LECTURE NOTES - Chapter 10
Eating Disorders
Outline
Eating disorders - diagnosis and description of conditions
Etiology of eating disorders
Treatments for eating disorders
Eating Disorders (ED) as a Mental Illness Diagnostic Category
Eating disorders appeared in the DSM for the first time in 1980
Eating disorders appeared as a subcategory of disorders beginning in childhood or adolescence
In the DSM-IV, the eating disorders anorexia nervosa and bulimia nervosa formed a distinct category
This reflects the increased attention that eating disorders received at the time from clinicians and researchers
Eating Disorders in the DSM-5
Binge eating disorder is a distinct diagnostic category that is now included in DSM-5
The DSM-5 introduced improved criteria for anorexia nervosa and bulimia nervosa
Canadian Information on Prevalence of Eating Disorders
Anorexia and bulimia are more common in females than in males, and binge eating disorder is equally common in women and men
The Enormous Toll of Eating Disorders
About 1 million Canadians have an eating disorder
Many people have undiagnosed eating disorders
Eating disorders are associated with high mortality
There are high rates of suicide and high rates of suicide attempts in this population
There are high rates of dieting in children from ages 11-14
Dieting puts children at risk of developing an eating disorder
Other Specified Feeding or Eating Disorder
This applies to atypical, mixed, or subthreshold conditions
Includes a variety of conditions, including subthreshold bulimia nervosa and subthreshold binge eating disorder
Night eating syndrome
Purging disorder
Can be used when there is insufficient information such as in hospital emergency room situations
Can be used when an eating-related disorder causes significant distress or impairment but does not meet criteria for another disorder
This can overlap with Other specified feeding or eating disorder, and seems to be mostly used for emergency situations
Orthorexia - Not Listed in the DSM
May fall in the category of other specified feeding or eating disorder
Similarities to OCD
The person is preoccupied with eating healthy foods to the extent that their behavior and feelings about their actions cause distress or impairment
It can become extreme and lead to an extremely restricted diet with nutritional deficiencies
Purging Disorder
People with purging disorder have levels of disturbed eating and associated forms of psychopathology that are comparable with patients with other eating disorders
One clear feature of purging disorder is high impulsivity
Commonalities of Anorexia and Bulimia
The diagnosis of anorexia nervosa and bulimia nervosa share several clinical features
The most important being the intense fear of being overweight
There are some indications that these may not be distinct diagnoses but may be two variants of a single disorder
Co-twins of people diagnosed with anorexia nervosa, for example, are themselves more likely than average to have bulimia nervosa
Anorexia Nervosa
Anorexia - loss of appetite
Nervosa - appetite loss due to emotional reason
DSM Criteria for Anorexia Nervosa Significantly Low Body Weight
DSM-5:
Restriction of energy intake resulting in significantly low body weight within the context of a person’s age, sex, and physical health status
The person has an intense fear of gaining weight and the fear is not reduced by weight loss
DSM Criteria for Anorexia
Distorted sense of body shape
They maintain that even when emaciated, they are overweight or that certain parts of their bodies, particularly the abdomen, buttocks, and thighs are too fat
To check on their body size, they typically weigh themselves frequently, measure the size of different parts of the body, and gaze critically at their reflections in mirrors
Linking Self-Esteem and Self-Evaluation with Thinness
The self-esteem of people with anorexia nervosa is closely linked to maintaining thinness
The tendency to link self-esteem and self-evaluation with thinness is known as over evaluation of appearance
Among people with acute anorexia nervosa, lower body weight is associated with increased self-esteem
Development of Anorexia
Typically begins in the early to middle teenage years, often after an episode of dieting and exposure to life stress
The prevalence of anorexia among children and adolescents is increasing
Comorbidity is high
Men and women at risk for eating disorders are also prone to depression, panic disorder, and social phobia
Women were at substantially greater risk for mania, agoraphobia, and substance dependence
Comorbidity With Substance Use
High rate of co-occurring eating disorders and substance use disorders
A meta-analysis conducted in Spain found that there was no link between anorexia nervosa and illicit drug use, but there was a clear link evident between bulimia nervosa and drug use
Canadian investigators have specifically tied drug use to the binging and dieting cycle
Physical Changes with Anorexia
Decrease in blood pressure
Decrease in heart rate
Decrease in bone mass
Kidney and gastrointestinal problems
Dry skin
Nails become brittle
Hormone levels change
Mild anemia
Prognosis of Anorexia Nervosa
70% of patients recover
Recovery often takes six or seven years
Relapses are common
Death rates are five - ten times greater than general population
Death rates two times greater than patients with other psychological disorders
Longitudinal investigation found mortality rate for an AN is five times higher than the rate for the general population
