Quiz #3: Eating Disorders

Anorexia Nervosa

*** A refusal to maintain more than 85% of normal body weight : Example --> Female 5'5 110 ibs or less, Male: 5'8 I40 Ibs or less -BMI (Body Mass Index) used - Intense fears of becoming overweight -Distorted view of weight and shape -Amenorrhea The "typical" case: - A normal to slightly overweight female has been on a diet -Escalation toward anorexia nervosa may follow a stressful event: Separation of parents, more away from home, experience of personal failure *** Most patient recover - 2% to 6% become seriously ill and die as a result of medical complications or suicide

Binge Eating Disorders

*** Difference: Don't have compensatory behaviors (don't get overweight because they balance it out with other healthy behaviors) - Repeated eating binges during which they feel no control over their eating - These individuals do not perform inappropriate compensatory behavior -AS a result of their frequent binges, around 2/3 of people with binge eating disorder become overweight or even obese

Psychodynamic Factors: Ego Deficiencies (Hilde Bruch)

*** Hilde Bruch developed a largely psychodynamic theory of eating disorders - Argued that eating disorders are the result of disturbed mother-child interactions, which lead to serious ego deficiencies in the child and to severe perceptual disturbances - Bruch argues that parents may respond to their children either effectively or ineffectively - Effective parents accurately attend to a child's biological and emotional needs - Ineffective parents fail to attend to child's needs; they feed when the child is anxious, comfort when the child is tired, etc. - Such children may grow up confused and unaware of their own internal needs and turn, instead, to external guides *** Clinical reports and research have provided some empirical support for this theory

Bulimia Nervosa Dx Checklist

*** Occurs, on average: Once a week for at least 3 months -Characterized by inappropriate compensatory behaviors (binging with lack of control) 1. Repeated binge eating episodes 2. Repeated performance of ill-advised compensatory behaviors (e.g., forced vomiting) to prevent weight gain 3. Symptoms take place at least weekly for a period of 3 months 4. Inappropriate influence of weight and shape on appraisal of oneself

Bulimia Nervosa

*** Patients are generally of normal weight - Often experience marked weight fluctuations - Some may also qualify for a diagnosis of anorexia AKA: "Binge-Purdge Syndrome" --> is characterized by binges: - "Binge-Eating Disorder" is a related diagnosis - Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting) - Bouts of uncontrolled overeating during a limited period of time - Eat objectively more than most people would/could eat in a similar period *** The "typical" case: - A normal to slightly overweight female has been on an intense diet - Research suggests that even among normal participants, bingeing often occurs after strict dieting

Anorexia Nervosa: The Clinical Picture

*** The key goal for people with anorexia nervosa is becoming thin ***The driving motivation is fear: - Of becoming obese - Of giving in to the desire to eat - Of losing control of body size and shape *** Despite their dietary restrictions, people with anorexia nervosa are preoccupied with food - This includes thinking and reading about food and planning for meals - This relationship is not necessarily causal - It is usually the result of food deprivation, as evidenced by the famous 1940s "starvation study" with conscientious objectors

AN: Thinking Process

***Persons with anorexia nervosa also think in distorted ways: - Usually have a low opinion of their body shape - Tend to overestimate their actual proportions - Hold maladaptive attitudes and misperceptions - "I must be perfect in every way" - "I will be a better person if I deprive myself" - "I can avoid guilt by not eating" - Self-esteem is narrowly anchored on weight/physical appearance - Externalize body rather than experiencing from inside

Treatments for AN

***The immediate aims of treatment for anorexia nervosa are to: - Regain lost weight - Recover from malnourishment - Eat normally again - Widen sources of self-esteem - Increase self-acceptance - Develop more connectedness with body so body is experienced from the inside instead of viewed as observer from the outside __________________________________________ - In the past, treatment took place in a hospital setting; it is now often offered in day hospitals or outpatient settings - In life-threatening cases, clinicians may need to force tube and intravenous feedings on the patient - This may breed distrust in the patient and create a power struggle - In contrast, behavioral weight-restoration approaches have clinicians use rewards whenever patients eat properly or gain weight - The most popular weight-restoration technique has been the combination of supportive nursing care, nutritional counseling, and high-calorie diets - Necessary weight gain is often achieved in 8 to 12 weeks - Researchers have found that people with anorexia nervosa must overcome their underlying psychological problems to achieve lasting improvement -In most treatment programs, a combination of behavioral and cognitive interventions are included *** On the behavioral side, clients are required to monitor feelings, hunger levels, and food intake and the ties among those variables *** On the cognitive sides, they are taught to identify their "core pathology" - Therapists help patients recognize their need for independence and control - Therapists help patients recognize and trust their internal feelings - A final focus of treatment is helping clients change their attitudes about eating and weight - Using cognitive approaches, therapists correct disturbed cognitions and educate about body distortions - Family therapy is important for anorexia nervosa treatment - The main issues are often separation and boundaries - The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa *** But even with combined treatment, recovery is difficult - The course and outcome of the disorder vary from person to person

