Eating Disorders

What are the diagnostic criteria for Anorexia Nervosa?

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

Significantly low weight defined as weight less than minimally normal or, for children + adolescents, less than minimally expected

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

C. Disturbance in the way in which one’s body weight or shape is experienced; undue influence of body weight and shape on self-evaluation or persistent lack of recognition of the seriousness of current low body weight

What are the specifiers of Anorexia Nervosa

Restricting type:

• In the last 3 months, the individual has not engaged in recurrent binge-eating episodes or purging behaviour. Weight loss achieved through dieting, fasting and/or excessive exercise

Binge eating / purging type

• last three months individual has engaged in recurrent episodes of binge eating / purging behaviour

Severity

• Mild: BMI >17

• Moderate: BMI 16-16.99

• Severe: BMI 15-15.99

• Extreme: BMI <15

Remission

• Partial, full criteria met, but A not met for a sustained period

• Full, None of criteria met for a sustained period of time

What are the defining features of Anorexia Nervosa

Extreme weight loss (<17.5 BMI)

Restriction of Caloric intake below energy requirements (15% below expected weight, roughly)

Intense fear of gaining weight

Marked disturbance in body image > not always dysmorphic

Comorbid psychological disorders

• 70% depressed

• higher than average rates of substance abuse and OCD

What damage done during anorexia nervosa cannot be undone?

Bone density, osteoporosis

What is the DSM criteria for Bulimia Nervosa

A. Recurrent episodes of binge eating, characterised by both of the following:

• eating, in a discrete period of time, large amounts of food

• A sense of a lack of control over eating episodes

B. Recurrent, inappropriate compensatory behaviours both occur on average at least once a week for 3 months

C. Binge + compensatory behaviours both occur on average at least once a week for three months

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

E. Disturbance does not occur exclusively during episodes of anorexia Nervosa

What are the specifiers of Bulimia Nervosa

Severity

• Mild: 1-3 episodes per week

• Moderate: 4-7 episodes per week

• Severe: 8-13 episodes

• Extreme: 14+ episodes

Remission

• Partial: some but not all criteria met for sustained period

• Full: None criteria met for sustained period

Defining features of Bulimia Nervosa

Binge eating

• hallmark of bulimia and BED

• excess amounts of food in a small amount of time

• perceived as uncontrollable

• hide behaviour from family members

• guilt, shame, regret

Compensatory behaviours

• Designed to make up for binge eating and prevent weight gain

• Purging: most common is vomiting, also can be laxatives and diuretics, exercise, restriction, fasting

Associated features of Bulimia Nervosa

• Most within 10% of normal body weight

• purging methods can result in severe medical problems

• Over concern with body weight and shape

• Fear of gaining weight

Comorbidity the norm

• 20% meet criteria for mood disorder

• 50-70% have met mood disorder at some time

• 80% have met criteria for anxiety disorder at some point

• nearly 2 in 5 abuse substances

• high morbidity and mortality

• BPD (and other personality disorders)

Differential diagnoses of EDs

Anorexia Nervosa always diagnosed if criteria are met, irrespective of binge /purge

Bulimia is diagnosed when at or above a normal weight

Binge-eating disorder: binge episodes by no compensatory behaviour

MDD with atypical features

• overeating common with depression, but they don’t have compensatory behaviours, or excessive concern with weight or shape

BPD

• binge eating is included in impulsive behaviour criterion for BPD - if both are met both diagnosis are given

Kleine-Levin syndrome:

• neurological disorder resulting in disturbed eating, lack psychological symptoms of Bulimia Nervosa

DSM criteria Binge Eating disorder

A. recurrent episodes of Binge eating

B. eating episodes associated with 3 of the following

• eating more than normal

• eating until feeling uncomfortably full

• large amounts when not hungry

• Eating alone because embarrassed about how much

• feeling disgusted / guilty after

C. marked distress regarding Binge eating

D. Binge eating not associated with Bulimia nervosa.

What are the differences between binge eating disorder and anorexia or bulimia

BED was

• first included in DSM 5

• no associated compensatory behaviours

• excessive concern of body shape and weight may not be present

• high weight

Differential diagnosis BED

• no compensatory behaviours

• high weight (not all those with high weight have it though)

Comorbidity for BED

Bipolar and depressive disorders: higher appetite and weight gain seen with these disorders, however may or may not be associated with loss of control

BPD: binge eating included in impulsive behaviours

Associated features of BED

• 20% of those in weight loss programs have BED

• Half of candidates for bariatric surgery have BED

• better treatment response than other EDs

• Tend to be older than those with Anorexia nervosa and bulimia nervosa

• higher rates of psychopathology than non-binge eating obese individuals

What are the other eating and feeding disorders?

