Abnormal Psychology Chapter 10: Eating Disorders

restrained eating

Restricting intake of specific foods or overall number of calories (as occurs when dieting or trying to maintain one's current weight)

electrolytes

Salts that are critical for neural transmission and muscle contractions

significantly low weight

Defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected

binge eating

Eating much more food at one time than most people would eat in the same period of time or context - Often feel out of control when binging; unable to stop

Medical Effects of Bulimia Nervosa

- Chronic vomiting (a purging method) can cause the parotid and salivary glands (in the jaw area) to swell (creating a kind of "chipmunk" look) and can erode dental enamel, making teeth more vulnerable to cavities and other problems - People who use syrup of ipecac to induce vomiting may develop heart and muscle problems - Use of laxatives regularly can lead to permanent loss of intestinal functioning as body comes to depend on chemical laxatives to digest food and eliminate waste. In such cases, malfunctioning intestinal section must be surgically removed. - Can produce constipation, abdominal bloating and discomfort, fatigue, and irregular menstruation - All forms of purging can cause dehydration and an imbalance of body's electrolytes (as mentioned with anorexia) which disrupt normal neural transmission and heart contractions - Medical effects of bulimia can create significant and enduring problems

Feedback Loops in Understanding Eating Disorders

- Most females in Western societies are exposed to images of thin women as ideals in media, but only some women develop an eating disorder because neurological factors (such as genetic vulnerability) may make some people more susceptible to psychological and social factors related to eating disorders - Young women who were preoccupied with weight were more prone to anxiety and were more likely to have families focused on appearance. Preoccupation both could result from anxiety and familial focus on appearance and could cause these effects. Preoccupation with weight can also lead to dieting, which can create its own neurochemical changes (neurological factor) that may lead to eating disorders. Stringent rules people may set for diet can lead them to feel out of control with eating if they "violate" those rules (psychological factor). People with higher levels of perfectionism and body dissatisfaction (psychological factors) may elicit comments about their appearance (social factor) or pay attention to appearance-related comments (psychological factor)

Efficacy of CBT for Treating Eating Disorders

- Most people with eating disorders who improve significantly with CBT do so within first month of treatment - Although CBT helps decrease bingeing, purging, and dieting behaviors, up to 50% of patients retain some symptoms after treatment ends - One study of patients who completely abstained from bingeing and purging after CBT found 44% had relapsed 4 months later. Various factors predicted which people relapsed, including more eating rituals, more food-related thoughts, and less motivation to change; stressful life events can also precipitate relapses - CBT may be treatment of choice and helps many people with eating disorders, but not a panacea

Excessive concern with weight and appearance

- One of the two kinds of AUTOMATIC, IRRATIONAL, and ILLOGICAL thoughts about weight, appearance, and food that people with eating disorders have - Excessive concern with, and tend to overvalue, weight, body shape, and eating (ex: may weigh themselves multiple times a day and feel bad about themselves when scale indicates gained half a pound). Some people so concerned with weight and appearance that food intake, weight, and body shape come to define self-worth - Two characteristics that are the most consistent predictors of onset of an eating disorder are 1) dieting and 2) being dissatisfied with one's body. Such concerns help maintain bulimia because people with these characteristics believe that their compensatory behaviors reduce overall caloric intake

Psychological and Social Effects of Starvation

- Starvation study- healthy young men given half their usual caloric intake for 6 months lost 25% of original weight and suffered other changes: more sensitive to sensations of light, cold, and noise; slept less; lost sex drive; and mood worsened. Lost sense of humor, argued with one another, showed symptoms of depression and anxiety. Obsessed with food, talking and dreaming about food and collecting and sharing recipes. Hoard food and random items such as old books and knick-knacks. Striking effects persisted for months after men returned to normal diets, and abnormal eating and ruminations about food continued even 50 years later. Even on this diet, participants in the starvation study still ate more each day than do many people with anorexia. Most people with anorexia develop anorexia develop disorder when they are younger than men in the study and maintain unhealthy eating patterns for a longer time than the 6 months of the study; consequences of restricting eating at a young age may be more severe severe than those noted in starvation study - Some people with anorexia may have such distorted thinking about weight and body they may come to believe there's really nothing wrong with their weight or restricted food intake. - A minority may come to view anorexia as lifestyle choice rather than disorder, BUT anorexia has serious physical and mental health consequences, which are swept under the rug by such positive views of condition

eating disorder

A category of psychological disorders characterized by abnormal eating and a preoccupation with body image - Approximately 90% of people diagnosed with eating disorders are females, but number of males with eating disorders has been slowly increasing

binge-eating/purging type of anorexia

A type of anorexia nervosa in which people reduce their weight by binging and then purging

Social factors of eating disorders

Influence of family and friends, culture (which can contribute to eating disorders by promoting an ideal body shape)

Disordered eating: "other" eating disorders

Many adolescents and adults with significantly disturbed eating do not meet all the criteria for anorexia, bulimia, or binge eating disorder; may be diagnosed with nonspecific "other" eating disorder - Does not specify particular criteria, thus people given this diagnosis have wide range in number, frequency, and duration of symptoms. BUT, often fall into one of two groups: 1) partial cases 2) subthreshold cases

