Eating Disorders Flashcards
(29 cards)
Learning objectives:
- To be able to define an eating disorder, and understand the diagnoses involved
- To know how many cases of eating disorders exist in the population
- To be able to detail theories of causation and of maintenance
- To be able to use this understanding of causation and maintenance to explain cases and how treatment might be planned
The stereotype attached to eating disorders
Young, white, thin and female - driven by early theories, by where the early research was done, by access to services, and possibly by being seen as a ‘woman’s problem’
• e.g., a ‘retreat from female maturity’ (Crisp, 1973)
However, that stereotype is of limited validity
– present across the age range
– proportional numbers in non-white people
– 10-15% are male
> Fairburn & Harrison (2003) Most are not thin… - Anorexia nervosa (15% of cases) - Bulimia nervosa (35%) - Eating disorder not otherwise specified (50%)
- To be able to define an eating disorder, and understand the diagnoses involved
Define “eating disorder”
This proves highly elusive - probably the best accepted is as follows
• “A persistent disturbance of eating behaviour or behaviour intended to control weight, which significantly impairs physical health or psychosocial functioning” (Fairburn & Walsh, 2002)
• Issues around this definition
– always an issue of ‘in the eye of the beholder’
– where do exercisers, models, gymnasts and ballerinas fit?
- To be able to define an eating disorder, and understand the diagnoses involved
Why does eating behaviour become pathalogical?
- Contradictory advertising
- Changing body ideals pushed by the media
Results in overeating (bulimia/ binge eating disorder) or under-eating (anorexia)
Pathological eating patterns are often associated with the use of denial as a means of avoiding confronting the eating disorder and challenging dysfunctional beliefs surrounding that eating.
- Many women consider themselves to be overweight, despite having a BMI in the normal range
- Dieting is often a significant precursor to anorexia nervosa symptoms, and contributes to the persistence of symptoms as it becomes an entrenched habit.
- 6.3% of the UK population exhibit disordered eating patterns
- To know how many cases of eating disorders exist in the population
Anorexia nervosa
Symptoms, effects of symptoms
Main symptoms/ features:
- self-starvation
- refusal to maintain a minimally normal weight
- pathological fear of gaining weight
- distorted body image, even when really underweight suffers continue to insist they are overweight
- weight loss is viewed as an important achievement and weight gain, as a significant loss of self- control
- even when individuals admit that they might be underweight, they often deny the important medical implications of this, and continue to eat pathologically
Effects of self-starvation include;
- tiredness cardiac arrhythmias hypertension, low blood pressure and slow heartbeats resulting from altered levels of electrolytes
- dry skin and brittle hair
- kidney and gastrointestinal problems
- development of lanugo (soft downy hair on the body)
- the absence of menstrual cycle (amenorrhea)
- hypothermia, often resulting in feeling cold (even in warm environments)
Starvation can severely weaken the heart muscles as the body uses muscles as a source of protein in absence of sufficient calories. As a result, mortality rates, including suicide in anorexia nervosa and bulimia nervosa are high, ranging from 5 to 8%, with one in five of those deaths being as a result of suicide
- To know how many cases of eating disorders exist in the population
Anorexia nervosa
Diagnostic criteria
Diagnostic criteria:
- a significantly reduced calorie intake relative to bodily requirement, leading to low weight
- intense fear of gaining weight or becoming fat
- disruption in the way that the patient evaluates their body or shape, putting undue influence on body weight or shape on self-evaluation
DSM 5 stresses objective levels for judging the severity of the symptoms, so the guidelines are strict and severity of the symptoms are based on body mass index (BMI). Guidelines adopted the World Health Organisation lower limit for normal body weight as a BMI of 18.5, given other criteria are met (also a lot of anorexia sufferers aren’t yet critically underweight). Criteria also emphasise the pathological fear of weight gain and the distortions of self-perception that accompany the disorder.
