Eating disorders

Question 1

What is the definition of an eating disorder?

Answer 1

“A persistent disturbance of eating behaviour or behaviour intended to control weight, which significantly impairs physical health or psychosocial functioning” (Fairburn & Walsh, 2002)

Question 2

What is the issue around this definition of an eating disorder?: “A persistent disturbance of eating behaviour or behaviour intended to control weight, which significantly impairs physical health or psychosocial functioning” (Fairburn & Walsh, 2002)

Answer 2

• This definition is fairly subjective
• could simply apply to obesity
• e are issues around where exercisers, models, gymnasts fit into this definition. This definition may not distinguish between these people.

Question 3

What is the diagnostic criteria for anorexia nervosa?

Answer 3

• A significantly reduced calorie intake relative to the requirements of the body, leading to a considerably low body weight.
• Intense fear of gaining weight or becoming fat
• A disruption in the way that the patient evaluated their body or shape, increasing undue influence of body weight on self-evaluation

Question 4

What are the two types of anorexia nervosa?

Answer 4

• Restrictive type AN – self-starvation is not associated with concurrent purging
• Binge-eating/purging type AN- where the sufferer regularly engages in purging activities to help control weight gain.

Question 5

What is the prevalence of anorexia nervosa?

Answer 5

• 0.4% 12 month prevalence rate = prevalence rate in population (Hoek 2006)
• lifetime prevalence rate = 0.8%. (stice, marti &rohde, 2013)
• male to female rate 10:1

Question 6

Describe the co-morbidity of anorexia nervosa and other mental health disorders?

Answer 6

High rates exist between anorexia and other psychiatric disorders (jordan et al, 2008).

• 50-68 % of anorexia sufferers also have a lifelong diagnosis of major depression - Halmi et al 1991.
• 15-69% of anorexia sufferers also meet diagnostic crtieria for OCD or OCPD at some time in their life (Hudson et al 1983)
• Anorexia & panic disorders= 25%
• Anorexia and social anxiety disorder = 30%
• Specific phobias (25 %)

Question 7

What are the health effects of anorexia nervosa?

Answer 7

1. Tiredess, cardiac arrhythmias , hyotension, low blood pressure and slow heartbeat.
2. Dry skin/ brittle hair
3. Kidney and gastrointestinal problems
4. The development of lanugo (soft downy hair)
5. Absence of menstrual cycles
6. Hypothermia
7. Muscular weakness

Mortality rates = 5-8%

Question 8

What are the diagnostic criteria for Bulimia Nervosa?

Answer 8

• Repeated incidents of binge eating
• Frequent inappropriate compensatory behaviours in order to avoid weight gain, such as self- induced vomiting, fasting or excessive exercise.
• Binge eating and compensatory behaviours both occur on average at least once a weak for 3 months
• View of oneself is overly influenced by body shape and weight.

Question 9

What is the prevalence of Bulimia Nervosa

Answer 9

• 1% = prevalence rate in population (Hoek 2006) 35% of all cases of anorexia (Fairburn & Harrison 2003)
• onset = late adolescence or early adulthood (16-20 years peak)
• 90% of bulimia sufferers are female (Gotestam & Agras 1995) incidence of bulimia may have decreased since the 1990’s , 1990’s peak may be due to media coverage of princess Diana.

Question 10

What are the health effects of Bulimia Nervosa?

Answer 10

• fewer than with anorexia.
• most common sign= loss of dental enamel as a result of regular induced vomiting.
• swollen parotid gland can produce a typical puffy face appearance - menstrual irregularity.

Question 11

What are the common co-morbidities with Bulimia Nervosa and other mental health disorders?

Answer 11

• 36-63% of bulimia sufferers also suffer major depression (Brewerton et al 1995) increases of bulimia in winter months linked with SAD
• link between bulimia and borderline personality disorder (33-61% of female bulimics met criteria for personality disorder)
• frequent co-morbidity between bulimia and personality disorders leads to proposal that - bulimia is part of ‘multi-impulsive’ syndrome- where individuals finds it difficult to control aspects of their behaviour.
• Alcohol and drug addictions

Question 12

What is the diagnostic critera for Binge eating disorder?

Answer 12

• Repeated incidents of binge eating
• Binge eating is accompanied by at least three of the following:
  1) Eating quicker than usual
  2) Eating until uncomfortably full
  3) Eating sizable amounts of food when not feeling hungry
  4) Eating along due to being embarrassed by the amount of food eaten
  5) Feeling disgusted, depressed or guilty after binge eating
• Distress regarding binge eating
• Binge eating not accompanied by inappropriate compensatory behaviour as seen in bulimia nervosa

Question 13

What is the prevalence of Binge Eating Disorder?