Anorexia Nervosa Dx Checklist

***These symptoms must be present for three or more months 1. Individual purposely takes in too little nourishment, resulting in body weight that is very low and below that of other people similar age and gender 2. Individual is very fearful or gaining weight, or repeatedly seeks to prevent weight gain despite low body weight 3. Individual has a distorted body perception, places inappropriate emphasis on weight or shape in judgments of herself or himself, or fails to appreciate the serious implications of her or his low weight. __________________________________________ Partial Remission: No longer meets criteria #1 but still meets #2 and/or #3 Full Remission: No symptoms but met criteria in the past

Body Dissatisfaction Facts

- Around 73% of all girls and women are dissatisfied with their bodies, compared with 56% of all boys and men (Mintem et al., 2014). - The vast majority of dissatisfied females believe they are overweight; in contrast, half of dissatisfied males consider themselves overweight and half consider themselves underweight. - The factors most closely tied to body dissatisfaction are perfectionism and unrealistic expectations (Wade & Tiggemann, 2013). - Body dissatisfaction is the single most powerful contributor to dieting and to the development of eating disorders.

Negatives of Treatment for AN

- As many as 25% of patients remain troubled for years - Even when it occurs, recovery is not always permanent - Anorexic behavior recurs in at least one-third of recovered patients, usually triggered by new stresses - Many patients still express concerns about their weight and appearance - Lingering emotional problems are common

Multicultural Factors: Racial and Ethnic Differences

- A widely publicized 1995 study found that eating behaviors and attitudes of young African American women were more positive than those of young white American women - Specifically, nearly 90% of the white American respondents were dissatisfied with their weight and body shape, compared to around 70% of the African American teens - The study also suggested that the groups had different ideals of beauty - Eating disorders among Hispanic American female adolescents are about equal to those of white American women - Eating disorders also appear to be on the increase among Asian American women and young women in several Asian countries -Males account for only 5% to 10% of all cases of eating disorders - Western society's double standard for attractiveness is, at the very least, one reason - A second reason may be the different methods of weight loss favored: **Men are more likely to exercise **Women more often diet - It seems that some men develop eating disorders as linked to the requirements and pressures of a job or sport - The highest rates of male eating disorders have been found among: *Jockeys *Wrestlers *Distance runners *Body builders *Swimmers - For other men, body image appears to be a key factor - Last, some men seem to be caught up in a new kind of eating disorder - reverse anorexia nervosa or muscle dysmorphobia

BN Facts

- About 90%-95% of cases occur in females - The peak age of onset is between 15 and 21 years - Symptoms may last for several years with periodic letup - Many teenagers and young adults go on occasional eating binges or experiment with vomiting or laxatives after they hear about these behaviors from their friends or the media - 25 to 50 percent of all students report periodic binge eating or self-induced vomiting (Ekern, 2014; Zerbe, 2008; McDermott & Jaffa, 2005). - Only some of these individuals qualify for a diagnosis of BN - In Western countries about 5 percent of women develop the full syndrome (Ekern, 2014; Touchette et al., 2011). - Among college students the rate may be much higher (Zerbe, 2008).

Bulimia Nervosa: Compensatory Behaviors

- After a binge, people with bulimia nervosa try to compensate for and "undo" the caloric effects ***The most common compensatory behaviors: - Vomiting: * Fails to prevent the absorption of half the calories consumed during a binge * Repeated vomiting affects the ability to feel satiated ⇒ greater hunger and bingeing -Laxatives and diuretics: * Also largely fails to reduce the number of calories consumed --Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating *** Over time, however, a cycle develops in which purging ⇒ bingeing ⇒ purging...