- To know how many cases of eating disorders exist in the population
Anorexia nervosa
Historical examples
Historical examples
- cases of self-starvation have been reported in classical and mediaeval times, often as a means of achieving heightened spirituality among religious devotees. Bell, 1985 called this holy anorexia. One prominent case was Mary, Queen of Scots.
- To know how many cases of eating disorders exist in the population
Bulimia Nervosa
Symptoms, effects of symptoms
Main symptoms/ features:
- recurring episodes of binge eating (often eating more than a normal person’s full daily intake of food in one episode)
- and recurrent inappropriate compensatory behaviours to prevent weight gain (such as vomiting or the misuse of laxatives)
- a self-evaluation that is unduly influenced by body shape and weight
Triggers and the binge/purge cycle of behaviour;
- disorder is frequently triggered by concerns about body weight and shape, so it may have its origins in a period of dieting.
- what is perplexing about bulimia and distinguishes it from anorexia, is that they have strong concerns about their body, but indulge in bouts of overeating. Suggests that they have lost control over their eating patterns, and because this control is so important to them they become ashamed of their binges, try to conceal them.
- binges tend to occur quickly and in private, with easy to consume foods
- binges can be triggered by dysphoria, depressed mood, stress or intense hunger following a period of restrictive eating
- due to the perceived lack of control, individuals report high levels of disgust, low levels of self-esteem, feelings of inadequacy and depression
- however, the purging behaviour tends to give them relief from the physical discomfort of eating, and also reduces guilt and fear of gaining weight. Therefore, purging acts to reinforce the behaviour and may become a goal in itself, reduces anxiety and depression
Physical symptoms;
Bulimia has fewer physical symptoms than anorexia, but include
- permanent loss of dental enamel as a result of vomiting
- swollen parotid glands, producing a puffy face appearance
- menstrual irregularity
- To know how many cases of eating disorders exist in the population
Bulimia Nervosa
Diagnostic criteria
Diagnostic criteria:
DSM five criteria include;
- repeated incidents of binge eating
- frequent inappropriate compensators behaviours, in order to avoid weight gain
- binge eating and compensator behaviours, both occur on average at least once a week for three months
- a view of oneself is overly influenced by body shape and weight
Most bulimia sufferers are not usually overweight, nor do they usually become underweight as a result of purging - this distinguishes them from those suffering from the binge eating/purging anorexia nervosa subtype.
- To know how many cases of eating disorders exist in the population
Bulimia Nervosa
Historical examples
Historical examples
- historical examples of bulimia are much rarer than those of anorexia
- in the 17th century Silverman 1987 reports a description of fames canina, a disorder characterised by large intake of food, followed by vomiting
- the symptoms of bulimia reported in historical writings, mostly involve men, which is quite unlike today’s representation of the disorder
- To know how many cases of eating disorders exist in the population
Binge eating disorder
Symptoms, effects of symptoms
Main symptoms/ features:
- recurrent episodes of binge eating, but without the associated purging or fasting associated with bulimia
- as a result, those with binge eating disorder tend to be overweight and have a long history of failed attempts to diet and lose weight
- individuals tend to feel a lack of control over their eating behaviours, and it causes them significant distress
- typically ashamed of their eating problems, as so attempt to conceal their symptoms and eat in secrecy
- triggers can include interpersonal stress, dieting, negative body image and boredom
- To know how many cases of eating disorders exist in the population
Binge eating disorder
Diagnostic criteria
Diagnostic criteria:
> repeated incidents of binge eating, accompanied by at least three of the following…
- eating quickly
- eating until uncomfortably full
- eating lots of food when not hungry
- eating alone, due to embarrassment.
