Module 8: Eating disorders Flashcards
1. Module background 1-12, 2. Lecture 13-56, 3. Treasure et al., 57-81, 4. Aardoom 82-96, 5. Steinglass 97- (104 cards)
1
Q
What are some psychological and emotional consequences of eating disorders like AN?
A
Guilt, shame, depression, loneliness, and obsessive focus on weight, diet, and exercise.
2
Q
How is anorexia nervosa (AN) similar to addiction according to patient reports? (4)
A
Patients describe compulsive behavior, loss of control, withdrawal-like experiences, and obsessive focus—similar to addiction.
3
Q
How can dieting in AN patients shift from goal-directed to habitual behavior?
A
Repeated behaviors (e.g., food restriction, exercise) become ingrained through reinforcement and stress, leading to rigid habits.
4
Q
AN patients often
A
- eat considerably less than the body needs –> sig. low body weight
- have an intense fear of gaining weight or becoming fat
- disturbance in the way one views their body weight or shape
- do not recognize the severity of their low body weight
5
Q
what are some harmful effects of AN on health? (8)
A
- exhaustion
- low body temperature
- problems with heart
- problems with blood vessels
- osteoporosis
- stomach complaints
- intestinal complaints
- hormonal inconsistencies
-> reduced func. of thyroid glands, absence of menstruation, reduced metabolism and skin problems
6
Q
What types of reinforcement contribute to habit formation in AN? (2)
A
- Positive reinforcement (e.g., weight loss, control)
- negative reinforcement (e.g., avoiding weight gain or anxiety).
7
Q
What cognitive control impairments are observed in AN patients? (2)
A
- Poor set shifting (more perseverative errors)
- Poor decision-making (Iowa Gambling Task)
BUT Better delayed gratification than in substance abuse :D
- no consistent information on response inhibition
8
Q
What brain area shows hyperactivity during food-choice behavior in AN, and what is its function?
A
The caudate nucleus, which is involved in goal-directed control
9
Q
So there is disturbed/altered activity within the corticostriatal networks that are considered important for the balance between the dual processes. BUT what is not known
A
the direction of that change is not in line with the idea of a shift in the balance towards habits
10
Q
What role does perfectionism play in habit formation in AN?
A
It leads to strict dietary rules and stable routines that reinforce stimulus-response links, accelerating habit formation.
11
Q
What has research shown about general habit propensity in AN compared to healthy controls?
A
No significant difference; AN patients performed similarly on habit-related tasks like the slips-of-action task.
12
Q
How might starvation in AN indirectly accelerate habit formation?
A
Starvation increases stress, and stress has been shown to speed up habit formation.
13
Q
Can someone with AN have frequent binge eating episodes?
A
ye
14
Q
AN subtypes (2)
A
- Restrictive subtype
- binge/purging subtype
- binges can be small but feel like they are huge
- involves compensatory behaviors
15
Q
Bulimia Nervosa (BN) 3 criteria (DSM-5)
A
- Objective binge eating episodes
- inadequate compensatory behaviors
- self-evaluation is unduly influenced by body shape and weight
Criteria with AN often overlaps with BN but those with BN are not required to be underweight
16
Q
Binge eating disorder (4) DSM-5 criteria
A
- Recurrent episodes of binge eating
- At least 3 of the following:
- Eat more rapidly than normal
- Eating until uncomfortably full
- Eating even when not hungry
- Feeling disgusted with oneself, guilty, depressed
- Marked distress regarding binge eating is present
- there is no compensatory behaviors
A somatic consequence is weight gain but that is not a criteria for the disorder
17
Q
What do all (AN,BN and BED) have in common?
A
d) Over-evaluation of weight and shape
18
Q
Avoidant/restrictive food intake disorder (ARFID), what it is + criteria (4)
A
Persistent failure to meet appropriate nutritional and/or energy needs
- Weight loss
- Nutritional deficiency
- Tube feeding
- Marked interferencee with psychosocial functioning
!! No body image disturbance or fear of weight gain
19
Q
Subtypes of avoidant/restrictive food intake disorder (3)
A
- Sensory based avoidance
- Arousal or interest based avoidance
- seen mostly in autism - Concern or fear based avoidance
- e.g., when there is a fear of swallowing food due to a fear of choking
20
Q
Prevalence of eating disorders: what is the most prevalent one, which one is most noticeable?
