PSY20003 W5 Eating Disorders 1 (L)

Question 1

What is an eating disorder?

Answer 1

Best accepted definition as: “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

How are eating disorders diagnosed?

Answer 2

The diagnoses change over time, suggesting that we are not really there yet. ICD tends to follow DSM: using DSM-5 after this.

Question 3

How many cases of eating disorders exist in the population?

Answer 3

only 15% of cases are underweight.
answer

Question 4

What is homeostasis?

Answer 4

Internal balance mechanism.
Keeps us eating evenly and diversely, to ensure that we are well nourished.
Hunger -|- Satiety

Question 5

What are problems with homeostaisis?

Answer 5

Genetics, Learning, Social learning affect hunger.

Social pressures, food industry, toxic environment affects satiety.

Question 6

What are some issues with the best accepted definition?

Fairbum & Walsh 2002

Answer 6

Always an issue of ‘in the eye of the beholder’
Where do exercisers, models, gymnasts and ballerinas fit?
Is it purely about weight?
Gender, age, ethnicity

Question 8

What’s weight got to do with anything?

Answer 8

BMI: Body mass index: Weight in kg / (Height in m)2 .
For most people, that will be in the range 19-25 (healthy range). Not biologically determined, varies with factors such as ethnicity.
BMI is not very meaningful for younger people: use expected weight for height, adjusted for age. <85% underweight, <70% dangerously underweight.

Overweight = BMI > 25
Obese = BMI > 30, various additional levels (e.g., morbidly obese)

Question 9

What is anorexia nervosa?

Answer 9

Persistent restriction of energy intake leading to significantly low body weight. In context of what is minimally expected for age, sex, developmental trajectory, and physical health).

Question 10

What are key features of anorexia nervosa?

Answer 10

• Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain - even though significantly low weight.
• Disturbance in the way one’s body weight or shape is experienced OR
• Undue influence of body shape and weight on self-evaluation OR
• Persistent lack of recognition of the seriousness of the current low body weight

Question 11

What are the subtypes of anorexia nervosa?

Answer 11

Restricting, binge eating, purging type

Question 12

What suggestions have been given over the years?

Answer 12

adjust for specific ethnic groups, weight for height is used for adolescent no always great, people generally tend to overestimate height and understimate weight.

Question 13

How does the BMI scale say about atheles?

Answer 13

Athletes tend to count as overweight (more muscle). Ballerina and gymnasts sanctioned to be underweight. [what is driving this]
Weight is not a surefire indicator of anorexia

Question 14

Is starvation always linked to eating disorders?

Answer 14

the Dutch Hunger Winter. The Dutch famine of 1944–1945, also known as the Hunger Winter was a famine that took place in the German occupied Netherlands especially in the densely populated western provinces north of the great rivers, during the relatively harsh winter of 1944–1945, near the end of WWII.

Question 15

What is bulimia nervosa?

Answer 15

Recurrent episodes of binge eating: eating, in a discrete period of time more than most people would eat during a similar period and under similar circumstances and a sense of lack of control, overeating during the episode.
Recurrent inappropriate compensatory behaviour in order to prevent weight gain: self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

Question 16

What are the key features of bulimia nervosa?

Answer 16

Binges and compensatory behaviours both occur, on average, at least once a week for three months. Self-evaluation unduly influenced by body shape/weight. Does not occur exclusively during episodes of anorexia nervosa

Question 17

What is Ozempic?

Answer 17

diabetes drug
used for weight oss

Question 18

What is a binge?

Answer 18

Subjective (loss of control)
Objective (loss of control + excessive intake): even then, what counts as excessive? Over 2000/3000 calories?
Defining compensatory behaviours: is vomiting always self-induced? is exercise for health or to control weight?
How often do the behaviours have to happen? - why keep changing the number needed for

Question 19

What are the diagnostic criteria of binge eating disorder?

Answer 19

Recurrent episodes of binge eating
Episodes associated with […]
Marked distress regarding binge eating
Bingeing at least once a week for three months (mean)
No purging or compensatory behaviours

Question 20

What are binge episodes usally associated with?

Bige-eating disorder diagnostic criteria

Answer 20

Eating much more rapidly than normal
Eating until feeling uncomfortably full
Eating large amounts of food when not feeling physically hungry
Eating alone because of feeling embarrassed by how much one is eating
Feeling disgusted with oneself, depressed or very guilty afterward

Question 21

What are some examples of recurrent episodes of binge eating?

Answer 21

Eating, in a discrete period of time more than most people would eat during a similar period and under similar circumstances;
A sense of lack of control over eating during the episode

Question 22

What is a critical question for binge-eating and bulimia nervosa?

Answer 22

What is a binge?

Question 23

Why did binge eating disorder become a DSM-5 diagnosis in 2013?

Answer 23

Genuine distress and need for treatment
But there was a second reason…access to insurance funding for clinicians as a way of treating a lot of overweight/obese patients

Question 24

What are Other Specified Feeding and Eating disorders (OSFED)?

