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

1
Q

Describe normal eating?

A

A pattern of eating behaviours which:

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

1:14:50

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2
Q

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

A
  • Constant “dieting”
  • Morbid Obesity
  • Anorexia nervosa
  • Bulimia nervosa
  • Binge Eating Disorder
  • Eating disorders are not secondary to other disorders, they are primary disorders
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3
Q

How common are eating disorders?

A
  • one of most common disorders in western world
  • alongside depression & anxiety
  • one of the most common to result in death of a patient
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4
Q

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

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

1:18ish

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5
Q

What is the DSM-5 Criteria for Anorexia Nervosa?

A
  • 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

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6
Q

What are the two sub-types of Anorexia Nervosa?

A
  • 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

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7
Q

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

A
  • Body Mass Index (BMI)
    121: 40
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8
Q

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

A
  1. Current
  2. Ideal
  3. Attractive (what they think is attractive)
  4. Other Attractive (what others think is attractive)
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9
Q

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

A

High on Distorted Attitude

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10
Q

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?

A
  • **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
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11
Q

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

A
  • No real gender difference between ideal distortions
  • Men tend to overestimate their current weight
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12
Q

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

A
  • 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

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13
Q

What are the Psychological changes associated with anorexia

A
  • Patient is no longer rational
  • Personality changes

124:10

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14
Q

Who most typically suffers with anorexia nervosa?

What may be some early indicators in this demographic?

A
  • 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

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15
Q

What is the prognosis for anorexia?

A
  • 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

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16
Q

What is the prevalence of Anorexia In the overall poulation?

A
  • Rare disease – 1% or less of the population
    • (but 3rd most common disease in young girls)
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17
Q

What other disorders/conditions are often comorbid with anorexia?

A
  • Depression
  • Anxiety
  • Obsessive Compulsive Disorders
  • Phobias

125:25

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18
Q

Do patients swap between Anorexia & Bulimia?

i.e., cross-over disorders

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

1:27

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19
Q

What is the DSM-5 criteria for Bulimia Nervosa?

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

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1:27:10

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20
Q

What feature distinguishes Bulimia from Anorexia?

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

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21
Q

Why would someone with Bulimia maintain ‘normal’ weight?

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

128:00

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22
Q

Who is most typically develops Bulimia Nervosa?

A
  • 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

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23
Q

How does Bulimia Nervosa usually start?

A
  • 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

24
Q

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

A
  • 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

25
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 slide12 131:10
26
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
27
What is the **DSM-5** criteria for **Binge Eating Disorder**?
* 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.** slide13
28
What is the **main difference** between **Bulimia & Binge Eating Disorder**?
* **No compensatory behaviour** in Binge Eating Disorder 133: 00
29
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
30
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
31
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
32
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 slide14 133:45
33
What are some factors that may lead to BED?
* Factors leading to BED: * Childhood obesity * Negative weight comments * Depression * Childhood abuse
34
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
35
What **factors** are considered in the **aetiology** of **eating disorders**?
* Genetic factors * Neurobiological factors * Psychodynamic/Environmental factors * Cognitive Behavioural factors
36
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
37
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
38
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
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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
40
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
41
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
42
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
43
What **environmental factors** may contribute to eating disorders?
* Early menarche * Stress in mothers during pregnancy * Premature birth or cephalhematoma in newborn babies
44
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
45
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
46
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 
47
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)
48
When **restrained from purging**, what **physical symptoms** are seen in a person with Bulimia?
* When restrained from purging * ↑ anxiety and skin conductance when eating
49
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.**
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?
* 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.
51
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
52
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 * 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
53
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.
54
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!
55
**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