Chapter 10 (Lecture - ch 8 in textbook ED)

Question 1

photo and excerpt at the opening of the chapter:

Answer 1

• describe eating disorder symptoms (doubt, anger, disgust) and highlights role of distorted body image
• interconnection between body and mind (both somatic and mental components in relation to eating disorders)
• voice: people experience ED differently, these are her own words and how she felt
• recovery often involves reclaiming one’s body and voice by correcting ideas about eating, body image, and self perception (including self-narrative)

Question 2

Intro to eating disorders

Answer 2

• the range of ED’s examined are characterised by different kinds of preoccupations with food and weight
• among Canadian women ages 15-24, 1.5% had an ED in 2002 - it is believed that this percentage has increased
• mid to late adolescence is the time of life with the highest prevalence of eating disorders (given the importance of early detection, time of onset should be targeted)

Question 3

ED can have very serious consequences for physical health

Answer 3

• Anorexia nervosa has the highest mortality rate of ANY psychiatric illness - 10% of those diagnosed die within 10 years of onset
• people w anorexia nervosa have about a 20-25 reduction in life expectancy
• it may be helpful to think of ED and their symptoms as existing along a continuum of severity, rather than as a binary (ill or not ill)

Question 4

One important concept used to under them is body image - what is body image?

Answer 4

body image: how people think about and act towards their bodies

• people w ED usually have measurable difference in their perceptions of their own bodies compared to people without ED (distorted or inaccurate image)

Question 5

DSM-5 identifies the following features as being core to the experience of ED

Answer 5

• persistent disturbances of eating or eating related behaviours, resulting in alterations in consumption of food
• changed eating behaviour which significantly impacts health or functioning
• key diagnoses in the DSM-5 include: anorexia nervosa, bulimia nervosa, and binge eating disorder

Question 6

Anorexia Nervosa - diagnostic criteria include

Answer 6

a. behaviours such as food restriction, purging, misuse of medications, over-exercising, which interfere with maintaining an adequate weight for health
b. powerful fear of weight gain/becoming overweight
c. overestimation of body size (inaccurate perception)
d. denial of the seriousness of the condition and its impact

• potentially life-threatening, high mortality rate stemming from cardiac arrest, suicidality and other causes

Question 7

Bulimia Nervosa - diagnostic criteria include

Answer 7

• food restriction, binging, and purging to prevent weight gain
• a cycle of behaviours occurring at least once a week over a period of at least three months
• people with bulimia often experience extreme feelings of shame and hide these behaviours (may lead to more guilt)
• negative perception of body weight/shape, and over-valuation of these characteristics
• often people w bulimia are often average weight, but may experience fluctuations
• associated with depression, self-harm, suicidality

Question 8

Binge Eating Disorder - new to DSM-5

Answer 8

• consumption of an unusually large amount of food over a short period of time (different from overeating, which is very common)
• produces psychological distress
• person feels out of control about what they are eating, how much they are eating, and when they are able to stop
• does not feature compensating behaviours (e.g., excessive exercise, induced vomiting, misuse of laxatives/diuretics), distinguishing it from bulimia nervosa
• considered a disorder when it occurs at least once a week for at least three months

Question 9

Prevalence rates for men and women for all 3 ED

Answer 9

Anorexia nervosa: women 0.9%, men 0.3%

Bulimia nervosa: women 1.5%, men 0.5%

Binge eating disorder: women 3.5%, men 2.0%

Question 10

Residual diagnosis of ED - Avoidant Restrictive Food Intake Disorder (ARFID)

Answer 10

• usually starts in infancy/childhood, may stem from traumatic experience involving food (like becoming ill)
• involves unusual avoidance of particular types/textures/colours of food
• severe enough to impair adequate nutrition
• not stemming from inadequate access to food or other medical condition (allergies, intolerance)
• not stemming from limited access to food or a medical condition
• does not feature body dissatisfaction or preoccupations with weight/shape
• if untreated, can lead to anorexia nervosa or bulimia nervosa in adolescence or adulthood

Question 11

Residual diagnoses of ED - Rumination disorder

Answer 11

• consistent (effortless) regurgitation of chewed and/or partially digested food over a period of at least one month - common among infants
• rumination may be a symptom of anorexia nervosa or bulimia nervosa
• rumination differs from what we discussed as part of OCD

Question 12

Residual diagnoses of ED - Pica

Answer 12

• persistent consumption of non-food items over a period of at least one month (paper, dirt, hair, chalk) - normal during childhood, term used to described presence in other life stages

