| ICD-9-CM: |
| 306 - | Physiological Malfunction Arising from Mental Factors; Psychogenic: Physical Symptoms Not Involving Tissue Damage, Physiological Manifestations Not Involving Tissue Damage |
| 306.4 - | Physiological Malfunction Arising from Mental Factors, Gastrointestinal; Aerophagy; Cyclical Vomiting, Psychogenic; Nervous Gastritis; Psychogenic Dyspepsia |
| 306.8 - | Psychophysiological Malfunction, Other Specified; Bruxism, Teeth Grinding |
| 307 - | Special Symptoms or Syndromes, Not Elsewhere Classified |
| 307.1 - | Special Symptoms or Syndromes, Not Elsewhere Classified; Anorexia Nervosa |
| 307.5 - | Special Symptoms or Syndromes, Not Elsewhere Classified; Other and Unspecified Disorders of Eating |
| 307.50 - | Special Symptoms or Syndromes, Not Elsewhere Classified; Eating Disorder, Unspecified |
| 307.51 - | Special Symptoms or Syndromes, Not Elsewhere Classified; Bulimia Nervosa; Overeating of Nonorganic Origin |
| Eating disorders are psychological disturbances related to body image and eating habits. Anorexia nervosa and bulimia nervosa are two primary eating disorders recognized today. Both are serious, life-threatening conditions that are difficult to treat. A third condition, binge eating disorder, has been described and is in the process of being validated.
Anorexia nervosa, a potentially life-threatening condition, is characterized by obsessive concern over one's body weight, specifically the fear of appearing fat. As a result, individuals with this disorder rigidly restrict their dietary intake, are markedly underweight, and often suffer from malnutrition. Frequently the individual will abuse laxatives or deliberately cause vomiting in an effort to avoid what is regarded as excess calories. The individual may exercise excessively. Because their self-image is greatly distorted, individuals may see themselves or parts of their bodies as grossly overweight even though they may appear emaciated to others. A major feature of this eating disorder is denial. While the problem is painfully evident to those around them, the afflicted individual is blind to it. Even when the condition is brought to the individual's attention, there is little or no change in eating habits until failing health finally forces medical attention.
Bulimia nervosa, a closely related condition, is characterized by episodes of "binge" eating followed by desperate measures to avoid weight gain. Usual measures include dieting, purging (self-induced vomiting), laxative and/or diuretic abuse, and, in some cases, excessive exercise. Like anorexia, body image is distorted and there is a preoccupation with physical appearance. Unlike anorexia nervosa, however, most individuals with bulimia are of normal or near normal weight, or may even be somewhat overweight. Individuals with bulimia are at risk for a number of potentially serious health hazards including malnutrition, electrolyte imbalances, esophageal ulcers or rupture, and rampant dental decay.
While the cause of anorexia nervosa is unknown, social factors, especially the desire to be thin, appear to be important. Bulimia, on the other hand, stems from a combination of factors. Personality traits include impulsiveness, vulnerability, feelings of low self-esteem and helplessness, and the fear of becoming fat and unattractive. Although bulimia and other eating disorders are considered learned behavior, a suspected genetic link may also explain why they tend to run in families. Biochemical abnormalities may help to explain why some bulimic women cease to have their monthly menstrual period and also the relationship between eating disorders and depression, as evidenced by the unusually high suicide rate among bulimics.
Binge eating disorder has recently been identified as an eating disorder. Unlike bulimia nervosa, the binging in the binge eating disorder is not followed by purging. Occurring most commonly in individuals who are already obese, the additional caloric intake leads to increasing body weight. These individuals struggle with eating behavior. The binges occur at least twice a week for a 6-month period but the pattern does not meet full criteria for bulimia nervosa (Brotman 140).Risk: Anorexia nervosa and bulimia nervosa predominantly afflict adolescent and younger-adult females, and are about 10 times more common in women than in men. Individuals with binge eating disorder tend to be older than those who have anorexia nervosa or bulimia nervosa, and nearly half of them are male. There is an increased risk of anorexia nervosa for individuals with first-degree relatives diagnosed with the disorder (DSM-IV-TR 588). Incidence and Prevalence: An estimated 0.5% of females (usually late adolescence and young adult) meet criteria for anorexia nervosa. The data for males are insufficient to provide an accurate estimate of occurrence (DSM-IV-TR 588-589).
