Impulse Control and Eating Disorders

Changes from DSM-IV to DSM-V

• Impulse control disorders
  • Intermittent explosive disorder: criteria expanded to include verbal aggression and non-destructive/non-injurious behaviour ****in addition to physical aggression. A minimum age of 6 years is now required
  • Trichotillomania: now classified under Obsessive-compulsive and related disorder
• Eating disorders
  • Anorexia nervosa: requirement for amenorrhoea has been eliminated since it takes into account post-menopausal patients, patients on OCPs, and male patients. It is, however, still a good marker for anorexia.
  • Bulimia nervosa: minimum average frequency of binge eating and inappropriate compensatory behaviour has changed from twice weekly to once-weekly

Impulse control vs OCD

Impulses are egosyntonic, Compulsions are egodystonic

Impulse control disorders

Overview of impulse control disorder

Kleptomania

Impulse: Stealing

In kleptomania, the patients steal unnecessary objects (the objects are easy to steal, and the object is usually not the goal). The goal is to feel pleasure from stealing.

• Differentials
  • Antisocial PD: steal for want, steal to hurt others
  • Manic episode: has other Sx of mania, stealing may be a feature
• Treatment
  • SSRIs or mood stabilizers
  • Psychotherapy: CBT, Group therapy

Trichotillomania

Impulse: Hair-pulling, may include eating hair

• Signs and symptoms
  • Bald spots
  • Trichobezoar (can cause intestinal obstruction)
• Differentials
  • Alopecia: uniformity rather than patchiness in most cases
  • Tinea capitis: white plaques common, get KOH prep
  • Intestinal obstruction d/t other causes (intussusception, sigmoid volvulus, diverticulosis etc.)
• Treatment
  • SSRIS
  • Psychotherapy: CBT, group therapy

Pyromania

Impulse: setting things off fires

Pyromania requires at least 2 acts of fire-setting without any apparent move. There is usually an intense urge to set fire to objects, a feeling of tension before fire-setting and relief from the tension after fire-setting. Preoccupation with thoughts or mental images of fire-setting or issues relating to fire e.g. abnormal interest in fire-engines is also present. Interestingly, individuals may take on fire-safety volunteering roles or even join the fire service.

The patient will have a **history of legal issues.**No effective treatment exists.

• Triggers for an episode of fire-setting
  • Feeling stressed
  • Boredom
  • Recent interpersonal conflict
• Differentials
  • Antisocial PD: destructive behaviour is not limited to setting fires
  • Schizophrenia: psychotic symptoms (delusions, commanding hallucinations etc.) as the reasons surrounding behavior
• Treatment
  • Antidepressants
  • Mood stabilisers
  • Antipsychotics
  • Psychotherapy
  • Anti-androgens (in the small sub-group that report sexual arousal from fire-setting)

Intermittent Explosive Disorder

Impulse: aggression

Often a history of legal issues. Takes out anger on objects, animals, and other people. Road rage!

• Differentials
  • Psychiatric
    • Antisocial PD: less intermittent (continuous hx), will not report anxiety before episode
    • Borderline PD: labile mood, suicidal ideation
    • Schizophrenia: psychotic sx surrounding the event
  • Medical
    • Neurodegenerative disease: Pick’s disease (frontotemporal dementia) and Huntington’s disease
    • Brain tumours: frontal tumours; symptoms consistent with SOL. Exclude with CT-scan
    • Sertoli-Leydig cell tumour: sx of elevated testosterone (male-pattern baldness, voice-depending, hirsutism)
• Treatment
  • SSRIs (preferred), Mood stabilizers, or antipsychotics (second-line)
  • Psychotherapy

Pathological Gambling

Impulse: Gambling

Patients with pathological gambling have a history of prominent social deterioration (loss of job, loss of spouse, credit declining/financial problems). There is usually a concomitant substance dependence. They may resort to illegal acts to obtain money from gambling.

• Differentials
  • Manic episode: has other symptoms of mania. More short-lived. Less social deterioration.
  • **Adverse effect of pramipexole (**DA agonist used to treat Parkinson’s and RLS)
• Treatment
  • Group therapy (Gambler’s anonymous)
  • Individual therapy

Eating Disorders

Eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder avoidant/restrictive food intake disorder, pica, rumination disorder, and OSFED (other specified feeding or eating disorders – atypical anorexia, subthreshold bulimia or binge eating and purging disorder)

