Clinical - Anorexia

Question 1

What are the two types of AN?

Answer 1

-Restricting type : person restricts food intake on their own
-Binge eating/ Purging type: person self-induces vomiting or misuses laxatives

Question 2

What are the symptoms of Anorexia?

Answer 2

-Significantly low body weight
-Intense fear of gaining weight
-Body dysmorphia (disturbance in the way ones body weight/shape is experienced)

Question 3

Symptoms of partial remission?

Answer 3

-After the full criteria for AN was met, Criteria A hasn’t been met for a sustained period but Criteria B or C is still met

Question 4

Symptoms of full remission?

Answer 4

-After full criteria for AN were previously met, none of the criteria have been met for a sustained period of time

Question 5

Features of AN?

Answer 5

• Onset
  Starts in teenage years
  Affects 1:150 15 yr old girls and 1:1000 15 yr old boys
• Course
  50% fully recover after an episode
  30% follow an episodic pattern of weight gain and relapse
  20% never fully recover and need hospitalisation
• Incidence
  In 2007, 1.9% of women and 0.2% of men experience AN in any year
  Usually the condition lasts for 6 years

Question 6

How does Epinephrine explain AN?
(Biological explanation of AN)

Answer 6

-Causes increase in blood pressure, HR and blood sugar levels
-Decreased levels of epinephrine have been associated with AN

Question 7

How does Norepinephrine explain AN?
(Biological explanation of AN)

Answer 7

-Involved in body image and the way a person sees themselves
-Excess norepinephrine in the ventromedial hypothalamus causes a person to stop eating

Question 8

How does Serotonin explain AN?
(Biological explanation of AN)

Answer 8

-Has a well confirmed role in regulation of eating behaviour
-Excess serotonin in the ventromedial hypothalamus causes a person to stop eating.
-This is because it leads to a high level of anxiety, leading to binging/purging behaviours.
-Can also lead to high levels of fear of gaining weight

-Over time serotonin levels can appear low due to malnutrition from not eating

-Barbarich (2002) reports that high levels of serotonin in AN and OCD shows they may both be causes by serotonin dysfunction therefore explaining some of the perfectionist and compulsive behaviour seen in anorexics.

Question 9

How does Dopamine explain AN?
(Biological explanation of AN)

Answer 9

-Involved in reward pathway

-Over activity in dopamine receptors of the basal ganglia is linked to difficulty in associating food with the pleasurable feeling

-Dopamine over activity also seems to increase anxiety in anorexics instead of a pleasure response

Question 10

Strength of neurotransmitter explanation (Serotonin)
(Biological explanation of AN)

Answer 10

-Research evidence for the role of serotonin
-Bailer et al found significantly higher serotonin activity in the women recovering from the purging type of AN compared to healthy controls.
-Highest levels of serotonin activity in women who showed the most anxiety, suggesting persistent disruption of serotonin levels leads to increased anxiety, triggering AN

Question 11

Strength of neurotransmitter explanation (Dopamine)
(Biological explanation of AN)

Answer 11

-Kaye et al compared dopamine activity of 10 women recovering from AN and 12 healthy women.
-In the ANs they found over activity in dopamine receptors in the basal ganglia and reward centres where dopamine affects the interpretation of harm and pleasure.
-Therefore this shows that dopamine is linked to anorexia

Question 12

Weakness of neurotransmitter explanation
(Biological explanation of AN)

Answer 12

-There are issues with research methods used to investigate biological explanations for anorexia such as Co-morbidities
-We don’t know what the exact cause of behaviour is, it may be one of the other MH issues

Question 13

APFC of Contemporary Study (Guardia)

Answer 13

Aim - To continue research to see if patients with AN found it difficult to gauge their own body size and if they’d be able to fit through a door frame.

Procedure - 25 female patients, 24 yrs old, who met DSM criteria for AN
(12 restrictive type, 13 binge/purge type)
-25 healthy female controls who were all students
-51 Door frame shape projected onto a wall varying from 30-80cm wide
-Projected in a random order and each frame was presented 4 times and asked if they could fit through
-Then asked if a female researcher in the room could fit through

Findings - AN patients showed a significant overestimation of body size in themselves
-Much more accurate in predicting the body size of the other person in relation to their ability to pass through the frame.
-Patients that lost weight in the last 6 months showed a greater difference between their own and the other person passability perceptions

Conclusion - The brain still perceives the body to be a larger size despite visual information contradicting this
-Patients with AN continue to strive to lose weight as their brain doesn’t perceive their current size accurately

Question 14

AO3 of contemporary study (Guardia)

Answer 14

S - Matched groups on age and education level. This ensures individual differences are ruled out.

