Week 4 Lecture 4b - Eating Disorders (112:50) (DN) Flashcards
Lecture Content Eating Disorders: Diagnosis and Prognosis 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Binge Eating Disorder Aetiological Factors Genetic; Neurobiological; Psychodynamic; Environmental; Cognitive Behavioural Socio-Cultural Factors Gender; Cross-Cultural; Ethnic; Personality & Child Abuse Treatment Options Prescribed Reading Ch11 Exam based on chapter & lecture content
Describe normal eating?
A pattern of eating behaviours which:
- Maintains normal weight
- Ensures adequate nutrition
- Conforms with cultural/religious requirements
- Enjoyable
1:14:50
What are some of the consequences of ‘abnormal’ eating?
- Constant “dieting”
- Morbid Obesity
- Anorexia nervosa
- Bulimia nervosa
- Binge Eating Disorder
- Eating disorders are not secondary to other disorders, they are primary disorders
How common are eating disorders?
- one of most common disorders in western world
- alongside depression & anxiety
- one of the most common to result in death of a patient
What are some of the disorders not otherwise specified in the DSM-5?
- pika - eating odd things
- rumination - eating, vomiting & re-eating it
1:18ish
What is the DSM-5 Criteria for Anorexia Nervosa?
- Restriction of energy intake relative to requirements, leading to significantly low body weight (for age, sex, etc)
- Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain.
- Disturbance in the way one’s body weight or shape is experienced.
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1:18:50
What are the two sub-types of Anorexia Nervosa?
-
Restricting Type
- Not regularly engaged in binge eating or purging behaviours
-
Purging Type
- Regularly engaged in binge eating and purging behaviours.
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120:30ish
What is the Anorexia Nervosa severity scale in DSM-5 based on?
- Body Mass Index (BMI)
121: 40
What are the 4 criteria on the Distorted Attitude Toward Eating Scales?
- Current
- Ideal
- Attractive (what they think is attractive)
- Other Attractive (what others think is attractive)
How would a person with anorexia most likely score on Zellner’s Distorted Body Image Scale?
High on Distorted Attitude
What is the main difference between a high & a low scorer
in the visual appearance of the 4 scoring criteria on the Distorted Attitude Toward Eating Scale?
- **High: **the criteria are spread out
- i.e., the difference between current & ideal weight is greater
-
Low: the criteria are more clumped together
- i.e., the difference between current & ideal weight is much closer
Are there any gender similarities/differences on the ‘Distorted Attitude Toward Eating Scale’?
- No real gender difference between ideal distortions
- Men tend to overestimate their current weight
What are some physical outcomes of the chronic starvation associated with in anorexia nervosa?
- Basal rates slow significantly
- Blood Pressure & Heart Rate
- Kidney and Gastro-Intestinal problems
- Bone mass reduced significantly
- Skin dries out
- Neurological impairments
- Reduction of important electrolytes (e.g. Na+, K+) (dangerous)
- can develop cardiac arythmia
- Endorphins may be released (may act as reinforcers for disordered behaviours in relation to eating)
- Tiredness, fatigue, cognitively impaired
- May lead to death
- because of extreme physical changes
123:10
What are the Psychological changes associated with anorexia
- Patient is no longer rational
- Personality changes
124:10
Who most typically suffers with anorexia nervosa?
What may be some early indicators in this demographic?
- Typically a disease of young female adolescents (90%).
- May start off as
- extreme & rigid dietary control
- obsession with
- food
- weight gain
- some of these people will remit from these early behaviours & others will develop an eating disorder
124:30
What is the prognosis for anorexia?
- Approx. 70% recover to some extent
- takes about 5 – 7 years.
- not treatable overnight - recovery takes a long time
- typically only 20% will show remission within first year
- 10-20% will never recover, may remit & then fall back into disorder
- Death rate – from physical complications and suicide is high
- 1 - 8% death rate (too high)
- 3rd most common cause of death
1:26
What is the prevalence of Anorexia In the overall poulation?
