13 - eating disorders and body dysmorphia

Question 1

What is the meaning of the word anorexia nervosa?

Answer 1

→ An: Lack of
→ Rexia: appetite
→ Nervosa: of the nervous system

Question 2

What are the 2 main features of anorexia nervosa?

Answer 2

1) Active restriction of energy intake, relative to what the person needs which leads to a significant low body weight in the context of age, sex, developmental trajectory, and physical health
→ you can compare weight to percentile, to developmental growth
2) Overvaluation of shape, weight, and their control
→ judging self-worth, largely or exclusively in terms of shape, weight and the ability to control them
→ core psychopathology of eating disorders (the core ingredient of eating disorders)

Question 3

What is the meaning of the word bulimia nervosa?

Answer 3

→ Bu: ox (animal)
→ limia: appetite
→ (i.e., having the appetite of an ox, so eating a lot)

Question 4

What are the 3 main features of bulimia nervosa?

Answer 4

1) Recurrent binge eating
→ an episode of eating an objectively large amount of food
→ objective vs. subjective binge (important to make this distinction)
→ sense of loss of control
2) Extreme method (one or more) of weight control
→ p.ex: purging, using medication that make you lose weight faster, etc.
3) Overvaluation of shape, weight and control (core ingredient)
The binge eating and inappropriate compensatory behaviours are required to occur, on average, at least once a week for 3 months

Question 5

The extreme methods of weight control in bulimia are a lot like…

Answer 5

• These extreme methods of weight control are a lot like safety behaviours, BUT we have to ask what the function is of that behaviour
  → p.ex: to undo the effects of food that you’ve eaten; to relieve feelings of anxiety
  → just because you’re seeing self-induced vomiting, doesn’t mean it’s necessarily an ED

Question 6

What is binge eating disorder?

Answer 6

• No core ingredient of overvaluation of shape and weight, it’s really just a sense of loss of control
• One primary feature of recurrent binge eating
  –> Occurs in the absence of the extreme weight-control behaviour seen in bulimia
• Marked distress regarding binge eating, accompanied by shame and self-criticism
  Required to occur at least once a week for 3 months

Question 7

What are other specified eating disorders?

Answer 7

• Atypical anorexia nervosa: anorexia BUT not at a significantly low weight
• Bulimia nervosa (of low frequency and/or limited duration)
• Binge-eating disorder (of low frequency and/or limited duration)
• Purging disorder
• Night eating syndrome

Question 8

Why is it difficult to frame EDs in categories?

Answer 8

→ it’s difficult to frame EDs in this way because a lot of people aren’t falling into the categories, but do still present symptoms

Question 9

What is body shape dissatisfaction?

Answer 9

• Refers to not liking smt about your body, which is extremely common) or “normative discontent” vs. “overvaluation of shape/weight”
  → “body shape dissatisfaction” is contrasted by shaping your entire sense of self on your body image

Question 10

What is the family-based approach?

Answer 10

Treatment manual for anorexia nervosa
- Focused on getting the family involved in the intervention, because when young people are at significantly low weight, it really is an emergency (can lead to heart problems, bad bones, etc.)
→ we have to see how they lost a significant amount of weight over a period of time, not only if they look like they’re at a normal weight
- “Establish that there is a crisis in the family and begin the process of defining and enhancing parental authority to manage the crisis”
→ in a lot of problems, we usually have a lot of lee-way to let people go at their own pace BUT, with anorexia, as someone continues to be below weight, there’s an impairment in thinking that’s occurring (less flexible in thinking)
→ so, we’re on a life or death timeline here, we need to establish that this is incredibly serious
- “You are the people with the biggest investment of love and commitment to your daughter, so you are also the ones most likely to help the most with this problem”
→ because the interventions really have to play out in the home at meal times
→ parents play a big role in turning it around
→ “Your daughter is desperately ill and something very drastic has to happen for you to save her life” AND “You must be devastated and worn out by this terrible ordeal…”
→ this is a therapeutic bind: disorient the family AND be kind and containing at same
→ this is often the balance that needs to be found with any crisis
→ you’re trying to really up the anxiety in the parents, they need to see it as a crisis with a time-limit

Question 11

EDs are usually ___ at the start, this is common thinking (i.e., “this is good that I have control over my eating”)

Answer 11

Egosyntonic: meaning they’re happy with it and it aligns with their goals
- BUT, with time, they become egodystonic

Question 12

How do we coach parents in the family-based approach?