Feedback loops in treating eating disorders

Successful treatment should resolve medical crises and normalize eating and nutrition, directly or indirectly. - For person with anorexia, means increasing her eating. Better nutrition leads to improved brain functioning (neurological factor) and cognitive functioning (psychological factor) - For person with bulimia, means normalizing meals; make sure eating adequately throughout the day but also getting enough of the various food groups. Eating in this way decreases likelihood of extreme hunger, binges, or eating that feels out of control (psychological factor) - In most cases, enduring changes in eating result from changes in way person thinks about food and her beliefs about weight, appearance, femininity, and control. CBT may contribute to these enduring changes (psychological factor). Additionally, support of family and friends and improved quality of these relationships, which may come from IPT or family therapy (social factor), can help patient more realistically evaluate appearance, weight, and body shape. Improved family interaction patterns can increase mood and satisfaction with relationships, which can decrease level of attention person pays to cultural pressures toward an ideal body shape (psychological factor)

Understanding Eating Disorders

- Anorexia and bulimia are best understood of the eating disorders and treatments for these two disorders have been researched most extensively. Moreover, up to half of people who have anorexia OR bulimia have had or will have another of these disorders, so it makes sense to examine etiology of these disorders collectively RATHER than individually - Once eating disorder has develop, it is difficult to disentangle CAUSES of the eating disorder from widespread EFFECTS of eating disorder on neurological (and, more generally, biological), psychological, and social functioning. Thus do not know which of the neuropsychosocial factors that are ASSOCIATED with eating disorders actually PRODUCE the disorders. All that can be said at this time is that number of factors are associated with emergence and maintenance of eating disorders - Additional challenge is high rate of comorbidity of other psychological and medical disorders with eating disorders, which makes it difficult to determine degree to which risk factors uniquely lead to eating disorders rather than being associated more generally with comorbid disorders

Dieting, restrained eating, and disinhibited eating

- Continuing to adhere to restrictions can be challenging, and at times the diet may feel so constraining that you get discouraged and frustrated and simply give up--which can lead to a bout of disinhibited eating (bingeing on a restricted type of food or simply eating more of a nonrestricted type of food). Dieters and people with eating disorders often alternate restrictive eating with disinhibited eating. - Restrained eaters can become insensitive to internal cues of hunger and fullness. In order to maintain restricted eating, may stop eating before normal feeling of fullness, and so end up trying to tune out sensations of hunger. If they binge, may eat past point of normal fullness. They therefore need to rely on external guides, such as portion size or elapsed time since last meal to control food intake; HOWEVER, using external guides to direct food intake requires cognitive effort (ex: monitor clock or calculate how much food was last eaten and how much food should be eaten next). When thinking about other tasks (such as job or homework assignment) may temporarily stop using external guides and simply eat, which in turn may lead to disinhibited or binge eating.

Eating Disorders Across Cultures

- Eating disorders occur throughout world but are found mainly in industrialized Western or Westernized countries. Immigration to Western country and internalization of Western norms increases risk of developing symptoms of eating disorder. Westernization (or modernization) of culture similarly increases dieting, which is a risk factor for eating disorders. - As girls and women move into a higher socioeconomic bracket, increasingly likely to develop an eating disorder. - Within United States, prevalence rates of eating disorders vary across ethnic groups, based on different ideals of beauty and femininity: Native Americans have a higher risk for eating disorders than do other ethnic groups and Black Americans have had the lowest risk. However, prevalence rates are increasing among Black and Latina women perhaps because of growing number of ethnic models in mainstream ads who are as thin as White counterparts

CBT for Bulimia

- Focuses on thoughts, feelings, and behaviors that: 1) prevent normal eating; and 2) promote bingeing, purging, and other behaviors that are intended to offset the calories eaten during a binge - Also addresses thoughts, feelings, and behaviors that are related to body image and appearance and that maintain the symptoms of bulimia - May address issues associated with perfectionism, low self-esteem, and mood - Uses many of the same methods as CBT for anorexia: psychoeducation, cognitive restructuring, self-monitoring, and relaxation. In addition, may employ method used to treat obsessive-compulsive disorder (OCD): exposure with response prevention- involves exposing patient to anxiety-provoking stimuli, such as foods typically eaten only during a binge. Patients asked to consumer moderate amount of the binge food during therapy session (the exposure), and response prevention involves NOT purging or responding in another usual way to compensate for calories taken in