S - Previous research by Guardia found that AN didn’t think they could pass through an opening that was clearly wide enough
-Schneider et al also found that people with AN misjudge their own body size, overestimating their body parts by about 30%

W - Researchers suggested that there were significant differences between the control group and the anorexia group, their shoulder width and BMI
-However the weight and size of the experimenters body matched those in the control group much more than those in the AN group

W - Making a visual judgement of a persons ability to pass through a virtual door frame is different to actually attempting to walk through the projected shape.
-Therefore a better methodology may have been to have a participant approach the opening to see if they walk as if thy can fit or if they begin to turn or slow down as if they will not fit.

Question 15

Biological Treatment for Anorexia - Antipsychotics

Answer 15

-Olanzapine
-Treats schizophrenia also
-Olanzapine blocks DS/D3 receptors on post-synaptic receptors, stopping dopamine from being absorbed
-Blocks 5-HT2A receptors for serotonin in neural pathways in the brain
-Alters motivation and reward perception, reducing obsessive thoughts about food in those with AN

-Weight gain is a side effect a it increases hunger hormone (ghrelin)

-Molina et al (2003) found that patients who took olanzapine reported lower levels of anxiety and less difficulty with eating

Question 16

Biological treatment for Anorexia -Antidepressants

Answer 16

-Selective Serotonin Reuptake Inhibitors (SSRI’s)
-e.g Fluoxetine

-Block the reuptake of serotonin in pre-synaptic neuron causing levels of the neurotransmitter to increase in the synapse, so more serotonin is passed to the post synaptic neuron.

-Beneficial in maintenance of appetite
-AN patients are less likely to drop out of psychological therapy

Question 17

Strengths of drug treatment for AN

Answer 17

-There is supporting evidence which demonstrates its effectiveness
-Jensen and Mejlhede (2000) found case studies of 3 patients who had taken Olanzapine.
-The patients showed an increase in positive body image which was also more realistic of what they actually looked like.
-Therefore it seems that drug treatment can be an effective therapy for treating anorexia, and should be considered as a course of treatment perhaps alongside psychological therapies.

HOWEVER
-Small sample sizes are used in these trials, for example 3 patients in this case so this may lead to questions about the reliability of the data since evidence from small scale research is difficult to replicate.
-Therefore it is difficult to make strong conclusions about the effectiveness of drug treatment

-

Question 18

Weakness of drug treatment for AN

Answer 18

-Not all research suggests drug treatment is effective at treating the disorder
-Ferguson et al (1999) found there was no significant difference between patients given SSRIs compared to those patients on the ward who weren’t given SSRIs in relation to body weight or anxiety.
-Therefore the role of drugs in treating anorexia appears limited
-Drugs are focusing on the symptoms rather than the causes of AN.
-So even if they are successful, it is a merely temporary reduction in symptoms that would be revered if the person stopped taking the drug.

Question 19

Non-Biological Explanation of AN - Socio-cultural Theory

Answer 19

-Social Factors = SLT (Attention, Retention, Reproduction, Motivation)
-SLT suggests we may learn our eating behaviours through observation of others in our household for example

-Cultural Factors:
-AN is more likely to occur in dance or modelling students compared to other female university students because these groups value the ‘slim body image’ as part of their image as ‘dancers’ and ‘models’ as it’s more normal (Garner & Garfinkel 1980)

-Schwartz et al(1982) conducted a review of Miss America beauty pageant competitors and found that over a 20 year period, the average weight of contestants decreased but the actual average of US females was slightly increasing

Question 20

A03 of non-biological explanations of AN

Answer 20

STRENGTH
-Support for the idea of a socio-cultural explanation of AN comes from the increase in diagnoses in 1950s
-This increase in diagnoses links with the change towards slimmer models and the preoccupation with body image and dieting in the media
-Furthermore, an increase in males with AN has coincided with changes in ‘men’s magazines’ to include more diet, fitness and body image articles
WEAKNESS
-Cultural explanations might combine with other factors such as a perfectionist personality
-Other factors must make some people more vulnerable to images compared to others
-Evidence shows patients with AN score highly on measures of ‘perfectionism’ - a trait associated with serious concern over making mistakes

STRENGTH
-Support for socio cultural explanation for AN comes from research. Becker (2002) found that in Fiji before TV, girls were unlikely to be concerned about diet or slimming but after TV was introduced, evidence shows they were concerned about body weight and image
-0% said they self-induced vomiting to control weight in 1995 compared to 11.3% in 1998

WEAKNESS
-However, there is good evidence to suggest that biological approaches may be a better explanation of AN (neurotransmitters)
-Therefore, considering both biological and social explanations are well evidenced, perhaps it is possible that some individuals are biologically predisposed to AN but that social conditions influence the development of the disorder.

