INTRODUCTION
Night eating syndrome (NES) is a syndrome characterized by morning ano-rexia, evening hyperphagia and insomnia. The nocturnal food ingestion is 50% > of daily calories intake and it occurs three times a week for a period of 3 months. NES is commonly associated with obesity and often has an underlying psychosocial problem (Allison et al, 2005). Though it is a fairly common syndrome it is often being overlooked. More often than not the emphasis is more towards medical and cosmetic reasons without paying serious attention on the underlying psychosocial issues which often lead to an unsuccessful outcome.
CASE REPORT
Mr AW, A 65 year old Malay widower, a retired army sergeant, was referred to the psychiatric clinic for psychiatric assess-ment. He had multiple medical illnesses and was chronically feeling depressed and had problems with excessive weight gain since the age of 41 (for 24 years). During the same period he retired from the army and said that his wife left him to elope with her ex-boyfriend. The symptoms worsened when his son who was staying with him decided to move out in 2002. He became more depressed and had insomnia, re-maining awake at night and could only sleep by 0500 hours. When he could not sleep he would cook despite not feeling hungry. He ate a lot of high calory and junk food such as fried rice and chicken, nug-gets, cream, biscuits, cake or ice-cream. He also had large amounts of food stocked up in the refrigerator which he kept in his bedroom. He had peculiar eating patterns when he would skip breakfast and take a late lunch. His urge to eat increased during the night. However, he had no compensa-tory behaviour such as self-induced vomit-ting, consume laxatives, pills or diuretics. He was diagnosed with diabetes, hyperten-sion, ischemic heart disease and conges-tive cardiac failure for 10 years. With these illnesses he was admitted several times. Currently, his physical state and illnesses are stable and are under control. In the past he was admitted to the psychiatric ward for depression but was discharged well without medication. There was no history of manic swings. His father was a traditional healer and an alcohol depend-ent; he was rather passive and was ineffec-tive as a father. His mother was severely obese and was described as very strict, harsh and domineering. All his siblings were obese. At school, the patient was an average student and joined the army at the age of 21. He was promoted to sergeant four years later until he retired at the age of 41. Subsequently he worked as a security guard for 20 years until the age of 60. He is now survived on his pension. His perso-nality traits are a mixture of obsessional and borderline traits, characterized by punctuality, determination, impulsiveness, low self-esteem and chronic boredom. His weight was 120kg, height 167.5 cm with waist circumference of 159.5 cm. His body mass index (BMI) was 45.
The management consists of a multi-disciplinary teams comprising of a dietician, psychiatrist, psychologist, physician and surgeon. The patient was put on Escitalo-pram 10mg to treat his depression and at the same time underwent cognitive beha-vior therapy. The principal of management in this patient is that while the physician takes care of his physical illnesses, the therapist guides the patient to exercise self-monitoring and to keep a food diary. This is a crucial component of the therapy to enhance awareness of his eating habits and pattern. Since his BMI was 45, and with the presence of co-morbid conditions, he was also referred to a surgeon who recommended him to undergo bariatric sur-gery. However, surgery was later cancel-led because the patient could not afford it. The only option left was the non-surgical interventions. The dietician educated him on proper nutrition to help him identify his main source of calories as this would help him to lose and maintain his weight. The therapist also stressed on healthy lifestyle and regular exercises. With the help of therapists Mr AW identified many types of triggers that precipitated his eating epi-sodes which include long gaps between meals and negative emotions such as boredom, frustration and familial stressors. He was then educated on stimulus control techniques, trained in problem solving skill, cognitive restructuring and relapse prevent-ion. He soon responded to treatment and his eating patterns improved and he could sleep well at night. The NES behaviour has stopped and his weight has reduced from 123 to 91kg over a period of 18 months.
DISCUSSION
The comprehensive management of this case need a multidisciplinary team ap-proach comprising of the assessment and the management of issues related to medical, nutritional, psychological and psy-chiatry problems (Labib 1994). Research has demonstrated that depression, inter-personal problems, boredom, prolonged fasting could all lead to the development of night eating syndrome (Allison et al, 2005). All these are present in this patient. Al-though eating disorders usually develop in adolescence or young adulthood, they could also affect people above 40 and in children. This patient came late for treat-ment which is 20 years later. This is not un-common because usually people with an eating disorder do not reveal their problems or even conceal them due to denial or lack of awareness. They may also feel ashamed or are ignorant of the treatment available (Annie 1999).
Although patients with an eating disorder may be unwilling to enter treatment the clinicians could persuade them by showing lots of empathy, understanding and take a non judgmental approach. Of course, the patient’s motivation is the key component for success in any kind of treatment. Generally, the psychiatric assessment of patients with eating disorders would center around establishing a correct diagnosis, identifying co-morbidity and evaluating the underlying psychosocial issues and con-flicts (Labib 1994). Obviously the psycho-social issues in this patient are loneliness, boredom and frustration. He also has low self esteem and depression. Many obese individuals would perceive food as an attempt to decrease emotional upheavals.
Biologically, a neurobiological investiga-tion showed that there was an association between psychopathology, weight regula-tion and eating behavior (Hasler et al 2004). While dopamine modulates the rewarding effects of food and the develop-ment of obesity (Rye and Jankovic 2002), it also has an important role in the patho-physiology of sleep-wake disturbances (O’Reardon et al. 2004). The Serotonin has been implicated in the control of impulses of eating behavior and depression (Ricca et al. 2002). In our case, escitalopram was chosen because it is the best selective serotonin re-uptake inhibitor for those with depression and poor impulse control asso-ciated with multiple medical illnesses for it has less drug interaction property (Sproule et al. 1997). The other important substance is the appetite-regulating hormone. A study reported that ghrelin levels were lower in NES than in control subjects in the early morning hours when patients remained awake (Wang et al. 2001). There was evi-dence to show that psychopathology and weight problems might share common genetic factors. Findings of a twin study demonstrated an association between de-pression and obesity in which familial / genetic factors influence the vulnerability to depression as well as obesity (Hasler et al. 2004). Cultural factors also contributed to obesity. It was noted that people originating from Eastern Europe and living in the United States had a higher incidence of obesity than people from Western Europe (Bray 1976). Generally the contributing factors to the development of obesity are biological factors, abundance of food, decrease physical activity, basic food habits which include food of high calories and emotional disturbances. Regardless of the cause or factors that contribute to obesity, it can create difficulties that will affect emotional well-being, sexuality, physical and occupa-tional identities as well as the social role. Therefore this problem needs an urgent and comprehensive intervention compri-sing of the bio-psycho-social approaches.
CONCLUSION
An integrated approach is required to understand the aetiology and treatment of obesity. The successful management of morbid obesity requires a coordination of care from multiple disciplinary groups namely physician, psychologist, nutritionist, surgeon and psychiatrist, with varied ex-pertise working together as a team to assist patient care.
ACKNOWLEDGEMENTS
The authors would like to thank the patient and all staffs who have helped in the management of this case.