- feeling disgusted, depressed or guilty after bingeing
> distress regarding binge eating
> not accompanied by an inappropriate compensatory behaviour
Other DSM 5 eating disorders
DSM five also specifies other feeding and eating disorders that might cause distress
Pica – persistent eating of non-nutritive and non-food substances e.g. soap, paper, cloth, hair, ash
Rumination disorder - repeated regurgitation of food
Avoidant restrictive food intake disorder – avoidance or restriction of food intake, resulting in failure to meet requirements for nutrition or sufficient energy intake, may manifest as a lack of interest in food, avoidance based on the sensory characteristics of food or concerns about the aversive consequences of eating
- To know how many cases of eating disorders exist in the population
Cultural factors and eating disorders
Cultural differences are most striking in relation to bulimia:
- Keel and Klump (2003) found no studies reporting the presence of bulimia in individuals without exposure to Western ideals
- and there does not appear to be a form of bulimia that is not related to weight concerns generated by exposure to Western cultural ideals
- (When people from non-Western countries exhibit symptoms of bulimia, it’s usually because they’ve been exposed to Western standards)
Anorexia nervosa and culture:
Even within Western societies, individual ethnic groups show differences in the prevalence of eating disorders that can be attributed to differences in cultural ideals and practices
- For example, African American women are less likely than white women to have eating disorders, because they have larger ideal physiques and are more satisfied with their body shapes
- more likely to develop eating disorders that don’t drive towards thinness (bilinear rather than anorexia)
- To know how many cases of eating disorders exist in the population
Demographic factors and eating disorders
Demographic factors within cultures
- Females are 10 times more likely to develop an eating disorder than males
- sex-linked effect appears to be the result of the idealisation of female weight, size, and body shape by the Western media
Eating disorders in males are significantly higher in groups of males whose body weight and shape is of more significance to them - in bodybuilders, athletes, ballet dancers and also among gay men, reflecting the greater importance placed on physical appearance and attractiveness by gay subculture.
- To know how many cases of eating disorders exist in the population
Trans-diagnostic approach to eating disorders
Diagnosis of specific eating disorders does not do what it should
– 40-50% of cases do not fit neatly into diagnoses
– atypical cases (EDNOS) are the largest group
– many fail to stay in one diagnosis
• Shift away from rigid diagnoses to a transdiagnostic model (Waller, 1993; Fairburn et al., 2003)
- To know how many cases of eating disorders exist in the population
Comorbidity in eating disorders
Highly comorbid with;
- anxiety disorders
- depression
- personality disorders
- alcohol and substance use
- To know how many cases of eating disorders exist in the population
Prevalence
- 6.3% of the UK population exhibit disordered eating patterns
- 40-50% of cases do not fit neatly into diagnoses
Hoek (2006) – prevalence rates in the population
– Anorexia nervosa = 0.3%
– Bulimia nervosa = 1.0%
– Other cases = 2-3%
- To be able to detail theories of causation and of maintenance
Problems figuring out causation
Different theories over time. The biggest problem is that the individual usually presents a long time after the onset of the disorder
- Shame
- Control
So, we do not really see the causal process
- To be able to detail theories of causation and of maintenance
Biological/ genetic
Various suggestions over time
– hypothalamic disturbance (appetite regulation)
– temporal lobe disturbance (body image problems)
– blood flow to the brain
– hyper-reactive neural circuits for anxiety
– genetic loading
– competition for mating rights (yes, really)
This is an area that is plagued by small samples (if any data exist) and inconsistent findings
– e.g., the hunt for a genetic locus…which just keeps moving around…
> Genetic influences
- evidence that eating disorders run in families, which would suggest there was a genetic component to the disorders
- 1st degree relatives of females with both anorexia and bulimia, are significantly more likely to develop these disorders
- -> Twin studies
- suggest there is an inherited component - indicate that genetic factors account for approximately 40 to 60% of liability to anorexia, bulimia and binge eating disorder
- however, while twin studies indicate a genetic influence they also suggest an impact of the unique environmental factors (like interactions with parents), implying eating disorders are developed through complex interaction between inherited characteristics and individual experiences
> Neurobiological factors
Eating disorders involve appetite, so theories of both anorexia and bulimia suggests the role of brain areas involved in regulating appetite, particularly the hypothalamus and neurotransmitters associated with change in appetite
—>Animal studies
lesions to the lateral hypothalamus cause appetite loss, resulting in self-starvation, which is behaviourally similar to anorexia
- but there’s reason to suggest that this is not the only thing influencing anorexia, because these studies show a lack of hunger in the animals whereas, people with anorexia usually have intense hunger, but starve themselves as a method of control
- also, the lack of hunger in the animals appears to be the result of hormonal imbalances, usually the same hormonal imbalances are found in anorexia suffers but as a result of the disorder rather than a cause
- To be able to detail theories of causation and of maintenance
sociocultural influences
–> Media influences body dissatisfaction and dieting
> Eating disorders are largely restricted to females, and there is acknowledgment that the general increase in incidence is associated with changes to the ideal female body shape communicated by the media. Media is regularly accused of distorting reality by betraying female bodies as either naturally thin (representing a small part of the population) or unnaturally thin (representing nobody in the population.)
