Eating disorders

What is more clinically useful than classifications when we look at eating disorders?

Cognitions, emotions, behaviours, and physical state

What is the hallmark trait of anorexia nervosa?

Extreme weight loss

BMI < 17.5

Restriction of calorie intake below energy requirements (15% below expected weight/85% expected weight)

When is it more challenging to determine the extreme weight loss criteria of AN?

When people have had AN since they were very young, we don’t know what healthy looks like, including weight, eating habits, and sexual functioning

What is the limitation of using BMI to assess healthy weight and anorexia nervosa?

People can have all the features of AN without falling under the red line, or have a BMI that is unhealthy for them, but it is not considered low enough

Healthy ranges are rarely actually healthy

They spread the message everyone’s body is meant to be the same

How does AN typically begin?

Often begins with dieting

If someone meets all criteria for AN without being under the weight cut-off, what would they be diagnosed with? How does this affect severity, treatment, and psychological symptoms?

Atypical Anorexia Nervosa

Treatment is the same apart from percentage body fat and mass, and severity and psychological symptoms are indistinguishable

What are comorbidities for Anorexia Nervosa?

Depression - 70% are depressed at some point

Higher than average rates of substance abuse and OCD

How does anorexia nervosa affect physical functioning?

Starving body borrows energy from internal organs, leading to organ damage including cardiac damage.

Affects the brain, hair/skin, heart, blood, intestines, hormones, kidneys, bones, and muscles

Most things come right after treatment except bone health, with osteoporosis presenting risks of breakages later in life in individuals with AN hx

How does AN affect the brain?

Preoccupation with food/calories

Fear of gaining weight

Headaches

Fainting

Dizziness

Mood swings

Anxiety

Depression

What is the DSM criteria for AN? (A-C)

A. Restriction of energy intake relative to requirements, leading to significantly low body weight in context of age, sex, developmental trajectory, and physically health. Significantly low weight is defined as a weight that is less than minimally normal or expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even at a significantly low weight

C. Disturbance in the way one’s body weight or shape is experienced, 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 are the (required) specifiers for AN?

Restricting type - No binge eating or purging, where weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

Binge-eating/purging type - During last 3 months, individual has engaged in recurrent episodes of binge-eating or purging behaviour

How is current severity defined in anorexia nervosa?

WHO categories for thinness in adults. For children and adolescents, corresponding BMI percentiles. Level of severity may be increased to reflect clinical symptoms, degree of functional disability, and need for supervision.

Mild: BMI > 17 kg

Moderate: BMI 16-16.99 kg

Severe: BMI 15-15.99 kg

Extreme: BMI < 15 kg

What are remission specifiers for Anorexia Nervosa?

In partial remission - after full criteria has been previously met, low body weight has not been met for a sustained period, but B and C still met

In full remission - After full criteria has been previously met, none of the criteria have been met for a while

What is binge eating? (definition, perceptions, feelings, behavior, type of food)

Eating excess amounts of food in a discrete period of time

Eating is perceived as uncontrollable

May be associated with guilt, shame, or regret

May hide behaviour from family members

Foods consumed are often high in sugar, fat, or carbohydrates

What are the defining features of bulimia nervosa?

Binge eating

Compensatory behaviours designed to make up for binge eating and to prevent weight gain

What are examples of compensatory behaviours?

Purging

• Self-inudced vomiting (most common)

• Diuretic or laxative misuse

Excessive exercise

Food restriction

Fasting

Many other behaviours intended to control weight/shape

What is DSM-5 diagnostic criteria for bulimia nervosa? (A-E, includes clinical features, duration/frequency, exclusion)

A. Recurrent episodes of binge eating characterised by:

• Eating, in a discrete amount of time, an amount of food that is definitely larger than most people would eat during a similar period of time under similar circumstances

• A sense of lack of control over eating during the episode

B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain

C. Binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months

D. Self-evaluation is unduly influenced by body shape and weight

E. Disturbance does not occur exclusively during episodes of AN

If someone meets the criteria for both AN and BN, how would they be classified?

AN with binge-purge subtype

How is severity for BN determined?

Based on frequency of inappropriate compensatory behaviours

Mild - 1-3 episodes

Moderate - 4-7 episodes

Severe - 8-13 episodes

Extreme - 14+

What are medical features of bulimia nervosa?

Most are within 10% of normal body weight

Purging methods can result in severe medical problems

Substantial overlap with AN, but unique mouth issues

Damage to teeth through acid erosion which does not recover after treatment

What are common comorbidities of BN?

Mood disorders

Anxiety disorders

Substance abuse

Personality disorders (especially BPD)

How are binge episodes differentiated between diagnoses?

AN is always diagnosed if criteria are met, irrespective of B/P

BN is when at or above normal weight

BED: Binge episodes in absence of compensatory behaviors

WHat are common differentials of binge eating episodes?

MDD with atypical features (overeating common in about 40% of those with depression, but no compensatory behaviors or excessive concern with weight and shape)

Borderline personality disorder - Binge eating included in impulsive behaviour criterion of BPD. If criteria for both met, both dx should be given

Kleine-Levin syndrome - neurological disorder resulting in disturbed eating, but lack psychological symptoms of BN

What is the diagnostic criteria for binge-eating disorder?

