Week 4 Lecture 4b - Eating Disorders (112:50) (DN)

Question 1

Describe normal eating?

Answer 1

A pattern of eating behaviours which:

• Maintains normal weight
• Ensures adequate nutrition
• Conforms with cultural/religious requirements
• Enjoyable

1:14:50

Question 2

What are some of the consequences of ‘abnormal’ eating?

Answer 2

• Constant “dieting”
• Morbid Obesity
• Anorexia nervosa
• Bulimia nervosa
• Binge Eating Disorder
• Eating disorders are not secondary to other disorders, they are primary disorders

Question 3

How common are eating disorders?

Answer 3

• one of most common disorders in western world
• alongside depression & anxiety
• one of the most common to result in death of a patient

Question 4

What are some of the disorders not otherwise specified in the DSM-5?

Answer 4

• pika - eating odd things
• rumination - eating, vomiting & re-eating it

1:18ish

Question 5

What is the DSM-5 Criteria for Anorexia Nervosa?

Answer 5

• 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

Question 6

What are the two sub-types of Anorexia Nervosa?

Answer 6

• 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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Question 7

What is the Anorexia Nervosa severity scale in DSM-5 based on?

Answer 7

• Body Mass Index (BMI)
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Question 8

What are the 4 criteria on the Distorted Attitude Toward Eating Scales?

Answer 8

1. Current
2. Ideal
3. Attractive (what they think is attractive)
4. Other Attractive (what others think is attractive)

Question 9

How would a person with anorexia most likely score on Zellner’s Distorted Body Image Scale?

Answer 9

High on Distorted Attitude

Question 10

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?

Answer 10

• **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

Question 11

Are there any gender similarities/differences on the ‘Distorted Attitude Toward Eating Scale’?

Answer 11

• No real gender difference between ideal distortions
• Men tend to overestimate their current weight

Question 12

What are some physical outcomes of the chronic starvation associated with in anorexia nervosa?

Answer 12

• 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

Question 13

What are the Psychological changes associated with anorexia

Answer 13

• Patient is no longer rational
• Personality changes

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Question 14

Who most typically suffers with anorexia nervosa?

What may be some early indicators in this demographic?

Answer 14

• 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

Question 15

What is the prognosis for anorexia?

Answer 15

• 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

Question 16

What is the prevalence of Anorexia In the overall poulation?

Answer 16

• Rare disease – 1% or less of the population
  
  • (but 3rd most common disease in young girls)

Question 17

What other disorders/conditions are often comorbid with anorexia?

Answer 17

• Depression
• Anxiety
• Obsessive Compulsive Disorders
• Phobias

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Question 18

Do patients swap between Anorexia & Bulimia?

i.e., cross-over disorders

Answer 18

• Anorexia can develop into Bulimia
  
  • but rarely the other way around

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Question 19

What is the DSM-5 criteria for Bulimia Nervosa?

Answer 19

• 1. Recurrent episodes of binge eating
     * In 2 hours food intake > normal
     * Lack of control over eating during the period
• 2. Recurrent inappropriate compensatory behaviour to prevent weight gain.
     * Vomiting/laxatives/diuretics/excessive exercise
• 3. Symptoms at least once a week for 3 months
• 4. Self evaluation is unduly influenced by body shape and weight.
• 5. The disturbance does not occur exclusively during periods of Anorexia Nervosa.

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Question 20

What feature distinguishes Bulimia from Anorexia?

Answer 20

• People suffering from Bulimia are usually of ‘normal’ weight

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Question 21

Why would someone with Bulimia maintain ‘normal’ weight?

Answer 21

• they are not restricting their calories
  
  • they take in too many calories & then purge
• whereas anorexia (severe calorie restriction)

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Question 22

Who is most typically develops Bulimia Nervosa?

Answer 22

• Typically found in older adolescents/ young women.
  
  • 90% of cases are female
  • Low incidence : 1-2% of the population

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Question 23

How does Bulimia Nervosa usually start?

Answer 23

• 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

Question 24

What are some secondary (comorbid) physical risks associated with Bulimia?

Answer 24

• 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

Question 25

How likely is recovery from Bulimia?

Answer 25

• 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

Question 26

What is the difference between the DSM-5 severity rating for

Anorexia Nervosa & Bulimia Nervosa

Answer 26

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

Question 27

What is the DSM-5 criteria for Binge Eating Disorder?