The Role of Culture in Eating Disorders

- Only a small increase in number of cases of anorexia. In contrast, incidence of bulimia substantially increased from 1970 to 1990, suggesting a CULTURAL influence, because bulimia arises only in context of concerns about weight. - 3 elements come together to create engine driving culturally induced increase in eating disorders 1. cultural ideal of thinness 2. repeated media exposure to thinness ideal, and 3. person's assimilation of the thinness ideal - Tracked measurements of Miss America contestants and Playboy centerfold playmates over time found that their waists and hips gradually became smaller. In fact, while size of playmates' bodies decreased over time (as assessed by body mass index, or BMI, an adjusted ratio of weight to height), average BMI of women age 20-29 increased. During same period, prevalence of eating disorders increased in United States. Not clear whether contestants and playmates were creating or following cultural trend in ideal body shape, but clear that society's pressure to be thin increases women's--and girls'--dissatisfaction with bodies, which is a risk factor for eating disorders; presenting an increasingly unattainable ideal - Cultural influence on weight and appearance isn't limited to women: men who regularly engage in activities such as modeling and wrestling, which draw attention to appearance and weight, are increasingly likely to develop eating disorders. - Men who have a heightened awareness of appearance, such as some in the gay community, are also more likely to develop eating disorders

The power of the Media on Eating Disorders

- Prior to 1995, no television in Fiji. Traditional Fijian culture promoted robust body shapes and appetites, and no cultural pressures for thinness or dieting. Data from adolescent girls shortly after introduction of television in 1995 and again 3 years later. At beginning of study, when large body size was cultural ideal, found almost no one who felt they were "too big or fat". After 3 years of watching television, primarily shows from Western culture, 75% reported that they felt "too big or fat" at least some of the time. In addition, feeling too big associated with dieting to lose weight, which had become very prevalent: 62% of the girls had dieted within the prior 4 weeks - Similar process might be occurring in industrialized societies, where ideals of thinness saturate environment through television, movies, magazines, advertisements, books, and even cartoons. - Associations between media exposure and disordered eating. The more time adolescent girls spent watching television, the more likely they were to report distorted eating a year later. HOWEVER, not all girls and women who view these media images end up with an eating disorder. Some people are more affected than others, perhaps because of combination of neurological, psychological, and social risk factors. For them, chronic exposure to these types of images may tip scales and set them on course toward eating disorder.

Operant Conditioning: Reinforcing Disordered Eating

- Psychological factor of eating disorders - 5 ways operant conditioning affect disordered eating: 1. Symptoms of most eating disorders (anorexia, bulimia, or binge eating disorder) may inadvertently be reinforced through operant conditioning. Never-ending preoccupations with food, weight, and body are negatively reinforced because they provide relief from what person might otherwise be preoccupied about (ex: preoccupations with food and weight or bingeing and purging can provide distractions from work pressures, family conflicts, or social problems). (Negative reinforcement is still reinforcement, but occurs when something aversive is removed, which is not the same as punishment) 2. Operant conditioning occurs when restricting behaviors are positively reinforced by person's sense of power and mastery over appetite, although such feelings are mastery are often short-lived as disease takes over 3. People are positively reinforced for "losing control: of their appetite and bingeing. They've set up rules so that they get to eat certain foods they enjoy (positive reinforcement) only when they let themselves lose control of their food intake; that is, during a binge, people eat foods they normally don't eat at all or eat only in small quantities--typically fats, sweets, or carbohydrates. This means only way some people can eat foods they may enjoy (ex: cake, ice cream, fried foods) is by being "out of control" 4. Bingeing can induce an endorphin rush, which creates a pleasant feeling much like a "runner's high," which is positively reinforcing. 5. Operant conditioning may occur because purging can be negatively reinforcing by relieving the anxiety and fullness created by overeating

The Role of Family and Peers in Eating Disorders

- Researchers have trouble disentangling influences of genes on eating disorders from influences of family for 2 main reasons: 1) family members provide model for eating, body image, and appearance concerns through their own behaviors (ex: parents who spend a lot of time on appearance before leaving house model that behavior for children) 2) family members affect child's concerns through responses to child's body shape, weight, and food intake (ex: if parent inquires daily about how much food child ate at lunch or weighs child daily, child learns to pay close attention to caloric intake and daily fluctuations in weight). Children whose parents are overly concerned about these matters are more likely to develop eating disorder, BUT this finding can also reflect shared genes - Peers can shape person's relationship to eating, food, and body, especially if they tease or criticize person concerning weight, appearance, or food intake; such comments can have lasting influence on person's (dis)satisfaction with body, willingness to diet, and self-esteem. Such influences can make person more vulnerable to developing an eating disorder. - Many girls and women feel symptoms of eating disorders, particularly preoccupations with food and weight, are "normal" and talking about these topics is a way to bond with others

Treating Eating Disorders

- When treating patient with anorexia, help attain a medically safe weight by helping her eat more and/or purge less often; if that safe weight cannot be reached with outpatient treatment (treatment that does not involve an overnight stay in a hospital), then inpatient treatment becomes imperative. In patient treatment for eating disorders may also take place at special stand-alone facilities - When someone with an eating disorder is not underweight enough to require inpatient treatment, many different factors can be initial targets of treatment. - Intensity of treatment for eating disorders can range from hospitalization, to day or evening programs, to residential treatment (staffed facilities in which patients sleep, take breakfast and dinner, and perhaps participate in evening groups), to weekly visits with a therapist. In all these forms of treatment, cognitive-behavior therapy (CBT) generally consider the method of choice. Regardless of severity of eating disorder, frequent visits with an internist or a family doctor are an important additional component of treatment. Physician determines whether patient should be medically hospitalized and, if not, whether she is medically stable enough to partake in daily activities