A. Recurrent episodes of binge eating

B. Binge-eating episodes are associated with three or more of the following:

• Eating much more than normal

• Eating until feeling uncomfortably full

• Eating large amounts when not hungry

• Eating alone because embarrassed how much one is eating

• Feeling disgusted/guilty after eating

C. Marked distress regarding binge eating

D. Binge eating not associated with bulimia nervosa

How is BN differentiated from BED?

People with BN use compensatory behaviours and demonstrate dietary restriction in order to influence body weight and shape

How is BED distinguished from Bipolar, depressive disorders, and borderline personality disorder?

Bipolar and depressive disorders have an increase in appetite but may or may not be associated with loss of control

BPD: B.E. is included in impulsive behaviors

What are characteristics of Pica?

Eating non-nutritive, non-food substances

Usually no aversion to food

Not socially or culturally normative

Not ingestion following normal mouthing of objects by infants

The behaviour warrants attention above that required for any co-occurring psychological disorder

Often comes to attention due to intestinal obstruction/bezoar or other medical complications

What is rumination disorder?

Regurgitation of food

Food is re-chewed, re-swallowed, or spat out

Behaviour can occur as part of another ED—for ex., aversion to vomitting in BN

Dx’d in absense of another ED

What is avoidant/restrictive food intake disorder?

Formerly feeding disorder of infancy or early childhood

Avoidance or restriction of food intake with associated problems:

• Weight loss/failure to gain weight if growing/failure to thrive or

• Nutritional deficiency or

• Need for nutritional supplements or enteral feeding or

• Interference with psychosocial functioning

Not related to food unavailability or cultural practice

No disturbance in body image

What are Other specified feeding or eating disorders?

Atypical anorexia nervosa

Bulimia nervosa (of low frequency and/or limited duration)

BED (of low frequency and/or of limited duration)

Purging disorder

Night eating syndrome

What is atypical anorexia nervosa?

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

What is criteria for BN (of low frequency and/or limited duration) and BED (of low frequency and/or limited duration?

All criteria for BN or BED are met, except that associated behaviours occur less than once a week &/or for less than 3 months

What is purging disorder? Why does this bring up extra concern for severity?

Purging after any eating or after eating anything that feels “bad” — easier to purge after bigger quantities of food, and much more difficult to eliminate smaller quantities. Therefore purging needs to be more extreme, leading to more pain, blood, severe esophageal and abdominal pain

What are important clinical considerations of OSFEDs?

They are the most common class of eating disorders

Subthreshold and atypical forms are not necessarily less severe

Supports transdiagnostic formulations

What is AN epidemiology?

Lifetime prevalence is 1% in women, <.5% in men, .7% in Maori

Clinical populations are 9:1 F:M, Ratios are changing (men are getting EDs more)

AN typically begins in adolescence or young adulthood but can occur at any time

What is BN epidemiology?

9:1 F:M

Lifetime prevalence 1.5% females & .5% males

• Lifetime prevalence 2.4% for Maori

Onset often in adolescence or young adulthood

Avg age at onset 19.7 yrs

Some cross over to AN, then many revert back to BN

Mean duration 8.3 years

Males less likely to seek treatment

What is BED epidemiology?

3.5% females 2% males

Onset later than AN and BN

Mean duration ~ 8.1 years

Dieting more often occurs after developing of binge eating

Remission rates higher for BED than for BN and AN

Crossover to other EDs less common

What are genetic factors that influence Eating disorders?

6-10 fold increased risk in families

11x more likely to have AN if first-degree relatives have one

Eating disorders are heritable

Genes play substantial role in liability to EDs

Gene loci from GWAS largely unreplicated

What are other biological/developmental factors?

Being female

Adverse prenatal, perinatal, and neonatal events

Feeding and sleeping difficulties during infancy

Childhood high weight; early prepubertal maturation

Transition to adolescence

Low serotonergic activity

Altered hormones associated with appetite regulation

What are environmental factors influencing EDs?

Critical comments about weight and shape, modelling of abnormal eating behaviours

Parents with distorted perception of food, eating, weight, and shape may restrict children’s intake

Family conflict; insecure attachment

Family or peer concern with external appearance — even good concern

Disordered eating strains fmaily relationships

What are psychological factors influencing EDs?

Internalisation of a thin ideal

Body dissatisfaction

Low self-esteem

Overvaluation of shaped and weight

Perfectionism

Mood intolerance; negative affect; emotional regulation deficits

Impulsivity

Low sense of personal control

What is the gene-environment interaction?

Complex interaction between genes and environment

• Genetic predisposition to internalise thin ideals

• ED heritability may be partly acocunted for by heritability of perfectionism

How does dieting cause eating disorders?

Adolescents dieting = 8x greater risk

Adolescents tend to internalise the standards of friendship groups

May paradoxically cause weight gain

During periods of restricted food intake, people become preoccupied with food and eating

What is the most important factor in causing eating disorders not typically considered in other disorders?

Media and cultural considerations

Cultural emphasis on dieting

Standards of ideal body size

Particularly for women and increasingly also in men

What is the key consideration for consumption during binge eating episodes?

Feeling out of control or unable to stop

What are the dual factors that drive over-eating in BN, according to Stice’s Dual Pathway model?

Pressure to be thin + thin-deal internalisation = body dissatisfaction

Body dissatisfaction leads to dietary restraint and negative affect, which combine to create bulimic symptoms