Last Week Eating Disorders Flashcards
ANOREXIA NERVOSA overview of. Criteria
DSM 5 criteria:
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.
Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
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.
Subtypes:
Restricting type
Binge-eating/purging type
DSM-V: FEEDING AND EATING DISORDERS
Pica
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder
Anorexia Nervosa
Restricting type
Binge-eating/purging type
Bulimia Nervosa Binge-Eating Disorder
Other Specified Feeding or Eating Disorder Unspecified Feeding or Eating Disorder
ANOREXIA NERVOSA: CORE FEATURES
PERSISTENT ENERGY INTAKE RESTRICTION
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.
Severity in DSM-V depends on BMI
BMI =
weight in kg height in meters 2
Mild: BMI > 17
Moderate: BMI = 16–16.99 Severe: BMI = 15-15.99 Extreme: BMI < 15
BMI is not the only consideration
18.5 BMI “cutoff” used by Centers for Disease Control and Prevention and WHO
But can depend on clinical history; treatment aim usually BMI = 20
For adolescents, compare to expected developmental trends (e.g., failure to make weight gain)
ANOREXIA NERVOSA: CORE FEATURES
INTENSE FEAR OF GAINING WEIGHT
Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
Phobia of gaining weight
Fear of gaining weight may not be alleviated by weight loss (may actually increase)
Fear of gaining weight at times denied: focus on behaviour preventing weight gain
DISTURBANCE IN SELF-PERCEIVED WEIGHT OR SHAPE
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.
Distortions in self-view (not always present): overall or specific body parts
Excessive focus on body weight and shape (e.g., frequent weighing, using tape measure, mirror)
Body weight and shape tied to self-esteem and self-concept
Thinness valued over health concerns
Can also overvalue the “control” of weight itself (seen as an accomplishment or mark of discipline)
ANOREXIA NERVOSA: SUBTYPES
RESTRICTING TYPE
Weight loss primarily accomplished through dieting, fasting, and/or excessive exercise.
Forbidden foods
Small portion sizes or specific ways of eating (e.g., small plates, small utensils)
PURGING TYPE
Binge eating or purging behaviour (self-induced vomiting, misuse of diuretics, laxatives or enemas)
Compared to bulimia, small portions and more consistent purging
Characterized by underweight, small portions. Aside on insulin purge
About 50% of patients correspond to either type
Unclear whether truly distinct
Severity?
Continuum? (common to change subtype)
Personality traits
ANOREXIA NERVOSA: CLINICAL CORRELATES
Rigid, inflexible thinking
Difficulty thinking about alternatives; don’t like change; cling to preconceptions Impediment to treatment
Depressive symptoms
E.g., depressed mood, social withdrawal, feelings of ineffectiveness
Self critical intensify symptoms
Perfectionism
Especially self-critical perfectionism
Intensifies certain aspects of the ED (e.g., extreme standards are applied to eating, weight, and shape)
Obsessive-compulsive features
Both related and unrelated to food (e.g., hoard food, collect recipes, obsessive weighing, counting calories) Concerns about eating in public
Strong need to control one’s environment
BULIMIA NERVOSA
DSM-V criteria
Recurrent episodes of binge eating:
A) Eating, in a discrete period of time (e.g., within 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 circumstances.
B) 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).
Recurrent inappropriate compensatory behaviours in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months.
Self-evaluation is unduly influenced by body shape and weight.
BULIMIA NERVOSA: CORE FEATURES
BINGE EATING
Objectively large amounts of food: must ask in assessment
Roughly 1500 calories in a binge; discomfort at fullness
Shame, often kept secret
COMPENSATORY BEHAVIOURS
Severity based on frequency of compensatory behaviours per week
Mild: 1-3, Moderate: 4-7, Severe: 8-13, Extreme: 14+ In
In clinical samples, vomiting is most common
behaviour (2/3 of patients)
In community samples, exercise and strict
diet are most common compensatory behaviours (only 1/5 vomiting)
BULIMIA NERVOSA: CORE FEATURES
SELF-EVALUATION
Dominated by shape and weight
Unlike AN, weight typically in normal range
Episodes often triggered by low mood, interpersonal stressors, intense hunger following restriction, or feelings re: body shape or weight
Binges/purges can provide temporary relief from tension, dysphoria, or fullness
Often followed by low mood, shame, self-criticism
Subtypes removed in V non purging removed
BN: CLINICAL CORRELATES
Impulsivity
E.g., in relation to purging but also other behaviours Emotional instability and erratic dietary pattern
Substance abuse
Subgroup that engages in substance abuse (common overlap)
Self-injury and BPD
Subgroup meets criteria for Borderline Personality Disorder
Childhood abuse?