- The BMI of Playboy centrefolds between 1980s and late 90s continuously fell to a point where almost 50% of those images had a BMI of less than 18, which is considered severely underweight, and is underneath the boundary at which the WHO says can be contribute to an ED, namely anorexia
- resulted in young women adopting an ideal body shape that is only achievable by around 5% of women.
—> influence of diet
Over the past 30 to 40 years. Eating fashions, and diets have changed so low-calorie diets are more fashionable and are likely to promote restricted eating.
- individuals with an EDs are considerably more likely to have been vegetarian compared to controls
Becker (2004) TV Fiji study
Puhl et al (2008) Weight stigma is the second most common form of discrimination reported by women
Nickson et al. (2016) – less likely to hire “overweight” people for customer facing roles, stronger effect for women
Phelan et al. (2015) Blood pressure cuffs, weighing scales and waiting rooms chairs can be too small
…All of these things inevitably give rise to fear of being fat or obese and reinforces dieting and body dissatisfaction.
Hard to say how body dissatisfaction and dieting cause eating disorders but they are vulnerability factors
- demonstrated by the fact that occupations that require an individual to control and monitor their weight of higher incidences of eating disorders, including; fashion models, actors, athletes, figure skaters and ballet dancers.
- To be able to detail theories of causation and of maintenance
experiential factors
Some evidence that life experiences may act as a vulnerability factor for eating disorders.
> Rastam and Gilberg 1992 found that 14% of anorexia sufferers (compared with 0% of healthy controls) had experienced and negative life experience within the three months prior to the onset of the disorder.
One particular adverse life experience that has been implicated as a risk factor is childhood sexual abuse
Childhood sexual abuse is a risk factor for a wide range of psychiatric disorders, so why do some people with this history specifically develop eating disorders?
> One explanation is that adverse early life experiences generate other forms of psychopathology that mediate the development of eating disorders
- argued that eating disorders provide a means of coping with more generalised psychopathology, such as depression that result from sexual abuse
- helps the individual to cope with emotional and identity problems
- To be able to detail theories of causation and of maintenance
Trans-diagnostic models.
Loads of risk factors for eating disorders contribute to all the disorders (not just specific ones) leading researchers to suggest that there is some process or maintaining factors that are common across all the eating disorder categories.
This model is the transdiagnostic cognitive behavioural model suggested by Fairbairn
- model argues that a dysfunctional system of self-evaluation is central to the maintenance of all eating disorders and that self-worth is defined in terms of control of overeating weight and shape, which in turn lead to dietary restraint
- others subsidiary mechanisms reinforce this - dispositional personality factors
- To be able to use this understanding of causation and maintenance to explain cases and how treatment might be planned
Maintenance
(cognitive-behavioural perspective)
2 central beliefs
Two central beliefs in eating disorders:
- Overvaluation of eating, shape and weight
– e.g., “I am only acceptable if I am thin” - The broken cognitive link between eating and weight
– e.g., “Whatever I eat, my weight will shoot up, so I have to avoid food”
Both have clear links to behaviours and affect
