Chapter 10: Eating Disorders

1. Chapter 10: Eating Disorders Fall, 2012 Dr. Mary L. Flett, Instructor

2. Overview • Eating disorders are severe disturbances in eating behavior resulting from obsessive fear of gaining weight • Dieting disorder may be more accurate term • Two types of eating disorders • Anorexia Nervosa (refusal to maintain a minimally normal body weight) • Bulimia Nervosa (repeated episodes of bingeing, followed by inappropriate compensatory behaviors

3. Anorexia Nervosa • Anorexia means “loss of appetite”, but individuals with this disorder are actually hungry all the time. • Symptoms include • extreme emaciation • disturbed perception of body • intense fear of gaining weight • for women, amenorrhea (cessation of menstruating)

4. Anorexia Nervosa • Refusal to Maintain Normal Weight • AN usually begins with an intention to lose “a few pounds” • DSM suggests “normal weight” is 85% of expected weight • Average victim of anorexia loses 25-30% of normal weight • Weight loss may become life threatening • Mortality due to starvation, suicide, or medical complications

5. Anorexia Nervosa • Disturbance in Evaluating Weight/Shape • Most victims steadfastly deny problems with their weight • May experience distorted body image • attention is drawn to imperfection • critical self-evaluation

6. Anorexia Nervosa • Fear of Gaining Weight • Intense fear of becoming fat is anxiety-based response to biological need to survive • Encouraging individual to eat is threatening to their self-concept

7. Anorexia Nervosa • Medical Complications • Frequent complaints about constipation, abdominal pain, intolerance to cold, lethargy • Effects due to semi-starvation on endocrine system • Lanugo – fine, downy hair on face or trunk • Anemia, infertility, impaired kidney function, cardiovascular problems, dental erosion, osteopenia • Electrolyte imbalance leading to kidney failure and/or cardiac arrest • Death

8. Anorexia Nervosa • Co-morbid Psychological Disorders • Struggle for control may reflect unconscious need to respond to a world that they experience as “out of control”. Self-denial is the ultimate discipline • OCD • Food obsession • Compulsive eating rituals • Mild depression • Bulimia

9. Bulimia Nervosa • Bulimia means “Ox appetite” • Typically have a normal weight and appetite • View bingeing as a failure of control • Usually ashamed and secretive about bingeing and purging • Anorexia and Bulimia share some symptoms; but not all. Anorexics may have episodes of bulimia

10. Bulimia Nervosa • Binge eating is defined as eating an amount of food clearly larger than most people would eat under similar circumstances in a fixed period of time (< two hours) • What is normal and what is pathological? • Over 35% of Americans report occasional binge eating • Many admit to using laxatives or self-induced vomiting to compensate for eating

11. Bulimia Nervosa • Binges may be planned in advance or be spontaneous • Elaborate efforts are made to conceal behavior • Typical binge foods include high calorie foods: • Ice cream • Cookies • Commonly triggered by unhappy mood • may begin with interpersonal conflict • self-criticism regarding weight or appearance • intense hunger following fasting

12. Bulimia Nervosa • Binges typically include a sense of lack of control (“feeding frenzy”) • Some describe a dissociative experience (watching self gorge)

13. Bulimia Nervosa • “Inappropriate Compensatory Behavior”, aka Purging • Most common form is self-induced vomiting • Others include laxatives, diuretics, enemas • Purging has only limited effectiveness • Vomiting prevents absorption of < ½ the calories consumed • Excessive exercise is another form of purging

14. Bulimia Nervosa • Excessive Emphasis on Weight & Shape • Shared symptom with Anorexia • Self-esteem is closely tied with body shape & weight • Highly self-critical of appearance • Individual’s sense of self linked to appearance, not personality, relationships, or achievement

15. Anorexia & Bulimia Compared

16. Bulimia Nervosa • Comorbid Disorders • Depression • Anxiety • Personality (particularly BPD) • Substance abuse

17. Bulimia Nervosa • Medical Complications • Dental enamel erosion from vomiting • Gag Reflex • Rumination • Enlargement of the salivary glands (puffy face) • Rupture of the esophagus or stomach

18. Diagnosing Eating Disorders • Only occurred rarely before 1960; first appeared in DSM in 1980 (DSM-III) • Current version lists • Anorexia Nervosa • Restricting type • Binge eating/purging type • Bulimia Nervosa • Purging type • Non-purging type

19. Diagnosing Eating Disorders • DSM-V is considering including • Binge eating disorder • Obesity • Controversial because not commonly considered a mental disorder • Factors other than psychological affect person’s weight • Obesity is not due to a lack of “will power”

20. Frequency of Eating Disorders • Rare in overall population; high among specific cohorts • “Cohort” is a group that shares common features (e.g., year of birth) • Cohort effects suggest eating disorders differ between those born before 1950 and those born after • Theories include media influence • Change in cultural standards of beauty • Age of onset typically in late adolescence or early adulthood

21. Causes of Eating Disorders • Social Factors • Cultural norms are hugely influential • Fields that emphasize weight and appearance have higher rates of disease • More common among middle and upper class whites; may be increasing in affluent African-Americans • Internalization of ideal of thinness is what distinguishes those with eating disorders from others

22. Causes of Eating Disorders • Family dynamics • Troubled family relationships may increase vulnerability • Enmeshment • Child sexual abuse may contribute; but not directly • Parental modeling

23. Causes of Eating Disorders • Psychological Factors • Struggle for perfection and control • introceptive awareness is lacking • Depression, low Self-Esteem, Dysphoria • Depression found particularly in Bulimia; may be bi-directional • Preoccupation with social self to the exclusion of other aspects (values, spiritual beliefs, achievement) • Negative mood states (dysphoria) may trigger episodes • Negative Body Image • “Current” vs. “Ideal” size

24. Body Contour Rating Scale

25. Causes of Eating Disorders • Psychological Factors • Dietary Restraint • Inappropriate dieting can contributed directly to subsequent binge eating • Quick weight loss is unhealthy; moderate loss is healthy (2-4 lbs per week)

26. Causes of Eating Disorders • Biological Factors • Set-point • Involves limited weight gain or loss due to interplay between • behavior (eating, exercise) • peripheral physiological activity (digestion, metabolism) • central physiological activity (neurotransmitter release) • Body does not “know” if you are dieting or starving

27. Causes of Eating Disorders • Biological Factors • Twin studies suggest there is some genetic influence on personality characteristics that, in turn, increase risk for ED • Neurophysiological issues • Elevations in endogenous opioids • low levels of serononin • diminished neuroendcrine functioning • Hypothalamic lesions may be found in people with ED

28. Treatment of Eating Disorders • Treatments differ for AN and BN • Anorexia has two goals • Help patient gain weight • May be done in hospital for medical reasons or to keep patient safe (suicidality) • Address broader eating and personal difficulties • Family therapy may be more effective than individual • Increase introceptive awareness and correct distorted perceptions • CBT to address negative thought process • Feminist therapy to challenge societal introject • Medications and nutritional counseling have high drop out rates

29. Treatment of Eating Disorders • Treatments differ for AN and BN • Bulimia • Most effective appears to be antidepressants and CBT • Interpersonal therapy surprisingly helpful • Course and Outcome • Although persistent, outcomes are more positive for bulimia than for anorexia where individuals receive treatment • Without treatment, disorders persist over lifetime

30. Prevention of Eating Disorders • Successful approaches to prevention focus on attacking the “thin ideal” rather than specific behaviors • Emphasis is on eating well and healthy exercise