Differences between Binge Eating Disorder and Bulimia

1) People with binge eating disorder DO NOT persistently try to compensate for the binges; for instance, do not purge or compulsively exercise 2) Most people with binge eating disorder are obese; people with bulimia generally range in weight from somewhat underweight to overweight but are NOT generally obese - People with binge eating disorder are also more likely to develop medical problems as a result of nutritional intake, such as diabetes, high blood pressure, high cholesterol, and heart disease. Binges are typically high in fats, sugars, and/or salt

3 Criteria for DSM-5 Diagnosis of Anorexia Nervosa

1. A significantly low body weight for the person's age and sex - Results from not ingesting enough calories relative to calories burned. Being slightly underweight is not enough 2. An intense fear of becoming fat or gaining weight, or behaving in ways that interfere with weight gain, despite being significantly underweight - This fear often primary reason person refuses to attain healthy weight. Obsessed with body and food, and thoughts and beliefs about these topics usually illogical or irrational (ex: wearing certain clothing size is "worse than death" - Feelings about herself rise and fall with caloric intake, weight, or how clothes seem to fit (ex: if someone with anorexia eats 50 more calories than she allotted for daily intake, may experience intense feelings of worthlessness. - People who suffer from anorexia often deny they have a problem and do NOT see low weight as source of concern 3. Distortions of body image (the person's view of her body). - People with anorexia often feel that their bodies are bigger and "fatter" than they actually are and overly value body weight or shape - People who have anorexia AND people who have body dysmorphic disorder BOTH have distorted body image, BUT people with anorexia focus on overall body shape and weight, whereas people with body dysmorphic disorder typically focus on face or single body part. People who have anorexia also typically have actual physical problem with body (significantly underweight) that they typically do not want to improve, whereas people with body dysmorphic disorder have no or minimal "defect" but perceive it to be significant and want to hide it or minimize it in other ways

Maudsley approach

A family treatment for anorexia nervosa that focuses on supporting parents as they determine how to lead their child to eat appropriately - Most effective for young women and girls who live with parents - Does NOT view family as responsible for causing problems and in fact makes no assumptions about causes of disorder - Focuses on: 1) helping parents view patient as DISTINCT from illness; and 2) supporting parents as THEY figure out how to lead child to eat appropriately. - Therapists asks parents to unite to feed daughter, despite anxiety and protests. Once weight is normal and child eats without a struggle, they gradually return control to her, and other family issues--including general ones of adolescent development--become the focus - Initial phase of treatment requires enormous commitment on part of the family. Parent must be home continuously to monitor daughter's eating. Maudsley approach not feasible for all families. - Research shows that it is perhaps the most effective treatment for adolescents and young adults with anorexia

restricting type of anorexia nervosa

A type of anorexia nervosa in which people reduce their weight by severely restricting what they eat; one of two ways to become extremely thin and maintain low weight - Low weight is achieved and maintained through severe undereating or excessive exercise (Mental health clinicians consider exercise to be excessive if person feels high levels of guilt when she postpones or misses workout) - NO binge eating or purging - Classic type of anorexia

Is Bulimia Distinct from Anorexia?

About half of people with anorexia go on to develop bulimia, which may indicate that anorexia and bulimia are not distinct but rather represent phases of same eating disorder, with symptoms shifting over time. Some researchers argue that person's diagnosis may better reflect where person is in the course of the eating disorder at the time she is diagnosed. - Characteristics of binge eating/purging type of anorexia have more in common with bulimia than with restricting type of anorexia. All the distinguishes the binge eating/purging type of anorexia from bulimia is the LOW WEIGHT

bulimia nervosa

An eating disorder characterized by binge eating along with vomiting or other behaviors to compensate for the large number of calories ingested - Maladaptive eating behaviors often start as attempt to cope with negative feelings about weight, appearance, or eating "too much" - Key feature is repeated episodes of binge eating followed by inappropriate efforts to prevent weight gain (such as vomiting or using diuretics, laxatives, enemas) or engaging in other behaviors to prevent weight gain (such as fasting or excessive exercise) - Like anorexia, typically overvalue appearance and body image - Often, people with bulimia do not simply eat normally at meals and then binge between meals. Rather, they try to control what they eat, restricting their caloric intake at meals (trying to be "good" and eat less), but later become ravenous, and their hunger feels out of control. Then binge eat, which in turn makes them feel physically and emotionally "bad: because they "lost control" of themselves. As a result of such feelings, they may purge and subsequently strive to eat less, restricting caloric intake at meals and creating VICIOUS CYCLE of restricting, bingeing, and usually purging