Answer 24

Also known as ‘atypical’ cases: used to be EDNOS (eating disorder not otherwise specified) in DSM-IV.
Present with many of the symptoms of other eating disorders, but do not meet the full criteria for diagnosis

Question 25

Why was OSFED introduced?

Answer 25

These are people with real problems that would benefit from help?
The insurance industry will only pay out on diagnosed case?
People with eating disorders are stubbornly individual, and do not neatly fit our diagnoses?

Question 26

What are other example of specified feeding and eating disorders?

Answer 26

Atypical anorexia nervosa: despite significant weight loss, the individual’s weight is within or above the normal range
Atypical bulimia nervosa: of low frequency and/or limited duration
Atypical binge-eating disorder: of low frequency and/or limited duration
Purging Disorder
Night eating syndrome

Question 27

What is Avoidant/Restrictive Food Intake Disorder (ARFID)?

Answer 27

Primarily (but not exclusively) found in children and young people

Disturbance in eating or feeding:
substantial weight loss/lack of weight gain
nutritional deficiency
dependence on supplements

Absence of typical beliefs about food or fear of weight gain
Replacing and extending what was called ‘selective’ or ‘fussy’ eating e.g., living on marmite sandwiches; refusing all vegetables; only eating white foods

Question 28

What are the subtypes of ARFID?

Answer 28

Sensory-based avoidance: refuses food intake based on smell, texture, colour, brand, presentation

Lack of interest: in consuming the food, or tolerating it nearby

Food associated with fear-evoking stimuli: that have developed through a learned history

Effective treatments are primarily behavioural, focusing on anxiety/exposure

Question 29

Are all these diagnoses needed anyway?

Answer 29

Fairburn et al. (2003) pointed out something very important…Diagnosis of specific eating disorders does not do what it should.

40-50% of cases do not fit neatly into diagnoses
Atypical cases (OSFED) are the largest single group
Many fail to stay in one diagnosis
Does not even indicate the best treatment (see next lecture: eating disorders ii)

Consequently, there is something of a shift away from rigid diagnoses transdiagnostic model (Fairburn et al., 2003; Waller, 1993). So, the rest of today we will not focus much on specific diagnoses.

Question 30

What are some co-morbid psychological problems?

Answer 30

Anxiety disorders [obsessive compulsive disorder, social anxiety]
Depressed mood [low serotonin]
Complex emotional and relation needs: anciety and impulsivity based
Alcohol use and substance use/alcohol as the higher risk

Question 31

What is the effect of eating disorders on ones health?

Answer 31

High mortality rates due to a range of problems:
Cardiac complication
Muscular weakness (including cardiac failure)
Osteoporosis
Liver damage
Oesophageal tearing
Fainting

Question 32

What’s incidence?

Answer 32

Number of new cases in a set window of time

Question 33

What is prevalence?

Answer 33

Number of current cases (point prevalence) or number of people who have had the problem over the past year (annual prevalence), or case over lifetime (lifetime prevalence)

Question 34

How do we calculate incidence?

Answer 34

Slow onset + secrecy + slow diagnosis = hard to calculate incidence
Therefore, we focus on prevalence

Question 35

When do eating disorders happen?

Answer 35

When psychosocial and neurobiological factros run into difficulties:
In a cultural context, where control is important and thinness is valued
Strongly gender-biased for that reason

Question 36

What are some lifetime rates ?

Answer 36

Anorexia nervosa= 4% of women, 0.3% of men (van Eeden et al., 2021)

Bulimia nervosa = 3% of women, 1% of men (van Eeden et al., 2021)

Binge eating disorder= 2.8% of women, 1% of men (Galmiche et al., 2019)

Some indication that OSFED has the highest lifetime prevalence (Galmiche et al., 2019)

In Western cultures: prevalence of binge eating up to 6.1% of women and 0.7% of men (Silen & Rahkonen, 2022)

Question 37

Do medical records reviews tell us the nb of cases?

Answer 37

Unfortunately not, because they only tell us how many cases were “spotted” – not how many there were: so beware of reports about ‘epidemics’ and ‘rocketing numbers’

Question 38

Are GPs good at spotting cases?

Answer 38

GPs are not perfect at spotting cases
- even where the person is very underweight
- especially not if the person is not young, white and female
So, when this happened it was not about new cases. More about awareness being raised Currin et al. (2005)

Question 39

How does westernisation impact eating?

Answer 39

We are now very clear that westernisation is related to increasing identification and prevalence

Curacao study: showing more cases among non-whites in recent years (Hoek, 2006)

Fiji study (Becker et al., 2011): a clear link to the introduction of western media, both TV and more social-network based exposure (e.g., home DVD players).

Question 40

What are some proposed causal factors?

Answer 40

Lots and lots of sociocultural and neurobiological factors: see the helpful diagrams in the Davey book (p.344)
Early parenting, abuse, bullying, emotional invalidation, childhood obesity, parental mood/eating, puberty, childhood anxiety, etc…
Probably some of them are relevant
Very week causal evidence

Question 41

Why is the evidence for proposed causal factors weak?

