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Chapter 291: Eating Disorders

Gemma C. Lewis

INTRODUCTION AND EPIDEMIOLOGY

Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge-eating disorder, are psychological pathologies characterized by disordered relationships with food. Eating disorders are challenging to diagnose in the ED because physical manifestations may be subtle and historical features may not be elicited unless the disorder is suspected from medical complications or comorbidities. It is important for the emergency physician to recognize these conditions, however, because they are among the most deadly of psychiatric illnesses.1 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders refines the diagnostic criteria of eating disorders from the previous edition (Table 291-1).2

TABLE 291-1Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Criteria for Eating Disorders
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TABLE 291-1 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Criteria for Eating Disorders
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder
Restriction of caloric intake relative to requirements, leading to a lower than expected body weight in the context of age, sex, development, and physical health (<85% predicted)

Recurrent episodes of binge eating characterized by both:

  1. Eating in a discrete time period an amount of food that is larger than most people would eat in the same period under the same circumstance

  2. A feeling of lack of control over eating during an episode

Recurrent episodes of binge eating characterized by both:

  1. Eating in a discrete time period an amount of food that is larger than most people would eat in the same period of time under the same circumstance

  2. A feeling of lack of control over eating during an episode
Fear of weight gain or becoming fat, despite lower than predicted body weight Recurrent, inappropriate compensatory behaviors to prevent weight gain including self-induced emesis; abuse of laxatives, diuretics, or other medications; caloric restriction; or excessive exercise

The episodes are associated with three of the following:

  1. Eating much more quickly than normal

  2. Eating until feeling uncomfortably full or overfull

  3. Eating large amounts of food even when not feeling hungry

  4. Eating alone because of embarrassment about how much one is eating

  5. Feeling disgusted, depressed, or guilty afterward
Derangement in the way the patient's body weight or appearance is experienced, undue effects of body weight on self-evaluation, or denial of the dangerousness of the current low body weight Binging and purging at least 1 time a week for 3 weeks The patient exhibits marked distress regarding binge eating.
Self-evaluation is unduly influenced by body weight and appearance The binge eating occurs at least 1 time a week for 3 months.
The disturbance does not occur exclusively during episodes of anorexia The binge eating is not associated with inappropriate compensatory behavior and does not occur exclusively during the course of anorexia, bulimia, or avoidant/restrictive food intake disorder.

There are two subtypes of anorexia, restrictive and binge/purge, with crossover between the two subtypes.3 Patients with a predominantly ...

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