Mixed evidence from research
CHANGES FROM DSM-IV eating disorders ednos
Prior to DSM-V, many eating disorder patients were diagnosed as EDNOS (Eating Disorder Not Otherwise Specified):
No amenorrhea
AN symptoms but healthy weight
Frequency of binge/purge
Other syndromes (e.g., chew and spit)
To address this problem, changes were applied to the DSM-V criteria:
Anorexia: removed requirement for amenorrhea
Bulimia: reduced frequency from 2x/week to 1x/week on average
Wilson & Sysko, 2009: literature review demonstrated that the clinical characteristics for both groups were similar
Creation of binge eating disorder diagnosis
Clinical correlates and course are different from those of other EDs
Reliably diagnosed
BINGE EATING DISORDER
Recurrent episodes of binge eating:
A) Eating, in a discrete period of time (e.g., within 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 circumstances.
B) 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).
The binge-eating episodes are associated with 3 or more of the following:
A) Eating much more rapidly than normal.
B) Eating until feeling uncomfortably full.
C) Eating large amounts of food when not feeling physically hungry.
D) Eating alone because of feeling embarrassed by how much one is eating.
E) Feeling disgusted with oneself, depressed, or very guilty afterward.
Marked distress regarding binge eating is present.
The binge eating occurs, on average, at least once a week for 3 months.
Severity based on frequency of binge eating episodes / week.
The binge eating is not associated with the recurrent use of inappropriate compensatory behaviour.
May be overweight or not
BINGE EATING DISORDER correlates
Individuals with BED differ from in meaningful ways from individuals with AN and BN
More likely to be obese
Age of onset is later
Course of BED is different e.g., dysfunctional dieting follows onset of BED whereas dysfunctional dieting often precedes onset of BN
Individuals with BED differ from individuals who are obese but do not have BED Greater psychiatric co-morbidity
Poorer functioning
CBT and IPT are associated with significantly greater improvement in functioning relative to weight loss programs alone in treatment of BED
PREVALENCE
ANOREXIA:
Prevalence: approx. 1% (APA, 2000)
Gender differences: more females than males
Males sometimes underdiagnosed
Thinness vs. athleticism
Influence of sexual orientation? (Yelland & Tiggeman, 2003; Martins et al., 2007
PREVALENCE
Bulimia
BULIMIA:
Prevalence: approx. 2%
Gender differences: more females than males
BINGE EATING DISORDER: prevalence
Prevalence: approx. 1-3.5% (1.6% of adolescents)
Gender differences: Gender ratio less skewed, but more females than males
Heritability of eating disorders
Biological factors
Based on family studies with ED probands, controls and first-degree relatives
AN heritability: 58-76% BN heritability: 30-83%
Part of etiology
Etiology of eating disorders
Family environment
Parent’s attitudes towards eating and weight
Frequent dieting or encouragement of child to diet
Social influences
Peer influence, social contagion
Preadolescence obesity linked to later EDs (teasing)
Cultural influences
Media, societal pressures
CULTURAL INFLUENCE
ANOREXIA: unlike bulimia
Evidence for AN across cultures and history
Modest increase in AN prevalence coinciding with increasing idealization of thinness (meta-analysis by Keel & Klump, 2003)
Most prevalent in industrialized cultures, Western societies
BULIMIA:
Greater influenced by culture
MEDIA INFLUENCES:
THE ADVENT OF TELEVISION IN FIJI
Typically difficult to study effects of media
Becker et al., 2002: The Advent of Television in Fiji
1990s: one reported case of anorexia
63 girls interviewed 1 MONTH AFTER TV
65 girls interviewed 3 YEARS AFTER TV
1995
Two groups did not differ on age, weight, or ethnicity.
8 out of then and then 19 laters
Suggests media had effect on eating patterns. I
MEDIA INFLUENCES:
THE ADVENT OF TELEVISION IN FIJI
63 Girls interviewed < 1 month after t.v. introduced
65 Girls interviewed 3 years after t.v. introduced
Significantly disordered eating
8
Vomiting to control weight
0
Narrative data suggested that girls admired the women they saw on TV and wanted to emulate them (hairstyles, clothing, body size)
77% reported that TV had influenced their body image
COURSE OF EATING DISORDERS
Usually appear during passage to adolescence or young adulthood
Diathesis-stress model
Dieting is often trigger
Fluctuating course, with high rates of relapse
AN: less than 50% recover (approx. 1/3 unremitting)
Harder to treat the longer it persists
BN: Recovery 50-75% (higher than AN)
Body dissatisfaction may remain high
BED: More likely to improve than AN or BN
Little cross-over between diagnoses
CONSEQUENCES OF EATING DISORDERS
ANOREXIA
Physical symptoms
Dry mouth, dry skin, losing hair, sensitivity to cold, loss of bone density, gastro-intestinal symptoms, heart problems, etc.
