Wk 9 - eating disorders

Academy for eating disorders nine truths (Bulik)

• Many people with eating disorders look healthy, yet may be extremely ill

• Familiries are not to blame and can be the patients and providers best allies in treatment

• An eating disorder diagnosis is a health crisis that disruptes personal and family functioning

• Eating disorders are not choices, but serious biologically influenced illnesses

• Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations and socioeconomic status

• Eating disorders carry an increased risk for both suicide and medical complications

• Genes and environment play important roles in the development of eating disorders

• Genes alone do not predict who will develop eating disorders

• Full recovery from an eating disorder is possible. Early detection and intervention are important

AED also created truths about eating disorders regarding

weight and weight stigma

Different types of eating disorders

• Binge eating disorder

• Bulimia nervosa

• Anorexia nervosa

• Otherwise specified feeding or eating disorder

• Unspecified feeding or eating disorder

• Avoidant restrictive food intake disorder (ARFID)

• Others

  • Pica

  • Rumination disorder

  • Muscle dysmorphia (BDD specifier)

  • Orthorexia nervosa (ON) proposed criteria

DSM-5 for anorexia nervosa

• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health.

• Intense fear of gaining weight, or persistent behaviour that interferes with weight gains, even though at a significantly low weight

• Disturbance in the way in which one's body weight or shape is expereience undue influence of body weight or shape on self-evaluation or persistent lack of recognition of the seriousness of the current low body weight

What was dropped in the DSM-5 criteria that existed in DSM-4?

absence of at least 3 consecutive non-synthetically induced menstrual cycles

Different types of AN

restricting type, binge-eating/purging type

ICD-11 for anorexia nervosa

• characterised by significantly low body weight for the individual’s height, age and developmental stage that is not due to another health condition or to the unavailability of food.

• BMI less than 18.5 kg/m2 in adults and BMI-for- age under 5th percentile in children and adolescents.

• Rapid weight loss(e.g.morethan20%oftotal body weight within 6 months) may replace the low body weight guideline as long as other diagnostic requirements are met.

• Exhibit failure to gain weight as expected based on the individual developmental trajectory rather than weight loss.

• Low body weight is accompanied by a persistent pattern of behaviours to prevent restoration of normal weight, which may include behaviours aimed at reducing energy intake (restricted eating), purging behaviours (e.g. self-induced vomiting, misuse of laxatives), and behaviours aimed at increasing energy expenditure (e.g. excessive exercise).

• Typically associated with a fear of weight gain.

• Low body weight or shape is central to the person's self-evaluation or is inaccurately perceived to be normal or even excessive.

3 subtypes of AN for ICD-11

• Anorexia nervosa with significantly low body weight - BMI under 18.5

• AN with dangerously low body weight - BMI under 14

• Among individuals who are recovering from AN - BMI over 18.5

DSM-5 severity specifiers for AN

• Mild BMI >17

• moderate BMI 16 - 16.99

• severe BMI 15-15.99

• extreme <15

Bulimia

• recurrent episodes of binge eating - an episode of binge eating is characterised by:

  • eating in a discrete period of time an amount of food that is larger than what most individuals would eat in a similar period of time

  • sense of lack of control over eating during episode

Bulimia - recurrent inappropraite compensatory behaviours in order to…

prevent weight gain such as self-induced vomiting, misuse of laxatives, diuretics, fasting or excessive exercise

Severety specifiers for Bulimia

Average number of inappropriate compensatory behaviours per week

• Mild: 1-3

• Moderate: 4-7

• Severe: 8-13

• Extreme: 14+

 

ARFID

Eating disturbance (eg apparent lack of interest in eating, avoidance based on the sensory characteristics of food, concern about aversive consequencies of eating) as manifested by persistent failure to meet appropriate nutritional and energy needs

ARFID: This eating disturbance has to be associated with one of the following

• Significant weight loss

• Significant nutritional deficiency

• Dependence on external feeding or oral nutritional supplements. Market interference with psychosocial functioning

ARFID - Criteria states the disturbance is not better explained by…

 lack of available food or by an associated culturally sanctioned practice

ARFID - criteria states The eating disturbance does not occur exclusively during the course of _____, and there is no evidence of a disturbance in _____

AN/BN

in the way in which ones body weight or shape is experienced

Binge eating disorder is the most….

but….

