Anorexia Nervosa, Bullimia Nervosa and Binge eating disorder

Question 1

What is the lifetime prevalence of eating disorders in the US?

Answer 1

• AN (women 0.9%; men 0.3%)
• BN (women 1.5%; men 0.5%)
• BED (women 3.5%; men 2.0%)
• While there is a clear sex difference, it is still the case overall that 1 in 3 or 1 in 4 cases involve boys or young men.

Question 2

What is the prevalence of BED around the world?

Answer 2

• Lifetime prevalence of BED was higher than the rate for BN (1.4% vs. 0.8%).
• BN was also distinguished by having a longer persistence (6.5 years vs. 4.3 years).

Question 3

what is the prevalence of ED’s in Canada?

Answer 3

• 0.5% of Canadians 15 years of age or older reported an eating disorder diagnosis in the preceding 12 months.
• Among young women aged 15 to 24, 1.5% reported that they had an eating disorder.
• 1.7% of Canadians met 12-month criteria for an eating attitude problem.

Question 4

When did ED’s first appear in the DSM?

Answer 4

• EDs appeared in the DSM for the first time in 1980

Question 5

How did eating disorders change from the DSM-4 to the DSM-5?

Answer 5

In DSM-IV: AN and BN formed distinct categories reflecting the increased
attention they had received from clinicians and researchers. Eating Disorder - Not Otherwise Specified (EDNOS)
- In DSM-5: BED is distinct category. Removed EDNOS and replaced it with more
specific categories.

Question 6

What more specific categories replaced EDNOS in the DSM-5?

Answer 6

Unspecified Feeding Or Eating Disorder
- can be used for any condition that causes clinically significant distress or impairment but does not meet diagnostic thresholds.
- can be used when there is insufficient information such as in hospital emergency room situations.
The other broad category is “other specified feeding or eating disorder.”
- applies to atypical, mixed, or subthreshold conditions.
- includes a variety of conditions, including subthreshold BN and subthreshold BED.
- includes night eating syndrome, which is a repetitive tendency to wake up and eat during the night and then get quite upset about it.
- includes purging disorder - this is a form of bulimia that involves self induced vomiting or laxative use at least once a week for a minimum of six months in the absence of binge eating.

Question 7

What is Anorexia Nervosa?

Answer 7

• Anorexia—loss of appetite
• Nervosa—appetite loss due to emotional reasons
• The term AN is a misnomer because most patients do not lose their appetite or interest in food – they become preoccupied with food.

Question 8

What is the essential feature of AN?

Answer 8

Essential feature is that the individual refuses to maintain a minimally normal body weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the perception of the shape or size of her/his body.

Question 9

What is the Diagnostic criteria of AN?

Answer 9

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health.
B. Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or persistent lack of recognition of the seriousness of the current low body weight
- two specifiers/subtypes: restricting type or binge eating/purging type

Question 10

What is the relationship between self esteem and AN

Answer 10

• The self -esteem of people with AN is closely linked to maintaining thinness. The tendency to link self -esteem and self -evaluation with thinness is known as over-evaluation of appearance.
• Among people with acute AN, lower body weight is associated with increased self-esteem.
• Individuals with anorexia nervosa overestimate their own body size and choose a thin figure as their ideal

Question 11

When does AN typically develop?

Answer 11

• Typically begins in the early to middle teenage years, often after an episode of dieting and exposure to life stress.
• The prevalence of anorexia among children and adolescents is increasing.

Question 12

Is AN typically comorbid with other disorders?

Answer 12

• Comorbidity is high.
• Men and women at risk for eating disorders are also prone to depression, panic disorder, and social phobia
• Women were at substantially greater risk for mania, agoraphobia, and substance dependence.
• Substance use disorders

Question 13

What are the AN death rates?

Answer 13

AN death rates are:

• 10x greater than general population
• 2x greater than patients with other psychological disorders
• Longitudinal investigation found mortality rate for AN is 5x higher than the rate for the general population
• There is no other disorder that matches the mortality risk inherent in AN

Question 14

What is Bulimia Nervosa and what does it involve?

Answer 14

Bulimia is from a Greek word meaning “ox hunger.”

• It Involves…
• • episodes of rapid consumption of a large amount of food (binge) accompanied by a lack of self-control
• • followed by compensatory behaviours (purging).
• • Binge = eating excessive amount of food in < 2 hours
• • Typically occur in secret
• • May be triggered by stress
• • Purge = vomiting, fasting, or excessive exercise

Question 15

What is the diagnostic criteria for BN?