binge eating disorder

An eating disorder characterized by binge eating without subsequent purging - Marked by specific pattern of out-of-control binge eating in which person must have AT LEAST THREE of the following symptoms: eat faster than normal, eat until uncomfortably full, eat a lot even when not hungry, eat alone because of being embarrassed by quantity eaten, or have significant negative feelings about himself or herself about amount eaten - DO NOT typically fantasize about food or enjoy eating (either when bingeing or when not bingeing) and the bingeing causes DISTRESS - Involves OUT-OF-CONTROL BINGE EATING and NOT WEIGHT per se; being overweight is NOT a psychological disorder - Gender difference typically of other eating disorders is LESS PRONOUNCED with binge eating disorder - MORE common than anorexia nervosa and bulimia nervosa combined

anorexia nervosa

An eating disorder characterized by significantly low body weight along with an intense fear of gaining weight or using various methods to prevent weight gain - Will not maintain at least a low normal weight and employs various methods to prevent weight gain - Despite medical and psychological consequences of a low weight, continue to pursue extreme thinness - High risk of death; about 10-15% of people hospitalized with anorexia eventually die as a direct or indirect consequence of disorder - Distorted perceptions of the size of their meal portions, overestimating how much food is in a portion - Develop bizarre eating habits and a kind of tunnel vision focusing on food, on eating, and on not eating. Some symptoms overlap with obsessive-compulsive disorder (OCD) and related disorders: obsessions about symmetry, compulsions to order objects precisely, and hoarding. However, other symptoms of OCD, like obsessions of contamination and checking and cleaning do NOT overlap.

purging

Attempting to reduce calories that have already been consumed by vomiting or using diuretics, laxatives, or enemas

disinhibited eating

Bingeing on a restricted type of food or simply eating more of a nonrestricted type of food

CBT for Anorexia

CBT can be effective in reducing symptoms of anorexia and has been shown to prevent relapses. Targets psychological factors - Focuses on identifying and changing thoughts and behaviors that impede normal eating and that maintain symptoms of disorder. - Cognitive restructuring can decrease patient's irrational thoughts (such as belief that starving means having self-control) and help patient develop more realistic thoughts (ex: appropriate eating indicates ability to care for herself). - Therapist helps patient develop more adaptive coping strategies, such as expressing anger or disappointment directly to other people rather than hiding or denying such "negative" feelings. - Treatment may also involve psychoeducation (about disorder and its effects), training in self-monitoring (to notice hunger cues and become aware of problematic behaviors), and relaxation training (to decrease anxiety that arises with increased eating) - Because low weight can affect cognitive functioning, irrational thoughts may not change substantially until patient's weight increases

subthreshold cases

Cases in which patients have symptoms that fit all the necessary criteria, but at levels lower than required for the diagnosis of a disorder (ex: may have had anorexia or bulimia but then improved to point where symptoms no longer meet criteria for either disorder. NEVERTHELESS, these people still have clinically significant symptoms of an eating disorder)

partial cases

Cases in which patients have symptoms that meet only some of the necessary criteria but not enough symptoms to meet all the necessary criteria for the diagnosis of a disorder (ex: partial case of binge eating disorder would be someone whose symptoms meet all other criteria for disorder but does not eat quick, eat alone, or eat when not hungry; thus, diagnosed with nonspecific "other" eating disorder)

Targeting Psychological Factors of Eating Disorders

Cognitive-behavior therapy (CBT) is the most widely studied treatment of eating disorders that directly targets psychological factors, and is considered treatment of choice. CBT for eating disorders focuses primarily on changes in thoughts, feelings, and behaviors, that are related to eating, food, and the body, at least in initial stages. At outset of treatment, patient and therapist discuss who monitors patient's weight and at what point inpatient treatment would be recommended and pursued.

cognitive narrowing

Focus on immediate aspects of environment - People high in perfectionism try to decrease emotional distress by focusing on immediate aspects of environment