- Rare disease – 1% or less of the population
- (but 3rd most common disease in young girls)
What other disorders/conditions are often comorbid with anorexia?
- Depression
- Anxiety
- Obsessive Compulsive Disorders
- Phobias
125:25
Do patients swap between Anorexia & Bulimia?
i.e., cross-over disorders
- Anorexia can develop into Bulimia
- but rarely the other way around
1:27
What is the DSM-5 criteria for Bulimia Nervosa?
-
Recurrent episodes of binge eating
* In 2 hours food intake > normal
* Lack of control over eating during the period
-
Recurrent episodes of binge eating
-
Recurrent inappropriate compensatory behaviour to prevent weight gain.
* Vomiting/laxatives/diuretics/excessive exercise
-
Recurrent inappropriate compensatory behaviour to prevent weight gain.
- Symptoms at least once a week for 3 months
- Self evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during periods of Anorexia Nervosa.
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1:27:10
What feature distinguishes Bulimia from Anorexia?
- People suffering from Bulimia are usually of ‘normal’ weight
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Why would someone with Bulimia maintain ‘normal’ weight?
- they are not restricting their calories
- they take in too many calories & then purge
- whereas anorexia (severe calorie restriction)
128:00
Who is most typically develops Bulimia Nervosa?
- Typically found in older adolescents/ young women.
- 90% of cases are female
- Low incidence : 1-2% of the population
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1:29:15
How does Bulimia Nervosa usually start?
- similar to Anorexia
- rigid control of diet & fear of gaining weight
- very aware of intake
- may meet criteria for Anorexia early on
- but then bingeing/purging behaviour kicks in & end up moving into Bulimia
129:50
What are some secondary (comorbid) physical risks associated with Bulimia?
-
Suicide
- rates are high but lower than with Anorexia Nervosa
- Electrolyte imbalance/ depletion
- from frequent purging
-
Severe dental problems
- from frequent vomiting
- (ph balance destroyed – excess acidic gastric secretions destroy enamel on teeth).
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130:30
How likely is recovery from Bulimia?
- Prognosis is more optimistic than with Anorexia
- about 70% recover
- more successful treatment for Bulimia
- Recovery Depends on stage of disorder where intervention begins.
- Comorbity with other disorders.
Death rate: 0-2% (too high) but lower than Anorexia
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131:10
What is the difference between the DSM-5 severity rating for
Anorexia Nervosa & Bulimia Nervosa
Anorexia: BMI
Bulimia: number of times purging during a week
mild: 1-3
extreme: >14
for exam dont think about the numbers - think about the concept
128:40
What is the DSM-5 criteria for Binge Eating Disorder?
-
Recurrent episodes of binge eating
* > food intake in 2hours
* Lack of control
-
Recurrent episodes of binge eating
- The Binge eating episodes are associated with 3 or more of the following:
* Eating more rapidly than normal
* Eating until uncomfortably full
* Eating large amounts when not hungry
* Eating alone because of embarrassment
* Feeling disgusted/guilty/upset afterwards
- The Binge eating episodes are associated with 3 or more of the following:
- Marked distress regarding binge eating episode
- Binge eating occurs 1/wk for > 3mths
- NO compensatory behaviour.
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What is the main difference between Bulimia & Binge Eating Disorder?
-
No compensatory behaviour in Binge Eating Disorder
133: 00
Are there any gender differences in the prevalence of Binge Eating Disorder?
If so, how does the gender disparity compare to Anorexia & Bulimia?
- Women: more prevalent than men
- Gender disparity is much closer than Anorexia & Bulimia
133: 20
134: 35
How does the prevalence of Binge Eating Disorder compare to the other eating disorders?
- Binge Eating Disorder is more prevalent than Anorexia & Bulimia
133: 00
How does a classification within DSM impact the literature on eating disorders?