High death rate
Mortality rate of 5-10% (highest of all clinical diagnoses)
Death commonly from cardiovascular problems resulting from electrolyte imbalances (not starvation) electrolyte imbalance K/Ca
Potassium and calcium critical to normal heartbeat; disrupted by purging and underfeeding
Bradycardia (slowing of heart rate) is common cause of death
BULIMIA
Physical problems
Puffy cheeks/enlarged salivary glands, loss of dental enamel, tears in esophagus/stomach
Electrolyte imbalance and cardiovascular consequences
Fatigue, headaches
TREATMENT OF EATING DISORDERS
Common perceptions of treating EDs
One of hardest disorders to treat
Often chronic (many rounds of treatment)
Worries about patient’s physical health
High rate of mortality
Apprehension from therapists
Recommendation: multidisciplinary treatment team
Psychs no good at taking electrolytes need doc or nurse
WHY ARE EATING DISORDERS SO HARD TO TREAT?
Eating disorders are ego-syntonic
In line with desires/goals of the ego; consistent with one’s ideal self-image
Denial that there is a problem
Patients “like” some aspects of their disorder,
Secondary gains: thinness, attention, “badge of honor”, regulation of affect, control…b(music sense of control)
Affects first part of treatment
Patients are often very ambivalent about treatment
External sources of motivation
Enhancing motivation to change is key to any treatment
Motivational interviewing: non-coercive, help patient decide what is in their best interest :)
EFFECTIVE TREATMENTS FOR EDS
Effectiveness
CBT found to be effective in treating bulimia
Limited evidence for effective treatments for anorexia
Ethical problem of random assignment to conditions
Rare incidence of disorder: difficult recruitment
Robin et al., 1999: Recruited 37 participants for a study between 1988 and 1994
Common approaches:
Individual treatment (typically cognitive-behavioural therapy)
Family therapy FOR YOUTH
CBT-E FOR BULIMIA
CBT-E (Chris Fairburn): 2 phases of treatment
PHASE 1
Phase 1 is primarily behavioural
Explain structure of treatment
Set goals for treatment
Formulation of the problem
Psychoeducation
Events and associated mood change
Over-evaluation of shape and weight and their control
Strict dieting; non-compensatory weight-control behavior
Binge eating
Compensatory vomiting/laxative misuse
Regular eating (3 meals/day + 3 snacks, every 4 hours)
Portions, exposure to forbidden foods
Replace bingeing with pleasurable activities
Weekly weigh in and food journal, nor stand triggers
CBT FOR BULIMIA
Phase 2 deals with cognitions
Identify maladaptive cognitions
“If I gain weight, my swim times will be slower,” or “If I eat white rice, I will become fat.”
Cognitive restructuring
Thought records & behavioural experiments
Examining the evidence: create hypotheses and test them
CBT FOR BULIMIA
Identifying and addressing maintaining mechanisms Excessive weighing
Body checking
Highly restrictive rules for eating
Target FEAR OF WEIGHT GAIN
Emotional regulation
“Fat” is not an emotion – what is really going on?
Event-contingent symptoms Problem-solving
CBT FOR BULIMIA
Outcome evidence
50% of BN patients cease bingeing and purging following 16-20 weeks of CBT
Best prognosis:
Large initial reductions in bingeing and purging
Worst prognosis:
Borderline personality disorder
Substance abuse
FAMILY THERAPY FOR ANOREXIA
AN as symptom of family problem AN as developmental setback
Goals: restore patient’s weight before complications arise or development is disrupted Patient cannot control symptoms
Parents must step in to save starving child
Weight first for children, then cognitions, due to dev. Issues.
FAMILY THERAPY FOR ANOREXIA
Phase 1: Parental refeeding
PHASE 1
PHASE 2
PHASE 3
Teenager is identified as unable to care for herself
Parents are coached to work as a team to develop and maintain a plan to feed child Efforts to prevent purging (e.g. remove bathroom door)
Eat all meals as a family
High calorie diet (to restore patient to adequate weight)
Treatment continues until patient begins to gain weight regularly
Phase 2: Cognitive distortions and family structure
Target patient’s distorted body image and beliefs about food
Problematic family patterns
Role of eating symptoms in family life
E.g. Does it maintain secondary gains? Does it express conflicts within the family?
Phase 3: Adolescent issues
Return responsibility for eating to the adolescent Foster adolescent autonomy
Teach problem-solving skills
FAMILY THERAPY FOR ANOREXIA
Outcome evidence
Data is promising for adolescent AN: 39-68% moderate or good outcome
Appropriate candidates for family therapy Younger than 18 years old
Live with their parents
Inappropriate for adult AN
Poor prognosis:
Parental criticism
Peers and parents may be contributing to symptoms: take this in account during treatment
COMMON CHALLENGES IN TREATMENT
Motivation
“Lack” of motivation?
Need to align therapist and patient goals as
much as possible
“What is in your best interest?”**
Resistance to weighing and food journals
Medical complications
Fainting, blood in vomit, low heart rate, low potassium
Regular blood tests
Liaison with medical departments and psychiatrists
‘Plateau’ of gains
Change in diagnosis, but continued symptoms
E.g., AN → BN, but still binging/purging
Chronicity
Relapse prevention
End of treatment often unplanned