Mortality in Eating Disorders
Predictors of death include lower BMI and older age at first presentation for treatment and alcohol misuse
Death most often results from physical complications of the illness or from suicide
A BC survival analysis concluded that anorexia is associated with a 25-year reduction in life expectancy
Suicide in Eating Disorders
A review found that suicide rates are not elevated in bulimia nervosa as they are in anorexia nervosa
People with bulimia nervosa report having thoughts of suicide, but their suicide rate is much lower than for those with anorexia
One in five deaths attributed to anorexia involve suicide
Bulimia Nervosa (BN)
Bulimia is from a Greek word meaning “ox hunger”
Involves episodes of rapid consumption of a large amount of food (binge), followed by compensatory behaviours (purge)
Binge = eating excessive amount of food in < 2 hours
Typically occur in secret
May be triggered by stress
Involves feeling a lack of control over the behavior
Purging
Purge = vomiting, fasting, misuse of diuretics, laxatives or enemas, or excessive exercise
DSM-5 stipulates that the binge eating and compensatory behavior must continue at least once a week for three months
Bulimia nervosa is not diagnosed if the binging and purging occur only in the context of anorexia nervosa and its extreme weight loss; the diagnosis in such a case is anorexia nervosa, binge eating - purging type
Characteristics of Binging
Binging episodes tend to be preceded by poorer than average social experiences, self-concepts, and moods
Stressors that involve negative social interactions may be particularly potent elicitors of binges
There is a high levels of interpersonal sensitivity, as reflected in large increases in self-criticism following negative social interactions
Loss of Control
The person who is engaged in a binge often feels a loss of control over the amount of food being consumed
Foods that can be rapidly consumed, especially sweets such as ice cream or cake, are usually part of a binge
Shame and Concealment
People who have bulimia are usually ashamed of their binges and try to conceal them
Bulimia Nervosa and Fear of Gaining Weight
Garfunkel (2002) observed that “a morbid fear of fat” is an essential diagnostic criterion for bulimia nervosa because
1. It covers what clinicians and researchers view as the “core psychopathology” of bulimia nervosa
2. It makes the diagnosis more restrictive
3. It makes the syndrome more closely resemble the related disorder of anorexia nervosa
Development of Bulimia Nervosa
Bulimia nervosa typically begins in late adolescence or early adulthood
Extreme body dissatisfaction was found among 7-8% of both girls and boys in Nova Scotia
These children were only in grade 5
The data suggests that children particularly at risk can be identified at a fairly young age
Many people with bulimia nervosa are somewhat overweight before the onset of the disorder and the binge eating often starts during a dieting episode
Long-term follow-ups of bulimia nervosa clients reveal that about 70% recover, although about 10% remain fully symptomatic
‘Fat Talk’
This focus on fear of becoming fat and negative appraisals of the self for being fat are involved in a relatively new line of research on a phenomenon known as fat talk
Fat talk refers to the tendency for friends, particularly female friends, to take turns disparaging their bodies to each other
Both average weight and overweight target people were seen as more likeable if they were depicted engaging in fat talk
Fat talk sees to reflect highly defensive and negative sense of self
Other Features of Bulimia Nervosa
Physical side effects:
Potassium depletion
Diarrhea
Changes in electrolytes
Irregularities in the heartbeat
Tearing of tissue in the stomach and throat
Loss of dental enamel
Swollen salivary glands
Binge Eating Disorder (BED)
BED is a new DSM-5 for all diagnostic condition
This disorder includes recurrent binges (at least once per week for at least three months), lack of control during the bingeing episode, and distress about binge-eating, as well as other characteristics
Binge eating episodes must involve at least three of the following:
Eating more rapidly than normal
Eating until uncomfortably full
Eating alone due to feelings of embarrassment
Eating large amounts of food when not feeling hungry
Feeling disgusted with oneself or depressed or very guilty
It is distinguished from anorexia by the absence of weight loss and from bulimia by the absence of compensatory behaviours ( purging, fasting, or excessive exercise)
Binge Eating Disorder seems more treatment responsive than anorexia nervosa or bulimia nervosa
Risk Factors for Developing BED Include:
Childhood obesity
Critical comments regarding being overweight
Low self-concept
Depression
Childhood physical or sexual abuse
The average life-term duration of BED (14.4 years) may be greater than the duration of AN (5.9 years) or BN (5.8 years)
Etiology of Eating Disorders
Biological factors:
Genetics
The role of genetic factors in eating disorders has been largely ignored, relative to other types of disorders, because of a prevailing emphasis on sociocultural factors
Both anorexia nervosa and bulimia nervosa run in families
First-degree relatives of young women with anorexia nervosa are about four times more likely than average to have the disorder themselves
Twin studies of eating disorders also suggest a genetic influence
Most studies of both anorexia and bulimia report higher identical than fraternal concordance rates
Appetite and the Brain