A
Most prevalent: Other specified feeding and eating disorder (OSFED)
Most noticeable: Anorexia Nervosa
21
Q
Other specified feeding and eating disorders (OSFED)
A
For when the criteria for any specific eating disorder is not completely fulfilled
- 50% of patients in treatment have this diagnosis as most patients have characteristics of all ED subtypes
- in general population 75% of the people with an ED have this
22
Q
Is the prevalence of ED rising?
answer for AN and BN
A
AN: has stayed the same over a decade
BN: from 80s onwards has become less prevalent
- one possible reason is that general population has become overweight –> less need to engange in compensatory behaviors due to obesity and being overweight being the norm
23
Q
Detection by GP’s shows a trend when we divide by age
A
In the last decade there is a significant increase in AN in those from 10-14
Probably as we become more aware of eating disorders + know how to find help
24
Q
Diagnoses are not static, explain
A
There is a lot of shifts in diagnoses
People with an eating disorder can have many subtypes that they shift between.
e.g., someone with BN doesnt vomit anymore but still binges, then the diagnosis shifts to BN
AN-R <> AN-BP
BED <> BN
25
The role of control
Those with eating disorders often express a feeling of loss of control - eating disorders are not a choice
--> TED
26
# How can obsessive thoughts be controlled?
The characteristics of obsessive thoughts
* Recurrent, time-consuming, intrusive thoughts that cause anxiety and distress
* Content of the obsessions can differ, however often remarkably similar
* Obsessions and compulsions very similar to those in OCD, BDD, autism spectrum disorders etc
* High comorbidity ED, ASD, OCD and BDD
* Similar obsessive thoughts and behaviors across disorders, like obsessions with symmetry (Phillips & Kaye, 2007)
27
How do obsessions persist?- Need for control and rigidity (4)
* Deficits in mental flexibility (disturbed set shifting)
* Holding on to old habits (see background on Canvas)
* Extreme focus on details / difficulties in seeing the whole picture (i.e., weak central coherence)
* Perfectionism, extreme need for control
* Compulsive behaviors and obsessive thoughts
→ Strong routines, difficult to change behaviors
28
Controlling behaviors in ED (5)
1. body checking
2. counting calories all day
3. rituals and rules
- cutting food into small pieces, arranging food a certain way, eating in a specific order, specific times etc.
4. Prevention of weight gain
- Excessive exercise
5. Escape from or suppression of negative emotions
- To escape a negative mood -> binges are one way to forget (attention is away from stress and towards food)
29
Binge eating as an 'escape for awareness' / emotions (4)
| mechanism
* binge eating > escape from negative mood
* alleviates emotional stress
* attention is drawn away from emotional distress
* narrowing the focus to the immediate environment > food!! <3
30
Why do people have binges? --> to escape
| subjective experience
▪ Feeling numb while bingeing—”like you’re not really there or you’re on auto-pilot”
▪ Chewing helps to forget
▪ “Feels like being in a tunnel”
▪ Loss of control over eating: ‘I have no choice’
- Enjoyable in the beginning, after that it becomes uncontrollable
▪ The only thing on their mind is food
▪ ‘I deserve something nice'
Me
31
FIRST STAGE: positive consequences (6)
1. Provides a feeling of control
2. Relieves anxiety in the short-term
3. increased self-esteem
- this is what I do best, better than others
4. ID becomes related to eating behavior
5. weight gain is prevented
6. escape from negative emotions
32
SECOND STAGE: negative consequences (psychological, 7)
Psychological
1. Negative mood increases, more depressed, anxious, loneliness, guilt, disgust, shame
2. Stress
3. Obsessive behaiors increasing
4. More rules
5. Problems with concentration
6. Emotional numbness
7. Body avoidance
33
SECOND STAGE: negative consequences, social (6)
Social consequences:
* withdrawal from social occasions due to many of them being related to food
* Difficulties in social engagement
- From mental problems
* Conflicts with parents or spouses
- Dinners and meals are anxious periods
* Avoidance of situations involving eating or body exposure
* Avoidance of physical activities
- Obesity + eating disorder makes playing w children, running etc. Difficult
- Also being underweight makes physical activity difficult
* Not being able to work or go to school
34
# Consequences of restrictive eating/underweight
Lanugo
Hair starts to grow in your face and body, goes away after you eat again
35
# Consequences of restrictive eating/underweight
acrocyanosis
poor blood circulation
36
# Consequences of restrictive eating/underweight
Erythema ab igne
caused by hot water bottle on the stomach to warm oneself up
-- underweight people often feel cold all day
37
# Consequences of vomiting
Russell's sign
ruptures or marks on your hands from self induced vomiting
38
# Consequences of restrictive vomiting
teeth erosion
caused by acidic stomac content coming in contact with enamel
39
# Consequences of restrictive vomiting
Swelling of parotid and submandibular glands