Answer 41

Lack longitudinal data
Selective sampling (e.g., don’t ask people who do not have the problem)
Risk of selective memory and when asking (e.g., early teasing)
Risk of misinterpreting associations (e.g., parenting and eating problems)

Question 42

What are some neurobiological factors?

Answer 42

They are unclear. hpoethese are much more common than actual evidence.

Genetics has some evidence (dizygotic vs monozygotic twin studies) But where are those responsible genes? Are they responsible for eating disorders directly or other risk factors? perfectionism? serotonin mechanisms that predispose to impulsivity or compulsivity?

Hypothalamic damage, preventing hunger? but anorexia nervosa patients report lots of hunger
The problem of understanding neurobiology in eating disorders is exacerbated by the issue of causality: does the messed-up biology result in the eating disorder, or does the eating disorder result in the messed-up biology?

Question 43

What are some starvation effects that seem to go away when the person eats?

Answer 43

mood deficits
cognitive deficits
social isolation
behavioural inactivation

This becomes very important next time, when planning treatment

Question 44

What keeps an eating disorder going?

Answer 44

Cognitive pattern common in eating disorder (low self esteem, negative self attribution, perfectionism)

Self-maintaining cycle: Low self-esteem means that we do not look fo rpositive things about ourselves so our esteem remains low. High perfectionism is seen as meaning that we avoid getting things wrong rather than that we are good at anything so we have to keep striving.

Question 45

What are the two main cogntiive patterns?

Answer 45

Two central belief systems:
The ‘broken cognitive link’ between eating and weight. Drives restriction, then bingeing, then gaining weight, then restricting… Strong cognitive dissonance element. Assumption that even small amount of eating will lead to disproprionate weight gain. An assumption that any weight gain will be uncontrollable and unstoppable. The therapeutic task is help rebuild the link Waller & Mountford (2015)

Two central belief systems: Overvaluation of appearance and weight as defining we as being acceptable people. “I am only good enough if I am thin enough, but I never am thin enough…” see Fairburn et al. (2003)

Question 46

What are safety behaviours?

Answer 46

Behaviours that calm us temporarily when e are anxious such as binge eating, restricting, body avoidance/checking, exercice, burging.
But where the long-term consequence is that we feel worse: so we do the behaviour again to calm us, forms a vicious cycle
e.G.
Patient afraid of weight gain <=> Patient skips breakfast and other meals. [short-term: feels better/more control] [long-term: starvation makes patient more fearful of overeating)

Question 47

What are some emotional factors?

Answer 47

Anxiety is the biggest single emotional maintaining and triggering emotion for eating problems:
Anorexia nervosa, bulimia nervosa, binge-eating disorder, ARFID
Particularly related to those safety behaviours
Also see impact of several other emotions: anger, loneliness, boredom
Depression is more of a consequence than a cause: note the issue of serotonin deficits

Question 48

What are some perceptual factors?

Answer 48

Well established perceptual distortions in eating disorders. Individuals with an eating disorder see selves as c.25-30% larger than they are. Evidence of a temporal lobe issue? No, because the same applies to non-clinical women (c.10-15% overestimate). More about how we overestimate the size of valued objects in general.
We can also misperceive our weight: ‘thought-shape fusion’ when we see food

Question 49

What are some social factors?

Answer 49

Social pressure to be thin is widespread in western culture or heavily muscled. Evidence that reading fashion magazines, etc. worsens body image, self-esteem, etc. But now we have more aggressive social media: image-based sites encouraging comparison and self-criticism and ‘thinspiration’/pro-AN websites

Question 50

How do we formulate binge behaviour?

Answer 50

Completed with the individual to normalise what they do when they binge-eat. Helps to learn to identify risk. ‘how to make someone bulimic…’

Triggers?
-emotional distress
-availability of food/cue exposure
Setting conditions
- starvation
- disinhibition/permissive cognitions

Question 51

What is the binge graphe?

Answer 51

Starvation > Risk of using eating behaviour
Exposure > Risk of using EB
Emotion/Stress/Distress > Risk of using EB
Disinhibition (alcohol, drugs, dissociation) > Risk of using EB

Question 52

What is the A B C model?

Answer 52

Linking Antecedents, Behaviours and Consequences. Focus on feedback loops that maintain the problem.

Question 53

How do we formulate cases?

Answer 53

This is not a diagnostic process, but a way of understanding the functions of the eating disorders.

It allows for the way that individuals differ in their history and their potential causal and maintaining factors.
But assumes some core functions and processes that underpin most cases

Question 54

What is a more useful model?

Answer 54

Functional Analytic Mode Slade (1982)
Adapted in this version. Central role of control. Note that the stress is on the maintenance elements. e.g., food is critical at this point, but was less important at the beginning

Question 55

What is a model formulating cases?

Answer 55

Different models exist, but they have varying levels of evidence and complexity
Needs to be parsimonious to be useful
For example, the Fairburn et al. (2003) model is pretty complex, and the evidence for it is weak