The hypothalamus is a key brain centre in regulating hunger and eating
Animals with lesions to the lateral hypothalamus lose weight and have no appetite
Ghrelin is a hormone that is associated with hunger
Leptin is a hormone that is associated with satiation (fullness)
Biological Factors
The levels of some hormones regulated by the hypothalamus, such as cortisol, are chronically elevated in people with anorexia; rather than causing the disorder, however, these hormonal abnormalities occur as a result of self-starvation, and levels return to normal following weight gain
Cortisol is chronically elevated in people with bulimia and anorexia
Problems with Biological Explanations
The weight loss of animals with hypothalamic lesions does not parallel what is known about anorexia
These animals appear to have no hunger and become indifferent to food
Clients with anorexia continue to starve themselves despite being hungry and having an interest in food
The hypothalamic model doesn't account for the body-image disturbance or fear of becoming fat
Endogenous Opioids and Eating Disorders
Endogenous opioids are substances produced by the body that reduce pain sensations enhance mood, and suppress appetite, at least among those with low body weight
Starvation may increase the levels of endogenous opioids, resulting in a positively reinforcing euphoric state
Excessive exercise would increase opioids and thus be reinforcing
Hardy and Waller (1988) hypothesized that bulimia is mediated by low levels of endogenous opioids which are thought to promote craving; a euphoric state is then produced by the ingestion of food, thus reinforcing bingeing
Neurotransmitters Related to Eating Disorders
Low levels of serotonin metabolites and serotonin in people with bulimia
Serotonin metabolites have been linked with the negative mood and self-concept changes that precipitate binge episodes
Low Levels of Serotonin & Bulimia Nervosa
Hildebrandt et al. Have advanced a development model that links serotonin and estrogen in bulimia nervosa
Key premises of this model are that
1. Genetic polymorphism at birth limit the serotonergic system
2. Associated genes may be further limited by exposure to harsh environments in the form of maladaptive parenting styles
3. Subsequent environmental estrogens predispose female adolescents to weight gain, thus increasing the perceived need to engage in dieting that may become excessive
Socio Cultural Factors and Eating Disorders
Throughout history, the standards societies have set for the ideal body especially the ideal female body, have varied greatly
According to current standards, the famous nudes painted by Rubens in the seventeenth century are overweight
Playboy magazine centrefold models become thinner between 1959 and 1978
A follow-up investigation of Playboy centerfolds found the trend toward portrayals of increasing thinness has levelled off and has been reversing
Socio Cultural Variables: Barbie
When it comes to the promotion of unrealistic images, females consistently feel more pressure than males
To achieve the same figure as the Barbie doll, the average women would have to increase her bust by 12 inches, reduce her waist by 10, and grow over seven feet in height
The insidious effects of exposing young girls to Barbie dolls with unrealistic body images was shown in an experiment
Scarlett O’Hara Effect
Women respond to socio-cultural pressures by eating lightly in an attempt to project images of femininity
Research has confirmed that women who are portrayed as eating heavily are indeed seen as less feminine and more masculine than women who are portrayed as eating light meals
Pliner and Chaiken have coined the term the Scarlett O’Hara effect to refer to this phenomenon of eating lightly to project femininity
The High Prevalence of Obesity
While cultural standards and pressures to be thin were increasing, more and more people were becoming overweight
The prevalence of obesity has doubled since 1900; currently 25% of Canadians are overweight and there are continuing references to an obesity epidemic
Pinel, Assandand, and Lehman (2000) attribute the increasing prevalence of obesity to an evolutionary tendency for humans to eat excess to store energy in their bodies for a time when food may be less plentiful
Culture
Excessive body fat has negative connotations, such as being unsuccessful and having little self-control
Obese people are viewed by others as less intelligent and are stereotyped as being lazy
Investigations suggest this anti-fat bias is pervasive so that even the most obese people tend to endorse these views; however, the bias seems more automatic among thinner people, according to measures of implicit cognitive processing
The media promotes these stereotypes
A content analysis of 18 prime time television situation comedies conducted by researchers in Calgary found that:
Females with below average weights were over represented in these shows
The heavier the female characters the more likely she was to have negative comments directed toward her
Pro-Ana Websites
“Pro-Ana” websites glorify starvation and reinforce irrational beliefs about the importance of thinness and the perceived rewards of being dangerously thin
While some people seem to turn to these websites in a desperate search for coping advise, others may simply be looking for tips and techniques to help lose even more weight
A common theme among people viewing the sites is that they equated thinness with happiness
Gender Influences
