Notes: Feeding and Eating Disorders & Personality Disorders (Anorexia, Bulimia, Binge Eating, Borderline, Antisocial)

Feeding and eating disorders: definitions and recognition

• Based on DSM-5-TR: feeding and eating disorders are characterized by a persistent disturbance of eating or eating-related behaviour that results in altered consumption or absorption of food, significantly impairing physical health or psychosocial functioning.

• Most prevalent disorders in this category: Anorexia Nervosa and Bulimia Nervosa; binge eating disorder added in DSM-5/DSM-5-TR.

• In Australia, about 1{,}000{,}000 people are affected by an eating disorder each year.

• Lifetime prevalence estimates (National data) show eating disorders: 8.4\% for women and 2.2\% for men.

• Emerging evidence suggests eating disorders may be similar or higher among First Nations peoples.

Anorexia Nervosa

• Individuals intentionally starve themselves, exercise excessively, or use laxatives/induce vomiting to avoid weight gain.

• Weight criterion: maintain at least 15\% below their ideal body weight (IBW).

• Not about healthy weight loss; represents unhealthy levels of body mass index well below the healthy range.

• It is a life-threatening illness with the highest mortality rate among psychiatric diseases.

• Physical health consequences: brittle bones; potential death from heart failure.

• Distinguishing feature: individuals consistently maintain very low body weight.

• Core psychopathology: distorted body image, often perceiving themselves as overweight despite wasting away.

• Typical onset: adolescence or young adulthood; more common in women.

• Australian data: among people with eating disorders, 3\% have anorexia; 80\% of those are girls or women.

• Key contrast with bulimia: anorexia involves sustained very low weight rather than normal/overweight weight in some cases.

Bulimia Nervosa

• Characterized by binge-purge cycles: consuming large amounts of food in a short period followed by efforts to purge (vomiting, laxatives) or excessive exercise, or other compensatory behaviours.

• Purge behaviours often provide temporary relief and reduce anxiety about the large intake.

• Can be associated with depression and a sense of loss of control after binge episodes.

• Australian data: among people with eating disorders, 12\% have bulimia nervosa; 70\% of these are girls or women.

• Weight may be normal or above normal; not necessarily underweight.

Binge Eating Disorder (BED)

• Defined by uncontrolled consumption of large amounts of food in one sitting without compensatory behaviours (no excessive exercise, no laxatives).

• A new addition to the DSM-5 and DSM-5-TR.

• Prevalence in Australia: not yet established (data not yet available).

• Global data (World Mental Health Survey, WHO): prevalence is higher than that for anorexia nervosa or bulimia nervosa.

• Diagnostic distinction: absence of compensatory behaviours differentiates BED from bulimia.

Causes and contributing factors for eating disorders

• Family loading: tend to run in families.

• Biological factors: link with serotonin regulation.

• Behavioural and cognitive factors in harmful dieting:

  • Criticism or appearance teasing by family members.

  • Family members’ own body image issues and dieting behaviours.

  • Observing others’ dieting/self-criticism.

• Environmental and sociocultural factors:

  • Strong influence of social media on body image, especially in young people.

  • Transitions to work, relationships, and lifestyle choices heighten investment in self-presentation.

  • Exposure to often unrealistic appearance standards on platforms such as Instagram and TikTok.

• Distal vs proximal influences: multiple interacting factors contribute to development; binge eating can serve as comfort during distress for some individuals.

Personality disorders: overview

• Personality = enduring patterns of thought, feeling, motivation, and behaviour activated in social interactions.

• Key feature: patterns are socially peculiar, inappropriate, and inflexible.

• Characteristics of personality disorders:

  • Chronic and severe disturbances

  • Substantially inhibit one’s capacity to love and to work.

• Example (narrative): Narcissistic Personality Disorder (NPD) illustrates hallmark features:

  • Tendency to use others, hypersensitivity to criticism, sense of entitlement.

  • Grandiosity and lack of empathy; potential relationship/work difficulties.

• Prevalence: unknown exact population rate; best estimates around 10\%\sim 12\%.

• In this mini-lecture focus: Borderline Personality Disorder (BPD) and Antisocial Personality Disorder (ASPD).

• Gender distribution tendencies: BPD more prevalent in females; ASPD more prevalent in males.

• Introductory note: from a previous module, personality disorders are chronic, maladaptive patterns affecting interpersonal and occupational functioning.