aversive self-awareness

Heightened awareness of personal flaws that are real or imagined

Treatments for eating disorders that target social factors

Interpersonal therapy - Manual-based form of interpersonal therapy (IPT). Includes 4 to 6 months of weekly therapy. Focus is on problems i relationships that contribute to onset, maintenance, and relapse of the disorder. Central idea behind IPT for eating disorders is that as problems with relationships resolve, symptoms decrease, even though symptoms are not addressed directly by treatment - Hypothesized mechanism: 1) IPT reduces longstanding interpersonal problems; 2) resulting improvement of relationships makes people feel hopeful and empowered and increases self-esteem; and 3) these changes lead people to change other aspects of their lives, such as disordered eating; moreover, lead to less concern about appearance and weight and, therefore, less dieting and bingeing - IPT for anorexia not well researched, but studies have shown that IPT is effective alternative to CBT for bulimia Family therapy - Most widely used family-oriented treatment for anorexia is called Maudsley approach - Systems therapy is another type of family therapy provided to young women and girls with eating disorders. Family is viewed as system; when one member changes, change is forced on the rest of the system. Maladaptive family interactional patterns and structures are seen as problem and are the focus of change. Therapist may not specifically address patient's eating and food issues. Group-based inpatient treatment programs - Psychiatric hospitalizations/inpatient treatment for eating disorders often planned in advance and usually take place in units or free-standing facilities that specialize in treating people with eating disorders. - Recommended when less intensive treatments have failed to change disordered eating behaviors sufficiently - Hospital environment is a 24-hour community in which patients attend many different types of group therapy, including groups focused on body image, coping strategies, and relationships with food. These groups can decrease isolation and shame patients may feel and give patients opportunity to try out new ways of relating. - Also receive individual therapy and usually some type of family therapy; may also receive medication - Short term goals: increase person's weight to normal range, establish normal eating pattern (3 full meals and 2 snacks per day). curbing excessive exercise, and beginning to change irrational, maladaptive thoughts about food, weight, and body shape. For people who purge or otherwise try to compensate for caloric intake, additional goal is to stop or at least reduce such compensatory behaviors Prevention programs - Prevent eating disorders, particularly for people most at risk, namely people who have some symptoms of an eating disorder but do not meet all the diagnostic criteria. - Often seek to challenge maladaptive beliefs about appearance and food and to decrease overeating, fasting, and avoidance of some types of foods - May take place in a single session or in multiple sessions, may take form of presentations or workshops, or may even be provided via Internet

Targeting Neurological and Biological Factors of Eating Disorders

Neurologically and biologically focused treatments are designed to create a pattern of normal healthy eating and to stabilize medical problems that arise from eating disorder; nourishing the body. Treatments that focus on these goals include nutritional counseling to improve eating, medical hospitalization to address significant medical problems, and medication to diminish some symptoms of the eating disorder as well as symptoms of comorbid anxiety and depression - Focus on nutrition- increasing the nutrition and variety of foods eaten--and not purged--is critical. Nutritionalist will help develop meal plans for increasing caloric intake at reasonable pace. In process of nutritional counseling, nutritionist may identify patient's mistaken beliefs about food and weight; nutritionist then seeks to educate patient and thus help correct such beliefs. As people with anorexia begin to eat more, may experience gastrointestinal system discomfort because of lack of body fat, having more food in gastrointestinal system may compress section of the duodenum (part of the intestine) that is on top of an important artery; discomfort goes away as she recovers - Medical hospitalization- bodily effects of eating disorders--particularly anorexia--can be directly life-threatening. When medical problems related to eating disorders become severe, medical hospitalization rather than psychiatric hospitalization may be necessary. Medical hospitalization generally occurs in response to medical crisis, such as heart problem, gastrointestinal bleeding, or significant dehydration. Goal of medical hospitalization is treat specific medical problem and stabilize patient's health - Medication- Generally medications do not help people with anorexia gain weight; however, once patient's normal weight restored, selective serotonin reuptake inhibitors (SSRIs) may help prevent person from developing anorexia again. For bulimia, antidepressants--particularly SSRIs--may reduce some symptoms; compared to placebos, SSRIs can help decrease bingeing, vomiting, and weight and shape concerns, although other symptoms may still persist--including fear of normal eating. SSRIs may also reduce symptoms of comorbid depression. SSRI Prozac (fluoxetine) is mostly widely studied medication for bulimia, and FDA approved to treat bulimia. HOWEVER, studies of effects of Prozac on bulimia typically last no longer than 16 weeks so unclear how long medication should be taken. Additionally, as with other disorders, beneficial effects of medication used to treat eating disorders typically stop soon after medication discontinued.

Personality traits as risk factors for eating disorder

Particular personality traits are associated with--and are considered risk factors for--eating disorders: perfectionism and low self-esteem. - Perfectionism = persistent striving to attain perfection and excessive self-criticism about mistakes - People with eating disorders have higher levels of perfectionism - High perfectionism may lead to intense drive to attain desired weight or body shape and thus may contribute to the thoughts and behaviors that underlie an eating disorder. - Perfectionists are painfully aware of imperfections, which is aversive for them. This heightened awareness of personal flaws (real or imagined) = aversive self-awareness. Leads to significant emotional distress, which may temporarily be dulled by focusing on immediate aspects of the environment, such as occurs with bingeing. Thus, bingeing may provide escape from emotional distress associated with perfectionism. - People with low self-esteem may try to raise self-esteem by controlling food intake, weight, and shape, believing suck changes will increase self-worth (ex: "If I restrict my calories, that'll prove that I'm in control of myself and worthy of respect." BUT, efforts to increase self-worth in this way end up having paradoxical effect: to the extent that person fails to control food intake, weight, and shape, self-esteem falls even lower; feels that she's failed, yet again, to achieve something she wanted

Two types of Anorexia Nervosa

People with anorexia become extremely thin and maintain very low weight by using one of two methods: 1. Restricting type 2. Binge-eating/purging type