The primary reason for the greater prevalence of eating disorders among women than among men is that women appear to have been more heavily influenced by the cultural ideal of thinness
There is a growing belief that appearance pressures are increasing on young males as well
These increasing pressures are reflected by a heightened drive for muscularity, which can take the extreme form of muscle dysmorphia
Cross-Cultural Studies
Eating disorders are far more common in industrialized societies, such as the United States, Canada, Australia, and Europe, than in non-industrialized nations
However, it is also generally concluded that the gap is closing, with rising levels of eating disorder in non-Western cultures as well as rising levels of research interest, as reflected by an increasing number of publications
Young women who immigrate to industrialized Western cultures may be especially prone to developing eating disorders owning to the experience of rapid cultural changes and pressures
Cognitive-Behavioral Views
Cognitive-behavioural theories of anorexia nervosa emphasize fear of fatness and body-image disturbance as the motivating factors that make self-starvation and weight loss powerful reinforcers
Behaviors that achieve or maintain thinness are negatively reinforced by the reduction of anxiety about becoming fat
Dieting and weight loss may be positively reinforced by the sense of mastery or self-control they create
The Effects On Cognition When Exposed to Media
The media’s portrayal of thinness as an ideal, being overweight, and a tendency to compare oneself with especially attractive others all contribute to dissatisfaction with one’s body
Even brief exposure to pictures of fashion models can I still negative moods in young women and women who are dissatisfied with their bodies seem especially vulnerable when exposed to these images
The Timing of Binging
It is known that bringing results frequently when diets are broken
A lapse that occurs in the strict dieting of a person with anorexia nervosa is likely to escalate into a binge
The purging following an episode of binge eating can again be seen as motivated by the fear of weight gain that the binge elicited
Clients with anorexia who do not have episodes of bingeing and purging may have a more intense preoccupation with and fear of weight gain or may be more able to exercise self-control
Psychodynamic Views
The core cause lies in disturbed parent - child relationships; certain core personality traits, such as low self-esteem and perfectionism, are found among individuals with eating disorders
The symptoms of an eating disorder fulfill some need, such as the need to increase one’s sense of personal effectiveness (the person succeeds in maintaining a strict diet)
Hilde Bruch (1980) - anorexia nervosa is an attempt by children who have been raised to feel ineffectual to gain competence and respect and to ward off feelings of helplessness, ineffectiveness, and powerlessness
This sense of ineffectiveness is created by a parenting style in which the parents’ wishes are imposed on the child without considering the child’s needs or wishes
Children reared in this way do not learn to identify their own internal states and do not become self-reliant
When faced with the demands of adolescence, the child seizes on the societal emphasis on thinness and turns dieting into means of acquiring control and identity
Characteristics of Families
Self-reports consistently reveal high levels of conflict in the family among people with eating disorders
However, reports of parents do not necessarily indicate high levels of family problems
Disturbed family relationships do seem to characterize some families; however, the characteristics that have been observed, such as low levels of support, only loosely fit the family systems theory
These family characteristics could be a result of the eating disorder and not a cause of it
Childhood Sexual Abuse and Eating Disorders
Somme studies have indicated that self-reportss of childhood sexual abuse are higher than normal among people with eating disorders, especially those with bulimia nervosa
A study conducted in Toronto found that 25% of women with eating disorders reported the experience of previous sexual abuse
Bulimic women, relative to normal eaters, had higher levels of childhood abuse
The presence and the severity of abuse predicted more extreme psychopathology
Physical abuse and sexual abuse were significant predictors of having an eating disorder, according to the 2012 Canadiian Community Health Survey
Unethical Research on Starvation Alarming Examples from Canada’s Past
Hunger and malnutrition experiments were conducted in aboriginal communities in the 1940’s and 1950’s by leading nutritional experts employed by the Government of Canada
According to Mosby (2013), unethical, controlled experiments involving lack of informed consent were conducted in various regions, including research on the Northern Cree people in Northern Manitoba
It is alleged that researchers identified people, both young and old, who were starving and denied some of them food and nutrients so they could study them
Up to one thousand children were kept malnourished and sometimes starved because it suited research purposes
Etiology of Eating Disorders: Personality Factors
Retrospective Studies:
Retrospective research described clients with anorexia as having been perfectionistic, shy, and compliant before the onset of the disorder
Findings suggest that people with bulimia have the additional characteristics of histrionic features, affective instability, and an outgoing social disposition
