Prevention and Treatment of Children and Adolescent Body Image Problems and Eating Disorders

Introduction to Prevention and Treatment of Children and Adolescent Body Image Problems and Eating Disorders

Scope and Epidemiology of Eating Disorders

  • Eating disorder prevalence is increasing, with the onset occurring at younger ages.

  • This increase is largely observed in Other Specified Feeding and Eating Disorders (OSFED).

  • Globally, out of 306306 physical and mental disorders, anorexia nervosa and bulimia nervosa combined ranked as the 12th12^{th} leading cause of disability-adjusted life years (DALYs) in females aged 1515 to 1919 years in 20122012.

  • A 20122012 report commissioned by the Butterfly Foundation estimated the financial cost to the community in Australia for that year at approximately $69.7extbillion\$69.7 ext{ billion}. This cost has likely significantly increased in the last decade.

  • Beyond financial costs, the personal cost to patients and carers is enormous, involving lost years of functioning life for both sufferers and those who care for them.

  • **Prevalence in Australian Adolescents (Recent Survey Study - 1 month period surveyed, stringent criteria):

    • Anorexia nervosa: 0.5%</p></li><li><p>Bulimianervosa:0.5\%</p></li><li><p>Bulimia nervosa:3.3\%

    • Binge eating disorder: 0.8%</p></li><li><p>Otherspecifiedfeedingandeatingdisorders(OSFED):0.8\%</p></li><li><p>Other specified feeding and eating disorders (OSFED):6.6\%

    • Total (all eating disorders): 13.6%</p></li></ul></li><li><p>Usingmorelenientcriteria,theprevalenceinaone−monthperiodwasestimatedatnearlyathird(13.6\%</p></li></ul></li><li><p>Using more lenient criteria, the prevalence in a one-month period was estimated at nearly a third (32\%$) of adolescents, with a much higher preponderance in girls compared to boys.

    Overview of DSM-5 Diagnostic Criteria

    Anorexia Nervosa

    • A. Persistent restriction of energy intake leading to significantly low body weight in the context of what is minimally expected for age, sex, developmental trajectory, and physical health.

    • B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain.

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

    • Subtypes:

      • Restricting Type: Patient restricts eating behavior to maintain a low weight.

      • Binge-Eating/Purging Type: In addition to restricting, binge eating and purging behaviors are present.

    Bulimia Nervosa

    • A. Recurrent episodes of binge eating, characterized by both:

      • 1.1. Eating in a discrete period of time (e.g., 22 hours) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

      • 2.2. A sense of lack of control over eating during the episode (e.g., feeling unable to stop or control how much one is eating).

    • B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

    • C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 33 months.

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

    • E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

    Binge Eating Disorder

    • A. Recurrent episodes of binge eating (defined similarly to bulimia nervosa).

    • B. Marked distress regarding binge eating.

    • C. The binge eating occurs, on average, at least once a week for 33 months.

    • D. Binge eating is not associated with the recurrent use of compensatory behaviors.

    Other Specified Feeding and Eating Disorders (OSFED)

    • Includes a wide range of clinically significant problems and should not be considered less serious than anorexia or bulimia.

    • Examples:

      • Atypical Anorexia Nervosa: All criteria for anorexia nervosa are met, except that despite significant weight loss, the individual's weight is within or above the normal weight range. This often means they started at a high BMI, lost substantial weight, and are in a metabolically starving state with associated psychological features, but are not at a low BMI.

      • Purging Disorder: Recurrent purging behaviors to influence weight, but in the absence of binge eating.

    Causes of Eating Disorders

    • Eating disorders are complex, and causal factors vary for each individual.

    • Continuum of Eating Disorder Development:

      • Healthy body image, body satisfaction, healthy eating habits.

      • <br>ightarrow<br>ightarrow Body dissatisfaction, disordered eating (frequent weight loss diets, intermittent binge eating, bulimic-like behaviors).

      • <br>ightarrow<br>ightarrow Clinical eating disorders (clinically significant, diagnostic criteria apply).

    • Factors that push an individual up this continuum:

      • Modifiable Environmental Factors (Immediate):

        • Cultural pressures to be thin (media, peer, family).