Answer 12

→ “You have to provide your daughter, who is starving, the kinds of food that would restore her weight to normal”
→ “It is full-cream milk and pasta with a cream sauce that will make the difference, not salad”
→ the first step is usually this re-feeding process, because the girl is nutritionally lacking

Question 13

What is the therapy for adolescents with EDs?

Answer 13

Cognitive behaviour therapy for adolescents with EDs

Question 14

What is the transdiagnostic cognitive behavioural theory disorders?

Answer 14

• Starts with the core ingredient of overvaluation, then leading to strict-dieting or taking control over input
  → usually very restricting caloric intake, much smaller than needs
  → this restriction is usually the antecedent of binging
  → binging is preceded by restriction: if you don’t eat enough during the whole day, you feel like you need to eat more by the end of the day, your body is built to try to compensate for that
  → no one can handle that level of restriction for so long, so we binge, which then leads to the compensatory behavior (vomiting p.ex)
• Features of under-eating (weight is low or not): peoples minds become foggy, concentration decreases, flexibility in thinking decreases, changes in mood, etc.

Question 15

What happens in ED according to the transdiagnostic theory?

Answer 15

• You end up in cycles that are related to interoceptive feelings
  → p.ex: feeling full is interpreted as feeling fat
  → a body sensation that you basically have no choice but to have, but if it’s interpreted as “my worst fear has come true” then it’s gonna become a problem in the cycle

Question 16

What are downsides of having self-worth be determined by shape/weight/eating?

Answer 16

• We often see over-checking of shape and weight or complete avoidance of checking
• Preoccupation: topic that is very often on the person’s mind
• Mislabeling aversive states as “feeling fat”: low emotions, interoceptive feelings, etc.
• A lot of behavior and energy is surrounding this one domaine

Question 17

What occurs during the over-evaluation of shape and weight and their control?

Answer 17

• Dietary restraint
• Shape and weight checking and/or avoidance
• Preoccupation with thoughts about shape and weight
• Mislabelling adverse states as “feeling fat”
• Marginalization of other areas of life
  The last 4 having a bidirectinoal relationship with the overvaluaion

Question 18

What is the Minnesota experiment?

Answer 18

• During the 2nd world war
• 36 young men were conscientious objectors (part of free churches, that had passivism as a core belief, meaning they thought it was wrong to participate in a war, BUT they still wanted to help in how they could)
• The researchers fed them much less food than necessary
  → they had conditions where they tried to re-feed them in different ways to figure out the best way to re-nourish people, because there was a famine in Europe

Question 19

What were the effects (beheavioural, psychological, physical) of the Minnesota experiment?

Answer 19

Behavioural effects
- Eating rituals: eating slowly, cutting food into small pieces, ingesting very hot food
- Reading cookbooks and collecting recipes
- Increasing use of salt, spices, gums, hot soup & water, coffee and tea
- Nail-biting
- Increased smoking
- Binge-eating episodes
- Self-mutilation
Psychological effects
- Impairment of concentration
- Poor insight and critical judgement
- Preoccupation with food & eating
- Depression; mood swings; irritation; hunger; anxiety; apathy
- Psychotic episodes; personality changes; social impairment; social withdrawal
- Loss of sexual appetite
Physical effects
- Abdominal pain; gastrointestinal discomfort
- Sleep disturbances, vertigo
- Headaches; weakness; hypersensitivity to light and noises
- Cold intolerance

Question 20

What is “regular eating”?

Answer 20

• Early stage in intervention is “Regular eating”
  → if there’s severe restriction happening, this is inconsistent with it; this also makes binging less likely, because part of what causes binges is restriction, so if we eat every few hours, we interrupt the cycle
• Not very specific in what you eat, as long as you’re eating smt for each meal
  Pattern of eating:
• Breakfast
• Mid-morning snack
• Lunch
• Afternoon snack
• Evening meal
• Evening snack
  Points to note:
• Eat these meals and snacks, but do not eat between them
• Do not skip any meals or snacks
• Do not go for more than 4 hours w/o eating
• Eat what you like in the meals and snacks, but no vomitting or laxatives to compensate
• Always know when (and roughly what) you are going to eat next

Question 21

How does “feelings of fatness” vary along with actual weight?

Answer 21

• The feelings of fatness go up and down during the day, if you’re already vulnerable you’ll feel it more
• So we’ll have a set weigh-in every time they visit, and it’s graphed over time (and they can’t weigh themselves between this) to show them the actual stability in their weight
• The estimate of what it is is often inaccurate when based on feelings (we’ll ask what they think they’re weighing)
• We can do the same thing with shape (measuring tape over certain parts of the body over time)
  = We’ll show them the graph and their weight every time, BUT sometimes we only show it at the end

Question 22

What are some eating-related safety behaviours?