Medical Effects of Anorexia Nervosa

Serious negative effects on many aspects of bodily functioning. Because of daily deficit between calories needed for normal functioning and calories taken in, the body tries to make do with less, which comes at high cost. - Heart muscle becomes thinner as body, using available energy sources to meet its caloric demands, cannibalizes muscles generally and heart muscle in particular. When people with anorexia exercise, they are NOT building muscle but losing it, ESPECIALLY heart muscle, which can be fatal. Excessive exercise actively discouraged in people with anorexia, and even modest exercise may be discouraged, depending on person's weight and medical status. - Body adjusts to conserve energy, which may result in low heart rate and blood pressure, abdominal bloating or discomfort, constipation, loss of bone density (leading to osteoporosis and easily fractured bones), and slower metabolism (which leads to lower body temperature, difficulty tolerating cold temperatures, and downy hairs forming on the body to provide insulation). - Dry and yellow-orange skin, brittle nails, and loss of hair on the scalp - May develop lanugo hair (fine downy hair similar to that of newborns) on abdomen, back, and face. Disappears when normal weight attained - Irritability, fatigue, and headaches - Also appear to be hyperactive or restless, which is likely a by-product of starvation. - People with anorexia who purge may believe they are getting rid of all the calories eaten, but this is WRONG. In starved state, body so desperately needs calories that once food is in the mouth, digestive process begins more rapidly than normal, and calories may begin to be absorbed before food reaches stomach; even if vomiting occurs, some calories are still absorbed, although water the body needs is lost - Diuretics (substances that force body to excrete water) decrease ONLY water in body, NOT body fat or muscle. Laxatives and enemas simply get rid of water and body's waste before it would otherwise be eliminated. - ALL four methods of purging (vomiting, diuretics, laxatives, and enemas) can result in dehydration because they all deprive body of needed fluids. In turn, dehydration can create imbalance in body's electrolytes (salts that are critical for neural transmission and muscle contractions, including those of the heart muscle). When dehydration remains untreated, can lead to death - Long-term consequences of starvation during puberty indicate an increased risk of heart disease

Neurological factors of eating disorders

Set the stage 1. Brain systems -Differences between brains of people with eating disorders and those of control participants - People who have anorexia have unusually low activity in 2 key areas of brain: 1) frontal lobes, which are involved in inhibiting responses and in regulating behavior more generally (a deficit in such processing may contribute to eating too much or eating too little), and 2) portions of the temporal lobes that include the amygdala, which is involved in fear and other strong emotions (fear helps prevent people from putting themselves in danger, and dampening this emotion may contribute to eating disorders) - Structure of brain ITSELF changes with eating disorders. Anorexia associated with loss of both gray matter (cell bodies of neurons) and white matter (myelinated axons of their neurons) in brain. Gray matter carries out various sorts of cognitive and emotion-related processes, such as those involved in learning and in fear responses. Deficits in white matter may imply that different parts of the brain are not communicating appropriately, which could contribute to problems patients with anorexia have when they try to convert an intellectual understanding of their disorder into changes in behavior. - Many of these structural deficits IMPROVE when patient recovers, although they DO NOT necessarily disappear completely. Thus, an eating disorder may have LONG-TERM consequences for person's neural functioning, which in turn affects cognitive abilities and emotional responses 2. Neural communication: serotonin - Losing large amounts of weight, as occurs in anorexia, and associated malnutrition changes amounts of serotonin and other neurotransmitters - Serotonin involved in regulating wide variety of behaviors and characteristics associated with eating disorders, including binge eating and irritability - Serotonin receptors function abnormally in patients with anorexia and bulimia. HOWEVER, evidence seems to imply that the serotonin receptors are abnormal before patients develop anorexia. Serotonin is related to mood and anxiety; prior to developing anorexia, patients tend to be anxious and obsessional, and these traits persist even after recovery, suggesting a biologically based anxious temperament. This temperament may be related to serotonin levels or functioning - People with anorexia and bulimia are LESS RESPONSIVE to serotonin than normal. The worse the symptoms of bulimia, the less responsive to serotonin the patient generally is. 3. Genetics - As is true for people with mood disorders and anxiety disorders, people with an eating disorder are more likely than average to have family members with an eating disorder, BUT not necessarily the same disorder that they themselves have - Anorexia has substantial heritability, but estimates range from as low as 33% to as high as 88%. Twin studies of bulimia also indicate influence by genes and also yield a wide range of estimates of heritability, from 28% to 83%. Given that many people with bulimia previously had anorexia, not surprising that both disorders have same wide range of heritabilities; significant overlap in two populations. Large variation in heritabilities may simply indicate, once again, that genes ARE NOT DESTINY; way ENVIRONMENT INTERACTS WITH GENES is also important

abstinence violation effect

The result of violating a self-imposed rule about food restriction, which leads to feeling out of control with food, which then leads to overeating - One of the two kinds of AUTOMATIC, IRRATIONAL, and ILLOGICAL thoughts about weight, appearance, and food that people with eating disorders have - When violation of a self-imposed rule about food restriction leads to feeling out of control with food, which then leads to overeating - Many people who have an eating disorder engage in automatic, illogical, black-or-white thinking about food (ex: vegetables are "good," desserts are "bad") and they may come to view themselves in the same way- they are "good" when acting to lose weight and "bad" when eating a "bad" food or when they feel eating is out of control - Explains bingeing that occurs after person has "transgressed" (ex: taste friend's ice cream, thinks "I shouldn't have had any ice cream. I've blown it for the day, so I might as well have my own ice cream--in fact, I'll get a pint and eat the whole thing." Then after eating ice cream, tries to negate calories ingested during binge by purging or using some other compensatory behavior)

