Lecture 5

Canadian prevalence.

0.5% of Canadians 15+ reported an eating disorder diagnosis. Women are 10x more likely than men to report an ED. Among women 15-24, 1.5% reported having an ED. 1.7% of Canadians met the criteria for having an eating attitude problem. PRevalence for anorexia is 0.3-1%, bulimia is ~3x that at 3-10%. In young men, 0-0.3% have anorexia and 0.1-0.3% have bulimia. Most men with anorexia participate in sports that impose pressures on maintaining weight within a narrow range.

Key points

1. Anorexia nervosa is characterized by refusal to maintain normal body weight, intense fear of becoming fat and a distorted sense of body shape. 2. The symptoms of bulimia nervosa include episodes of binge eating followed by purging, fear of fat, and a distorted body image. 3. Both anorexia and bulimia begin in adolescence and have high comorbidity with other psychological disorders. 4. Binge eating disorder has been included as a separate diagnostic in the DSM-5. It is characterized by symptoms similar to bulimia but without purging behaviours. 5. Biological research on eating disorders suggests a genetic diathesis. Low levels of serotonin as predisposing factors. 6. Psychological causes of eating disorders include cultural standards for thinness, cultural factors, gender issues, parent-child relationships, racial factors, and personality characteristics such as perfectionism and low self-esteem. 7. The main biological treatment of eating disorders has been the use of antidepressants. However, the use of antidepressants has produced mixed results and, drop-out rates are high. 8. Behavioural interventions within hospital settings can achieve weight gain in anorexics, but long-term maintenance of weight gain has not been reliably achieved. 9. Bulimia has been treated with some effectiveness using both cognitive-behavioural and interpersonal psychotherapy. However, only about half of patients show improvements that last over time.

Clinical features of anorexia

1. Refusal to maintain weight at or above what is appropriate for age and height 2. Intense fear of becoming fat, most common clinical feature 3. Distorted body image Goal → thinness Motivation → fear Distorted thinking, maladaptive attitudes, and misperceptions. An obsession with food is present, even their dreams are about their food. OCD symptoms are present.

BED must have at least three symptoms

Eating more rapidly than normal. Eating until feeling 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.

Medical complications of anorexia

Extreme cases can be fatal. Losses of as much as 35% of body weight may occur, and anemia may develop. Dermatological problems such as dry, cracking skin; fine, downy hair; even a yellowish discoloration of the skin that may persist for years after weight is regained. Cardiovascular complications include heart irregularities, hypotension (low blood pressure), and associated dizziness upon standing, sometimes causing blackouts. Menstrual irregularities and amenorrhea. Muscular weakness; loss of height; osteoporosis. Death is usually caused by suicide.

BED: compulsive over-eaters

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 to alleviate bad moods.

Case study" Nicole, age 16

It's like a huge feeling that I'm not right. That I could be better. I feel like I am a heavy person. You know how really, really fat people must feel? That's how I feel. I could not tell you how I look in jeans. I always had to go shopping with my mom so she could tell me how they looked. I honestly don't know what I'm supposed to look like. It started the spring of sophomore year. People said I had a good body all the time, a nice butt. I would turn my head away and blush. I got compliments up until the time I came into the hospital. Guys said I looked hot and I was wearing children's size 14 jeans. I hated the curves. I've got to get rid of the curves. I think my legs are fat. And this muscle here. I never sit with my legs crossed. I always look in the mirror sideways. I used to spit out my food instead of throwing up. Tootsie Rolls, peanut butter, M&Ms, Starburst. I had Jane Fonda's Workout, Kathy Smith's Fat Burning Workout. They're addicting. I watched them in the basement. I did butt exercises, sit-ups, stretches. I was never too thin. I never had a goal weight; it was always just not yet. My boyfriend couldn't bear to touch me. He stopped sleeping with me because he said I was just bones. I tried to get thinner to look better and win him back, but it just repulsed him. I thought I could be more appealing to him because all of the most beautiful women, the sexiest, are the thinnest. All the women men desire are thin. In the movies, the desired women are thin. Magazines. I would look through them at night: Vogue, Mademoiselle, Seventeen, Cosmopolitan, Elle, Harper's Bazaar. I based how I felt about myself on the way a guy felt about me. I would try to be a good girlfriend and when I did get hurt, it was a big blow. I was readmitted because I tried to kill myself. In my car, in the garage. It was the most real attempt. Everyone said I was doing so good, and then when I wasn't, when they build it up, I get sick. A lot of it has to do with my relationship with my father. I was taught to be quiet. Girls should be quiet. I should not express myself. I've always wanted a father that I know I can never have. For 16 years, I've wanted a father that I can never have. Sometimes I still wish I could fit into my old jeans. And that empty feeling--on top of the world, like you could conquer anything. I loved it.