Question 21

Non- Biological treatment for AN - CBT

Answer 21

-CBT stands for Cognitive Behavioural Therapy
-(Enhanced CBT = CBT-E)
-Conducted on a 1-2-1 basis between the patient and the therapist

Stage 1:
-Focuses on patients eating behaviour
-Patient is weighed on a weekly basis and regular eating is encouraged
-Patient given information about AN

Stage 2:
-Progress update from stage 1
-Therapist may look into why progress isn’t being made in some instances

Stage 3:
-Main treatment phase consisting of 8-10 weekly sessions
-Directly address potential triggers

Stage 4:
-Patient draws up an agreed plan about how to prevent relapse and manage eating behaviour
-Post-treatment review 5-6 months after to see how the patient has progressed

Question 22

A03 for non-biological treatment for AN - CBT

Answer 22

STRENGTH:
-Flexibility of treatment
-CBT-E stages can be adapted to meet the requirements of the patient
-Different types of AN and the treatment programme can be tailored to each type
-Advantage as it means the treatment programme can be generated and adapted according to each individual’s circumstances
HOWEVER:
-Requires motivation and so won’t be effective for everyone
-the therapist has to recognise the signs that the patient is not yet ready

STRENGTH:
-Research support for use of CBT-E in treating AN
-Pike et al found the relapse rate for AN patients receiving outpatient CBT was lower (22%) than those receiving nutritional counselling (33%)
-Therefore this treatment is effective for AN
HOWEVER:
-Doesn’t work with comorbid disorders e.g. those with low self-esteem or perfectionist personalities

-Drug treatment may be better if the client isn’t willing to engage in the therapy from the beginning or motivated to change their eating habits
-Perhaps both drug and CBT should be used to provide the most effective treatment for AN patients

Question 23

Clinical Key Question - A01
(What are the implications for society if anorexia is a learned disorder?)

Answer 23

-Why it’s an issue for society?
-Cost of treatment and effect on the NHS
-Mortality rate of those admitted to hospital is over 10% due to starvation or suicide

-AO1:
-AN could be caused by images and cultural expectations
-Models used to advertise clothing to specific beauty such as ‘size-zero’ models
-90% of cases are females between 13-18yrs
-20% of patients have one episode and recover while 60% follow an episodic pattern of weight gain and relapse over a number of years

Question 24

Clinical Key Question - A02
(What are the implications for society if anorexia is a learned disorder?)

Answer 24

-OPERANT CONDITIONING
-Positive Reinforcement : Peer acceptance is particularly important during adolescence. As such teens may be more encouraged by praise given by others when they lose weight or stay slim

-Positive Punishment: Whereas teasing and bullying may have an effect on behaviour. Those who do not fit an idealised image may be made fun of for their weight

-The Use of Social Media: Fewer likes and interactions on social media after weight gain (negative punishment)

-SOCIAL LEARNING THEORY
-If they witness a role model that has AN not eat or have a very strict diet etc, they’ll remember and attempt to copy their role model, Eventually, after seeing their role model get praise for being super skinny etc, they’re more likely to do the same

Question 25

Clinical Key Question - A03
(What are the implications for society if anorexia is a learned disorder?)

Answer 25

-OPERANT CONDITIONING

-Jones and Crawford (2006) assessed the role of teasing and found that overweight girls and underweight boys were most likely to be teased by their peers
-Suggesting that through teasing, peers serve to enforce gender-based ideals such as the ‘need’ for women to be thin and therefore AN may be a learned disorder

-SOCIAL LEARNING THEORY
-Becker’s (2002) Fiji study found that after the introduction of western TV on the island, teens reported much higher rates of dieting and body image concerns.
-This suggests social influences on eating disorders are crucially important and careful consideration of media, images young people are exposed to is needed

Question 26

Clinical Key Question - Alternative Explanation
(What are the implications for society if anorexia is a learned disorder?)

Answer 26

-Biological Explanation
-Although there is widespread exposure to celebrity culture, only a small percentage of the population become anorexic
-This therefore suggests that the underlying cause of the disorder is biological and therefore not learned

-For example. Kaye et al (2005) used a PET scan to compare dopamine activity in the brains of 10 women recording from AN and 12 healthy controls

Question 27

What is Diagnosis and Prognosis

Answer 27

-Diagnosis is proposing a cause for a psychological (or medical) problem.
-It is followed by a prognosis which is a prediction about how the problem will develop with or without treatment

Question 28

4D’s of diagnosing mental disorders

Answer 28

-DEVIANCE
-Behaviours and emotions are viewed as unacceptable because they are rare
-A way of deciding whether behaviour is deviant is to consider how unusual it is statistically
-Another way is looking at social norms as when people violate social norms, it is seen as abnormal

