Eating Disorders

Question 1

Eating Disorders Are Common

Answer 1

• 90% Female
• 5 to 10 million girls and women
• Anorexia Nervosa .5-1% of females 13-35
• Bulimia Nervosa 2-5% of females 13-35
• Industrialized countries

Question 2

Anorexia Nervosa

Answer 2

a. Low body weight (<85%)
b. Intense fear of gaining weight
c. Distorted body image
d. Extreme Focus on shape/weight
e. Denial of seriousness of illness

f. Amenorrhea
i. an abnormal absence of menstruation

g. Age at onset teens (changing)
i. puberty is a high risk period

Question 3

Bulimia Nervosa

Answer 3

a. Recurrent binge-eating
– Unusually large amount of
food (by social comparison)
in a short amount of time

b. Feeling out of control

c. Compensatory behavior
– Vomiting
– Laxative abuse
– Excessive exercise
– Fasting

d. Extreme focus on shape/weight

Question 4

Eating Disorders are NOT disorders of Choice

Answer 4

a. Anorexia and bulimia were viewed as “disorders
of choice”

b. Devalued seriousness of disorders
c. Undermined treatment and recovery

d. Provided NO guidance for families: “If she would
only eat!”

e. Concept of “genes” that influence risk for eating
disorders viewed as absurd

Question 5

Eating Disorders: Mortality

Answer 5

Anorexia nervosa has the highest mortality rate of any psychiatric disorder.

Question 6

Anorexia Nervosa: Mortality Rates

Research

Answer 6

Swedish Research Counsel
–30 year period (1973 – 2003)
–6,000 subjects
–265 of 6,000 died

Question 7

Most Frequent Causes of Death

In anorexia

Answer 7

1. Suicide (32%) – Violent/Non-Violent
2. Anorexia (19%)
3. Cancer (11%)

• Average age at Death: 34 years old
– Death Rate for subjects between 1987 - 2003 was
substantially larger than for subjects between
1973 -1979

Question 8

Scary fact on anorexia

Answer 8

Fact

90% of young women who develop an eating disorder do so between age of 12-25.

Question 9

Predisposing Factors: Biological

Answer 9

a. Family history of eating disorders or
chemical dependency

b. Mood disorder, anxiety or depression
c. Traits/Temperament
d. Increased BMI prior to onset
e. Early onset puberty

f. Cognitive lags—set shifting/integrating
complexity

Question 10

Predisposing Factors: Environmental

Answer 10

• Go fast, highly competitive academic/social
environment

• Dieting culture—war on obesity
• High risk sports/industry
• Family history of severe dieting/exercise

• Family constellation—
enmeshed/disengaged

Question 11

Common Precipitants

Answer 11

The immediate precipitating factors is almost always an internal or external experience of being out of control.
– Onset of puberty between the ages of 11-14, i.e. four
years the average young women gains 40 pounds with a disproportionate fat ratio

– Major transitions—separation/individuation/identity

– Traumatic events—abuse/rejection/failure

– Family difficulty—divorce /disengagement

– Onset of co-morbid illness—anxiety/depression

– Innocent weight loss—increased exercise/performance
enhancement

Question 12

Etiology of Eating Disorders

Answer 12

• Gene – environment interaction

• EDs are familial illnesses
– 12 x risk for AN and 4 x for BN

• Heritability estimates
– 50-80% genetic influence
– Unique experiences but not shared experiences

• What is inherited?
– Temperamental traits
– Co-morbid anxiety, depression, OC tendencies

Question 13

Revival of Temperament

Answer 13

Genetic research has spawned a renewed interest
in temperament
• Eating disorders are complex traits
• Temperament believed to be pre-programmed
• Character influenced by experience
• Personality captures both temperament and
character
• Identification of core traits can assist in isolating
responsible genes

Question 14

Temperament in Anorexia

Answer 14

• Harm avoidant
• Neurotic
• Obsessional
• Anxious
• Reward dependent
• Perfectionistic
• Low novelty seeking
• Abysmal self-esteem