Answer 15

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following
1. Eating, in a discrete period of time (e.g., with any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstnaces
2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. Recurrent inappropriate compensatory behaviours to prevent weigh gain such as vomiting, misuse of laxatives, diuretics, or other medications; fasting or excessive exercise
C. The binge eating and inappropriate compensatory behaviours both occur on average, at least once a week for 3 months
D. Self evaluation is unduly influenced by body shape and weight
E. the disturbance does not occur exclusively during episodes of anorexia nervosa

Question 16

What are the predictors and characteristics of Bingeing?

Answer 16

• Binge episodes tend to be preceded by poorer than average social experiences, self-concepts, and moods.
• Stressors that involve negative social interactions may be particularly potent elicitors of binges.
• People with BN have high levels of interpersonal sensitivity, as reflected in large increases in self-criticism following negative social interactions.
• Continues until the person is uncomfortably full
• Binge episodes are often followed by deterioration in selfconcept, mood state, and social perception.

Question 17

What do people engaged in binges often experience?

Answer 17

• The person who is engaged in a binge often feels a loss of control over the amount of food being consumed.

Question 18

What kind of food is typically consumed during a binge episode?

Answer 18

• Foods that can be rapidly consumed, especially sweets such as ice cream or cake, are usually part of a binge.
• • Some people with BN sometimes ingest an enormous quantity of food during a binge, often more than what a normal person eats in an entire day.
• • Binges are not always as large as the DSM implies, and there may be wide variation in the caloric content consumed by individuals with BN during binge

Question 19

What kind of feelings are experienced by people with BN following a binge episode?

Answer 19

• People with BN are usually ashamed of their binges and try to conceal them.
• • They report that they lose control during a binge, even to the point of experiencing something akin to a dissociative state, perhaps losing awareness of what they are doing or feeling that it is not really they who are bingeing

Question 20

What is fat talk?

Answer 20

• The focus on fear of becoming fat and negative appraisals of the self for being fat are involved in a relatively new line of research on a phenomenon known as fat talk.
• Fat talk refers to the tendency for friends, particularly female friends, to take turns disparaging their bodies teach other.
• Both average weight and overweight target people were seen as more likeable if they were depicted engaging in fat talk
• Fat talk seems to reflect a highly defensive and negative sense of self.
• Research on ‘fat talk’ among university women was associated with: body dissatisfaction, negative affect, disordered eating, and more frequent checking of one’s body

Question 21

When and how does BN typically develop?

Answer 21

• Bulimia nervosa typically begins in late adolescence or early adulthood.
• Many people with BN are somewhat overweight before the onset of the disorder and the binge eating often starts during a dieting episode.

Question 22

What was found in the study of body dissatisfaction in girls and boys in Nova scotia?

Answer 22

• Extreme body dissatisfaction was found among 7–8% of both girls and boys in Nova Scotia.
• • these children were only in Grade 5
• • The data suggests that children particularly at risk can be identified at a fairly young age
• • It was found among only girls that as their body mass index increased, their body satisfaction decreased.

Question 23

What are some predictors of death in ED’s?

Answer 23

• Predictors of death include lower BMI and older age at first presentation for treatment and alcohol misuse

Question 24

What does death most often result from in people with ED’s?

Answer 24

Death most often results from physical complications of the illness or from suicide

Question 25

What is the approximate reduction in life expectancy for people with AN?

Answer 25

A survival analysis concluded that AN is associated with a 25-year reduction in life expectancy

Question 26

Is the suicide rate higher in AN or BN?

Answer 26

• A review found that suicide rates are not elevated BN like they are in AN
• • people with BN are more likely to have suicide ideation.
• • one in five deaths attributed to AN involved suicides

Question 27

What is the mortality rate in ED’s?

Answer 27

• A meta-analysis of 36 studies found that:
• • 5.1 deaths per 1,000 person years for AN
• • 3.0 deaths per 1,000 person years for EDNOS
• • .7 deaths per 1,000 person years for BN

Question 28

What commonalities exist between AN and BN?

Answer 28

• The diagnoses of AN and BN share several clinical features:
• • Intense fear of being overweight
• • Self-evaluation is unduly influenced by body/shape weight
• There are some indications that these may not be distinct diagnoses but may be two variants of a single disorder.
• Co-twins of people diagnosed with anorexia nervosa, for example, are themselves more likely than average to have bulimia nervosa
• Temporal studies also identify diagnostic crossover.
• More than 18% with AN eventually develop BN, while approximately 7% of those with BN eventually develop A

Question 29

What is the diagnostic criteria for binge eating disorder?