-DYSFUNCTION
-When the abnormal behaviour is significantly interfering with everyday tasks and living your life
-A person is considered abnormal if they’re unable to cope with the demands of everyday life e.g. looking after yourself, holding down a job, maintaining relationships with friends and family

-DISTRESS
-The view that abnormality involves being unhappy, relating to experiencing negative emotions e.g. anxiety, isolation, confusion and fear
-Abnormality is when these negative feelings occur inappropriately or persist longer than they should

-DANGER
-Consisting of: danger to self and danger to others
-If the behaviour in question become dangerous and excessively risky, then a diagnosis may be required

Question 29

A03 of 4D’s for diagnosis

Question 30

AP of Classic Study - Rosenhan (1973)

Answer 30

-AIM:
-To find out whether mental health professionals could distinguish between those who were genuinely mentally ill and those who were not

-PROCEDURE:
-Field experiment and ppt observation
-12 psychiatric hospitals with 8 ‘pseudopatients’ (5 men, 3 women) chosen via opportunity sampling
-Pseudopatients called up various hospitals for an appt and complained of ‘hearing voices’ (auditory hallucinations) and said they heard the words ‘empty, thud and hollow’
-7 pseudopatients admitted with diagnosed schizophrenia, 1 admitted with diagnosis of manic depression with psychosis
-They acted normally with staff and genuine patients, accepted but didn’t take medication given to them and didn’t report any more symptoms
-Pseudopatients observed and recorded qualitative and quantitative behaviour of staff
-A follow-up study took place in another hospital where the staff asked Rosenhan to send more pseudopatients over a 3 month period, claiming they’d definitely notice who was real or fake
-Rosenhan didn’t send any patients

Question 31

FC of Classic Study - Rosenhan (1973)

Answer 31

-FINDINGS:
-Quantitative findings is that the pseudopatients were hospitalised between 7 and 52 days (avg 19 days) prior to being discharged
-No doctors or nurses questioned their genuineness
-In 4/12 hospitals, no staff answered the pseudopatients when they asked questioned
-71% of doctors and 88% of nurses ignored the pseudopatient when questioned
-Qualitative findings is that 3 ‘normal’ behaviours were misinterpreted as ‘abnormal’ including note writing being interpreted by as nurse as ‘engaging in writing behaviour’ as though it was something only a person with a mental illness would do
-Another interpreted pacing up and down as a sign of nervousness when the pseudopatient was just bored
-Follow up study showed out of 193 cases, 41 of the patients were identified as fake by 1 staff member and 23 suspected fake by a psychiatrist but 0 were actually fake

-CONCLUSION:
-Mental health professionals can’t distinguish between real and fake patients, and they were willing to make a diagnosis based on one fake symptom
-‘Normal’ behaviour was misinterpreted as ‘abnormal’ to support their idea that the pseudopatients had a mental illness
-This suggests the validity of psychiatric diagnoses was low

Question 32

Strengths of Rosenhan Classic Study

Answer 32

-High Internal Validity
-The doctors and nurses in 12 hospitals were unaware they were being observed by the pseudopatients and therefore it is likely that they treated them in exactly the same way they would have treated any of their real patients
-Lack of demand characteristics means the study is very useful in highlighting issues surrounding the difficulty of diagnosing mental disorders

-High Ecological Validity
-Field experiment based on observations in real psychiatric settings
-Study used 12 real hospitals as well as real medical staff and patients
-Strength as it means we can be confident that the invalid nature of diagnoses apply to real hospitals, locations and medical teams
-However the hospitals were all in USA and the patients were all from the same culture and so the results may only tell us about USA in the early 70’s

Question 33

Weaknesses of Rosenhan Classic Study

Answer 33

-Ethnocentric:
-A western view on mental health
-Conducted in 12 US hospitals and focused on the use of DSM-II manual for diagnosing mental disorders
-Weakness as other cultures may not use the DSM-II manual and may not share some westernised symptoms, especially hallucinations
-We can’t assume the process of diagnosing mental disorders will show similar problems in other cultures and countries

-Ethical Issues:
-No staff gave permission to take part and they didn’t know they were being observed
-They may’ve felt distressed or angry that they were bring used w/o consent
-Pseudopatients deliberately deceived hospital staff claiming they heard voices, breaking ethical guidelines, wasting staff time
-Weakness as several guidelines today were breached which raises questions into whether the study should’ve been allowed
-The benefits to the field of mental health outweigh the cost of deception and lack of consent
-Rosenhan’s study has been replicated and has been influential in the way in which psychiatrists treat and diagnose individuals