10. Eating and sleeping disorders Flashcards
Eating as a mental disorder?
“Body image problems and eating disorders sit on a continuum which ranges from healthy body image and eating patterns through disordered eating and eating behaviours…to… diagnosable clinical eating disorders”.
the DSM 5 feeding and eating disorders
Pica Rumination disorder avoidant/restrictive food intake disorder anorexia nervosa blimia nervosa binge eating disorder unspecified feeding or eating disorder other specified feeding or eating disorder
How are feeding and eating disorders characterised in the DSM 5?
“Characterized by persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning”
Diagnostic criteria for ANOREXIA NERVOSA
Significantly low weight
Intense fear of gaining weight
Disturbance in experience of body weight or shape
Significantly low weight criteria of anorexia nervosa
– BMI below 18.5 – lower limit for normal weight
– BMI below 17 – ‘moderate to severe thinness’
– Rapid weight loss
– Percentage of ideal body weight for age, height, sex
– Threats to physical health
Extreme emaciation is not unusual
Most people with this diagnosis are 25-30%
below normal body weight
Defining Thinness
BMI – a popular indicator
• But only one metric – doesn’t capture other factors
elevant to health
– Waist size
– Fat, bone, muscle mass are not taken into account
• Other indices of health also need to be taken into account
Physical impact of low weight
• Amenorrhea
• Dry skin, brittle hair & nails
• Increased sensitivity to cold
• Lanugo: downy hair growth on face and limbs
• Dehydration
• Cardiovascular problems (e.g., low blood pressure, slowed pulse rate,
cardia arrythmia)
• Dizziness, episodes of fainting
• Low temperature – risk of hypothermia
• Extreme fatigue/physical exhaustion
• Osteopenia (low bone density) leading to osteoporosis/stress fractures
• If purging – electrolyte imbalance; dental problems; sensitized gag reflex
• Infertility, perinatal complications
Intense fear of gaining weight criteria for anorexia nervosa
• Intense fear of gaining weight, becoming fat,
OR
• Persistent behavior that interferes with weight gain, even though at a significantly low weight
• Often terror/panic at prospect of eating
• Not alleviated by weight loss and often becomes more intense with weight loss
Behaviours that interfere with weight gain in anorexia nervosa
– Restricting food intake – often drastically
– Excessive exercise
– Purging, even following very low intake
Disturbance in experience of body weight or shape criteria for anorexia nervosa
- Distorted body image
- Inaccurate perceptions of size/shape
- Weight/size the most important factor in self evaluation/sense of worth
- Poor recognition of low weight and seriousness of low weight
Poor recognition of low weight and seriousness of low weight
– Unable to recognise emaciation – perceive self as overweight
– Inability/refusal to acknowledge seriousness of low weight
Restricting type anorexia
During the episode of anorexia nervosa the person does not regularly engage in binge eating or purging behaviour. Low weight is maintained by extremely low food intake. May:
• Avoid food/eating altogether
• Eat certain foods only
• Have a very low calorie intake
Binge eating/purging type anorexia
During this episode of anorexia nervosa, the person has regularly engaged in binge eating or purging behaviour. Often alternating with periods of restricting. Purging may include: • Vomiting • Laxative use • Excessive exercise • Enemas
Associated features of anorexia nervosa
- Depressed mood
- Irritability
- Social withdrawal
- Insomnia
- Preoccupation with food and eating
- Inflexible thinking
- Food related obsessions – hoarding food, collecting recipes, cookbooks, pictures of food
- Compulsive eating rituals
- Common comorbidities include: Depression and OCD
Anorexia nervosa death rate
AN has highest death rate of all mental illness
– Partially due to medical factors
– Partially due to suicide
Course of AN
In longitudinal research
• ~20% remain significantly underweight
• ~5-20% estimated death rate
• Remainder are in healthy weight range
– While weight may be in normal range, preoccupation with diet, image, shape and weight often remain
– Depending on level of starvation, may have long term physical complaints (e.g. osteoporosis)
Bulimia nervosa diagnostic criteria
recurrent episodes of binge eating
compensatory behaviours to prevent weight gain
self-evaluation is unduly influenced by shape and weight
Define Binge eating
- Eating, in a discrete period, an amount that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances (usually less than 2 hours)
- Associated with a sense of lack of control
Binge eating as a criterion for Bulimia Nervosa
- Typically involves foods that are usually avoided by the person
- Sense of uncontrollability – unable to stop once started
- May describe dissociation during or after
- Often triggered by stressors – interpersonal conflict, boredom, negative feelings about self
- May describe a general state of negative affect/dysphoria
- Typically followed by intense dysphoria, disgust, shame
Compensatory Strategies (Purging) as a criteria for BN
Attempts to purge the foods consumed from the body
– Self-induced vomiting (most common)
– Laxative/diuretic use
– Exercise
– Fasting
– Enemas