Use Binge Eating Disorder as an example…
- Once a disorder has its own classification - an abundance of research is normally done
- Binge Eating Disorder has only just received a separate classification in DSM
- and there is very little research in literature
- this is likely to change with its separate classification in DSM-5 (2013)
133:40
What is an important distinction when considering obesity and Binge Eating Disorder (BED)?
- People with Binge Eating Disorder are likley to be obese
- but all obese people do not necessarily have BED
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133:45
What are some factors that may lead to BED?
- Factors leading to BED:
- Childhood obesity
- Negative weight comments
- Depression
- Childhood abuse
What are Outcomes of Binge Eating Disorder?
Outcomes are less severe than other eating disorders
Largely Psychological issues
- impairments in
- social functioning
- work
- self esteem
- more likely to engage in substance abuse
Health impacts are very different to Anorexia & Bulimia
- Directly related to the weight gain of the disorder
- Type 2 Diabetes
- Cardiovascular disease
- Breathing problems
- Sleep Apnoea
- Joint & muscular problems
not much in the literature likely to increase over the next 5-10 years with its inclusion in the DSM-5 as a stand alone disorder
135:15
What factors are considered in the aetiology of eating disorders?
- Genetic factors
- Neurobiological factors
- Psychodynamic/Environmental factors
- Cognitive Behavioural factors
Genetic factors
- Both major disorders are familial
- Anorexic Patients – 1st degree relatives 10 times more likely to have the same disorder.
- Bulimic Patients – 1st degree relatives 4 times more likely to have the same disorder
1:36:00
What have twin studies shown with regard to eating disorders? Nature or Nurture?
- Monozygotic - from same embryo
- Dizygotic - share 50% genetic
- Monozygotic twins ↑ concordance rate for eating disorders than dizygotic twins.
- this is evidence for a genetic component to eating disorders
1:36:35
Why is much more work needed in the area of genetic contribution?
- Mostly a social & psychological focus in the literature.
- Some genetic factors have been identified but low power
- further work required.
1:37:15
Neurobiological factors
-
Role of the hypothalamus?
- animal studies lesioned - led to decreased appetite
- but accompanied by an indifference to food
- (different to eating disorders where focus is on food)
-
Endogenous opioids
- enhances mood, suppresses appetite.
- ↑ during starvation & exercise
- Reinforcing state?
- Most severe Bulimia cases had lowest beta- endorphin
1:37:30
What role might serotonin play in eating disorders?
- Serotonin promotes satiety thus are binges due to serotonin deficit?
- AN and BN ↓ serotonin metabolites
- AN who recover less well respond worse to serotonin agonists.
- suggests serotonin may be playing a role in eating disorders
- SSRIs effective for eating disorder treatment
- question is - are you treating the disorder or symptoms e.g., depression, anxiety
1:39:35
Psychodynamic factors: what is the underlying thought in the literature?
idea is that the core cause is a disturbed parent-child relationship.
1:41:40
What elements of a parent-child relationship may be ‘disturbed’ when considering the psychodynamic factors in eating disorders?
- Children raised as ineffectual
- so do not develop behaviour to gain competence, respect and effectiveness
- Failure to develop sense of self because of conflicting mother- daughter relationship
- Food symbol of relationship
- Binging/Purging is the conflict
What environmental factors may contribute to eating disorders?
- Early menarche
- Stress in mothers during pregnancy
- Premature birth or cephalhematoma in newborn babies
Cognitive Behavioural factors of Bulimia Nervosa…
- Fear of fatness reinforced through successful dieting
- Media representations of “ideal”
- being overweight + comparison of self to other = body dissatisfaction
- Troubled family/personal relationships
- Difficulty expressing emotions
- History of bullying/being teased/ridiculed for weight
- Teased > body dissatisfaction > eating disorder
- History of physical and/or sexual abuse
- Family history of depression
- Weight loss Positively Reinforced by positive comments about weight loss
1:42:00
What were the findings of Polivy et al., 1976; 1988; 1994?