Positive treatment outcomes of anorexia nervosa treatment

Weight gain is often quickly restored. Menstruation often returns with return to normal weight. Death rate is declining.

Body dissatisfaction

Women may impose unreasonable pressures to achieve the "perfect body". Lead to maladaptive attempts to attain a desired body weight or shape.

Anorexia Nervosa

Women with eating disorders are more likely than normal weight women to have a distorted body image. Tends to start with people who perceive themselves about being overweight, especially when they are praised about losing weight. Most patients do not lose their appetite or interest in food - they become preoccupied with food. Anorexia nervosa usually develops between the ages of 12 and 18.

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 advice, others may simply be looking for tips and techniques to help become more anorexic. A common theme among people viewing the sites is that they equated thinness with happiness.

Prognosis of anorexia nervosa

70% of patients recover: recovery often takes six or seven years. Relapses are common: changing distorted thoughts about thinness is difficult; particularly, in cultures that value thinness. Death rates are 10x > than general population. Death rates 2x > than patients with other psychological disorders. There is no other disorder that matches the mortality risk inherent in anorexia nervosa. Some who recover have a life expectancy that is 25 years shorter.

Negative treatment outcomes of anorexia treatment treatment

As many as 25 percent of patients remain troubled for years. Even when it occurs, recovery is not always permanent. Lingering emotional problems are common.

Death by starvation

A leading fashion model, Brazilian Ana Carolina Reston, was just 21 when she died in 2006 from complications due to anorexia. At the time of her death, the 5'7" Reston weighed only 88 pounds. Anorexia nervosa continues to be a widespread problem among fashion models & athletes today.

Associated psychological disorders

Anorexia nervosa: mood disorders, OCD, substance abuse, suicide. Bulimia nervosa: anxiety and mood disorders, GAD; depression, borderline personality disorder; impulse control disorders.

Cognitive factors

Anorexia: significantly higher perfectionistic attitudes; higher the perfectionism score, the poorer the outcome; Fail to live up to the standards they place on themselves. Bulimia: perfectionistic and dichotomous ("black or white") thinking patterns; harshly judge themselves; dysfunctional cognitive style leads to exaggerated beliefs about negative consequences of gaining weight.

Emotional factors

Attempts at self-medication for emotional problems. Anorexics may restrict their food intake in a misguided attempt to relieve upsetting emotions by seeking mastery or control over their bodies. Links between negative emotional states to binge eating episodes, therefore binge eating may represent an attempt at coping with emotional distress. Bulimia is a way to cope with stress from physical or sexual abuse.

Binge-eating disorder (BED)

BED is included as a separate diagnosis in DSM-5. Includes recurrent binges (at least once per week for at least three months), lack of control during the bingeing episode, and distress about bingeing, as well as other characteristics. Similar preoccupations, distorted evaluations and misperceptions of self; dissatisfaction with body; feelings of depression, anxiety, perfectionism; substance use/abuse, as bulimia and anorexia.