Bulimia Nervosa VS. Anorexia Nervosa Similarities:

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

BN: Binges

- Between 1-30 binge episodes per week - Binges are often carried out in secret - Binges involve eating massive amounts of food very rapidly with little chewing - Usually sweet, high-calorie foods with soft texture - Binge-eaters commonly consume between 1,000 and 10,000 calories per binge episode -Binges are usually preceded by feelings of great tension and/or powerlessness - The binge itself may be pleasurable, but they are usually followed by feelings of self-blame, guilt, depression, and fears of weight gain and being discovered

Biological Factors

- Biological theorists suspect certain genes may leave some people particularly susceptible to eating disorders - Consistent with this idea: Relatives of people with eating disorders are up to 6 times more likely to develop the disorder themselves Identical (MZ) twins with anorexia: 70% Fraternal (DZ) twins with anorexia: 20% Identical (MZ) twins with bulimia: 23% Fraternal (DZ) twins with bulimia: 9% ***These findings may be related to low serotonin HYPOTHALAMUS: - Other theorists believe that eating disorders may be related to dysfunction of the hypothalamus - Researchers have identified two separate areas that control eating: *Lateral hypothalamus (LH) *Ventromedial hypothalamus (VMH) - Some theorists believe that the hypothalamus, related brain areas, and chemicals together are responsible for weight set point - a "weight thermostat" of sorts - Set by genetic inheritance and early eating practices, this mechanism is responsible for keeping an individual at a particular weight level * If weight falls below set point: ⇑ hunger, ⇓ metabolic rate ⇒ binges * If weight rises above set point: ⇓ hunger, ⇑ metabolic rate - Dieters end up in a battle against themselves to lose weight

Cognitive Factors (Bruch)

- Bruch's theory also contains several cognitive factors, like improper labeling of internal sensations and needs - According to cognitive theorists, these deficiencies contribute to a broad cognitive distortion that lies at the center of disordered eating (e.g., negative self-judgment based on body shape and weight)

Dark Sites of the Internet

- Dark sites of the Internet—sites with the goal of promoting behaviors that the clinical community, and most of society, consider abnormal and destructive - Eating Disorders Association reports that there are more than 500 pro-anorexia Internet sites, with names such as "Dying to Be Thin" and "Starving for Perfection" - Besides promoting eating disorders, might there be other ways in which pro-Ana sites are potentially harmful to regular visitors?

Higher Prevalence among those with AN of (Co-morbid with) :

- Depression (usually mild) - Anxiety - Low self-esteem - Insomnia or other sleep disturbances - Substance abuse - Obsessive-compulsive patterns - Perfectionism

Anti-depressant Medications for BN

- During the past 15 years, all groups of antidepressant drugs have been used in bulimia nervosa treatment Drugs help as many as 40% of patients - Medications are best when used in combination with other forms of therapy

Family Environment

- Families may play an important role in the development of eating disorders - As many as half of the families of those with eating disorders have a long history of emphasizing thinness, appearance, and dieting * Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves - Abnormal interactions and forms of communication within a family may also set the stage for an eating disorder *** Influential family theorist Salvador Minuchin cites "enmeshed family patterns" as causal factors of eating disorders - These patterns include over-involvement in, and over-concern about, family member's lives

BN: Non-purging Type

- Fasting - Exercising too much

BN: Purging-Type

- Forced vomiting, misusing laxatives, diuretics, or enemas

Other forms of psychotherapy for BN

- If clients do not respond to cognitive-behavioral therapy, other approaches may be tried - A common alternative is interpersonal therapy (IPT); a treatment that seeks to improve interpersonal functioning may be tried - Psychodynamic therapy has also been used - Various forms of psychotherapy are often supplemented by family therapy and may be offered in either individual or group therapy format *** Group formats provide an opportunity for patients to express their thoughts, concerns, and experiences with one another *** Group therapy is helpful in as many as 75% of cases

Anorexia Nervosa Subtype: Restricting Type

- Lose weight by cutting out sweets and fattening snacks, eventually eliminating nearly all food - Show almost no variability in diet

Anorexia Nervosa Subtype: Binge-Eating/Purging Type

- Lose weight by forcing themselves to vomit after meals or by abusing laxatives or diuretics - Like those with bulimia nervosa, people with this subtype may engage in eating binges ***Difference between anorexia binge/purging and bulimia is that anorexia is low weight and bulimia is not

Societal Pressures

- Most theorists believe that current Western standards of female attractiveness are partly responsible for the emergence of eating disorders - Western standards have changed throughout history toward a thinner ideal: *Miss America contestants have declined in weight by 0.28 lbs/yr; winners have declined by 0.37 lbs/yr *Playboy centerfolds have lower average weight, bust, and hip measurements than in the past -Members of certain subcultures are at greater risk from these pressures: *** Models, actors, dancers, and certain athletes - Of college athletes surveyed, 9% met full criteria for an eating disorder while another 50% had symptoms - 20% of surveyed gymnasts appear to have an eating disorder -Societal attitudes may explain economic and racial differences seen in prevalence rates - Historically, women of higher SES expressed more concern about thinness and dieting * These women had higher rates of eating disorders than women of the lower socioeconomic classes - Recently, dieting and preoccupation with thinness, along with rates of eating disorders, are increasing in all groups -The socially accepted prejudice against overweight people may also add to the "fear" and preoccupation about weight * About 50% of elementary and 61% of middle school girls are currently dieting * A recent survey of adolescent girls tied eating disorders and body dissatisfaction to social networking, Internet activities, and television browsing