Answer 27

• 1. Recurrent episodes of binge eating
     * > food intake in 2hours
     * Lack of control
• 2. 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
• 3. Marked distress regarding binge eating episode
• 4. Binge eating occurs 1/wk for > 3mths
• 5. NO compensatory behaviour.

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Question 28

What is the main difference between Bulimia & Binge Eating Disorder?

Answer 28

• No compensatory behaviour in Binge Eating Disorder
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Question 29

Are there any gender differences in the prevalence of Binge Eating Disorder?

If so, how does the gender disparity compare to Anorexia & Bulimia?

Answer 29

• Women: more prevalent than men
• Gender disparity is much closer than Anorexia & Bulimia

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134: 35

Question 30

How does the prevalence of Binge Eating Disorder compare to the other eating disorders?

Answer 30

• Binge Eating Disorder is more prevalent than Anorexia & Bulimia
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Question 31

How does a classification within DSM impact the literature on eating disorders?

Use Binge Eating Disorder as an example…

Answer 31

• 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)

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Question 32

What is an important distinction when considering obesity and Binge Eating Disorder (BED)?

Answer 32

• People with Binge Eating Disorder are likley to be obese
  
  • but all obese people do not necessarily have BED

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Question 33

What are some factors that may lead to BED?

Answer 33

• Factors leading to BED:
  
  • Childhood obesity
  • Negative weight comments
  • Depression
  • Childhood abuse

Question 34

What are Outcomes of Binge Eating Disorder?

Answer 34

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

Question 35

What factors are considered in the aetiology of eating disorders?

Answer 35

• Genetic factors
• Neurobiological factors
• Psychodynamic/Environmental factors
• Cognitive Behavioural factors

Question 36

Genetic factors

Answer 36

• 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

Question 37

What have twin studies shown with regard to eating disorders? Nature or Nurture?

Answer 37

• 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

Question 38

Why is much more work needed in the area of genetic contribution?

Answer 38

• Mostly a social & psychological focus in the literature.
• Some genetic factors have been identified but low power
• further work required.

1:37:15

Question 39

Neurobiological factors

Answer 39

• 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

Question 40

What role might serotonin play in eating disorders?

Answer 40

• 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

Question 41

Psychodynamic factors: what is the underlying thought in the literature?

Answer 41

idea is that the core cause is a disturbed parent-child relationship.

1:41:40

Question 42

What elements of a parent-child relationship may be ‘disturbed’ when considering the psychodynamic factors in eating disorders?

Answer 42

• 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

Question 43

What environmental factors may contribute to eating disorders?

Answer 43

• Early menarche
• Stress in mothers during pregnancy
• Premature birth or cephalhematoma in newborn babies

Question 44

Cognitive Behavioural factors of Bulimia Nervosa…

Answer 44

• 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

Question 45

What were the findings of Polivy et al., 1976; 1988; 1994?

Answer 45

• Individuals who score high on restraint scale ate more.
• Even when preload was perceived as fattenting
• Even when food unpleasant

Question 46

Briefly describe the experimental design Polivy et al., employed?

Answer 46

Low Restraint Pre-load No pre-load Rate Amount Measured High Restraint Pre-load No pre-load Rate Amount Measured 

Question 47

Briefly describe the cycle of bulimia nervosa?

Answer 47

• 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)

Question 48

When restrained from purging, what physical symptoms are seen in a person with Bulimia?

Answer 48

• When restrained from purging
  
  • ↑ anxiety and skin conductance when eating

Question 49

How does society impact the way women see themselves?

Are Socio-Cultural Influences vulnerable to the passing of time?

Answer 49

• 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.

Question 50

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?

Answer 50

• 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.

Question 51

What pharmacological interventions have been used in the treatment of eating disorders?

What are the problems with these interventions?

Answer 51

• 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

Question 52

What Psychological Interventions are used in the treatment of Anorexia Nervosa?

Answer 52

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
  
  • 1. Change patient role of anorexic
  • 2. Redefine issue as an interpersonal issue (not personal)
  • 3. Prevent parents using the disorder to prevent conflict
• Preliminary data suggest this is effective

Question 53

What Psychological Interventions are used in the treatment of Bulimia Nervosa?

Answer 53

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.

Question 54

What Psychological Interventions are used in the treatment of Binge Eating Disorder?

Answer 54

• Newly formed so data scarce.
• CBT and IPT most effective
• More work required!

Question 55

Lecture Summary

Answer 55

• 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