Answer 29

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., with any 2 hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstnaces
2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)
B. The bing eating episodes are associated with three or more of the following:
1. eating much more rapidly than normal
2. eating until uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed or very guilty afterward.
C. Marked distress regarding binge eating is present
D. the binge eating occurs at least once a week for 3 months
E. binge eating is not associated with recurrent use of innapropriate compensatory behaviour as in BN and does not occur exclusively during the course of BN or AN

Question 30

What has BED been found to be linked with?

Answer 30

• BED is linked with impaired work and social functioning,
  depression, low self-esteem, substance abuse, and
  dissatisfaction with body shape

Question 31

What are the risk factors for developing BED?

Answer 31

• childhood obesity,
• critical comments regarding being overweight,
• low self-concept,
• depression, and
• childhood physical or sexual abuse

Question 32

What is the average life term duration of BED?

Answer 32

The average life-term duration of BED (14.4 years) may be greater than the duration of AN (5.9 years) or BN (5.8) years

Question 33

What are the genetic components of ED’s?

Answer 33

• Little research on genes
• AN and BN run in families
• Overvaluation of appearance and body dissatisfaction appear to be heritable (twin studies)

Question 34

What is the role of the hypothalamus in ED’s?

Answer 34

• Regulates hunger and eating.
• Lesions in animals shows that they lose weight and have no appetite
• Regulates hormones that are abnormal in people with AN (e.g., cortisol). These abnormalities may results from starvation and return to normal with weight gain

Question 35

Why is the hypothalamus theory not a strong candidate theory for ED’s?

Answer 35

• not a strong candidate theory for understanding ED’s because people with ED’s really want to eat, they are self starving there’s a difference between this and lesions. Lesions make animals become indifferent to food, in ED’s people are preoccupied with food and choosing to starve. This theory doesn’t account for other things like overvaluation of weight

Question 36

What is the role of edogenous opiods and ED’s?

Answer 36

• Endogenous opioids are substances produced by the body that reduce pain sensations, enhance mood, and suppress appetite, at least among those with low body weight.
• • Starvation may increase the levels of endogenous opioids, resulting in a positively reinforcing euphoric state
• • Excessive exercise would increase opioids and thus be reinforcing
• Hardy and Waller (1988) hypothesized that bulimia is mediated by low levels of endogenous opioids, which are thought to promote craving; a euphoric state is then produced by the ingestion of food, thus reinforcing bingeing.

Question 37

What is the role of sociocultural factors in ED’s?

Answer 37

• The ideal attractiveness of males and females shifts with culture and time
• People attach certain expectations to looking a certain way (others will like you, you’ll be successful, you’ll be popular)
• Societal pressure to look a certain way (direct like being rejected on a blind date, or indirect like seeing models on Instagram)
• Dr. Ann Becker (conducted research in Fiji, what was valued in Fiji was eating well at the time (being more voluptuous). Then western media came to Fiji (e.g., tv shows) and the beauty ideal affected young girls in Fiji, they started engaging in non normative behaviours to try to look like attractive people in different cultures.

Question 38

What is the paradox between thinness ideals and society?

Answer 38

• While cultural standards and pressures to be thin were increasing, more and more people were becoming overweight.
• • The prevalence of obesity has doubled since 1900; currently 20 to 30% of North Americans are overweight and there are continuing references to an obesity epidemic.

Question 39

What do Pinel, Assanand and Lehman attribute the increasing prevalence of obesity to?

Answer 39

• They attribute the increasing prevalence of obesity to an evolutionary tendency for humans to eat to excess to store energy in their bodies for a time when food may be less plentiful.
• • If so, this tendency to over consume is clearly at odds with unrealistic pressures to maintain ideal body weights.

Question 40

Do children experience perceptions of being overweight?

Answer 40

• According the WHO’s 2002 Health Behaviour in School-aged Children (HBSC) Canadian Survey (see Government of Canada, 2006), 31% of Canadian young women from grades 6 to 10 thought that they were too fat.
• • The proportion increased with age and, by Grade 10, 44% indicated that they were too fat.

Question 41

How did the number of dieters increase from 1950-1999?

Answer 41

• The number of dieters increased from 1950 to 1999
• • Men 7% to 29%
• • Women 14% to 44%

Question 42

What did an Ontario study examining children’s eating habits and attitudes find?

Answer 42

An Ontario study found that among more than 2,000 girls aged 10 to 14, 29.3% were dieting and 1 in 10 had maladaptive eating attitudes, suggesting the presence of an eating disorder

Question 43

How does culture view people who are overweight? How is this view promoted?

