposure to Western media may increase the rate of eating disorders in non-Western countries. Recent studies from Fiji suggest that the introduction of popular television programs highlighting slimness and stigmatizing obesity launched widespread dieting behavior and led to the emergence of new cases of eating disorders in populations that were previously unconcerned with these issues.[80]

Westernization is not the only cultural factor playing an etiological role in eating disorders. Some studies have found an increased prevalence of disordered eating behaviours (as measured by Eating Attitude Test scores) in ethnic minorities in Western countries;[81] and a correlation between disordered eating behavior and a “traditional” South Asian cultural orientation. It was hypothesized that difficulties in integration into the Western society led to the disordered eating behavior. However, even this evidence points to the importance of cultural factors in the pathogenesis of eating disorders, even as it clarifies that more than one cultural factor may play a role.

Some cases of eating disorder are hypothesized to be a caused and maintained by family pathology.[35]

MANAGEMENT OF EATING DISORDERS

The core treatment goals for all eating disorders are as follows:[1]

• Attaining and maintaining a normal, healthy, individualized, stable body weight;

• Stopping all abnormal eating behaviors, such as food restricting, binge eating, or purging, and associated abnormal behaviors, especially compulsive exercise;

• Dismantling the core overvalued beliefs and unhealthy cognitive “schemas” of automatic cognitive distortions, replacing them with healthy, balanced views of self (not primarily dependent on body weight or shape) and the capacity for emotional and behavioral self-regulation;

• Treating the comorbid conditions, psychiatric and medical; and

• Planning for ongoing relapse prevention for approximately 5 years after acute improvement.

The management of eating disorders begins with forming of a therapeutic alliance, followed by a comprehensive psychiatric and medical evaluation (including body mass index). The need for laboratory analyses should be determined on an individual basis. Bone density examinations should be obtained for patients who have been amenorrheic for 6 months or more.

Treatment planning requires matching the intensity of treatment to the severity of illness. The decision about whether a patient should be hospitalized on a psychiatric versus a general medical or adolescent/pediatric unit should be made based on the patient's general medical and psychiatric status, the skills and abilities of local psychiatric and general medical staff, and the availability of suitable programs to care for the patient's general medical and psychiatric problems.

The methods of treatment include medical, nutritional, educational, psychotherapeutic, behavioral, and pharmacological components.

NUTRITIONAL REHABILITATION

The goals of nutritional rehabilitation for seriously underweight patients are to restore weight, normalize eating patterns, achieve normal perceptions of hunger and satiety, and correct biological and psychological sequelae of malnutrition. The initial short-term goal is to restore patients fully, safely, and promptly to the ideal healthy range as specified in population weights for age, height, and gender or the weight at which there is a 50% chance of return of menses for adolescent girls. Caloric intake should be carefully tailored to avoid refeeding syndrome. Caloric intake levels should usually start at 30–40 kcal/kg/day (approximately 1000–1600 kcal/day). During the weight gain phase, intake may have to be advanced progressively to as high as 70–100 kcal/kg/day for some patients.

PHARMACOTHERAPY

Antidepressants, antipsychotics, anticonvulsants, prokinetic agents, opiate antagonists, appetite suppressants, tetrahydrocannabinol, cyproheptadine, zinc, and ondansetron have been tested for the treatment of eating disorders. Available evidence shows that fluoxetine may be beneficial in relapse prevention of anorexia nervosa after weight restoration.[82] Cyproheptadine has been shown to have some modest benefits in the weight restoration phase of anorexia nervosa treatment.[83] Antidepressants, especially selective serotonin reuptake inhibitors, at a higher dose (e.g., 60 mg of fluoxetine) may be useful in the treatment of bulimia nervosa and BED.

PSYCHOTHERAPY

Psychotherapies aimed at modifying and altering core pathological beliefs and other contributing psychopathological issues are key elements of treatment. Available evidence strongly favors treatments based on cognitive-behavioral therapies (CBT). Patients of anorexia nervosa without weight concern respond as well with CBT.[27] Additional alternative psychotherapeutic interventions based on interpersonal therapies, family therapies, or psychodynamically informed psychotherapies – particularly those using self-psychology and “focal analytical” approaches – may also be beneficial.[1]

INDIAN STUDIES ON EATING DISORDERS

Jha and Awadhia[84] were probably the first to report a case of eating disorder in India. They describe the case of a 42-year-old female with self-induced starvation of 3 weeks duration with the belief that fasting would improve her memory. She was not reported to have any weight concerns or body image disturbance. The case report did not mention the extent of weight loss and history regarding amenorrhea. Neki et al.[85] reported a pair of monozygotic twin females aged 15, who presented with the rejection of food, loss of weight and secondary amenorrhea. These cases also lacked body image disturbances. Chadda et al.[86] reported a case of anorexia nervosa that met the DSM-III criteria in a 13-year-old female with comorbid systemic lupus erythematosus. This patient had an onset of illness following taunts by parents and siblings regarding her steroid induced weight gain. Khandelwal et al.[22] reported a case series of 5 patients who had many features of anorexia nervosa but no body image disturbances. Following this there have been recent reports of binge/purging type of anorexia nervosa[87] and bulimia nervosa.[88]

EPIDEMIOLOGY

Although some authors have commented that anorexia nervosa is not as rare in India as previously reported,[89] no general population study has been conducted in India. Some studies have been done in special populations, but almost all of them have depended on self-report inventories (for case identification) or chart reviews. Bhugra and King[90] have questioned the applicability of the self-report instruments for eating attitudes in non-Western cultures, when no attempt is made to ascertain the respondent's understanding of the often subtle and Western orientation of many questions.