Definition of terms

Historical Perspective

Characteristics of eating disorders

• Etiology of eating disorders
  • Biological factors
    • Genetic components have been suggested by family and twin studies
    • Might have a shared etiology with depression and anxiety disorders due to the high comorbidity
    • Abnormalities in Dopamine/Serotonin neurotransmission and BDNF levels
    • Obstetric complications
    • Abnormal levels of leptin (anorexigenic) and ghrelin (orexigenic)
    • Reduced gray matter in many brain regions including the anterior cingulate cortex and cerebellum, and reduced volume of the caudate
    • Functional MRI shows reduced blood flow in the temporal lobes
    • Disturbed gustatory processing may lead to restricted intake (due to impaired processing) or binge-eating (due to exaggerated perception)
  • Social factors
    • Family dysfunction
    • Early childhood eating or gastrointestinal problems
    • Childhood sexual abuse
    • Primarily a culturally influenced disorder (due to preoccupation of Wester societies with thinness)
    • Occupation: models, actors, TV personalities, dancers, and sports
  • Psychological factors
    • Poor self-esteem or excessive self criticism is seen in both anorexia nervosa and bulimia nervosa
    • Perfectionism and OCPD is associated with anorexia nervosa
    • Impulsivity and BPD is associated with bulimia nervosa
    • Critical comments made by others may trigger anorexia in vulnerable children or adolescents
    • Positive comments after initial weight loss may positively reinforce self-starvation and other maladaptive behaviors so as to lose more weight
• Comorbidities of eating disorders
  • Depression (most common)
  • Anxiety disorders
  • Personality disorders
  • Psychosis, OCD and PTSD are more common in anorexia nervosa
  • Alcohol and substance abuse are more common in bulimia
• Investigations
  • Complete blood count
  • LFTs
  • UEC
  • TFTs
  • Glucose
  • Baseline EKG: both Bulimia and anorexia are risk factors for arrhythmia
• Rating scales used in the assessment of eating disorders
  • Eating Disorder Inventory (EDI)
  • Eating Attitudes Test (EAT)
  • Binge Eating Scale (BES)
  • Yale-Brown-Cornell Eating Disorder Scale
  • Anorectic Behavior Observation Scale
  • SCOFF Questionnaire: similar to CAGE Questionnaire used in Alcohol Use Disorder. More than 2 answered positively warrants further testing
    • Do you make yourself Sick because you feel uncomfortably full?
    • Do you worry that you have lost Control over how much you eat?
    • Have you recently lost more than One stone (14 pounds or ~ 7 kg) in a 3-month period?
    • Do you believe youself to be Fat when others say you are too thin?
    • Would you say that Food dominates your life?

Anorexia Nervosa

Anorexia nervosa is defined as self-induced reduced body weight resulting in a body weight that is < 85% for age/height/gender, or BMI less than 17.5. Anorexia is initially a misnomer since it happens later in the course (earlier on patients have a normal appetite). Eventhough the patient is thin they have a self-perception that they are fat (denial of thin appearance). There is a body image disturbance somewhat similar to body dysmorphic disorder (dysmorphophobia, this is non-diagnostic). Thinness as a source of self-esteem > weight > body shape. It is more severe than bulimia since the patient is underweight and more malnourished. Diagnosis is clinical.

Lifetime prevalence of 1% in the community. Anorexia is 10 – 20 times more common in females than men. It is more common in females, affecting 1.4 % of women and 0.2 % of men (10:1 F:M ratio). The incidence is 8 per 100,000 population. It is more common in adolescent, with the highest incidence in the 15 to 19 years old age group.

Types of Anorexia nervosa

• Etiology
  • Biological: paraventricular dysfunction, increased CRH, Neuropeptyde Y and TSH
  • Genetics (86%)
  • Job (5%) – balet, modelling and wrestling
  • Adverse life events (small percentage)
  • Sexual orientation (gay > lesbian)
  • Psychological: thinness for validation, starvation inhibits growth of invading mother (psychoanalysis)
• Methods of self-induced weight loss in anorexia nervosa
  • Restriciton of food intake or starvation
  • Vomiting
  • Excessive exercise
  • Misuse of laxatives, diuretics, and appetite suppressants
• Behaviors seen in anorexia nervosa
  • Wearing multiple layers of clothing
  • Cutting food into small pieces, eating very slowly, picking at food or inflexibility regarding the food items that one eats
  • Counting calories in food items before eating
  • Preparing elaborate meals for others
• Post-mortem findings
  • Decreased grey matter in the frontal lobe, cingulate and hippocampuss
• Signs and symptoms
  • Reduced BMI
  • Bradycardia
  • Hypotension
  • Enlarged salivary glands
• Physiological abnormalities
  • Hypokalemia
  • Low FSH, LH, oestrogen and testosterone
  • Raised cortisol and growth hormone
  • Impaired glucose tolerance (hyperglycemia)
  • Hypercholesterolaemia
  • Hypercarotinaemia
  • Low T3
• Differentials
  • Any condition that may cause weight loss: Cancers (esp. ALL, AML which come on insidiously), Hyperthyroidism
  • Bulimia: apparent based on the appearance of patient (
• Comorbidities
  • Obsessive Compulsive Disorder (70%)
  • Major Depressive Disorder (65%)
  • Borderline Personality Disorder
  • Body Dysmorphic Disorder
• Treatment
  • Admit
  • Consult an internist or paediatrician for correction of malnutrition (emphasize weight gain rather than feeding)
  • Group therapy (with positive or negative reinforcement)
  • Family therapy
  • Treat comorbidities appropriately
  • Atypical antipsychotic: particularly olanzapine for weight gain, to reduce hyperactivity used by patients as a weight losing tactic, and if body image disturbance is delusional in nature. Studies show that dopamine is increased in anorexia.
  • Zinc supplementation 14 mg elemental zinc daily for 2 months: neurotransmitter function, appetite stimulant effect, cheap and well tolerated
  • Amitriptyline
  • Treat comorbid depression or anxiety
• Prognosis
  • 30% have spontaneous recovery
  • 18-20% die by suicide