The prevalence of binge eating disorder in diet clinic samples is about 30%; in general population samples, it is less than 5% (Brotman 140). The prevalence of eating disorders in female athletes has been estimated to range from 15% to 62% (Rome 357). |
Source: Medical Disability Advisor
| History: Because the individual may consciously or unconsciously hide the disorder from others, laboratory and physical examination data may be used to support the diagnosis. Diagnostic criteria are published in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision).
The critical elements under DSM-IV-TR necessary to make the diagnosis of anorexia nervosa are: body weight less than 85% of what is normal for age, sex, and height; an intense fear of becoming fat or gaining weight; disturbed body image and/or denial of the problem; and, in women of childbearing age, loss of menstrual cycling due to malnutrition. Although half the individuals with anorexia nervosa binge and then purge (or similar compensatory measures), the other half simply restrict the amount of food that they will eat.
Individuals with bulimia nervosa rarely admit to their behavior. Behavior includes repeated episodes of excessive eating, while feeling a loss of control over what is consumed. Binges are followed by intense guilt and repeated efforts to prevent weight gain by purging, vigorous dieting, and excessive exercise. Although body weight actually tends to fluctuate around normal, self-esteem is overly dependent on their perceived body image. To be considered bulimia nervosa, the above must occur at least twice a week for 3 months, and these symptoms must present apart from episodes of anorexia nervosa.
An unspecified eating disorder refers to any condition similar to the above, but which fails to meet all of the criteria. Examples would include anorexia nervosa where menstrual cycling still occurs, or purging after even small meals. Binge eating disorder refers to a pattern of binge eating without purging. Although binge eating disorder does not result in the physical complications that can occur with bulimia nervosa, individuals with this disorder are distressed by it. Approximately 50% of binge eaters are depressed, compared to only about 5% of obese individuals who do not binge. Increased body weight leads to the medical complications associated with obesity. Physical exam: Because individuals with eating disorders rarely admit to their behavior, the physician may be alerted to the condition by unexplained symptoms. Signs of anorexia include emaciation, low blood pressure, low body temperature, skin dryness, fine downy hair covering the skin surface (lanugo), a severely slow heart rate (bradycardia), brittle nails, and thinning hair. Symptoms of bulimia include loss of dental enamel on teeth and tooth decay, enlarged salivary glands, irritation of the esophagus, sores or calluses on the index finger or knuckle, and scars on the back of the dominant hand as a result of the hand rubbing against the teeth during forced vomiting episodes. Bulimia may not be evident until persistent vomiting causes a serious metabolic disturbance or internal bleeding. In some cases, attempted suicide is the first obvious indication. Symptoms associated with the excess body weight of binge eating disorder include shortness of breath (dyspnea); fatigue; joint pains in the hips, knees, and ankles; and a general dissatisfaction with their state of health. Tests: Laboratory testing is useful in making the diagnosis and monitoring for complications, such as blood salt imbalances, hormonal disturbances, heart problems, and dehydration. Another useful aspect of testing is to monitor compliance with treatment recommendations and to watch for relapse.
Two psychological screening instruments useful in eliciting the symptoms of anorexia nervosa and bulimia nervosa are the Eating Disorder Inventory-2 (EDI-2) and the Bulimia Test–Revised (BULIT–Revised). |
Source: Medical Disability Advisor
| Individual and family therapy are designed to address the physical, emotional, and behavioral elements involved in anorexia nervosa and bulimia nervosa. A variety of treatment approaches have been tried with moderate success. The more successful treatments involve multiple disciplines and include behavioral modification, psychotherapy, and careful medical attention. Individual therapy may be supplemented with an eating disorders group therapy.
When weight loss from anorexia has been rapid or severe (more than 25% below ideal body weight), restoring body weight is crucial. Because such weight loss can be life-threatening, the individual is usually hospitalized so that experienced staff members can firmly but gently encourage the individual to eat. If unsuccessful, the individual may have to be fed intravenously or through a tube inserted in the nose and passed into the stomach.
Anti-depressant medication has been found to be helpful for some individuals with bulimia, whether or not there is accompanying depression. In contrast, anti-depressant medication is typically not helpful for individuals with anorexia, unless it is used to treat accompanying depression.
Specific treatment for binge eating has been based on the treatment of bulimia nervosa. Although antidepressants and appetite suppressants are proving to be reasonably effective in controlling binge eating, psychotherapy appears to have longer-lasting effects.