Answer 22

• Breaking food into pieces (that normally wouldn’t be)
• Odd mixing of foods
• Odd utensil use (fork for yogurt)
• Slow/quickened pace of eating
• Excessive small bites of food
• Eating foods in a certain “safe” order
• Leaving some food on plate

Question 23

What are some eating disorder-related safety behaviours?

Answer 23

→ Weight control behaviors
→ restriction
→ excessively drinking liquids (“hydro-loading”)
→ abusing diet pills
→ purging
→ excessive exercise
→ abusive laxatives/diuretics
→ fasting

Question 24

What are some exercise-related safety behaviours?

Answer 24

→ Excessive bending/stretching
→ Purposely choosing longer route to walk somewhere
→ Tensing muscles
→ standing when sitting would be appropriate
→ extraneous movement (p.ex: bouncing legs)
→ walking on toes

Question 25

What are some body-image related safety behaviours?

Answer 25

→ comparing self to others → checking appearance in mirror → extreme avoidance of body image → p.ex: never looking at a mirror, having the lights off to change even by yourself, not going swimming, not going to the gym → avoidance contexts where you’d see your body → poking/pinching various body parts → seeking reassurance from others → using clothing to check for weight gain/shape changes → Attempts at manipulating body areas (p.ex: pushing stomach to be flat)

Question 26

What is a hierarchy of fears?

Answer 26

- Get a list of exposures and have the client rate them each on a scale of 1-10 in terms of how feared they are - Going from least feared, to most, the client will undergo each of these exposures * depending on what the feared outcome is, you’ll have to adjust the exposure → “i’m terrified that I won’t be able to control myself and eat more than I want to”

Question 27

Explain the types of exposures we can do.

Answer 27

1) **Food / eating-related exposure** - p.ex: eating foods that are on the “forbidden” list; eating in public or with friends 2) **Body-focused exposure for body image anxiety** - Body image disturbances play a central role in the development and maintenance of EDs - Post-treatment body image anxiety is a consistent risk factor for relapse - Objective: Encourage client to confront stimuli they commonly avoid because of anxiety about body image 2) **cue exposure for binge-eating** - Where you don't necessarily have overvaluation of shape weight and control, but there are objective binges that have taken over and they really have a big sense of loss of control → binges are often cued by times of day, settings, types of food - On-purpose cue certain intense cravings: have the food in the room with you, handle it, smell it, taste the food, then throw it out → thus NOT fulfilling the craving → the person isn’t allowed to eat the food for the next 24 hours

Question 28

How can we encourage the client to confront stimuli they avoid with body-focused exposures for body image anxiety?

Answer 28

1) Mirror exposure: Gazing at one's physique in full-length mirror - Just let the thoughts and judgements roll in and verbalise them (pure mirror exposure) → this is favoured OR - Actively talk about the parts of your body that you like (cognitive dissonance) → kind of like OCD, stop fighting the thoughts, just sit with the reactions to your own physical self - Either way, just seeing the body can be a trigger that starts off one of these cycles 2) Wearing "revealing" clothes items (sleeveless tops) 3) Uncomfortable/unflattering body postures

Question 29

What are the types of checking behaviours?

Answer 29

1) Those best stopped altogether - Unusual, non-normative, forms of behaviour --> p.ex: pinching parts of the body to assess "fatness"; touching abdomen, thighs and arms repeatedly, looking down when sitting to assess how the abdomen sticks out over the waistband - Those that are usually secretive, as they would be embarrassing if someone else found out --> p.ex: using a tape measure to check thigh circumference; checking whether there is a gab between the thighs 2) Those best modified - These are more normative forms of behaviour, whose frequency or extent may be an issue --> p.ex: mirror use, comparison checking

Question 30

Addressing comparison making involves two steps; what are they?

Answer 30

1) *Addressing subject bias* - Patients should walk along a street and compare themselves to every third person their age and gender, and then reflect on what they discover - In comparing to other people, we’re often picking a wild sample of people to compare ourselves to → this gets around the whole thing of comparing yourself to the most attractive people you see, this helps us see that most people look very average and that there’s a lot of diversity - Even just acknowledging that there’s a level of absurdity of being in a body can help 2) *Addressing assessment bias* - They should then furtively scrutinize that person's body, focusing on what they dislike about their own body, and then reflect on what they find → choose someone who you would typically find very attractive, follow along in a changing room and scrutinize their body the way you would your own → this helps because you don’t look at others the way you look at yourself in the mirror, if you scrutinize a person you find attractive, you’ll find flaws that weren’t noticed before

Question 31

What are some fear cues in EDs?