Question 15

Temperament in Bulimia Nervosa

Answer 15

• Harm Avoidant
• Neurotic
• Obsessional
• Perfectionistic
• Anxious
• Low self-esteem
• Higher novelty seeking
• Impulsive
• Affective dysregulation

Question 16

Clinical Components

of Good Treatment

Answer 16

• Full Continuum of Care
– Medical Unit with Eating Disorder and Psychiatric Expertise
– Inpatient
– Residential
– Seven Day per Week, 11 Hour/Day, Partial Hospitalization
– Outpatient
– Long Term Transitional Living Alternative

Question 17

Case Study
“Ms. D.”
A 20-year old, Caucasian female with
Anorexia- Restricting Type

History
• Anorexia began at age 13
• Multiple changes:
– Mom went to work full time
– Latchkey kid
– Pressure to perform academically and in
dance
• 16 years old - major depression
– Weight went from 88 to 73 pounds
• Hospitalized for a few months for Anorexia

Over next 6 years (16 – 22) hospitalized 8
times.
• Summer 2007 weight in 60’s, hospitalized for 5
½ months
• Discharged January 2008 at a weight of 105

• In 2008, in and out of hospitals for low
body weight and dehydration
• Began college but was hospitalized after 3
days the first week of September for
hypoglycemia
• Remained hospitalized until December
2008 when she was air ambulanced to
Denver

• Admission Height: 5’1 ¼. Weight: 46.16 lbs
• Liver failure
• Spontaneous pneumothorax
• Developed sepsis
• Spent one week in Pediatric ICU
• Length of stay was approximately 2 months

Answer 17

• Upon admission to
Inpatient program in
February 2009, Ms. D.
had progressed in her
recovery to have normal
liver and pulmonary
function tests.

• Ms. D. was 5 feet 1 ¼
inches tall, and weighed
54.4 pounds (BMI = 10.2)
at the time of admission.

 Ms. D.’s scores are typical of
Restricting Anorexics
• Temperament Type: Cautious
– High Harm Avoidance, low
Novelty Seeking, and above
average Reward Dependence =
a high-strung, careful, and
cautious temperament.
• Character Type: Dependent
– Low Self-Directedness, high
Cooperativeness, and low SelfTranscendence
= a reactive,
trusting, slightly moody

– Inpatient: 2/11/09 – 4/20/09
– Residential: 4/21/09 – 5/13/09
– Partial Hospitalization Program:
5/14/09 – 8/11/09
– Ms. D. discharged from our program
with plans to return to college.
– Ms. D. had weight restored to 100.4 pounds,
which is 97% of her ideal body weight.
– Sense of self
– Assertiveness/ Anger
– Family therapy
– Collaboration with Treatment Team in New Jersey

Question 18

Anorexia nervosa

Summary points

Answer 18

a. Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by a low weight, fear of gaining weight, a strong desire to be thin, and food restriction.

b. Many people with anorexia see themselves as overweight even though they are in fact underweight.
i. If asked they usually deny they have a problem with low weight.
ii. Often they weigh themselves frequently, eat only small amounts, and only eat certain foods.

c. Some will exercise excessively, force themselves to vomit, or use laxatives to produce weight loss.

d. Complications may include osteoporosis, infertility and heart damage, among others.
i. Women will often stop having menstrual periods

Question 19

Bulimia nervosa

Summary points

Answer 19

a. Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging.

b. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed.
i. This may be done by vomiting or taking laxatives
ii. Other efforts to lose weight may include the use of diuretics, stimulants, water fasting, or excessive exercise.

c. Most people with bulimia are at a normal weight.
d. The forcing of vomiting may result in thickened skin on the knuckles and breakdown of the teeth.

e. Bulimia is frequently associated with other mental disorders such as depression, anxiety, and problems with drugs or alcohol.
i. There is also a higher risk of suicide and self-harm.