seen as swelling in and around the jaws
40
# Consequences of binge/overeating
Physical consequences: the invisible signs (8)
* low blood sugar (hypoglycemia)
* heart problems
* underweight: slow hearbeat, hypertension, refeeding syndrome
* lack of growth in children (not reversible)
* amenorrhea (sometimes infertility as a result)
* osteoporosis
* kidney problems
* problems with electrolytes: low sodium, potassium and their effects on muscles like the heart
41
Course and mortality of ED's
AN and BN:
* 50% recover fully
* 30% recover partially
* 20% chronic
--> nowadays the number of recovery is much higher
* ED highest mortality rate of all psychiatric disorders
* standardized mortality rates: 5,86 (AN), 1,93 (BN), 1,92 (EDNOS)
* one in five with AN who died had committed suicide
42
# course and mortality
Meta-analysis Arcleus et al. 2011 (2)
* one in 5 ppl with AN had died by suicide
* standardized mortality ratios are 5,86 (AN), 1,93 (BN), 1,92 (EDNOS/OSFED)
43
# Treatment
Barriers to help seeking (4) + 2 detrimental side effects this leads to
* Lack of knowledge about the illness
--> Both sufferers and professionals (dietitions, gp's)
* Acknowledgement of ED is difficult
--> Sufferer wants to continue with the behavior because there is always a function to it
* Shame fear of stigmatization, problems with disclosure
* Lack of knowledge about treatment
* 3 to 5 years on average between onset of illness and professional help
* More than 50% of people with an ED never receive treatment
--> You don't always have to receive treatment at a mental health facility
!! The sooner you seek treatment the better the outcome
44
# Treatment
The stepped care disease management model
Ther are many avenues for treatment like different facilities that offer it not just clinics
* support groups
* parent chat
* e-health
45
# treatment
why e-health? + an example
its accessible for those who do not present themselves to clinics and practitioners
Also because it takes 4-5 years for an admission to a gp
example: online support groups who organize a chat every night on social media platforms
46
# treatment
Featback intervention
an automated monitoring and feedback system
it is tailored to:
* excessive concern with body weight and shape
* unbalanced nutrition and dieting
* binge eating
* compensatory behavior
1. Questionnaire every week
2. tailored responses to answers
--> these answers are compared with previous ones to see if there is improvement etc.
47
AN/BN Dutch guidelines
* first choice is outpatient treatment (e.g., CBT)
--> focus on weight recovery, abstinence from binge eating & purging, restoration of negative body image & dysfunctional cognitions
* intensity up when outpatient does not lead to prolonged weight recovery
* youth: first choice multi-fam treatment
* psychotropic medication limited effect only as supplement in case of:
-- therapy resistance
-- to avoid relapse
-- comorbid disorders
48
BED Dutch guidelines (3)
* outpatient CBT first choise
(followed by weight loss treatment if appropriate)
* supplemented by anti-depressants
* self-help programs based on CBT
49
# BED example treatment
multidisciplinary team (6)
* Psychologist
* Psychiatric nurse
* Dietitian
* Physical therapist
If applicable:
Psychiatrist
Somatic physician (if BMI>40)
50
# BED example treatment
CBT is done in group format
Semi-structured, problem-oriented=what happens now
- Tools to help you with stopping the binges here and now
24 sessions
- 20: psychologist/psychiatric nurse
- 4: dietitian
51
# BED example treatment
Preparation phase
* First four phases
- Psychoeducation
- Formulation of therapy goals
- Enhancement of motivation
- Engaging family or partners, friends for example
52
# BED example treatment
phase of change
* First phase (10 sessions)
- Development of regular eating pattern (3 meals a day and 3 snacks regularly every 2-2,5h)
--> because we know that hunger can trigger a binge so preventing it is important
- Learning how to resist binge eating (asking how long they can resist the binge, try to make it as long as possible, explain that the urge to binge passes away)
- Identify and correct dysfunctional cognitions (e.g., black-and-white, all-or-nothing thinking)
2 sessions with dietitian
53
# BED example treatment
The self-monitoring sheet
Patients encouraged to keep an eating journal
- Monitor the time, what they eat, where, whether binged and thoughts, emotions and feelings
- Fill during the day for accuracy
Important because it can give a lot of insight on binging behavior, easy to monitor what works and what doesn't
54
# BED example treatment
second phase: outpatient group CBT (5)
8 sessions
* underlying problems like body image, self-eseemm stress management, problem solving, weight loss issues
* plan how to incorporate exercising
* keeping an exercising diary
* dysfunctional thoughts and cognitions
* recognize thinking errors, work on them and replace with more realistic helpful thoughts
55
# BED example treatment
Third phase: relapse prevention plan (5)
▪ Write down several risk factors for relapse
▪ Make a plan how to avoid these risk factors
▪ What are the first small signals?