Answer 31

**Feared foods** **Feared eating scenarios** - Other people present - who and how many - Locations (p.ex: restaurants, friends homes, etc.) - Idiosyncratic scenarios (p.ex: rate, size of bites, being first to finish, etc.) **Body image-related cues** - Seeing reflection - Other people seeing body image (p.ex: bathing suit) - Certain clothing types (p.ex: form-fitting tops) - Postures/positions **Internal stimuli** - Feelings of fullness, bloating, warmth, hunger - Worrisome thoughts about gaining weight and/or body shape changes **Environmental stimuli** - Media depiction of "thin ideal" - Others' comments about weight, eating, shape **Binge eating cues** - Foods typically consumed during binge - Locations where binge often takes place - Emotional antecedents to binge eating

Question 32

What are some feared consequences seen following fear cues?

Answer 32

**Important for feared foods** - Most patients report "classic" fear of weight gain - Other patients may describe different concerns --> "I will lose control and binge on___" --> "I will feel unbearably guilty for (breaking dietary rule)" **What to do when core concern is "I'll get fat"** - Probe for anticipated consequences associated with this belief "What would be so bad about getting fat?" --> "No one will want me" --> "Everything in my life will fall apart" --> "I'll always hate myself"

Question 33

How can someone with an ED attack their feared foods?

Answer 33

- According to their SUDS rating of each food, create a table categorizing each food into SUDS 1 - 10 - The client can then tackle any foods that are in these lists and cross them off as they go → introduce one of these foods at every meal for exposure (slow reintroduction of foods) → they’ll become less feared and more included in every meal

Question 34

What can we say about exposures for eating-related fear and avoidance?

Answer 34

- Many individuals with EDs fear eating certain quantities or types of food --> Most common fear is significant, uncontrollable weight gain --> Many individuals believe they are not able to tolerate their distress --> Other fears can include choking, vomiting, and other negative health-related outcomes - Selective avoidance of eating normalized quantities of food or certain "forbidden" foods perpetuates these fears - Food exposure can reduce eating-related fear and allow individuals to experience violation of their fear expectancies

Question 35

What are some targets for exposure?

Answer 35

**Feared foods** - Foods associated with weight gain - Binge foods **Feared eating scenarios** - Eating with friends and family members - Eating at crowded restaurants **Avoidance of body image or weight** - Looking at self in mirror, wearing form fitting clothing items - Having weight taken in session

Question 36

What are some cue exposures for binge-eating?

Answer 36

- Classical conditioning properties are often involved in the development and maintenance of binge-eating - Stimuli that immediately precede binge-eating can develop ability to elicit physical (i.e., conditioned) response experienced as "craving" --> Seeing, smelling, tasting food --> Negative emotional antecedents to binge-eating --> Physical locations where binges have previously occured - Even if nutritional needs are met, patients may continue to binge due to conditioned stimuli cueing strong cravings to overeat

Question 37

What do cue exposures for binge-eating look like in practice?

Answer 37

- Prior to beginning exposures, patients should have engaged in normalized eating for at least a week - During exposure, patients are encouraged to focus attention on their thoughts and the intensity of their cravings - Goal is to reduce cravings in response to cues (extinction)

Question 38

What are the main topics to cover when educating patients about purging?

Answer 38

**Self-induced vomitting** - It is used as a compensatory behaviour after an objective or subjective episode of overeating - It is dangerous to health - It requires secrecy and produces feelings of guilt - It is only partially effective in eliminating the calories introduced because in the vomit, there is only about half the calories taken in during a binge episode - It maintains the binge-eating episodes because a deterrent against binge eating is undermined → deterrent undermined: if during the binge you think “i can engage in a CB that will cancel it out, then i’m okay to binge” but it doesn’t actually cancel out its effects entirely **Laxative misuse** - It is used as a compensatory behaviour after an objective or subjective episode of overeating and/or routine form of weight control - It is dangerous to health - It requires secrecy and produces feelings of guilt - It is ineffective means of eliminating the calories ingested because laxatives eliminate only water and electrolytes - It maintains the binge-eating episodes because a deterrent against binge eating is undermined - It is expensive

Question 39

What are the main topics to cover when educating patients about excessive exercising?