Typically, treatment is carried out over months to years. In severe cases, inpatient treatment may be necessary. Medical complications may require hospitalization. Because eating disorders are potentially life-threatening, good medical care, including frequent physical exams, is important.
For binge eating disorder, research suggests that cognitive behavioral therapy focused on modifying the binge, coupled with antidepressants (particularly the SSRIs) may result in better outcome.
The professional discipline of psychotherapists treating individuals with eating disorders is said not to be as important as their competence. Desirable characteristics include specialized knowledge; personality traits like non-possessive warmth and perseverance; training in scientific, manual-based psychotherapy; and supervised experience. |
Source: Medical Disability Advisor
| Because eating disorders are usually quite complicated, it is difficult to predict the outcome. Generally, the younger the age at which the symptoms appear, the poorer the prognosis. Over a 5-year span, approximately one-third of individuals will have a complete or near complete remission of their symptoms, one-third will show significant improvement, while the remaining one-third either fail to improve or deteriorate. Death rate (mortality) is significant.
When an individual becomes malnourished, either from not eating or from constant purging, every major body system can be affected. The most dangerous are problems with the heart and fluid or electrolyte imbalances. As the heart gets weaker, less blood is pumped throughout the body. As the blood becomes more acidic (metabolic acidosis), potassium levels may decrease. Vomiting, laxatives, and diuretics worsen the situation. Resulting abnormal heart rhythms can lead to sudden death. Anorexia nervosa has a mortality rate of 4% to 5%, but some studies place it as high as 20%. |
Source: Medical Disability Advisor
| Eating disorders can lead to serious medical problems, depression, and suicide. Complications associated with anorexia include absence of menstrual cycling, and other hormonal problems, and malnutrition. Severe imbalances in blood chemistry can cause irregular heartbeat, seizures, coma, and death. Muscle wasting, kidney failure, problems due to poor liver function and superior mesenteric artery syndrome are other possible complications. Weight can drop to less than 75% of normal, a very dangerous condition requiring hospitalization.
Individuals with bulimia also risk severe blood chemistry imbalances with associated complications, including rupture of the stomach or esophagus, and advanced dental decay. Depression, irritability, insomnia, and generally poor mental functioning are some of the more common psychological complications. Suicide is unusually high among bulimics.
Excessive accumulation of body fat (obesity) from binge eating disorder can lead to degenerative joint disease, arthritis, diabetes, and high blood pressure. |
Source: Medical Disability Advisor
| Work restrictions or accommodations are necessary only infrequently for the most serious cases. When they are necessary, time-limited accommodations are based on individual need because of the variety of serious complications possible with eating disorders. Any job duty that heightens awareness of physical appearance such as modeling or dancing is apt to make these conditions worse. Highly stressful situations may worsen these illnesses or trigger a relapse. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual's condition meet the criteria for an eating disorder? Has the diagnosis of anorexia nervosa or bulimia nervosa been confirmed?
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Have psychiatric disorders and underlying medical conditions with similar symptoms been ruled out?
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Does individual have an underlying condition that may impact recovery?
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If there is evidence of drug or alcohol abuse, how are these issues being addressed?
Regarding treatment:
- Is individual being seen by a physician with training or experience in treating eating disorders? Does individual feel comfortable with the physician?
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Does the therapist have special training and expertise in the treatment of eating disorders?
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Does the physician routinely monitor the individual for medical complications?
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What type of therapy is individual involved in? Is therapy individual or family oriented? Does individual feel comfortable with the therapist? Does current therapy mode appear to be effective?
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Would individual benefit from being involved in a group therapy with other eating disorder individuals?
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Have medications such as antidepressants or appetite suppressants been effective in controlling binge eating?
Regarding prognosis:
- How motivated is individual to cooperate with his or her own health care?
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Do treatment goals need to be revisited? Are expectations realistic?
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Does individual need assistance finding referrals, making appointments, and getting to appointments?
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Does individual have support from family, friends, and co-workers?
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Source: Medical Disability Advisor
| Brotman, A. W. "Eating Disorders." Jacobson: Psychiatric Secrets. Eds. James L. Jacobson and Alan M. Jacobson. 2nd ed. Philadelphia: Hanley & Belfus, Inc., 2001.Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000. Rome, E. S. "Eating Disorders." Occupational Medicine Practice Guidelines 30 (2003): 357-377. |
Source: Medical Disability Advisor
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