Borderline Personality Disorder (BPD)

• Core features: extremely unstable interpersonal relationships, mood swings, unstable sense of self, intense fears of separation/abandonment, manipulation, impulsivity, self-mutilation.

• Prevalence in Australia: approximately 0.4\%\sim 5.9\% of the population.

• Hospital presentations associated with BPD can be as high as 43\% of cases.

• Suicide risk: about 10\% of people with BPD die by suicide; between 10\%\sim 30\% of all suicides are among individuals with BPD.

• Cognitive/interpretive style: splitting (viewing others as all good or all bad); tendency to attribute malevolent intentions and expect abuse/rejection.

• Impact: high distress and increased likelihood of acting on distress relative to those without BPD.

Antisocial Personality Disorder (ASPD)

• Core features: irresponsible, socially disruptive behaviour across multiple settings.

• Common symptoms: stealing, property destruction, lack of empathy, lack of remorse for misdeeds.

• Occupational/relational impact: difficulties maintaining jobs due to absences, harassment, lying, vandalism, impulsivity, recklessness.

• Presentation: individuals may be charming or manipulative (often described as con artists).

• Onset: evolves by age 15; diagnosis typically made after age 18; linked to history of conduct disorder in childhood (conduct disorder must be present before age 18 for ASPD diagnosis).

• Conduct disorder vs ASPD: not all with childhood conduct disorder progress to ASPD.

• Causes and contributing factors:

  • Psychodynamic and cognitive-behavioural perspectives emphasize physical abuse, neglect, and absent or criminal male role models.

  • Adoption studies: an adopted child with a biological parent with ASPD is about three times more likely to develop aggressive behaviour than someone without biological vulnerability; similarly, adoption from a parent with ASPD increases risk of developing the disorder even without predisposition.

  • Twin studies: environmental factors more important in predicting ASPD in adolescence; genetic factors more influential as individuals age.

Causes of borderline and antisocial personality disorders

• Core etiological themes:

  • Difficult or insecure attachment relationships in childhood.

  • Exposure to abuse or chaotic home life increases risk for BPD.

  • For ASPD, physical abuse, neglect, and absent/criminal male role models are more commonly implicated.

  • Genetic predisposition interacts with environmental factors.

• Adoption and familial transmission data suggest both genetic and environmental contributions, with varying emphasis across development.

Summary of key points

• Feeding and eating disorders are identified by persistent disturbances in eating/eating-related behaviour that impair health and functioning; main disorders include Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder (BED).

• DSM-5/DSM-5-TR classification and prevalence data provide a framework for understanding risk and distribution across genders and populations; global estimates and national data show notable gender differences and shifts in diagnosed conditions.

• Anorexia Nervosa: severe underweight, distorted body image, high mortality risk, adolescence/young adulthood onset; predominantly female in Australia (approx. 80\% of anorexia cases are female among those with eating disorders).

• Bulimia Nervosa: binge-purge cycle, typically normal or above-average weight, substantial mental health comorbidity; in Australia, the disorder accounts for about 12\% of eating disorders with a female predominance of approx. 70\%.

• BED: defined by uncontrolled binge eating without compensatory behaviours; higher global prevalence than anorexia/bulimia in some surveys; local Australian prevalence not yet established.

• Causes of eating disorders involve a mix of biological (serotonin regulation), psychological (self-criticism, distortion of self-image), familial (appearance-focused criticism), and sociocultural factors (media influence, social platforms).

• Personality disorders are enduring maladaptive patterns affecting thoughts, feelings, and behaviours, with chronic impairment in functioning.

• Borderline Personality Disorder (BPD): unstable relationships, mood instability, identity disturbance, fear of abandonment, impulsivity, self-harm; significant suicide risk; prevalence in Australia 0.4\%\sim 5.9\%; hospital presentations up to 43\%; suicide risk around 10\%; a subset of suicides involve individuals with BPD at rates of 10\%\sim 30\%.

• Antisocial Personality Disorder (ASPD): persistent pattern of disregard for rights of others, manipulation, deceit, and risk-taking; onset by age 15 and diagnosed after 18; linked to childhood conduct disorder; discussion of adoption and twin studies shows a strong interaction between genetic predisposition and environmental exposure; environmental factors more influential in adolescence, while genetic factors gain prominence with age.

• Overall, etiologies span psychodynamic, cognitive-behavioural, biological, and environmental domains; prevention and treatment require addressing attachment issues, abuse histories, and social-contextual factors.