Week 4 - Lecture - Eating Disorders Flashcards
definition of ED
Severe, psychiatric disorders characterised by a dysfunctional relationship with food and distorted perceptions about the body, that significantly impairs physical health and/or psychosocial functioning. (APA, DSM-5).
AN in DSM 4 compared to DSM 5
DSM-4:
- Refusal to keep body weight above minimal healthy level (85%)
- Fear of weight gain
- Disturbance of body experience
- Amenorrhea
DSM-5:
- Restriction of intake leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Fear of weight gain
- Disturbance of body experience
subtypes of AN
- Restricting
- Binge-eating/purging
BN in DSM4 and 5
DSM-4:
- Recurrent episodes of binge-eating
- Compensatory behaviours
- Bingeing & compensation happen twice per week over at least 3 months
- Self-evaluation is unduly influenced by body shape & weight
- Not simply a phase of anorexia
DSM-5:
- Recurrent episodes of binge-eating
- Compensatory behaviours
- Bingeing & compensation happen once per week over at least 3 months
- Self-evaluation is unduly influenced by body shape & weight
- Not simply a phase of anorexia
binge-purge cycle
cycle:
strict dieting
diet slips or difficult situations arise
binge eating is triggered
purging to avoid weight gain
feelings of shame and disgust
binge eating disorder
- Newish binge eating disorder (BED)
- Recurrent episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances; eating very fast in the absence of hunger.
- Marked by feelings of loss of control and guilt, embarrassment, or disgust.
- Bingeing happens once per week over at least 3 months.
- Mild 1-3, 4-7,8-13, extreme 14+ binge periods a week
- Can binge over 10000 at a time
Eating disorders: not otherwise specified; EDNOS; DSM-IV
- Atypical anorexia nervosa (significant restriction and fear of weight gain but is of normal weight)
- Low frequency bulimia nervosa (not meeting the thresholds)
- Low frequency binge eating disorder (not meeting thresholds)
- Purging disorder (self-induced vomiting, laxatives, exercise etc but no binging)
- Night eating syndrome (eat lots of food a night not related to hunger)
Pica (consume non-nutritious substances - non-food)
Rumination disorder (regurgitate part digested food)
Avoidant/restrictive food intake disorder (such a restricted diet they are unable to make their nutritious needs, impact physical and psychological health)
sub-threshold disorders
- 40-50% of cases do not fit neatly into diagnosis
- Atypical cases (OSFED) are the largest group
- Many people move from one diagnosis to another
- Sub-threshold disorders are most common
shift away from rigid diagnoses
model
- Transdiagnostic model (Waller, 1993; Fairburn et al., 2003)
incidence and prevalence of ED
- 62% of people with eating disorders have symptoms before the age of 16 (PwC, 2016)
- All figures taken from Westernised cultures (similar across countries)
- Peak age of onset is slightly younger in AN (14-16 years vs 18-20 years; but many cases are younger or older).
- BED: compared to other eating disorders, more common in males and older people.
- Female: male ratio (approx. 20:1 > more recent suggestions = 10:1)
- Anorexia nervosa (0.5-1.0% of teenage girls)
○ 21 new cases per 100000 population per year - Bulimia nervosa (1-2% of women aged 16-35)
○ 30 new cases per 100000 population per year - BED (epidemiological studies are lacking. Extrapolation estimates are 3.6% of women and 2.1% of men aged 18-70)
○ Similar to BM in terms of new cases per year but not known yet - OSFED (2-3% of women aged 16-35)
why might ED rates differ?
○ Definitions used for diagnosis (DSM-4 vs 4)
○ Individual assessors/therapist opinion
○ Sample - clinical cases only or self-reported
○ Other researcher variables, e.g. new cases only, not re-referrals
○ Across cultures; less ED? Less acceptable? Fewer treatment opportunities?
covid 19 and ED
- Systematic review of 53 studies (Devoe et al., 2022)
- Evidence to suggest that the pandemic led to:
○ increased diagnoses of EDs (↑15%);
○ increased hospital admissions for EDs (↑48%)
○ and increased ED symptoms. - Increased co-morbidity (e.g., anxiety, depression, suicidal ideation; Taquet et al., 2021)
- Decreased access to care and treatment, changes to routine and loss of structure, social isolation.
- Evidence to suggest that the pandemic led to:
diagnosis and treatment
- Takes 15 months between spotting symptoms and starting treatment on average (PwC, 2015)
- Hamilton et al., (2022) – 5.28 years between symptom onset and treatment seeking in Australian sample (n = 119).
death and ED
- Meta-analysis from Arcelus, Mitchell, Wales & Nielsen (2011).
○ Elevated risk of death for all patients with eating disorders.
§ Significant increase for those with AN.
○ In practice: If I see 1000 patients with AN a year in my clinic, 5 will die and 1.3 will die of suicide
○ Patients with AN have nearly 6 times more chances of dying than people without AN
○ Older on assessment →higher mortality
disability-adjusted life years
- Australian Institute of Health & Welfare
○ EDs are 6th in terms of disability-adjusted life years: from early mortality and reduced quality of life for ages 15-24.
risk factors for ED
- Female
- Adolescent/young adult
- Sociocultural pressures and expectations “thin ideal”
- Biological: genetic predisposition
- Biological: serotonin dysfunction
- Family history of depression (or other psychological illness), substance/alcohol abuse, eating disorder, obesity, chronic dieting
- Experiences: parenting (invalidating environment), abuse, critical comments, pressures to be slim
- Individual characteristics: low SE, perfectionism, anxiety problems, obesity, early menarche
genetic model of ED
○ Eating disorders appear to run in families.
