Chapter 15

Eating Disorders

•   Eating Disorder: Anorexia Nervosa

– DSM-5 Criteria

–   

–  For age, sex, developmental trajectory, physical health

–  Children and adolescents: less than minimally expected

–  Intense fear of gaining weight

–  Disturbance in body weight or shape experience, undue influence on self-evaluation, or lack of recognition of the seriousness of low body weight

– Specify :

–  Past 3 months: restricting type or binge-eating/purging type

– Specify:

–  Based on weight: mild, moderate, severe, or extreme

•   Eating Disorder: Bulimia Nervosa

– DSM-5 Criteria

–   

–  Recurrent inappropriate compensatory behaviors

–  Co-occur, on average, 1x week for 3 months

–  Self-evaluation unduly influenced by body shape and weight

– Specify:

–  Based on compensatory behavior per week: mild, moderate, severe, extreme

•   Eating Disorder: Binge Eating Disorder 

– DSM-5 Criteria

–   

–  Binge-eating episodes are associated with (at least 3):

–  rapid eating

–  feeling uncomfortably full

–  eating a lot when not hungry

–  eating alone due to embarrassed

–  feeling disgusted, depressed, or guilty

–  Marked distress regarding binge eating

–  On average, 1x per week for 3 months

–  No compensation measures

– Specify:

–  Based on binge-eating episodes per week: mild, moderate, severe, extreme

Eating Disorders: Mental Health Associated Conditions

•   Eating Disorder: Associated Conditions

– Mental Health Problems

–  Depression and Suicide

–  

– Onset:

–  AN and BN: after the onset of ED, may persists after intervention

–  BED: before the onset of ED

– Elevated rate for suicidal behavior

–  40%: suicidal ideation

–  10%: suicide plan

–  15%: suicide attempt

•   Eating Disorder: Associated Conditions

– Mental Health Problems

–   

– Social anxiety comorbidity: 30% to 50%

–  Onset: AN and BN: after the onset of ED, may persists after intervention

– OCD comorbidity: 30% to 50%

–  Onset: AN and BN: after the onset of ED, may persists after intervention

–   

– Substance use disorders comorbidity: 20% to 25%

–  Common: nicotine, alcohol, marijuana, prescription pain medication

– Frequent binge eating: 3x more likely to experience SUD

– Onset: during or after the onset of ED

•   Eating Disorder: Associated Conditions

– Mental Health Problems

–   

– AN

–  Perfectionist

–  Rigid and overcontrolled

–  Emotional guarded and reserved

–  Dichotomous thinking

– BN

–  Low self-esteem

–  Emotionally labile and impulsive

–  Temper issues and acting out

–  Problems with emotion regulation

Eating Disorders: Prevalence and Course

•   Eating Disorder: Prevalence

– Eating Disorders

–  Rates:

–  AN: 0.3%

–  BN: 0.9%

–  BED: 2.5%

– Maladaptive Eating Behavior

–   

–  Age 5: 20%

–  Age 9: 33%

–  Preadolescents: 50%

–  Adolescent Girls:

–  Body dissatisfaction: 80%

–  Dieted to lose weight: 70%

–  Purged at least once: 16%

–  Subclinical ED: 14%

•   Eating Disorder: Prevalence

– Gender Differences

–   

–  Gain weight, mass, muscle: boys more than girls

– Culture, Ethnicity, and SES

–  Cross-Cultural Differences

–  Exist across countries and cultures

–  Greater risk: Western societies and industrialized nations

–  In the United States

– Exist across all ethnic groups

– Exist across all SES groups

•   Eating Disorder: Course 

– Course of AN and BN

–  Onset: typically adolescence (usually not after age 25)

–  AN: between 11-14 years

–  BN: between 17-25 years

–  Course of AN

–  50%: recovery

–  30%: improvement but meet criteria for AN or BN

–  10%-20%: chronic symptoms of AN

–  Course of BN

–  36%: subclinical for eating disorder

–  15%: chronic symptoms of BN

–  41%: criteria for MDD

–  Diagnostic Migration

–   

–   

•   Eating Disorder: Course 

– Course of BED

–   

– Weight problems or obesity in childhood

– Binge eating in late childhood and dieting after a few years

– Common: depression, anxiety, family problems

– Risk: BN as adults

–   

– Weight problems in early adulthood

– Dieting before engagement in binge eating

– Less related to BN

–  Recovery from BED: best of all the EDs

Eating Disorders: Risk Factors

•    Eating Disorders: Risk Factors

– Biological Influences

– Genetic

– Family and twin study support

– Neurobiological

–  

–  Involvement: regulate metabolism, mood, and personality

–  ED: high levels; dysregulation of serotonin

–  

–  Involvement: triggers satiety and regulates the amount of food consumed

–  ED: Low levels 

– Eating Disorders: Risk Factors

– Child and Adolescent

–  

– Weight History

– Personality (e.g., perfectionism, impulsivity)

– Low self-esteem

– Dysregulation of emotions and functioning

– Sexual Abuse

– Eating Disorders: Risk Factors

–  Family Influences

– Family

–   

–  Mental health problems

–  Parental discord

– Parental attitudes and beliefs: eating, weight, body shape

– Parental Behavior

–  Low parental contact and high parental expectations

–  Controlling and overprotective

–  Indifferent and rejecting

– Eating Disorders: Risk Factors

– Social and Cultural Influences

–  

–  ED develop through:

–  Dietary restriction

–  Idealization of the thin ideal contributes to body dissatisfaction 

–  Negative affect

–  Not reaching the thin ideal can create negative affect, which bingeing can temporarily alleviate

–  Possible guilt from binging – compensatory behaviors 

– Eating Disorders: Risk Factors

– Social and Cultural Influences

–  

–  ED influenced by peers, parents, and media

–  Three pathways to ED:

–  Directly affect eating behavior by motivating a youth to diet

–  Influence the internalization of the thin ideal

–  Allow for appearance comparisons with others

– Eating Disorders: Risk Factors

– Risk Factors for Binge Eating Disorder

– Genetic risk

–  Family and twin study support 

– Neurobiological

–  May be unusually sensitive to certain food properties

–   

– Child factors

–  Being overweight or obese

–  Negative childhood experiences

– Social factors

–  Parental wight problems

–  Parental mental health problems 

–  Negative comments about weight and eating patterns

–  Overcontrolling about food

–  Peer alienation and teasing

Eating Disorder: Assessment

•   Eating Disorder: Assessment

– Assessment and diagnosis of an eating disorder can be challenging:

–  Deny difficulties

–  Avoid contact with medical or mental health professionals

– Assessment

–  Self-report interviews and questionnaires

–   

–  Parental interviews and questionnaires

Eating Disorders: Intervention

•   Eating Disorders: Intervention

– General Points of Consideration

–  More research support for intervention with BN, but less with AN

–  Interventions targeting adolescents have received limited attention

–   

•   Eating Disorder: Intervention

– Anorexia Nervosa

– Inpatient Treatment

–

– Group and Individual Therapy

– Maudsley Hospital Approach

– Parental control of eating to young person control of eating and developmental autonomy  

•   Eating Disorder: Intervention

– Anorexia Nervosa

–  

– Focus: quality and patterns of relationships between family members

–  Belief that the ED and focus on it are a distraction from the real problem, family relationships and communication

–  

•   Eating Disorder: Intervention

– Bulimia Nervosa

–  

– Break the cycle of negative reinforcement by exposing youth to normal amounts of food and prohibiting compensatory behavior

–  

– Focus on relationships with family and friends

– Teaches about BN and how interpersonal problems may be contributing

•   Eating Disorder: Intervention

– Anorexia Nervosa and Bulimia Nervosa

– Medication

– AN

–  Antidepressant medications are commonly used

–   

– BN

–  Antidepressant medications are commonly used

–  Effective in controlling BN in perhaps the reduction of symptoms, but not elimination of them

•   Eating Disorder: Intervention

– Binge Eating Disorder

–  

–  Teach clients to recognize the situations, feelings, and thoughts that lead to a binge

–  Work to alter the antecedent events and negative thoughts

–  Adults with BED: CBT demonstrates effectiveness

–  

–  Identification of interpersonal problems associated with low self-esteem and binge eating

–  Collaborate to solve the interpersonal problem and improve mood and social functioning

–  Adults with BED: IPT demonstrates effectiveness

Anorexia nervosa (AN): A DSM-5 eating disorder characterized by (1) caloric restriction leading to significantly low body weight, 2 intense fear of gaining weight or becoming fat, and 3) disturbance in one's body weight or shape.

Appetite manipulation: Children are provided with fluids and essential electrolytes to maintain hydration but are prohibited from snacking between meals; increases the motivation of children with ARFID to eat.

Avoidant/restrictive food intake disorder (ARFID): A DSM-5 feeding disorder characterized by (1) a lack of interest in feeding, (2) avoidance of food based on its sensory qualities, or (3) concerns about the negative consequences of eating; causes weight loss, nutritional deficiencies, or other health/social impairment.

Binge eating disorder (BED): A DSM-5 eating disorder characterized by (1) recurrent episodes of binge eating, (2) associated features le.g., eating rapidly, eating when depressed, feeling ashamed), and (3) marked distress; occurs at least once a week for at least 3 months.

Bulimia nervosa (BN): A DSM-5 eating disorder characterized by (1) recurrent episodes of binge eating, (2 recurrent inappropriate compensatory behaviors to prevent weight gain, and (3) self-evaluation that is unduly influenced by one's body shape or weight; occurs at least once a week for at least 3 months.

Cholecystokinin (CCK): A hormone that is secreted by the small intestines that signals satiety and reduces eating in healthy individuals.

Diagnostic migration: The tendency of people with eating disorders to change diagnostic classification over time, most commonly from AN to BN.

Dichotomous (black-or-whitel thinking: A cognitive distortion in which the individual rigidly views herself, others, and the world as either all "good" or all "bad".

Dual pathway model: Posits that eating disorders develop through two pathways: (1) dietary restriction and (2) negative affect.

Ego-dystonic: A term used to describe a condition or disorder that the person views as problematic or shameful or is inconsistent with the person's goals and values.

Ego-syntonic: A term used to describe a condition or disorder that the person does not view as problematic or is consistent with the person's goals and values.

Electrolyte imbalance: Disturbance in the minerals found in the body le.g., calcium, sodium, potassium] that regulate hydration and metabolism; can be caused by purging.

Enmeshment: A term used by structural family therapists to describe family relationships in which boundaries between parents and children were blurred or diffuse.

Facial screening: A form of positive punishment sometimes used to treat pica; the mouth is temporarily screened with a bib or loose-fitting mask to avoid substance ingestion; used only with caregiver assent when other interventions have failed and ingestion is potentially harmful.

Failure to thrive (FTT): A medical condition characterized by nutritional deficiency and weight below the fifth percentile for age and gender on standardized growth charts.

Feeding disorders: A class of DSM-5 disorders characterized by a persistent disturbance in eating-related behavior that results in altered consumption or absorption of food and that interferes with physical health; includes pica, rumination disorder, and ARFID

Hypokalemia: Low potassium levels; potentially fatal; associated with recurrent purging.

Maudsley Hospital approach: A method of treating youths withAN; components include (1) initial refeeding by parents,(2) structural family therapy to improve communication, and (3) increased autonomy for the adolescent.

Osteopenia: Reduced bone mass; often seen in individuals with anorexia.

Perfectionism: A personality trait sometimes shown by youths with anorexia; characterized by a rigid and unrealistic pursuit of absolute standards of behavior (athletics, academics, social); associated with excessive compliance, a strong desire to please others, and a lack of an autonomous sense of self.

Pica: A DSM-5 feeding disorder characterized by persistent eating of nonnutritive, nonfood substances over a period of at least 1 month; must be developmentally and culturally unexpected.

Pica box: A box containing foods that have similar sensory properties as objects that are eaten by the child with pica.

Refeeding syndrome: Cardiac and other health-related problems shown by patients with anorexia during the first 7 to 10 days of treatment.

Rumination disorder: A DSM-5 feeding disorder characterized by repeated regurgitation of food over the period of at least 1 month; must not be attributable to a medical condition or purging behavior shown by people with eating disorders.

Supportive confrontation: A technique sometimes used in inpatient are there for eating disorders; senior group members are encouraged to challenge the cognitive distortions and food obsessions of newer members.

Thin ideal: According to social-cultural theories of eating disorders, an unrealistic and culturally constructed notion of the perfect female body that is perpetrated in the media and through social interactions.

Transactional model for feeding disorders: Posits that feeding disorders arise through parent-child interactions characterized by children with (1) high physiological arousal and (2) difficult temperament and (3) parents who are anxious about their child's food intake.

Tripartite influence model: Posits three risk factors for the development of eating disorders: (1) peers, (2) parents, and (3) the media; these factors lead to internalization of the thin ideal, social comparison, and body dissatisfaction over time.