▪ Think of actions after first signals
▪ Be aware of high risk foods
▪ etc
56
What distinguishes anorexia nervosa from avoidant-restrictive food intake disorder?
AN is distinguished by an intense fear of weight gain or a disturbed body image that motivates severe dietary restriction or weight loss behaviors
avoidant-restrictive food intake disorder involves food avoidance or restriction without these specific weight or shape concerns.
57
What are the two main categories of eating disorders that Treasure summarizes findings into for the purpose of discussing pathophysiology?
* restrictive-type eating disorders (like anorexia nervosa)
* binge spectrum disorders (like bulimia nervosa and binge eating disorder).
58
What is the recommended first-line psychological treatment for adolescents with anorexia nervosa according to international evidence-based guidelines?
family-based interventions focused on eating disorders as the first-line psychological treatment.
59
What is the difference between binge eating disorder and bulimia nervosa?
BED:
* distressing, recurrent episodes of binge eating
* fewer compensatory behaviors than in BN
BN:
* has both binges and compensatory behaviors (just more compensatory behaviors)
60
Pica
eating non-nutritive or non-food substances for a period of a month or more
61
What are the triggers of Pica (4)
* taste of the substance
* boredom
* curiosity
* psychological tension
62
Rumination disorder
regurgitation of food after eating in the absence of nausea, involuntary retching or disgust
63
What are the most common psychiatric comorbidities in people with eating disorders? (3)
* mood and anxiety disorders
* neurodevelopmental disorders
* personality disorders
64
People with diabetes have an increased prevalence of eating disorders, given an example of how this can happen in diabetics
e.g., when insulin omission is used to compensate for eating
65
who are at most risk for eating disorders?
adolescents with AN starting earlier than BN or BED
66
the age of onset of AN general facts (2)
* onset after 30 years, is rare
* age of onset seems to be decreasing
67
in adult populations, the clinical profile is.. (4)
* dominated by binge spectrum disorders
* less gender differences than in adolescents
* higher than average risk in ethnic minorities
* higher than average risk in individuals with higher weight
68
what are incidence rates like for AN, BN, BED and unspecified eating disorders?
AN:
* stable
BN:
* stable or declining
BED & unspecified
* rising
69
globally the prevalence of eating disorder
* has increased by 25%
(only 20% of these people present for treatment
70
Duration of untreated eatind disorder (before the start of first treatment) for AN, BN, BED
AN:
* 29,9 months
BN:
* 53,0 months
BED:
* 43,8 montsh
71
duration of untreated eating disorder before the start of first treatment (children vs adolescents and adults)
Children:
* 9,8 months
Adolescents / adults:
* 34,7 months
72
Standardized mortality rates for AN, BM, BED
AN:
* 5,9
BN:
* 1,9
BED:
* 2,3
73
What is the median illness duration for anorexia nervosa reported in long-term follow-up studies?
Long-term follow-up studies (>20 years) of patients with anorexia nervosa report a median illness duration of about 10 years.
74
Besides self-induced vomiting, name two other common compensatory behaviors seen in bulimia nervosa (3)
* inappropriate use of medicines like laxatives
* fasting
* extreme exercise
75
What are some common controlling behaviors in eating disorders mentioned in Treasure? (5)
* severe dietary restriction
* weight loss behaviors
* recurrent episodes of binge eating
* compensatory behaviors to prevent weight gain
* overcontrol of weight and eating
76
What are the negative physical consequences of food restriction, underweight, and related behaviors (like purging) in eating disorders, according to Treasure? (11)
* medical complications affect all organs and systems (due to malnutrition)
* gastrointestinal symptoms
from starvation of purging
* haematologic
* metabolic, endocrine
* cardiovascular
* gastrointestinal
* dermatological
* neurological
* skeletal
* liver
* reproductive
77
service-related controversies
* strictly enforced transitions between services (e.g., moving from treatment for children to treatment for adults immediately when someone turns 18)
--> causes distress, delays, disruptions and potentially lead to poor outcomes
78
Does the source provide arguments for or against E-health replacing standard treatments like CBT, or suggest it's better as an add-on?