Answer 13

• Often found in children & adolescents.
• Lifetime prevalence= around 3% - peak of 16-20 years
• Majority of sufferers are female- but only 1.5 % higher in women than men.

Question 14

What health effects are associated with Binge Eating disorder?

Answer 14

overweight- sometimes obese

Question 15

What are otherwise specified eating and feeding disorders?

Answer 15

Present with many of the symptoms of other eating disorders, but will not meet full criteria for diagnosis.

Question 16

Give examples of otherwise specified eating and feeding disorders?

Answer 16

1. Atypical anorexia nervosa
2. Low frequency or limited duration Bulimia nervosa
3. Low frequency or limited duration binge eating
4. Purging disorder
5. Night eating syndrome

Question 17

What is atypical anorexia nervosa?

Answer 17

Despite significant weight loss, individuals weight is within or above the normal range

Question 18

What is the transdiagnostic approach?

Answer 18

Fairburn’s transdiagnostic approach, proceeds from the notion that all eating disorders have similar characteristics (Favaro, Ferrara, & Santonastaso, 2003) and underlying psychopathology reflected in analogous attitudes and behaviors (Fairburn, Cooper, & Shafran, 2003).

Question 19

Why have people argued that the transdiagnostic approach is a better way of viewing eating disorders?

Answer 19

• 40-50% of cases do not fit neatly into diagnosis
• Atypical cases (EDNOS) are the largest group many fail to stay in one diagnosis

Question 20

What are the cultural differences in eating disorders?

Answer 20

• Appear more common in ‘westernised countries’?
  e.g Klump (2003) looked through literature and found no studies reporting the presence of bulimia in individuals without exposure to western ideals.
• Culture- African American females larger than Causasian females.
  The culture appears to not place as much value on ‘slimness’ and so they are more likely to develop bulimia if they were to develop an eating disorder rather than anorexia. As non-western countries and ethnic minorities within western countries become more influenced by western ideals, the rates of eating disorder appear to rise. E.g (Curacaeo study: shows more cases among non-whites in recent years- Hoek 2006)
• Media effect: Fiji study (Becker et al 2011) clear link to introduction of western media both TV and more social-network based exposure- e.g home DVD players
• within cultures females are 10 times more likley to develo an eating disorder than males.

Question 21

What have studies shown about the impact of genetics in eating disorders?

Answer 21

• First-degree relatives of females with both anorexia and bulimia are significantly more likely to develop these disorders.
• Twin studies – show inherited component: genetic factors account for around 40-60% of liability to anorexia nervosa, bulimia nervosa and binge eating disorder.

—-HOWEVER: twin studies also show importance of environment . Molecular genetic studies identified potential target genes (serotonergic genes) which impact on appetite regulation, food intake, and feeding & (dopaminergic genes) which impact on food reward sensitivity and weight regulation. (however studies in infancy)

-Anorexia found to be not culture bound unlike bulimia- therefore may be more resultant from genetics.

Question 22

What are the three main categories of eating disorders?

Answer 22

• Anorexia
• Bulimia
• Binge eating disorder

Question 23

What are the familial causes/sugestions for causes of eating disorders?

Answer 23

Family attitudes and dynamics may impact on behaviour- cause eating disorder.

Minuchin et al (1978) has argued that eating disorders are best understood by considering the family structure of which the sufferer is a part. (family systems theory).
Minuchin – families show one or more of the following characteristics…

• Enmeshment- parents are intrusive, overly involved in children’s affairs & dismissive of child’s emotions.
• Overprotection- members are overly concerned with parenting and with one another’s welfare- child= coercive parental control.
• Rigidity- tendency to maintain the status quo within family Lack of conflict resolution- families avoid conflict or are in continual stat of conflict.
• Mothers of child with eating disorder more likely to have dysfunctional eating patterns and psychiatric disorders- effects offspring at an early age.
• Mothers of sufferers also critical of appearance, weight and attractiveness.

………HOWEVER, most studies are retrospective and correlational in nature and so do not imply causation. - although there is probably some form of intra-familial transmission of disordered eating, it is quite likely to be other factors (biological, psychological and experiential) that trigger the severe symptoms.

Question 24

Adverse life event factors seem to play a role in the creating of eating disorders?

Answer 24

• Adverse life experiences may act as a vulnrabiltiy factor for eating disorders & precipitating factor for the onset of an eating disorder.

Rastam & Gillberg (1992) found:
14% of anorexia sufferers had experiences a negative life experience within 3 months prior to the onset of the disorder. -individuals with bulimia report signficiantly more adverse life events prior to symptoms.
* childhood sexual abuse = big risk factor for anorexia and bulimia! but not binge-eating disorder.
WHY? - possibly because adverse early life experiences generate other forms of psychopathology that mediate the development of eating disorders.
* Eating disorders allow the individual to construct a coherent sense of self by focusing attention on one limited aspect of their lives. This provides them with rewards that many otherwise have been missing from their lives.