Complications of anorexia nervosa

Bulimia nervosa

Bulimia nervosa is characterized by recurrent episodes of binge eating with a strong desire or compulsion (craving to eat), large amounts of food consumed within a short period (under 2 hours), and lack of control over eating. At least one episode per week is required for at least 3 months. These episodes are followed by attempts to counteract ‘fattening’ by self-induced vomiting, abuse of laxatives and periods of starvation. The patient has a self-perception of being fat despite being around a normal body weight. Obsession is more appearance-related, rather than dysmorphic. Outwards symptoms are less severe than anorexia, but require intense psychiatric involvement. Binge-purge >> fasting.

The lifetime incidence is 2%. Incidence is about 12 per 100,000 population. It is more common in women than men (5:1 F:M ratio). Age of onset is in the 15 – 19 years old age group.

• Etiology
  • Childhood sexual abuse
• Types of laxatives abused
  • Stimulant: most commonly abused e.g. Senna and Bisacodyl. They directly stimulate colonic motility and have a relatively rapid effect in producing watery diarrhoea
  • Osmotic
  • Bulk-forming
• Features
  • Post-binge anguish
  • Ego dystonic
  • Buslimos – appetite of an ox
• Comorbidities
  • Borderline Personality Disorder
  • Anorexia Nervosa
• Treatment
  • Cognitive Behavioral Therapy: first line treatment. To identify dysfunctional patterns and belief that predispose and maintain the eating disorder. Behavioral interventaions to break bingeing-purging cycle (exposure and response prevention)
  • Interpersonal therapy
  • SSRI e.g. High-dose Fluoxetine: reduces bingeing urges and obsessional preoccupation with weight
  • Tricyclic antidepressants
  • Topiramate: appetite reducing effects

Complications of bulimia nervosa

Binge eating disorder

Binge eating disorder is characterised by binge eating episodes (as described in bulimia nervosa). It is not associated with compensatory behaviors e.g. purging or starvation.

More common than anorexia and bulimia. The lifetime prevalence is 4% in women and 2% in men, with a F:M ratio of 2:1. The peak age of incidence is between 25 and 34 years.

• Etiology
  • Implicated ghrelin, leptin and a family history
  • Food and comfort to relieve emotions (learned behavior)
• Features of a binge eating disorder
  • Emotional disturbance after binge eating (feeling disgusted with self or guilty afterwards)
  • Eating more rapidly than usual
  • Eating alone (due to embarrassment)
  • Eating even when not hungry
  • Do not purge
  • Do not obsess over thinness
• Treatment
  • Similar to bulimia nervosa
  • Weight-los sprogrammes or individual coaching to help with obesity
  • Bariatric surgery for binge-eating disorder associated with morbid obesity
• Complications of binge-eating disorder
  • Psychological distress due to inability to control binge urges
  • Binging may take precedence over other aspects of life e.g. work, family and social activities
  • Obesity-related problems: Type II Diabetes, hypertension, dyslipidaemia, GERD, arthritis, gall stones and sleep apoea

Anorexia Nervosa vs Bulimia Nervosa

• Common features of anorexia nervosa and bulimia nervosa
  • Common in adolescent females
  • The patient may binge/purge or fast
  • Physical signs signs include poor dentition (from vomiting), russel’s signs, Mallory-Weiss tears (painless hematemesis)
  • Labs may reflect frequent vomiting (hypochloremic hypokalemic metabolic alkalosis; may have arrhythmias from hypokalemia so it is appropriate to get an EKG)
  • Patients preoccupied with how they look
• Features that distinguish anorexia nervosa from bulimia nervosa
  • Anorexia patients will be severely underweight (BMI <17.5)
  • Anorexia patients will have missed 3 menstrual cycles (3 months of amenorrhoea)
  • Anorexia patients will show outward signs of malnutrition (hair loss, lanugo, peripheral oedema) and physical signs (bradycardia, hypotension)

Other eating disorders

Avoidant/restrictive food intake disorder: a child (usually) avoids certain food based on temperature, consistency, colour etc. They usually grow out of it as they become adults.

Pica: Eating inedible substances such as clay, chalk, paint, cigarette ash, paper etc. It is seen in normal developing children, pregnant malnourished mother, intellectual disability, and vitamin and mineral deficiency. Pica can be comorbid with OCPD, schizophrenia, IDD, ASD, trichotillomania and excoriation disorder

Rumination disorder: usually an infant or young child who regurgitates food that has been swallowed and chews it again.

Other specified feeding or eating disorders (OSFED):

Atypical anorexia nervosa: some criteria are not met e.g. normal weight

Subthreshold bulimia nervosa or binge eating episodes: binge eating episodes not a severe in terms of frequency or duration.

Purging disorders: recurrent self-vomiting, misuse of laxatives and diuretics etc. without binge eating

Night eating syndrome: recurrent episodes of eating at night when waking up from sleep, independent of any mental illness or sleep disorder