Srinivasan et al.[91] studied 210 medical students with standardized instruments and found that none of the students could be diagnosed as having anorexia nervosa or bulimia nervosa. However, around 15% of students suffered from a subthreshold disorder which they labeled “Eating Distress Syndrome.”

Bhugra et al.[92] conducted a study on 504 students in an all-girls private college in an industrial town in north India using the Hindi translation of the Bulimia Investigatory Test, Edinburgh. They found that 2 patients scored above the cutoff for bulimia nervosa, giving a prevalence of around 0.4%.

Mammen et al.[93] conducted a retrospective chart review of children and adolescents (<18 years) attending the Child and Adolescent Psychiatry Unit, Christian Medical College and Hospital, Vellore, from January 2000 to December 2005. The 6-year period prevalence of eating disorder as per ICD 10 was 1.25%. The most common diagnosis was psychogenic vomiting (85.4%); only six cases (14.6%) of anorexia nervosa were reported. About 43.9% of patients with eating disorder had a psychiatric comorbidity, with common comorbid diagnoses being mood disorder (27.8%), intellectual disability (22.2%), and dissociative disorder (16.7%). This study differed from most other studies by including psychogenic vomiting as an eating disorder.

Some studies have demonstrated that weight concerns and abnormal eating behaviors are common in Indian adolescents. Chugh and Puri[94] assessed 150 adolescents from an affluent background in Delhi. They found that 96% of obese, 88% of normal-weight, and 42% of underweight subjects were dissatisfied with their current weight. While the majority of the obese subjects (63:3%) wanted to lose more than 16 kg, even subjects in the normal-weight (88%) and underweight (32%) groups wanted to lose between 5 and 16 kg. The frequency of dieting was greater in obese subjects (76:6%) but was also reported in normal weight (38%) and underweight (14%) subjects. Gupta et al.[95] compared students from India and Canada and found that after the effect of body mass index was statistically controlled, the Canadian and Indian women scored similarly on some of the core features of eating disorders, as measured by the Drive for Thinness and Body Dissatisfaction subscales of Eating Disorder Inventory. Similarly, Rubin et al.[96] did not find any evidence of difference on body image discrepancy and eating pathology in school children from India, France Tibet, and the United States of America. These studies suggest that eating disorders do occur in India and with increasing level of Westernization, the prevalence may increase in future, although, further studies are needed to confirm this supposition.

CLINICAL FEATURES

Khandelwal et al.,[22] reported a series of 5 patients. All the patients presented with most of the symptoms of eating disorder but lacked the disturbance of body image, drive for thinness or fear of becoming fat. But, the patients were indifferent to their loss of weight and emaciation and rationalized their decreased food intake. The authors hypothesized that fear of fatness might be a common but inessential feature of anorexia nervosa. Weight concern and consequent slimming may be the most frequent mode of entry into the disorder in some cultures but not in others.

Srinivasan et al.[91,97] reported that subsyndromal forms of eating disorder are more common in the Indian population and suggest the term “Eating Distress Syndrome” for such cases with the following criteria:

• Eating habits and body shape as a source of conflict and concern with the need to change them

• Felt need for or sought professional help

• Bingeing once a week: Short lived binges associated with guilt but no counter-binge behaviors like starvation, vomiting, purging, etc

• Strict dieting, but no rigorous measures like full day starvation or use of diet pills. Slimming exercises practiced

• No significant change in body weight because of above measures.

However, this syndrome has not been studied further.

SUMMARY OF STUDIES DONE IN INDIA

Most of the early literature on eating disorders have been in the form of case reports and chart review, which have demonstrated that various forms of eating disorders do exists in our population. This was not followed by any population-based epidemiological study; hence, the prevalence of these disorders in our country is currently unknown. Recent studies have shown that abnormal eating behaviors and weight concern is common among the student population and cross-cultural studies have shown that it may be nearly equal to that of Western nations. The clinical presentation of eating disorders in India is similar to that of other developing nations, with the absence of weight concern in most of the reported cases. This has both diagnostic and treatment implications, as models of psychotherapy which focus on weight concern may not be applicable in this population.

FUTURE DIRECTIONS

The study of eating disorders in developing countries like India could be illuminating, as it provides a unique opportunity for testing the role of culture in the etiology of eating disorders. The relative rarity of eating disorders in psychiatric centers (about one case per year) may pose a problem in this regard.[89,93] It may be possible that the bulk of patients with eating disorders, particularly if they have somatic rather than body shape/weight concerns, may be seeking care from general physicians and gastroenterologists/endocrinologists. Hence, chart reviews of general medical records may be able to identify “hidden” cases.

Epidemiological studies are needed to assess the burden of these diseases in our population. Indigenously designed culturally appropriate instruments may be needed for this. It would also be interesting to study the “atypical” clinical presentation of eating disorders in India (i.e., without weight concern). This would have widespread implications in refining the nosology and clarifying the pathophysiology of eating disorders. There has been no research on the treatment of eating disorders in India. Given the clinical presentation, it would be necessary to study whether usual models of psychotherapy would work, or other indigenous models would be needed to cater to the unique needs of our population.

CONCLUSIONS

Eating disorders have long been considered as culture bound syndromes, restricted to countries with Western culture. Current evidence shows that culture may have a formative as well as the pathoplastic effect on eating disorders. It has been hypothesized that there may be multiple pathways of entry into eating disorder pathology, but weight concern and body dissatisfaction may be the most common pathways, even in developing countries (through westernizing influences). Research in eating disorders in India may be useful in understanding the pathophysiology of these disorders and for planning services (preventive and therapeutic) in the country.