Question 13

Residual diagnoses of ED - Other Specified Feeding or ED (OSFED)

Answer 13

Examples include:
- atypical anorexia nervosa
- bulimia nervosa of low frequency and/or limited duration
- purging disorder (persistent purging, no binge eating)
- night eating syndrome (night-time eating causing distress and impairing functioning)

These disorders relate to AN, BN, and BED (the 3 primary diagnoses discussed) w minor differences in diagnostic criteria

Unspecified feeding or ED: symptoms do not meet criteria for full diagnosis (of AN, BN, BED, OSFED, or ARFID), but cause distress and impaired functioning - not currently recognised in the DSM

Question 14

Anorexia athletica (compulsive exercising) - not part of DSM-5

Answer 14

• over-exercise to the point of neglecting other priorities in life
• exercise goals take ultimate priority
• exercise used to control body shape and weight
• exercise used provide a sense of power, control, self-respect

Potential controversies:
- would be very common among professional athletes
- and recreational athletes
- out culture could be seen as actively promoting this type of disorder - we often commend and celebrate this type of relentless dedication to behaviours viewed positively (like “work addiction”)
- we may simultaneously glamourise AND pathologies this potential disorder

Question 15

Orthorexia - NOT part of DSM-5

Answer 15

• an obsession with healthy food
• a cluster of food and weight related symptoms, involving obsessive focus on food
• eating only foods perceived to be “healthy”
• relying only on “natural remedies” for illness
• finding more pleasure in following food rules than in the experience of the food itself, feelings of intense despair when failing to follow food rules
• may appear to be a positive or “healthy” behaviour, but can result in social isolation and ill health

Question 16

Body Dysmorphic Disorder

Answer 16

Classified in DSM-5 as a form of “obsessive compulsive disorder” (not categorised as an ED, but may be comorbid with an eating disorder)

• involves preoccupation w appearance - focusing on non-existent or minor flaws in physical appearance
• often includes repetitive mirror checking, excessive grooming rituals, skin picking, and other behaviours
• preoccupation impairs daily functioning, steering from repetitive behaviours
• subtypes have been proposed (muscle dysmorphia, concerns about being insufficiently muscular)

Question 17

Treatment for ED

Answer 17

• ED are very varied and so are treatments: no single treatment for ED due to the range of different ED’s and diversity in lived experiences
• early detection is very important, screening should be a part of regular health checks
• treatment is often multi-disciplinary (due to physical and psychological components) and multi-modal: nurses, therapists, psychologists, physicians, dieticians - was previously in-patient (residential), now out-patient and community based
• many different types of therapy may be used: CBT, psychoanalysis, nutritional education, and equine therapy
• treatments address both somatic and psychological symptoms
• normalising eating is a key goal of treatment, education and re-education about eating and nutrition is a component
• people in treatment often need to gain weight (as one of the first steps to stabilise physical health) - this can be very challenging for a person living with an eating disorder, who has established and specific eating routines and rules
• concurrent treatment for other (co-occurring) mental health disorders may be necessary

Question 18

Treatment table - Nov 6

Question 19

Guideline by the BC Ministry of Health provides a decision making tool to assist in identifying the proper intensity of care for patients with ED
The STATED tools evaluates the:

Answer 19

1. patient medical risks and psychiatric symptoms
2. level of disruption in life caused by the disorder
3. patients motivation to engage with the treatment

While recognising that these 3 factors vary and occur independently on a continuum

Question 20

Based on evaluation of these 3 factors, the STATED tool can be used to choose between the following four levels of care:

Answer 20

• low intensity outpatient treatment
• high intensity treatment (day programs, residential inpatient)
• variable intensity outpatient treatment with inpatient support
• high intensity inpatient hospitalization

Question 21

How to treat the physiological/somatic and psychological symptoms of ED

Answer 21

Physiological/somatic symptoms: are addressed through normalising eating by learning how to eat without dieting and education about the physical, behavioural, and cognitive effects of disordered eating behaviours
- aims to return to a healthy weight and as result other aspects of a persons health are likely to improve (e.g., menstruation, physical function)
- weight gain can be challenging because individuals fear the outcome of gaining weight

Psychological symptoms: can be addressed through psychological therapy focusing on individual causes of eating-disordered behaviours (e.g. childhood trauma) and acknowledging and promoting body appreciation and acceptance

Question 22

causes and risk factors - class and culture

Answer 22

These are better understood as working in combination with one another - as an accumulation of risk - rather than as one sole cause of disordered eating
- there may be synergy or reinforcing interactions between risk factors