– In those with diabetes, omitting or reducing insulin
Physical implications of Bulimia
• Physical complications are secondary to purging pattern
Depend on the nature of purging
– Fluid and electrolyte imbalances (cardiac arrhythmia, renal failure)
– Erosion of dental enamel
– Enlargement of salivary glands
– Sensitive gag reflex
– Callusing on fingers and back of hand from contact with teeth and throat to stimulate gag reflex
– Intestinal problems (e.g., colon damage) if laxative abuse
– Can become dependent on laxatives to stimulate bowel movements
– Rare but potentially fatal complications include esophageal tears and gastric rupture
Self-evaluation unduly influenced by shape and weight as a criteria for BN
- Often high dissatisfaction with weight and shape
- Self-worth tied to weight and diet
- Seek to lose weight/avoid gaining weight
- Comparisons to others resulting in negative selfevaluation
Associated features of BN
- Of normal weight or overweight
- May engage in dieting/restriction of food intake between binges
- Typically deeply ashamed of pattern
- Binge eating often occurs in secrecy
- Depression is often comorbid
The co-existence of symptoms of AN and BN
Often not seen in “pure” form – symptoms of both AN and BN typically co-exist
– 50% of persons with Anorexia engage in bingeing and
purging
– Many people with bulimia have a history of anorexia
– Diagnostic flux – high rates of movement between diagnoses
• Longstanding criticism of the classification of eating disorders is the high rate of use of DSM Unspecified/Not otherwise specified categories
Binge eating disorder
BED involves recurrent episodes of binge eating without compensatory behaviour
– Large amount of food in 2 hrs
– Loss of control over eating
– 3 or more associated symptoms – rapid eating, disgust, embarrassment, secrecy
– Marked distress
– Occurs once a week or more for 3 or more months
Should DSM-5 have included obesity?
- Does obesity cause subjective distress / impairment?
- Is the involvement of biological factors sufficient reason NOT to include it? [Arguments against its inclusion include the potency of “biological” factors]
- If not as an eating disorder, then as an addictive disorder (Moreno & Tandon, 2011)
The effect of including obesity as a mental illness in the DSM-5?
what is the effect of including obesity in DSM on our conceptualization of mental illness? Would it mean that the number of people diagnosed would conflict with rarity notions of “abnormal” behaviour?
Are eating disorder concepts too narrow?
- Are there other ways distortions in body image can unduly influence our behaviour?
- Should behaviours other than eating be considered here?
- How else might distorted body image show up in behaviour?
Prevalence of eating disorders
– Highest rates are in young women
– AN and BN each occur in approximately 1% of the population
• AN 0.5-1%, BN 1-1.5%
– Cohort effects – the lifetime prevalence of BN is much higher in women born after 1960 than those before 1950
– ? Role of change in cultural standards
AN as a culturally specific disorder?
– Highest prevalence in Western industrialised countires
– Previously thought to occur in Western/first world countries only
– Some evidence occurring in other countries such as Japan (unsystematic interviews with health workers).
Who is most at risk of eating disorders?
young females from high SES groups
age and gender as risk factors of eating disorders
- Women are more likely to be affected by ED’s but men may also experience them
- Both AN and BN typically have onset in adolescence and early adulthood
- Weight and dieting (and the presence of EDs) decreases as adolescent girls become women (esp. following marriage & parenthood)
- Men become more concerned with weight with age
Eating disorders in men
• Eating disorders do occur in men
• Rates are lower (~0.3%)
• Often documented in subgroups including
– wrestlers (pressure to “make weight”)
– Athletes (AFL player case examples)
– Dancers
• Age of onset of eating disorders in men & women similar
Cultural factors that cause eating disorders
– Value placed on thinness
– Reinforcing centrality of appearance in acceptance
– Those who participate in sports/activities with a strong focus on weight, appearance are at higher risk
– E.g. ballet, athletics, gymnastics, ice-skating, modelling
other sociocultural factors of eating disorders
• Acceptance (or promotion) of dietary restraint – in family, workplace, social groups, online groups
• Role modelling
• In many families, direct messages about appearance and weight
may be shared
Role modelling as a cause of eating disorders
observations of relatives engaging in dieting, negative self-evaluation, disordered eating (Lieberman, Gauvin, Bukowski, & White, 2001; Pike & Rodin, 1991)
Psychological aetiologies for eating disorders
• Thin ideal internalisation
• Perfectionism, emotional constraint, rigidity represent risk factors for
AN
• Poor interoceptive awareness – difficulty tuning into bodily signals
• Anxiety associated appearance of self to others
• Distorted perception of body size/weight
• High level of dissatisfaction with body
• Self worth tied to appearance, weight, body shape and size
Thin ideation internalisation
the degree to which identifies with cultural value of thinness – how much do you believe thin = attractive