○ Strober et al (2000): female relatives of AN patient x11 more likely to develop AN.
○ Some specificity for ED type; but risk for all EDs is higher among first degree family members.
○ Heritability estimates up to 0.74 for AN
○ 55% identical twins concordant for AN.
○ Much weaker for BN (less is known about the genetic pathways for other EDs).
○ Significant genetic correlations between AN and other psychiatric disorders (e.g., schizophrenia).
○ Large genetic studies identified certain patterns of genes
that seem to be important.
psychoanalytic (psychodynamic) model of ED
○ Way of understanding patients’ experiences
○ Emphasise meanings attached to symptoms and function of them
§ Restriction = success / personal effectiveness / avoidance of sexuality (Bruch, 1974)
§ Vomiting = rid oneself of traumatic sexual experience or fantasy pregnancy
§ Hunger = greed (Dare & Crowther, 1995)
○ Emphasise role of infancy and subsequent experiences in shaping a person.
§ Control
§ Avoidance of maturation
cognitive behavioural model of ED - transdiagnostic cognitive-behavioural model
○ Both AN and BN (transdiagnostic)
○ Core behaviours established via positive and negative reinforcement
○ Can include cognitive state
○ Transdiagnostic = not eating disorder specific and can be applied to all eating behaviours
○ Core self-esteem = overevaluation of importance on the body and eating etc.
significant events and ED
○ Sexual abuse
§ About 30% of ED patients (Connors and Morse, 1993)
□ But may be more significant in men
○ Childhood loss
§ Face validity but not supported by evidence
family systems approach and ED
○ Family not the cause, but context in which ED is embedded (Eisler, 1995)
§ Symptoms as communicative acts
§ The homeostatic family - families may be resistant to change so recovery may be difficult.
§ Boundaries
§ Conflict avoidance
sociocultural model and ED
○ Expression of social values
○ Culture-bound or ethnic disorder
§ Gender role conflicts – traditional feminine role may be protective (Silverstein et al., 1986); Japan.
§ Superwoman Syndrome (Thornton et al., 1991)
§ Identity: child vs independent
§ Strong but look tiny
§ Representations of beauty through unattainable levels of thinness.
§ Evidence to suggest increase in EDs when exposed to westernised ideals (e.g., introduction of TV in Fiji; Becker, 2004; social networking; Becker et al., 2011).
neural model and ED
○ AN may have lower levels of chemicals in brain that might be involved in intake regulation,
§ I.e. Do not feel hungry and so do not eat.
comorbidities
- Self-harm
- Anxiety disorders
- Depression and other mood disorders
- Substance use
- Personality disorders
- Temporal relationships are not always clear
medical treatments
- Re-feeding for nutritional deficits
○ Life-saving
○ Mood stabilisation
○ Inpatient care for the most unwell patients
treatment for AN (NICE)
- Individual CBT-ED (40 sessions over 40 weeks)
- Maudsley AN treatment (MANTRA; 20 sessions)
- Specialist supportive clinical management (20 weekly sessions)
- ED focused focal psychodynamic therapy (40 sessions, 40 weeks)
- AN-focused family therapy for children and young people (20 sessions over 1 year).
Focus on:
- Reaching a healthy body weight or BMI for their age
- Psychoeducation
- Monitoring of weight, mental and physical health.
- Multidisciplinary care, coordinated between services.
- Nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self-esteem and relapse prevention.
- Enhancing self-efficacy
treatment for BN (NICE)
- First line of treatment is BN-focused manualised guided self-help
- Or: Individual CBT-ED (20 sessions over 20 weeks, twice weekly sessions in the first instance).
- BN focused family therapy for young people (or individual CBT-ED).
Focus on:
- Establishing a regular pattern on eating
- Addressing eating psychopathology (e.g., urge to binge eat in response to difficult thoughts/feelings, concerns about body shape and weight, dietary restraint).
- Psychoeducation and engagement
treatment for BED (NICE)
- First line of treatment is BED-focused manualised guided self-help
- Or: Group CBT for EDs (16 weekly sessions over 4 months)
- Or: Individual CBT (16-20 sessions)
Focus on:
- Psychoeducation, self-monitoring of the eating behaviour, analyse problems and goals
- Identifying binge eating cues
- Daily food intake plans
- Body exposure training (to identify and change negative beliefs about the body)
- Coping with risks and triggers
treatment outcomes
- Remission rates for EDs are poor
○ at 1-2 year follow up for AN, remission rates range from 13-50% (e.g., Brockmeyer et al., 2018); 30-40% in BN (Quadflieg & Fichter, 2019; Gorrell et al., 2020)
○ AN – if treatment efforts fail during adolescence, then at risk of “severe and enduring anorexia nervosa” (Wonderlich et al., 2020).
○ Equivalent outcomes for males and females (e.g., Strobel et al., 2019)- Lack good evidence of superiority for any therapies in:
○ multi-impulsive eating disorders
○ eating disorders characterised by exercise
○ most ‘atypical’ cases
○ the majority - And that is where the research is going…
- Lack good evidence of superiority for any therapies in:
