Eating Disorders

Anorexia Nervosa (DSM-5-TR)

  • restriction of energy intake leading to significantly low body weight

  • intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain

  • disturbance in the way body weight or shape is experienced

    • undue influence of body weight or shape on self-evaluation

    • persistent lack of recognition of the seriousness of the currently low body weight

  • specify:

    • restricting type

      • no reoccurring episodes of binge eating or purging behavior over the 3 months

      • weight loss is primarily due to dieting and fasting

    • binge eating/purging type

      • reoccurring episodes of binge eating or purging over the last three months

    • remission status

      • partial remission - criterion A has not been met for a substantial period, B or C is still occurring

      • full remission

  • level of severity

    • BMI

      • mild: BMI >= 17 kg/m2

      • moderate: BMI 16-16.99 kg/m2

      • severe: BMI 15-15.99 kg/m2

      • extreme: BMI <15 kg/m2

    • not in the DSM, but something to consider… BMI is problematic

  • physical complications

    • one of the deadliest psychological disorders

      • irregular heart rate

      • low blood pressure

      • heart damage when body forced to use muscle as an energy source

      • kidney disease

      • bone loss

      • organ failure

  • prevalence + age of onset

    • 0.05% 12-month prevalence rate

    • more common in women than men

    • more common in rich, industrialized countries

    • lower in Latinx + non-Latinx Black Americans than non-Latinx White Americans

    • Begins during adolescence or young adulthood - rarely onsets after 40

Bulimia Nervosa (DSM-5-TR)

  • recurrent episodes of binge eating

    • a discrete period of time where the amount of food consumed is significantly more than most people would eat during a similar time period

    • lack of control over eating

  • recurrent inappropriate compensatory behavior to rid the body of the excessive calories

    • vomiting

    • laxatives/diuretics

    • excessive exercise

  • binge-compensatory behavior cycles occur at least once a week for 3 months or more

  • self-evaluation is unduly influenced by body shape + weight

  • disturbance does not occur exclusively during episodes of anorexia nervosa

  • specify

    • remission status

      • partial remission - after full criteria was previously met, some but not all of criteria have been met for a substantial period of time

      • full remission

    • severity (based on compensatory behavior)

      • mild: an average of 1-3 episodes per week

      • moderate: an average of 4-7 episodes per week

      • severe: an average of 8-13 episodes per week

      • extreme: an average of 14 or more episodes per week

  • physical complications

    • colon, liver, kidney damage

    • coating of teeth wears off

    • stomach lining + esophagus damage

    • dehydration

    • heart issues

  • prevalence + age of onset

    • 0.14-0.3% 12 month prevalence rate

    • more common in women than men

    • more common in rich, industrialized countries

    • similar among U.S. ethnic and racial groups

    • begins during adolescence or young adulthood - rarely onsets after 40

Binge Eating Disorder

  • most common eating disorder in the US

  • recurrent episodes of binge eating

  • binge-eating episodes are associated with 3+

    • eating quicker than usual

    • eating until uncomfortably full

    • eating large amounts even if not hungry

    • eating alone

    • feeling disgust with oneself or being depressed

  • distress regarding binge eating is present

  • binge eating episodes occur least once a week for 3 months or more

  • not associated with compensatory behaviors

  • Specify:

    • remission status

      • partial - after full criteria was previously met, binges occur less than 1x a week for a sustained period of time

      • full remission

    • severity

      • mild: 1-3 episodes per week

      • moderate: 4-7 episodes per week

      • severe: 8-13 episodes per week

      • extreme: 14+ episodes per week

  • physical complications

    • risk of being overweight

    • type 2 diabetes

    • high blood pressure

    • high cholesterol levels

  • prevalence + age of onset

    • 0.44-1.2% 12 month prevalence rate

    • more common in women than men

    • comparable across US ethnic + racial groups

    • more common in rich, industrialized countries

    • age of onset - unknown in DSM

Empathy is Important

  • it’s not as simple as “just eat”, “just don’t throw up”, “just stop eating”

Biological Etiology of Eating Disorders

  • genetic predisposition

  • twin studies - estimates of heritability

    • 50-60% for anorexia nervosa

    • 60% for bulimia nervosa

    • 40-60% for binge-eating disorder

  • brain parts

    • hypothalamus?

  • neurotransmitters

    • dopamine - more dopamine = less hungry

    • serotonin - esp for binge eating

Psychological Etiology of Eating Disorders

  • preoccupation with body weight + shape during early adolescence

  • low self-esteem

  • personality traits → passivity, lack of assertiveness, perfectionism, impulsivity

  • desire for control

Social Etiology of Eating Disorders

  • tripartite model of social influences: combination of parents, peers, and the media constitute the key influence on body image (and eating disorders)

  • family

    • negative comments/teasing about body

    • heavy emphasis on weight, exercising to lose weight, etc

    • comments about own weight or eating behavior

    • weight/appearance-based compliments

  • peers

    • having friends who focus on dieting + exhibit disordered eating

      • in adolescence

      • in college

    • fat talk makes us feel worse

      • makes us feel bad when other people talk about their own body

  • media

    • the thin ideal

    • body shaming - rampant in early 2000s

    • photoshopping

    • praise for weight loss

Sociocultural Etiology of Eating Disorders

  • western (and white) beauty standards

    • thin = attractive for girls

    • lean body fat, big muscles for boys

    • male body builders

  • social comparison

    • high body dissatisfaction → increased feelings of guilt and depression → “solutions” (extreme dieting, purging, etc.)

  • who is at risk?

    • ED is more commonly diagnosed in girls than boys

      • Latinx boys more likely than white boys to report disordered eating

    • sexual and gender diverse individuals

      • ED prevalence is higher for sexual minority individuals compared to heterosexual individuals

      • relative to cisgender peers, transgender people have higher rates of eating disorders

Anorexia Treatment

  • collaborative effort

    • psychologist, medical doctor, psychiatrist, nutritionist/dietitian

    • may be hospitalized and/or rehabilitation

  • CBT-ED (CBT for eating disorders)

    • can be similar to regular CBT

    • can focus on mood intolerance, perfectionism, low self-esteem, etc.

    • family based therapy - useful for adolescents especially

      • helping the family understand that anorexia nervosa is a serious disease

      • exploring healthier methods for family communication

      • having the parents assist in the re-feeding process by planning meals

      • reducing parental criticism regarding eating patterns

Bulimia Treatment

  • treatment is collaborative

    • physical complications addressed

  • goal: normalize eating patterns

  • SSRIs can be helpful

  • CBT

    • identify triggers for binging episodes

  • exposures and response prevention (ERP) - used for OCD as well

    • response prevention - no compensatory bx; use relaxation techniques instead

Binge Eating Disorder Treatment

  • similar to bulimia

    • CBT

    • SSRIs

  • may focus on healthy ways to lose weight because weight may be a health concern

  • little research on how effective Ozempic or other GL-1 drugs are in helping with BED