Question 25

What personality traits seem to contribute to eating disorders?

Answer 25

1. Perfectionism - can be self-oriented or other oriented
2. Shyness
3. Neuroticism
4. Low self-esteem
5. High introspective awareness (awareness of bodily sensations)
6. Negative or depressed affect (linked to negative effect)
7. Dependence and non-assertiveness

Question 26

Talk about eating disorders and negative effect.

Answer 26

Eating disorder & negative effect are often highly comorbid > discussion as to whether negative effect is a cause or a consequence of the disorder.

But proposed to play a number of discrete roles in the aetiology of eating disorders.

Negative mood may not simply be a consequence of the disorder, but may play an active role in generating symptoms by increasing body dissatisfaction and being involved in processes of mood regulation which act to reinforce disordered eating behaviours.

Question 27

Describe how low-self esteem contributes to the creation of an eating disorder.

Answer 27

Low self-esteem- may be derivative of the specific negative views that those with eating disorders have of themselves (e.g being fat, having an unattractive body etc …)

…..However, may be that it has a role in development of eating disorders

… it is a significant prospective predictor of eating disorders in females eating disorders such as anorexia are viewed by some researchers as a means of combating low self-esteem by demonstrating control.

Question 28

Describe how perfectionism has a role in eating disorders?

Answer 28

Predictor of bulimic symptoms in women who perceive themselves as overweight.

Also predicts the maintenance of eating disorders at a 10 year follow-up.
Strober (1991) perfectionism pre-disposes individuals to eating disorders.

If perfectionism does play role –need to ask why it develops into eating disorder and not other disorder?

Question 29

Describe the trans-diagnostic cognitive behavioural model of eating disorder..

Answer 29

Fairburn (2008) Argues that a dysfunctional system of self-evaluation is central to the maintenance of all eating disorders, and that self-worth is defined in terms of control over eating, weight and shape, which in turn leads to dietary restraint.

Other subsidiary mechanisms that operate to maintain eating disorders=

1) Low self esteem
2) Clinical perfectionism
3) Interpersonal problems
4) Mood intolerance

^^^^ these additional maintaining factors differ across individuals with different forms of eating disorder e.g. mood intolerance = bulimia suffers.

Once the eating behaviours begin….

• Positive reinforcement cycle especially while weight is being lost sense of control and achievement, often against a lack of such experiences in the past
• Shifts to anxiety/terror about loss of control increased efforts to lose/maintain low weight purging, exercise, stricter rules, etc.
• Sense of loss of control of eating abstinence violation; binge-eating even stronger efforts to lose/control weight
• Cognitive dissonance results in more negative self-perception, to justify the behaviours - Body image gets worse
• Starvation effects kick in, as shown by two important studies.
  The Minnesota Study (Keys, 1950): 1)emotional instability (e.g. driving binge-eating) 2)cognitive narrowing (e.g., cannot get the ‘big picture’) 3)social isolation 4)behavioural changes
• The Dutch Hunger Winter

“hot-cross bun” model provides a framework for this.

Question 30

Describe the safety behaviours in eating disorders

Answer 30

Safety behaviors maintain psychopathology escape/avoidance conditioning Two stages

• Short term- safety behaviors reduce anxiety
• Long-term – the same behaviors make things worse Common to all anxiety disorders, as well as to eating disorders.

This suggests that the eating disorders have a lot of anxiety at their heart.

Examples of safety behaviors….

• Body-related safety behaviors each related to specific treatment techniques
• Body avoidance treated using mirror exposure (‘flooding’ method)
• Body comparison treated using behavioral experiments
• Body checking treated using behavioral experiments ‘Mind-reading’ treated using surveys

Question 31

Descibe what case formulation is and why its used.

Answer 31

Case formulation allows the theory of CBT to be applied to clinical practice. Uses our understanding of biology, behaviour, cognition, emotion and social functioning

Question 32

What are the sociocultural influences of an eating disorder?

Answer 32

• media influences that may result in body dissatisfaction (many women have adopted an ideal body weight that are unachievable)
• dieting fashions - the more likley that low-calorie diets become fashionable, the more likley to promote restricted eating which is a risk factor for developing eating disorder symptoms
• culture - western cultures disparage obesity
• parental factors
• peer influences - determine attitudes towards eating and body shape and have role in the development of disorders through peer pressure
• adverse life events
• this can lead to body dissatisfaction (the gap between ones ideal weight and ones actual shape). Body disatisfaction is a vulnerability factor for eating disorders