Answer 39

- It may be used as a compensatory behaviour after loss of control over eating and/or as a routine form of weight control - It is dangerous to health if you are underweight, and/or have osteoporosis or electrolyte disturbances - It requires secrecy and produces feelings of guilt - It is relatively ineffective as a means of controlling weight - It takes up a lot of time and impairs interpersonal relationships - It takes precedence over other activities

Question 40

What is a short-term maintenance plan template for ED behaviours?

Answer 40

*Overconcern about shape and weight* - Use mirrors carefully - Avoid weighing outside the set weekly time; do not interpret single readings - Maintain and develop other life interests *Dietary restraint and restriction* - Try to eat a flexible and varied diet - Practice eating socially - Take care not to avoid certain foods *Binge eating* - Conduct "binge analysis" to identify triggers and address - Practice problem solving triggers *Other weight-control behaviours* - Avoiding vomiting/taking laxatives/over-exercising as they keep the eating problem going *Weight regain and maintenance* - Weekly weighing on a set day is crucial - Maintain weight within goal weight range - If weight falls below the weight range --> alarm bells! Review pros and cons of weight regain taking a long-term perspective *Weight loss* - Trying to lose weight is risky if you have had an eating problem - The goal of weight loss is only appropriate if you are medically overweight - Avoid rigid and extreme dietary rules *Slip-ups and lapses* - Minor slip-ups are to be expected

Question 41

What are the diagnostic criteria for body dysmorphic disorder?

Answer 41

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. --> It’s experienced as very distressing and prominent by the individual, but if you asked another person, they wouldn’t even be able to see it all or note it as a very small difference B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. --> The purpose of the repetitive behaviour is to modify appearance C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. --> The difference between thai and an ED is that the CB don’t have their main element to do with food intake, here it’s more focused on the body **Specify if** - *With muscle dysmorphia*: Preoccupied with the idea that his or her body build is too small or insufficiently muscular **Specify if* - With good or fair insight - With poor insight - With absent insight/delusional beliefs

Question 42

True or false: The average level of insight in body dysmorphic disorder is poor insight.

Answer 42

True

Question 43

True or false: Body dysmorphic disorder is included in the eating and food-related disorders in the DSM.

Answer 43

False: It's paired with OCD

Question 44

What are the key areas of preoccupation in body dysmorphic disorder?

Answer 44

- Facial features - Hair - Body shape and size - Skin and complexion - Genitals - Symmetry and proportion → clearly no specification on eating in this → with alterations in these areas, it almost always goes very poorly, and people feel an increase in distress after the surgery → a very high % of individuals that are in line up for body interventions actually do have body dysmorphic disorder → “...men are more likely to have preoccupations with their genitals, body build (thinking they are too small or inadequately muscular), and thinning hair, whereas women are more likely to be preoccupied with weight (usually thinking that they weigh too much), breasts/chest, buttocks, legs, hips, and ‘excessive’ body hair.” → Similar prevalence in boys and girls (but may be more common in girls during adolescence) – ~2.4% in adults

Question 45

What is the older term for body dysmorphic disorder?

Answer 45

dysmorphophobia

Question 46

What are some general information about body dysmorphic disorder?

Answer 46

- Concern with body area ranges from “unattractive/not right” to “hideous” - Can focus on one or more areas - Muscle dysmorphia = almost exclusively boys - “BDD by proxy” → not preoccupied by a part of your own body, but of the body of someone else who is very close to you (parent, sibling) → would engage in similar repetitive behaviours - Repetitive behaviours (e.g., mirror checking, selfies, grooming, skin picking, hair pulling, reassurance seeking, exercising, tanning, clothing to hide body, beauty products, repetitive photo taking to compare progression or avoidance of pictures, growing bangs long to cover face, wearing high necks to cover more, etc.) OR mental acts (e.g., comparing)

Question 47

True or false: The majority of adults with BDD receive cosmetic treatments including dermatological and surgery.

Answer 47

True: and often with poor response → 11-13% among dermatology patients → 13%-15% among general cosmetic surgery patients → 20% in rhinoplasty surgery patients → 11% among adult jaw correction surgery patients → 5%–10% among adult orthodontia/cosmetic dentistry patients

Question 48

What are the interventions for body dysmorphic disorder?

Answer 48

- Interventions are similar to CBT-E → compare yourself to every third person, mirror exposures, SSRI meds, etc. - Exposure-like interventions seem to be helpful, but the habituation and the decreasing of distress is a lot slower than in other disorders