Role of Neuroticism:
People with anorexia and people with bulimia are high in neuroticism and anxiety and low in self-esteem
The role of neuroticism as a long-term predictor of anorexia was also confirmed in a recent twin study
Those people with AN or BN also score high on a measure of traditionalism, indicating strong endorsement of family and social standards
Narcissism, Perfectionism and Eating Disorders
Anorexia and bulimia clients are characterized by high levels of narcissism that persist even when the eating disorder is in remission
The use of a narcissistic defensive “poor me” style has treatment implications because it predicts greater treatment dropout
Eating disorders have been related to increased perfectionism
Perfectionism and Eating Disorders
Hewitt and Flett (1991b) created on multidimensional perfectionism scale
The two relevant forms of perfectionism include:
Self-oriented perfectionism (setting high standards for oneself)
Socially prescribed perfectionism (the perception that high standards are imposed on the self by others)
Weight-restored and underweight anorexics had elevated scores on self-oriented perfectionism
Underweight anorexics also had higher scores on socially prescribed perfectionism
Anorexic individuals who engage in excessive exercise are distinguished by remarkably high levels of self-oriented perfectionism
Three Factor Interactive Model of Bulimia: Perfectionism, Body Dissatisfaction, Low Self-Esteem
Bulimic symptoms are elevated among women who are characterized not only by perfectionism, but also by their body dissatisfaction and low self-esteem
Perfectionistic self-presentation
These individuals try to create an image of perfection and are highly focused on minimizing the mistakes they make in front of other people
“Stanford Duck Syndrome” - refers to university students who respond to strong social pressures and expectations by trying to seem very calm and collected on the surface (when in public), but are actually hiding their anxieties, fears, and tendencies to work especially hard
Limitation: causal role of these dimensions of perfectionism has yet to be firmly established by longitudinal, prospective research on the role of these dimensions in the onset of eating disorders
Treatment of Eating Disorders
It is often difficult to get a person with an eating disorder into treatment because the person typically denies that he or she has a problem
The majority of people with eating disorders, up to 90% of them, are not in treatment and those who are in treatment are often resentful
Hospitalization is required frequently to treat people with anorexia so that their ingestion of food can be gradually increased and carefully monitored
Weight loss can be so severe that intravenous feeding is necessary to save the person’s life
Some people with bulimia only wind up in treatment because their dentist has spotted one key indicator:
The erosion of teeth enamel
Relapse Rates
One vexing problem is a high rate of relapse in the treatment of eating disorder
A recent study of 100 anorexia nervosa patients in Toronto who were treated successfully found that 41% of them relapsed during the one-year follow-up period
Carter et al. (2012) found in their study that relapse was more likely for those clients who:
Binge-purge anorexia subtype
Had more OCD-like checking behaviors
Lower motivation to recover predicted subsequent relapse
Medications
Antidepressant medication is helpful for bulimia
Even so, more patients drop out of drug therapy in studies on bulimia than drop out of the kind of cognitive-behavioral interventions
No drugs have been found effective in treating anorexia nervosa
Psychological Treatment of Anorexia Nervosa
Therapy for anorexia is generally believed to be a two-tiered process
1. Immediate goal:
Help the person to gain weight in order to avoid medical complications and the possibility of death
2. Second goal of treatment
Long-term maintenance of weight gain
Family Therapy for Eating Disorders
Meta-analysis that family-based therapy and individuals-focused therapy were equally effective at the end of treatment
However, family-based treatment yielded superior outcomes assessed six to twelve months post-treatment
Enhanced Cognitive-Behavioral Therapy (CBT-E) for all Eating Disorders
CBT-E is the most successful treatment currently available for bulimia and BED
It is one of the potential treatments recommended for anorexia
Extra modules in CBT-E include assistance for mood intolerance, perfectionism, low self-esteem, and interpersonal difficulties
Treatment for Eating Disorders: Research on the CBT-E Approach
CBT is the leading evidence-based treatment for eating disorders
No other treatment has greater efficacy than CBT
Research on found that two-thirds of the participants with bulimia who were treated with CBT achieved remission versus about one-third who received Interpersonal therapy (IPT)
CBT appeared to work more quickly than IPT
Limitations of Treatment Effectiveness in CBT for Eating Disorders
At least half of the eating disorder clients in some CBT controlled studies do not recover
May be that significant numbers fo the patients in these studies have psychological disorders in addition to eating disorders, such as borderline personality disorder, depression, anxiety, and marital distress
Another possibility:
Individuals who begin with negative self-efficacy judgements about their ability to recover are more treatment resistant and take longer to recover