Answer 43

• Excessive body fat has negative connotations, such as being unsuccessful and having little self-control.
• People with obesity are viewed by others as less smart and are stereotyped as being lazy.
• Investigations suggest this anti-fat bias is pervasive so that even the most obese people tend to endorse these views; however, the bias seems more automatic among thinner people, according to measures of implicit cognitive processing
• The media promotes these stereotypes.

Question 44

What did a content analysis of 18 primetime television situation comedies (in calgary) find?

Answer 44

• A content analysis of 18 primetime television situation comedies conducted by researchers in Calgary found that:
• females with below average weights were over represented in these shows.
• the heavier the female character, the more likely she was to have negative comments directed toward her.
• these negative comments were especially likely to be reinforced by audience laughter.

Question 45

What are Pro-ana and Pro-mia websites?

Answer 45

• people who promote ED’s as lifestyles, rather than diseases.
• Used as support groups - users share tips, tricks and goals to stay thin and act as accountability partners.

Question 46

What do cross cultural studies show us about the prevalence of eating disorders?

Answer 46

• Eating disorders are far more common in industrialized societies, such as the United States, Canada, Australia, and Europe, than in non-industrialized nations.
• Eating disorders are more evident in western cultures
• • However, it is also generally concluded that the gap is closing, with rising levels of eating disorder in non-Western cultures as well as rising levels of research interest, as reflected by an increasing number of publications

Question 47

What group of women may be especially prone to developing an eating disorder?

Answer 47

Young women who immigrate to industrialized Western cultures may be especially prone to developing eating disorders owing to the experience of rapid cultural changes and pressures

Question 48

What is the CBT model of eating disorders?

Answer 48

• Overvaluation of body shape and weight (very difficult to treat)
• -argued to a risk factor and maintenance factor of ED’s
• sense of self is not well balanced/varied, all their self worth eggs are in one basket (c.f., pie chart). Self worth is heavily based on appearance, shape/weight and eating.
• there is growing evidence that overvaluation of body shape/weight is important in BED as well

Question 49

What are the effects on cognition when exposed to media?

Answer 49

• The media’s portrayal of thinness as an ideal, being overweight, and a tendency to compare oneself with especially attractive others all contribute to dissatisfaction with one’s body
• Even brief exposure to pictures of fashion models can instill negative moods in young women and women who are dissatisfied with their bodies seem especially vulnerable when exposed to these images

Question 50

What is the thinspiration effect?

Answer 50

It is an Exception to the effects of media on cognition:

• The thinspiration effect: Chronic dieters actually feel thinner after looking at idealized images of the thin body and this motivates them to diet
• This can begin a process of dieting that can ultimately lead to distress among dieters unable to attain unrealistic body-image standards.

Question 51

What are the psychodynamic views on ED?

Answer 51

• Most propose that the core cause lies in disturbed parent–child relationships and agree that certain core personality traits, such as low self-esteem and perfectionism, are found among individuals with eating disorders.
• Psychodynamic theories propose that the symptoms of an eating disorder fulfill some need, such as the need to increase one’s sense of personal effectiveness (the person succeeds in maintaining a strict diet) or to avoid growing up sexually (by being very thin, the person does not achieve the usual female shape)

Question 52

What is the relationship between Childhood sexual abuse and ED’s?

Answer 52

• Some studies have indicated that self-reports of childhood sexual abuse are higher than normal among people with eating disorders, especially those with bulimia nervosa (the severity of abuse predicted more extreme psychopathology)
• A study conducted in Toronto found that 25% of women with eating disorders reported the experience of previous sexual abuse; it also correlated a history of sexual abuse with greater psychological disturbance

Question 53

What types of abuse are significant predictors of ED’s?

Answer 53

• Physical abuse and sexual abuse were significant predictors of having an eating disorder, according to the 2012 Canadian Community Health Survey. Having at least three types of abuse, relative to one or two types, amplified the risk of having an eating disorder.

Question 54

What personality factors have been found to be associated with ED’s

Answer 54

• Meta-analysis studies demonstrate:
  – six personality factors were linked consistently with EDs– avoidance motivation,
  lower extraversion and self-directedness, neuroticism, perfectionism, and sensitivity to social rewards
  – factors such as trait negative emotionality and perfectionism have achieved
  “risk status” along with other factors such as sociocultural pressures for thinness and thin-ideal internalization
  -People with AN and BN are high in neuroticism and anxiety and low in
  self-esteem (neuroticism as a long term predictor confirmed in twin studies)
• People with AN or BN also score high on a measure of traditionalism, indicating strong endorsement of family and social standards

Question 55

What is the relationship between perfectionism and ED’s?