• Pica

• Rumination Disorder

• Avoidant/restrictive food intake disorder

• Other specified feeding or eating disorders

What is the most commonly diagnosed eating disorders

Other specified feeding or eating disorders

Define Pica

• Eating non-nutritive, non-food substances

• Usually no aversion to food

• Not socially or culturally normative

• Not ingestion following normative mouthing in infants

• Often comes to attention due to intestinal obstruction /bezoar or other medical complications such as infection, poisoning, or intestinal perforation

Define rumination disorder

Regurgitation of food

• food rechewed, reswallowed or spat out

• can occur as part of another disorder

• diagnosed in the absence of another E.D

People won’t tell you unless you ask

• shame, guilt, socially unacceptable, disgust response

Define ARFID

Avoidant/restrictive food intake disorder

• previously a feeding disorder of infancy or early childhood

• avoidance and restriction of food intake with associated problems

  • weightloss/failure to gain weight/failure to thrive

  • nutritional deficiency

  • 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 the other specified feeding or eating disorders

Atypical anorexia nervosa

• All criteria met except weight; i.e., despite significant weight loss, weight is within or above normal change

Bulimia Nervosa

• of low frequency or limited duration: all criteria for BN met except for binge eating and compensatory behaviour occur less than once a week and/or for less than three months

Purging disorder:

• recurrent purging behaviour to lose weight or shape in the absence of binge eating (after normal or very small amounts of food)

Night eating syndrome

• recurrent episodes of night eating as manifested by eating after waking from sleep or by excessive food consumption after evening meal. There is awareness and recall of eating

Genetic factors of E.Ds

• 6-10-fold increased risk; first-degree relatives of AN are 11x more likely to develop it

• Genes play a substantial role

Biological / developmental factors of E.Ds

being female, adverse prenatal/perinatal/neonatal events, feeding/sleeping difficulties as an infant, and high weight in childhood, early puberty, altered hormones associated with appetite regulation

• F:M 9:1

• LGBTQIA: EDs somewhat higher in gay than straight males

Environmental factors of E.Ds

Critical comments about weight and shape; modelling of abnormal eating behaviour

Parents with a distorted view may restrict children’s intake

Family conflict, family or peer concern about disordered eating strains family relationships

Abuse: increases risk of EDs and other psychological disorders

Psychological factors of E.Ds

Internalisation of a thin ideal

Body dissatisfaction

low self esteem

overvaluation of shape and weight

perfectionism

mood intolerance

negative affect

emotion regulation

impulsivity

low sense of personal control

Gene-environment interaction factors of E.Ds

Genetic predisposition to internalise thin ideals

ED heritability may, in part, be accounted for by the heritability of perfectionism

• Perfectionism may encourage individuals to strive for the perfect body type

What are the contributions of dieting to E.Ds

• adolescent dieting leads to an 8x greater risk of developing an ED

• Adolescents tend to internalise the standards of friendship groups

• During periods of restricted food intake people become preoccupied with food and eating (i.e., keyes study)

What did the Keyes study show

After starving, they became more dissatisfied with their bodies, started thinking, writing and reading more about food. More moved into food-related work.

Causes of E.Ds: Social factors

• media and cultural considerations; thinness linked to success, cultural emphasis on dieting

What are the theoretical models of E.Ds

Dual-pathway model of BN

Model of BN

Early cognitive model of BN

Newer cognitive behavioural model

Extended transdiagnostic model

Padeskys 5 factor model (not specific to E.Ds)

What does the dual pathway model posit

for Bulimia Nervosa

• not a complete model for formulation

Pressure to be thin and thin ideal internalisations > body dissatisfaction> dietary restriction and negative affect > bulimic symptoms

Eating becomes connected with negative emotions or positive ones.

What does the model of Bulimia Nervosa posit

Risk: Family

• abuse

• history

Risk: Society

• emphasis on thinness

Risk: Self

• poor problem-solving skills

• low self esteem

• perfectionism

all contribute to a behaviour > consequence > behaviour > consequence cycle

i.e.,

• behaviour (diet) > Consequence (starving, diet fails) > Behaviour (binge) > consequence (guilt, shame, fear, weight gain) > Behaviour (purge, relief) > Consequence (guilt, out of control)

What is the precursor to the extended transdiagnostic model of EDs?

newer cognitive behavioural model of EDs

What should you assess for in EDs

Eating behaviour

Binge eating

Monitoring food and fluid intake

Compensatory strategies

Physical health

body shape and weight (cognitions)

Comorbidity

Impulsive behaviours (self-harm, risky sexual behaviours)

Other psychological problems (anxiety, depression, perfectionism, personality, dissociation)

General health

Elevated medical risk

Elevated psychological risk

Diagnosis

The onion?

Level of beliefs

Core: unlovable (how could anyone love a fat person), helpless ( only a loser would binge), worthless (im never going to recover)

Intermediate: a thin body is better, being in control is important

Automatic: I must restrict, im over weight, if i eat I have to…