        • Appearance teasing.

        • Internalization of body ideals (appearance becomes central to self-evaluation).

        • Low self-esteem, depressive affect, negative affect.

      • Less Modifiable Background Factors (Difficult to change):

        • Genetic and Metabolic Factors: Strong familial and genetic component, especially in anorexia nervosa. Genes may relate to metabolic processes, increasing vulnerability.

        • Past Trauma.

        • General Temperament: Perfectionism, proneness to depressive symptomatology.

    • Interaction of Factors: Background factors can amplify the influence of cultural and immediate environmental factors. Once involved in extreme weight loss behaviors and believing appearance is crucial to self-value, individuals are at higher risk of developing more extreme eating behaviors and disordered thinking.

    Anorexia Nervosa: Medical and Psychological Factors, and Treatment

    Medical Complications of Anorexia Nervosa

    • Many complications are related to starvation, as demonstrated by the Keyes study during WWII, where volunteers on a starvation diet developed symptoms similar to anorexia nervosa.

    • Electrolyte Complications: Particularly low potassium, associated with cardiovascular problems (e.g., cardiac arrhythmias). Sodium and potassium are integral to nervous system function, affecting all bodily systems.

    • Gastrointestinal Complications: The entire gastrointestinal system can slow down.

    • Renal Complications: Water concentration defects.

    • Endocrine Complications: Amenorrhea (cessation of menstruation), lack of sexual interest. In mammals, severe weight loss suppresses reproductive systems (estrogen and testosterone) to prevent offspring in famine.

    • Dental Problems: Mainly associated with purging behaviors.

    • General Weakness and Hypothermia.

    • Osteoporosis: A significant concern because anorexia nervosa often develops during teenage and young adult years when bone calcification occurs. Reproductive hormones (especially estrogen) are needed for calcium deposition, and their suppression can lead to irreversible osteoporosis.

    Psychological Factors Associated with Anorexia Nervosa

    • A complex disorder, with individual differences.

    • Rigid Thinking: Often a consequence of starvation.

    • Distorted Values: Overvaluation of fitness and physical appearance as the primary measure of self-worth, with other strengths being devalued.

    • Distorted Body Image: Belief of being larger than actual size.

    • Loss of Self-Identity: Individuals may lose a sense of who they are beyond their physical appearance.

    • Sense of Control/Safety: Illness can provide a dangerous sense of control; controlling eating is seen as controlling other aspects of life.

    • Ego-Syntonic Nature: Anorexia nervosa is often considered an ego-syntonic disorder, meaning the thinness and associated control can be perceived as positive, giving confidence, which makes treatment challenging as the person may not initially see the behavior as harmful.

    Treatment for Anorexia Nervosa

    • Two Fundamental Aspects:

      • 1.1. Renourishment and Restoration: Absolutely essential to address medical problems and reduce cognitive rigidity caused by starvation, enabling participation in psychological therapies. Can occur in hospital or home settings (e.g., via family-based therapy).

      • 2.2. Psychological Therapy: Addresses core psychological issues like beliefs about self-worth, appearance, and regaining control over life.

    • Key Therapeutic Approaches: No single approach is reliably successful with all groups.

      • Maudsley Family-Based Therapy (FBT): Most effective for adolescents.

      • Enhanced Cognitive Behavioral Therapy (CBTE): Most helpful for older individuals/adults not in a family environment.

      • Other therapies tried: Motivational therapy, psychodynamic approaches, feminist therapy, interpersonal psychotherapy, narrative therapy, pharmacological therapies, dialectical behavior therapy (DBT), mindfulness.

    • Clinical Guidelines: Useful resources include the NICE guidelines (National Institute of Health and Care Excellence) and the Royal Australian and New Zealand College of Psychiatrists' clinical practice guidelines for evidence-based interventions.

    Maudsley Family-Based Therapy (FBT) for Adolescents

    • Most successful treatment for young people, widely available in Australia.

    • Core Concept: Views the family as a resource for recovery, not a cause of the disorder, a shift from earlier family therapy approaches.

    • Primary Goal: Refeed the child to a healthy weight, which is crucial for overcoming both medical and psychological problems.

    • Role of Parents: Supported to work together,