Answer 55

Hewitt and Flett (1991b) created a multidimensional
perfectionism scale that assesses:
- self-oriented perfectionism (setting high standards for oneself)
- other-oriented perfectionism (setting high standards for others)
- Socially prescribed perfectionism (the perception that high standards are imposed on the self by others)
- Weight-restored and underweight people with AN had elevated scores on self-oriented perfectionism.
- Underweight people with AN had higher scores on socially prescribed perfectionism.
- People with AN who engage in excessive exercise are distinguished by remarkably high levels of self-oriented perfectionism

Question 56

Why is it often difficult to get a person with an eating disorder into treatment?

Answer 56

• It is often difficult to get a person with an eating disorder into treatment because the person typically denies that he or she has a problem.
• The majority of people with eating disorders, up to 90% of them, are not in treatment and those who are in treatment are often resentful.

Question 57

What is one of the main reasons people with bulimia end up in treatment?

Answer 57

Some people with bulimia only wind up in treatment because their dentist has spotted one key indicator: the erosion of teeth enamel as a result of the stomach acid coming into contact with the teeth during
vomiting.

Question 58

What is required frequently to treat people with anorexia?

Answer 58

• Hospitalization is required frequently to treat people with anorexia so that their ingestion of food can be gradually increased and carefully monitored.
• • Weight loss can be so severe that intravenous feeding is necessary to save the person’s life.
• • Weight restoration is the immediate primary goal in the treatment of anorexia

Question 59

What is the best validated and current standard psychological treatment of bulimia?

Answer 59

• The cognitive-behavioural therapy (CBT) approach of Fairburn
• In Fairburn’s therapy, the client is encouraged to question society’s standards for physical attractiveness.
• • Uncover and then change beliefs that ‘starvation is necessary to avoid becoming overweight’.
• • See that normal body weight can be maintained without severe dieting.
• • See that unrealistic restriction of food intake can often trigger a binge.
• -Taught that all is not lost with just one bite of high-calorie food.
• • Taught that snacking need not trigger a binge that would be followed by induced vomiting or taking laxatives.
• • Altering all-or-nothing thinking can help patients begin to eat more moderately.
• • Taught assertion skills to help cope with unreasonable demands placed on them by others.
• • Learn more satisfying ways of relating to people.

Question 60

What research on the CBT approach to treatment found about its efficacy?

Answer 60

• A 2006 review concluded that CBT is the most commonly used and empirically supported treatment for body image disturbance in the normal population
• No other treatment has greater efficacy than CBT
• • However, almost half of the clients relapse after four months
• Research on BN found that two-thirds of the participants who were treated with CBT achieved remission versus about one-third who received Inter-Personal therapy (IPT)
• CBT appeared to work quicker than IPT

Question 61

What are the predictors for relapse in ED?

Answer 61

• Predictors of relapse include less initial motivation for change and higher initial levels of food and eating preoccupation

Question 62

What are the limitations of treatment effectiveness (CBT approach)

Answer 62

Limitations of Treatment Effectiveness:

• At least half of the eating disorder clients treated in some CBT controlled studies do not recover.
• May be that significant numbers of the patients in these studies have psychological disorders in addition to eating disorders, such as borderline personality disorder, depression, anxiety, and marital distress
• Another possibility: individuals who begin with negative self-efficacy judgments about their ability to recover are more treatment resistant and take longer to recover

Question 63

What is one vexing problem in the treatment of eating disorders?

Answer 63

• One vexing problem is a high rate of relapse in the treatment of eating disorder.
• A recent study of 100 anorexia nervosa patients in Toronto who were treated successfully found that 41% of them relapsed during the one-year follow-up period

Question 64

Carter et al. (2012) found in their study that relapse was

more likely for those clients who…

Answer 64

• Binge-purge anorexia subtype
• Had more OCD-like checking behaviours.
• Lower motivation to recover predicted subsequent relapse

Question 65

What is the hope for recovery from ED’s?

Answer 65

• The probability of non-recovery for people with BN is decreasing over time (in years)
• • Almost 10 or 11 years later, shows persistency of disorder
• With AN, there was some reduction but over 70% of people who entered the study at 12 years were not recovered. After another decade, more were recovered.
• this was a naturalistic observation study, there is hope that people will eventually recover.

Question 66

What are the gender differences in eating disorders in Canada?

Answer 66

• Women were more likely than men to report an eating disorder: 0.8% vs. 0.2%

Question 67

What age group are ED related hospitalization rates the highest for?

Answer 67

• Hospitalization rates are highest among young women in the 15 to 24 age range
• However, rates are also high among those aged 10 to1 1