Similarities of anorexia nervosa and bulimia nervosa

Begins after a period of dieting. Fear of becoming obese. Drive to become thin. Preoccupation with food, weight, appearance. Feelings of anxiety, depression, obsessiveness, perfectionism. Heightened risk of suicide attempts. Substance abuse. Distorted body perception. Disturbed attitudes toward eating.

Treatment of eating disorders - binge eating disorder

Binge Eating Disorder seems more treatment responsive than anorexia nervosa or bulimia nervosa. CBT Self-help approaches Drug therapy SSRIs Behaviour Modification

Integrative model for causes of anorexia and bulimia

Biological, social, psychological influences lead to restriction of eating. Excessive weight loss leads to restriction of eating which can lead to anorexia: binge or continued restriction. Binge leads to purging, both lead to reduced anxiety which then leads to excessive weight loss. Retaining weight leads to restriction of eating which leads to binge eating and then purging and reduced anxiety which leads back to retaining weight.

Causes of anorexia and bulimia - family factors

Eating disorders frequently develop against a backdrop of family problems and conflicts. Families tend to be more conflicted; less cohesive and nurturing; more overprotective; more critical. Mothers of adolescent girls with eating disorders: likely to be unhappy about family functioning, have their own issues with eating and dieting; believe that their daughters need to lose weight and are unattractive. Some adolescents refuse to eat to punish their parents for feelings of loneliness and alienation they experience in the home.

Causes of anorexia and bulimia - psychosocial factors

Cognitive factors Emotional factors Body dissatisfaction

Treatment of eating disorders: bulimia

Cognitive-behavioural therapy is useful for challenging self-defeating thoughts and beliefs, dichotomous thinking, and addressing the overemphasis on appearance in determining self-worth. Exposure with response prevention therapy. Hospitalization is used when outpatient treatment hasn't worked or the disorder is complicated by health issues, suicidal thoughts/attempts, or substance abuse. Drug treatments better with bulimia nervosa than anorexia nervosa: antianxiety medication and SSRIs (selective serotonin reuptake inhibitors). Goal is: establish good eating habits; and eliminate underlying causes. Usually get into treatment when their dentists notice damage due to acid in vomit.

Eating disorders

Disordered eating behaviors and maladaptive ways of controlling body weight. All forms are characterized with an obsession of being thin. Disorders under this category include: anorexia nervosa, bulimia nervosa, and binge eating disorder. These are comorbid with mood and substance disorders, Once only a Western problem, now becoming prevalent in non-Western countries.

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. Eating disorders are more evident in Western cultures. 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 owing to the experience of rapid cultural changes and pressures.

Subtype of anorexia: binge eating-purging type

Frequent episodes of binge eating and then purging. Problems related to impulse control - periods of rigid control and impulsive behaviours. People with bulimia do not lose weight as drastically as those with anorexia.

Risk factors

History of unsuccessful weight loss attempts; childhood obesity; critical comments regarding being overweight, low self-concept, depression, and childhood physical or sexual abuse. 20% of individuals in weight-loss programs engage in binge eating. Many cross over to bulimia.