- Individuals who score high on restraint scale ate more.
- Even when preload was perceived as fattenting
- Even when food unpleasant
Briefly describe the experimental design Polivy et al., employed?
Low Restraint Pre-load No pre-load Rate Amount Measured High Restraint Pre-load No pre-load Rate Amount Measured 
Briefly describe the cycle of bulimia nervosa?
- Low self-esteem & high negative affect
- dieting to feel better about self
- food intake is restricted too severley
- diet is broken
- binge
- Compensatory behaviours to reduce fears of weight gain
- (e.g., vomiting, laxatives)
When restrained from purging, what physical symptoms are seen in a person with Bulimia?
- When restrained from purging
- ↑ anxiety and skin conductance when eating
How does society impact the way women see themselves?
Are Socio-Cultural Influences vulnerable to the passing of time?
- Women are socialized to look ‘nice’
- pressure accompanied with that combined with other contributory factors may lead to an eating disorder
- Definition of ‘nice’ varies dramatically over time if visual records are used as a guide.
- Changes very marked during 20th and early 21st century,
- last 25 years popular culture has settled on an ideal of very thin women.
Are Socio-Cultural Influences vulnerable to the passing of time?
If so, how have these influences changes, and is there an impact on eating disorders?
- Yes
- Definition of ‘nice’ varies dramatically over time if visual records are used as a guide.
- Changes very marked during 20th and early 21st century,
- Circumstantial evidence suggested Rubens’ concept of beauty (full figured women) was common among his contemporaries
- Dieting is now more common
- (1950 vs. 1999: Men - 7% - 29%; women - 14% - 44%)
- Eating disorders often preceded by periods of dieting
- Body dissatisfaction
- (for whatever reason – overweight; exposure to societal “norms” in media) are risk factors for eating disorders.
- not causal
- last 25 years popular culture has settled on an ideal of very thin women.
What pharmacological interventions have been used in the treatment of eating disorders?
What are the problems with these interventions?
-
Anti-Depressants
- Fluoxetine ↓ binge eating and vomiting in BN compared to placebo.
- Also ↓ depression and distorted view toward eating.
- Problem = drop-out rate.
- 1/3 of women dropped out of study (side effects)
- Relapse when medication withdrawn
- AN does not respond well to anti- depressant medication
What Psychological Interventions are used in the treatment of Anorexia Nervosa?
Anorexia
-
Two tiered process:
- 1) Hospitalization immediate weight gain
- 2) Operant conditioning to achieve healthy weight
- CBT + Hospitalization = ↓ of anorexic symptoms after 1yr
- Family therapy
- Lunch meetings to
- Change patient role of anorexic
- Redefine issue as an interpersonal issue (not personal)
- Prevent parents using the disorder to prevent conflict
- Preliminary data suggest this is effective
What Psychological Interventions are used in the treatment of Bulimia Nervosa?
Bulimia
- CBT most valid and current gold-standard
- Cognition–i.e.challenge perception of “thin”
- Behaviour–i.e.being taught assertiveness skills
- CBT better than anti-depressants at 1, 6 and 10-y follow up
- Purging decreases by 70-90%
- However, LARGE individual differences.
- Interpersonal therapy and family therapy options.
What Psychological Interventions are used in the treatment of Binge Eating Disorder?
- Newly formed so data scarce.
- CBT and IPT most effective
- More work required!
Lecture Summary
- Anorexia nervosa and Bulimia nervosa, separate but related eating disorders of low incidence in population
- Bulimia more amenable to intervention and treatment
- Anorexia nervosa has life-threatening consequences in end stages of wasting that results
- Binge Eating Disorder – new classification in 2013.
- Aetiologies are speculative, at best, and this impedes treatment and prognosis for both groups
- Some treatment programmes report good recovery rates after one-year post-treatment, but relapses occur