common eating disorder but often underreported/recognised

Binge eating disorder definition

recurrent episodes of binge eating in the absence of compensatory behaviours

Atypical AN

• All the criteria for AN are met, except that despite significant weight loss, the individual weight is within or above the normal range

• Medical consequences as severe as AN

• Creates an unhelpful distinction

Set point theory

• Starvation - increased hunger, decreased metabolism

• overfed - decreased hunger, increased metabolism

Epidemiology

• Global lifetime prevalence of any eating disorder

• Males: 0.74% - 2.2%

• Females 2.58 - 8.4%

• Higher prevalence in adolescents/ young people:

• Eating disorders: 22.5%

• Disordered eating: 25.7%

the lifetime prevalence for eating disorders is approximately _____ of the australian population (Deloitte Access Economics, 2024)

10.46%

Furhter information on epidemiology of eating disorders

• 80% of people with Eds have co-occuring MH diagnosis

• Increasing prevalence and impact

• AN has one of the highest mortality rates of any psychiatric disorder

• LGBTQ individuals 6x increased risk

Challenges with diagnostic criteria

• Categorical vs spectrum based

• Underestimating severity of some presentations

• "not sick enough"

• Clusters of symptoms vs diagnostic categories

• Transdiagnositic treatments

• Implications for EDCP

Assessment for eating disorders

screening, self-report questionnaires, structured clinical interveiws

Screening

• SCOFF (5 items)

• Eating disorder examination questionnaire-short (12 items)

Self-report questionares for eating disorders

• eating disorder examination questionnaire

• eating attitudes test

• ED-15

• compulsive exercise test

Structured clinical interveiws for eating disorders

• Eating disorder examination

• Structured clinical interview for DSM-5

SCOFF (type of screening)

S- sick

C- control

O - lost one stone

F - fat

F - food

The minnesota starvation study (Keys, 1994)

• Wartime conscientious objectors

• 6 months semi-starvation

• Semi-starvation = 1500 calories + vigorous physical exercise

• -25% loss of body weight

The minnesota starvation study (Keys, 1994) results of 3 months of re-feeding

• Lean tissue took longer to recover than fat tissues

• 12 weeks of insatiable appetite: couldn't stop eating and remained preoccupied with food

• Small number still overeating after 8 months of restrictions lifting

Starvation syndrome (Keys, 1950)

• Physical changes

• Personality changes

• Food preoccupation

• Social behaviour

WAEDOCS guidelines for medical admission

lower blood pressure, heart rate, blood sugar, sodium, potassium, magnesium, phosphate, albumin

Evidence based treatments

• CBT-ED (CBT for eating disorders)

• FBT (family based treatments for AN)

• MANTRA (Maudsley model of AN treatments in adults)

Stages of CBT-ED

• early behavioural change

• normalising eating behaviours

• treatment reveiw

• addressing body image concerns

• relapse prevention

• follow up

CBT formulation for eating disorders

Poor cognitions about body weight and shape which lead to unhelpful behaviours such as restriction

CBT formulation for restriction only (AN)

Unhelpful beliefs → restriction → starvation syndrome

CBT formulation Binge-purge cycle

unhelpful beliefs → restriction → binge eating → purging

CBT formulation for binge eating only

Unhelpful beliefs → binge eating → distress

CBT formulation body image concerns

Triggers → overconcern + overvaluing of appearance → distress

Key treatment components

• Weekly in-session weighing

  • Correcting the broken cognition

• Self-monitoring of eating behaviours

• Focus on normalising eating behaviours

• Reducing concern about body weight/shape through body acceptance

• Exposure: facing fears in order to challenges false/unhelpful beliefs

• Other general CBT strategies: thought diaries, behavioural experiments etc.

• Understanding the number on the scale - have no emotional reaction to it. Don’t want weighing to be avoided but not checked regularly

Disordered eating

• Overly rigid and inflexible - very specific rules for themselves

• Chaotic and out of control - really restrictive and then binging

• Often oscillating between the 2

Normal eating

• flexible.

• It varies in response to your hunger, your schedule, your proximity to food and your feelings

Jeffery - RAVES for normal eating

Regularity

• Eat roughly every 3 hours to keep blood sugars stable

Adequacy

• Overall energy intake appropriate for their body

Variety

• Meeting nutritional needs with all types of food. Eg need carbohydrates to provide glucose to the brain

Eating socially

• Comfortably eat in front of other people

Spontenaity