Case study: Cait age 17

I was going to make myself perfect. I thought I had control of it. I didn't think I had a problem. I thought I was happy, but I can't really figure out what happy is. I ate every couple of days. Or I would have a rice cake. I was convinced that an orange was too much. I got to the point where everything was too much. I restricted everything. After a while you don't feel the hunger pains anymore. And you don't know when you're hungry. I started restricting more and more, and then after a while I was craving food and that's when the bingeing started. In the beginning I was throwing up healthy food, broccoli, carrots, apples. And then I thought, if I'm going to do this, I might as well binge on what I like. I left a party early because I had to have a binge. I told my boyfriend I was tired, got in my car, and went to McDonald's. God, it was scary while I was doing it. I ate a Big Mac, a large fries, an apple pie, a hot fudge sundae with nuts, and I wasn't done. There was a grocery store right there. I got, like, a thing of Ben & Jerry's ice cream, a couple of candy bars, a big, like, two-pound bag of Peanut M&Ms. I ate at McDonald's, I ate in my car, and I ate the rest of it at home. I felt good after because it was gone. But in the end it was not so much the bingeing, it was not eating at all. I wouldn't drink pop, not even diet pop. My logic was: why? I don't need it. It was something extra. I knew there were no calories, but I thought there had to be something in the pop. I didn't want anybody to find out. I would make food, SpaghettiOs, and give it to my dog. My boyfriend has never seen me eat. I would say, "Oh, I just ate," or "I'm not hungry." I didn't want him to think that I was a cow or a pig or something. Like, if we were out and other girls were eating, I would get satisfaction out of the fact that I wasn't. It made me feel better than them. I make people tired. I'm constantly on the go. I was doing a thousand and one things. It was easier to go a thousand miles an hour than to deal with anything. I think I wasn't really happy with the image I was living, but I didn't know what to do. I practice being gentle. I practice in front of the mirror saying hello. I want to present myself in the best possible way, and if I can present myself better, as happier, as more energetic, then I want to know how to do it. I want so badly to just be me. I want to get out of this person, this perfectionist that everyone admires.

Aftermath of bulimia nervosa treatment

Left untreated, bulimia nervosa can last for years. Treated, significant short- and long-term improvement for many. Relapse can be a significant problem: relapses are usually triggered by stress. Relapses are more likely when the person: had a longer history of symptoms, vomited frequently, had histories of substance use, has lingering interpersonal problems.

Medical complications of bulimia

Many medical complications stem from repeated vomiting: skin irritation around the mouth due to frequent contact with stomach acid, blockage of salivary ducts, decay of tooth enamel, and dental cavities; the acid from the vomit may damage taste receptors on the palate, making the person less sensitive to the taste of vomit with repeated purging; decreased sensitivity to the aversive taste of vomit may help maintain the purging behavior; abdominal pain, hiatal hernia, pancreatitis, laxative dependency, potassium deficiency producing muscular weakness, cardiac irregularities, and even sudden death; electrolyte imbalance.

Treatment of eating disorders: anorexia

May be hospitalized, especially when weight loss is severe or body weight is falling rapidly: they are usually placed on a closely monitored refeeding regimen. Cognitive Behavioural therapy to address the dysfunctional attitudes and distorted thinking patterns. Behavioural therapy is also used, with rewards made contingent on adherence to the refeeding protocol: commonly used reinforcers include ward privileges and social opportunities. Goal is: weight restoration; and long-term maintenance of weight gain and attitude change of how they view body shape/image. Hard to get people with EDs into treatment, most don't think they have a problem. Upto 90% of people with EDs aren't in treatment and the ones that are are often resentful. Hospitalization is the fastest way for someone to recover, but with repeated hospitalization, the patient learns how to get out faster.

Bulimia nervosa

Most common psychological disorder on university campuses. Characterized by recurrent episodes of gorging on large quantities of food, followed by use of inappropriate ways to prevent weight gain (compensatory behaviours). These may include purging by means of self-induced vomiting; use of laxatives, diuretics, or enemas; or fasting or engaging in excessive exercise. 2 or more ways to lose weight are common. Are normally normal weight but fear being fat. Can go from bulimia to anorexia. A cycle develops - purging allows more bingeing and bingeing necessitates more purging. Pattern begins during or after a period of intense dieting. Harder to see, people hide their purging and binging; they do this in secret which makes it hard to treat. Purging can be 30-60 minutes, usually less than 2 hours. Binging allows more purging which encourages more binging.

Overlapping patterns of anorexia nervosa, bulimia nervosa, and obesity

Obesity overlaps with normal-weight bulimia nervosa disorder which results in binge-eating disorder. Normal-weight bulimia nervosa disorder overlaps with restricting-type anorexia nervosa disorder which results in binge-eating/purging-type anorexia nervosa disorder.