objectification theory

The theory that girls learn to consider their bodies as objects and commodities - Explains how cultural ideal of thinness makes women vulnerable to eating disorders. - Western culture promotes view of male bodies as agents (instruments that perform tasks) and of female bodies as objects mainly to be looked at and evaluated in terms of appearance - Encourages eating disorders because female bodies are evaluated according to cultural ideal, and girls and women strive to have their bodies conform so that they will be positively evaluated. As they internalize the ideal of thinness, they increase their risk for eating disorders, especially in combination with learning to see their bodies as objects from the outside: if they hold an ideal of thinness and see bodies as objects, become more likely to pay attention to flaws and feel ashamed of their bodies, and these feelings motivate restrained eating. (Even preschool children attribute more negative qualities to fat women than to fat men) - Another possible explanation for gender difference in prevalence rates of eating disorders focus on politics of cultural ideal of thinness for women. As women's economic and political power has increased, female models have become thinner and less curvaceous, creating physical ideal of womanhood that is harder, if not impossible, to meet. Women then spend significant time, energy, and money trying to emulate thinner ideal through exercise, diet, medications, and even surgery, which in turn dissipates their economic and political power. - Males much less likely to develop any type of eating disorder than women but large gender discrepancy may not last. Data suggest male physical ideals increasingly unrealistic: male film stars and Mr. Universe winners increasingly muscular, paralleling changes in women's bodies in media. Just as women covet bodies similar to those promoted in media, so do males. 2/3 of men want bodies to be more similar to cultural ideals of male body. HOWEVER, rather than suffer from specific sets of symptoms for anorexia or bulimia, males more likely to develop a form of "other" eating disorder, with symptoms that focus on muscle building, either through excessive exercise or steroid use.

DSM-5 Distinction Between Anorexia Nervosa and Bulimia Nervosa

Those with anorexia may purge or fast, just like those with bulimia. The symptom that distinguishes anorexia and bulimia is that people with anorexia have SIGNIFICANTLY LOW WEIGHT whereas those with bulimia DO NOT. - Bulimia is TWO or THREE times more prevalent than anorexia, and like anorexia, is more prevalent among females than males.

Psychological Factors of Eating Disorders

Thoughts of and feelings about food. Many psychological risk factors are not uniquely associated with eating disorders. Factors such as negative self-evaluation, sexual abuse, and other adverse experiences, the presence of comorbid disorders (like depression and anxiety disorders), and using avoidant strategies to cope with problems are associated with psychological disorders generally. Factors specifically related to symptoms of eating disorders: factors associated with food, weight, appearance, and eating. 1. Think about weight, appearance and food. - People with eating disorders have AUTOMATIC, IRRATIONAL, and ILLOGICAL thoughts about weight, appearance, and food; two kinds of such thoughts: 1) Excessive concern with weight and appearance and 2) Abstinence violation effect- when violation of a self-imposed rule about food restriction leads to feeling out of control with food, which then leads to overeating. 2. Operant Conditioning: Reinforcing Disordered Eating - Operant conditioning plays a role in the development and maintenance of symptoms of disordered eating 3. Personality traits as risk factors - Particular personality traits are associated with--and are considered risk factors for--eating disorders: perfectionism and low self-esteem. 4. Dieting, restrained eating, and disinhibited eating 5. Other psychological disorders as risk factors - Factor associated with subsequent development of eating disorder is presence of psychological disorder in early adolescence, particularly depression. - Longitudinal study found that having depressive early adolescence associated with increased risk for later dietary restriction, purging, recurrent weight fluctuations, and emergence of eating disorder, even when statistically controlled for other disorders or eating problems before adulthood. - The more psychological disorders an adolescent, particularly female, has the more likely he or she is to develop an eating disorder

inpatient treatment/psychiatric hospitalization

Treatment that occurs while a patient is in a psychiatric hospital or in a psychiatric unit of a general hospital - Can improve eating and help change distorted thoughts about food, weight, and body. But in many cases, positive changes are NOT enduring. 12 months after discharge, 30-50% of patients relapse. - Reasons for high relapse rate: 1)some patients only accept the intensive treatment for health reasons or because of pressure from family members--and once out of hospital, not willing to continue changes they began 2) some patients do not receive appropriate outpatient care after leaving hospital, making it more difficult for them to learn how to sustain changed eating, weight, and views about bodies when they are not in a supervised therapeutic environment 3) economic pressures from insurance companies, which have cut approved length of hospital stays for people with eating disorders and for people with psychological disorders in general. Psychiatric hospitalizations have become increasingly short, which reduces amount of enduring change that can realistically be accomplished during stay

muscle wasting

When the body breaks down muscle in order to obtain needed calories