Bulimia Nervosa VS. Anorexia Nervosa Differences

- 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 -More than one-third of people with bulimia display characteristics of a personality disorder, particularly borderline personality disorder *** Different medical complications: - Only half of women with bulimia nervosa experience amenorrhea vs. almost all women with anorexia nervosa experience amenorrhea - People with bulimia nervosa suffer damage caused by purging, especially from vomiting and laxatives

Relapse of BN

- Relapse can be a significant problem, even among those who respond successfully to treatment *Relapses are usually triggered by stress *Relapses are more likely among persons who: *Had a longer history of symptoms Vomited frequently *Had histories of substance use *Have lingering interpersonal problems

Treatments for Binge-Eating Disorder

- Today's treatments for binge-eating disorder are often similar to those for bulimia nervosa - Cognitive-behavioral therapy, other forms of psychotherapy, and in some cases, antidepressant medications are provided to help reduce or eliminate the binge-eating patterns and to change disturbed thinking such as being overly concerned with weight and shape

Treatments for BN

- Treatment is frequently offered in eating disorder clinics - The immediate aims of treatment for bulimia nervosa are to: *** Eliminate binge-purge patterns *** Establish good eating habits *** Eliminate the underlying cause of bulimic patterns - Programs emphasize education as much as therapy ***COGNITIVE-BEHAVIORAL THERAPY (is particularly helpful) Behavioral techniques: - Diaries are often a useful component of treatment - Exposure and response prevention (ERP) is used to break the binge-purge cycle Cognitive techniques: - Help clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape - Typically teach individuals to identify and challenge the negative thoughts that precede the urge to binge - Left untreated, bulimia nervosa can last for years Treatment provides immediate, significant improvement in about 40% of cases - An additional 40% show moderate response - Follow-up studies suggest that 10 years after treatment about 75% of patients have fully or partially recovered

Positives of Treatment for AN

- Weight gain is often quickly restored - As many as 90% of patients still showed improvements after several years - Menstruation often returns with return to normal weight - The death rate from anorexia nervosa is declining

Anorexia Nervosa Facts

-Ninety to 95 percent of all cases occur in females - The peak age of onset is between 14 and 20 years - Between 0.5 and 4.0 percent of all females in Western countries develop the disorder in their lifetime - Many more display at least some of its symptoms (Ekern, 2014; Smink et al., 2013; Stice et al., 2013). - There has been a rise in eating disorders in the past three decades, especially in North America, Europe and Japan

Binge Eating Disorder Dx Checklist

1. Recurrent binge-eating episodes 2. Binge- eating episodes include at least three of these features: - Unusually fast eating - Absence of hunger - Uncomfortable fullness - Secret eating due to sense of shame - Subsequent feelings of self-disgust, depression, or severe guilt 3. Significant Distress 4. Binge-eating episodes take place at least weekly over the course of 3 months 5. Absence of excessive compensatory behaviors

Q. How are eating disorders treated?

A.Eating disorder treatments have two main goals: 1. Correct dangerous eating patterns 2. Address broader psychological and situational factors that have led to, and are maintaining, the eating problem ***This often requires the participation of family and friends

Q. What causes eating-disorders?

A.Most theorists and researchers use a multidimensional risk perspective to explain eating disorders: - Several key factors place individuals at risk -More factors = greater likelihood of developing a disorder *** Leading factors: - Psychological problems (ego, cognitive, and mood disturbances) - Biological factors - Sociocultural conditions (societal, family, and multicultural pressures)

AN: Medical Problems

Caused by starvation: - Amenorrhea - Low body temperature - Low blood pressure - Body swelling - Dry skin, brittle nail - Metabolic and electrolyte imbalances - Slow heart rate - Reduced bone density - Poor circulation - Lanugo: Fine, silky hair that covers some newborns

Overlapping Patterns of Anorexia Nervosa, Bulimia Nervosa and Obesity

Restricting-type anorexia nervosa disorder --> Binge-eating/Purging-type anorexia nervosa disorder --> Normal-weight bulimia nervosa disorder --> Binge-eating disorder --> Obesity