Differences of anorexia nervosa and bulimia nervosa

People with bulimia nervosa are more concerned about pleasing others, being attractive to others, and having intimate relationships. People with bulimia nervosa tend to be more sexually experienced and active. People with bulimia nervosa are more likely to have histories of mood swings, low frustration tolerance, and poor coping. People with anorexia nervosa are successful at losing weight. People with anorexia nervosa are proud of their diets/extraordinary control.

Clinical features of bulimea nervosa

Recurrent binge eating episodes characterized by: eating large amounts of food during a 2-hour period or less, loss of control over food intake, engaging in behaviors to prevent weight gain (compensating/purging), over concern with one's shape and body weight, average of at least 1 binge-purge episode per week for at least 3 consecutive months Bulimia nervosa is not diagnosed if the bingeing 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.

Diagnostic criteria for bulimia nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: eating, in a discrete period of time (within 2 hours), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances; a sense of lack of control over eating during the episode (feeling that one cannot stop eating or control what or how much one is eating). Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as a self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. the disturbance does not occur exclusively during episodes of anorexia nervosa.

Diagnostic criteria for binge-eating disorder

Recurrent episodes of binge eating. An episode of binge-eating is characterized by both of the following: eating in a discrete period of time an amount of food that is definitely larger than what most people would eat during a similar period of time and under similar circumstances; a sense of lack of control over eating during the episode. The binge eating episodes are associated with 3+ of: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, feeling disgusted with oneself, depressed, or very guilty afterward. Marked distress regarding binge eating is present. The binge eating occurs, on average, at least once a week for months. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Subtype of anorexia: restrictive type

Reduction of weight by restricting intake of food. Problems related to rigid, obsessively controlled diet. Little to no variation in their food; one person only ate rice cakes.

Diagnostic criteria for anorexia nervosa

Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or for children and adolescents, less than that minimally expected. Intense fear of gaining weight or persistent behavior that interferes with weight gain, even though at a significantly low weight. Disturbance in the way which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Restricting type: during the last 3 months, individual has not engaged in recurrent episodes of binge eating or purging behavior (self-induced vomiting or the misuse of laxative, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: during the last 3 months, individual has engaged in recurrent episodes of binge eating or purging.

Causes of anorexia and bulimia - biological factors

Serotonin plays a key role in regulating mood and appetite, especially cravings for carbohydrates. Antidepressants, (e.g. Prozac) can decrease binge-eating episodes in bulimic women. Link between a history of depression, imbalances of serotonin, and bulimia. Genetic link: first-degree relatives of young women with anorexia nervosa are 4x more likely than average to have the disorder themselves. Twin studies suggest a genetic influence. Studies of both anorexia and bulimia report higher identical than fraternal concordance rates. No adoption studies to date.

Effective treatments

Several psychosocial treatments are expensive including cognitive behavioral approaches combined with family therapy and interpersonal psychotherapy. Drug treatments are less effective at the current time. Less targeted treatments (as in just giving accurate information) works better than targeted. In view of the severity and chronicity of eating disorders, preventing these disorders through widespread educational and intervention efforts would be clearly preferable to waiting until the disorders develop.

Causes of anorexia and bulimia - sociocultrural factors

Sociocultural theorists point to social pressures and expectations placed on young women in our society as contributing factors in eating disorders. Among college women in one sample, 1 in 7 (14%) reported that buying a single chocolate bar in a store would cause them to feel embarrassed. In another study, peer pressure to adhere to a thin body shape emerged as a strong predictor of bulimic behavior in young women. Four out of five young women in the U.S. have gone on a diet by the time they reach their 18th birthday. A recent survey of college women found about 80% reporting dieting Body dissatisfaction is also linked to eating disorders in young men: muscle dysmorphobia.