Class and Culture:
- historically associated with white, middle class, young women: may be due to underreporting or under-diagnosis among other demographic groups
- internalisation of white, middle class, western ideals of thinness may be an important risk factor

Question 23

causes and risk factors - internalisation of the ideal

Answer 23

• body dissatisfaction plus internalisation of socialised ideals of beauty, including a preoccupation with thinness, may be a risk factor
• in western societies, thinness if often associated with happiness, desirability, and status in the popular imagination
• there are associations between media images, high personal drive for thinness, and anorexia nervosa

Question 24

causes and risk factors - social media

Answer 24

• combines media and peer influence and may have a strong effect on eating behaviours
• may promote unrealistic body images, especially when the individual perceives them to be real and uses them for comparison - images on social media are often heavily curated and may be manipulated (photoshop, etc)
• social media use is associated with other risk factors for ED, such as weight and shape concerns and idealisation of thinness

Question 25

causes and risk factors - sport pressures

Answer 25

• sports which emphasise appearance, size, weight and shape are risk factors for athletes (gymnastics, diving, body building)
• sports emphasising individual performance also increase risk (dance, running, figure skating)
• sports which emphasise low body weight (track and field, endurance cycling) increase risk
• elite athletes, particularly female athletes in aesthetic sports (dance, gymnastics, figure skating) are at particular high risk

Question 26

causes and risk factors - environmental factors

Answer 26

• childhood maltreatment (particularly physical/sexual violence as a trauma related event may be linked to development of an ED)
• parental pressure and treatment
• peer network and peer pressure
• psychoanalytic research points to “perfectionist tendencies” as potentially significant

Question 27

causes and risk factors - biological factors

Answer 27

• there is a strong genetic component although no single gene has been identified as being responsible… interestingly this is less often focused on in comparison to other disorders (think: schizophrenia and bipolar disorder)
• estimated heritability (amount of phenotypic [observable] variation in a population that is attributable to individual genetic difference) by disorder:
• anorexia nervosa: 28-74%
• bulimia nervosa: 54-83%
• binge eating disorder: 41-57%

Question 28

causes and risk factors - sex and gender influences

Answer 28

• women are more likely to be diagnosed with an ED
• gender role endorsement (the extent to which an individual closely identifies with particular norms associated with gender) may underlie the increased rates in women
• feminine gender role endorsement: drive for thinness orientation
• masculine gender role endorsement: muscularity concerns

Question 29

current issue and controversies - social influences

Answer 29

• the fashion industry has started to respond to critiques related to underweight models and digital phot manipulation - which may promote harmful “ideals”
• restaurant menus in many places now include calorie counts - an initiative intended to address high rates of obesity, but these policies may increase preoccupation with calories among people with ED

Question 30

current issue and controversies - social media

Answer 30

There are many body positive sites on social media, and also opportunities for those with ED to share their stories

There are also aspects of social media which perpetuate ED behaviour:
- pro-ana (pro-anorexia) sites and content
- “thinspiration” and “fitspiration:” posts may promote unhealthy and unattainable body ideals, or idealisation of thinness (although fitspiration content is intended to health and fitness through good nutrition, exercise, and self-care)

Question 31

Social movements: body image

Answer 31

Body image: how people may see, think, feel, and act towards their bodies
- body image can be impacted by sociocultural beliefs and norms (e.g., idealisation of thinness)
- exists independently of negative body image - you can experience both simultaneously

May influence development of ED:
- negative body image: individuals may view their body with doubt, hate, disgust, and dissatisfaction (often a symptom of eating disorders)
- individuals alter their eating behaviours and food consumption to address body dissatisfaction and/or achieve the “ideal” body

Question 32

Social movements: positive body image

Answer 32

positive body image:
- a core concept is body appreciation - bodies are more than appearance, there is also function and health (you only get one body in this life)
- tries to disentangle the association of self worth with appearance
- building media literacy: understanding that the image in media (and social media) are often manipulated and fabricated, and heavily curated (selective focus on glamorous activities and images)

• clinicians focus on promoting body appreciation, gratitude, self-care, in treatment and recovery
• focus on what body does, rather than how it looks

Question 33

Conclusion

Answer 33

• ED are a complex phenomenon: wide range of conditions and experiences, with diverse risk factors (individual psychological, biological, social)
• understandings of disorders and risk factors evolve and change over time
• treatment and recovery efforts continue to develop, with new concepts becoming more important (positive body image), but societal changes regarding emphasis on physical appearance move more slowly