* digital interventions have been found to be of benefit whn augmenting inpatient treatment --> suggests a role as an add-on
79
What cognitive control (executive function) impairments and related neurocognitive issues are mentioned in the source regarding Anorexia Nervosa (AN)? (3)
* cognitive rigidity
* anomalies in metacognition
* delay responding to rewards
80
What is suggested about the role of habits in Anorexia Nervosa (AN) and other eating disorders?
AN: habits and habitual learning mechanisms play a crucial role in the perpetuation of anorexia nervosa, particularly in maintaining restrictive eating patterns and other related behaviors,
anomalies in reward and habit learning contribute to the embedding of habitual eating disorder behaviors across the eating disorder spectrum, including binge spectrum disorders
81
What is the paper by Aardoom et al about
it reviews the emerging findings regarding E-health interventions for ED's and to critically discuss emerging issues as well as challenges for future research
82
lifetime prevalence for AN, BN and BED in the US
AN:
* 0,9%
BN:
* 1,5%
BED:
* 3,5%
83
Barriers to care according to Aardoom et al.
Social barriers:
* feelings of shame
* fear of stigma
* social stereotyping
as well as financial constraints and limited availability of specialized care.
84
How long does it take on average for patients to recognize and acknowledge that they were suffering from an ED + how long does it take to seek treatment
* 3,6 years to recognize and acknowledge that they are suffering from an ED
* 4,2 to 6,3 years to seek treatment
85
After seeking treatment
more than half of community based sample report delays in receiving treatment:
* due to waiting lists
* due to a delay of referral
86
Why are the delays in seeking treatment detrimental?
a shorter duration of the ED symptoms is associated with better outcomes and higher chances of recovery
86
What did Ter Huurne et al. (2016) find regarding Internet-based CBT compared to a waiting list control for individuals with BN, BED, and EDNOS?
Internet-based CBT was more effective than a waiting list control for these individuals.
87
What does the study by Ruwaard et al. (2013) suggest about guided interventions compared to unguided self-help?
suggested that guided interventions may be superior to unguided self-help based on their findings.
88
What were some predictors of dropout identified in Internet-based interventions for EDs? (2)
* higher baseline levels of depression and ED psychopathology (shape concerns, self-induced vomiting, binge-eating episodes)
* lower self-directedness
89
What is "blended care" in the context of E-health interventions for eating disorders?
Blended care refers to the combination of face-to-face and online components within an intervention for eating disorders.
90
What challenges do internet-based interventions have the potential to address?
decrease barriers to care
* shame
* stigma
* limited availability to specialized care)
91
What does the study by Ruwaard et al. (2013) suggest about guided interventions compared to unguided self-help?
guided interventions may be superior to unguided self-help based on their findings
92
According to Hötzel et al. (2014), what was Internet-based motivational enhancement therapy superior to for individuals with AN or BN?
Internet-based motivational enhancement therapy was superior to a waiting list in enhancing motivation to change and self-esteem, and reducing restraint
93
What was a limitation of the Internet-based maintenance intervention study by Gulec et al. (2014)?
the timing of the intervention being potentially too late and the 4-month timeframe being too short to detect an effect.
94
What conclusion did the reviews on smartphone applications for EDs reach regarding the use of evidence-based treatment strategies?
The reviews concluded that most apps only made limited use of evidence-based treatment strategies.
95
What is the primary characteristic of behaviors identified as "habits" in the context of anorexia nervosa (AN) according to the study?
habits are behavioral routines that are automatic and frequent, relatively independent of any desired outcome, and have potent antecedent cues.
96
What specific neural systems are thought to mediate habitual behaviors, according to neuroscience research cited in the paper?
mediated by dorsal frontostriatal systems, including the dorsal striatum and dorsolateral prefrontal cortex.
97
How was the concept of "habit strength" defined and measured in this study?
defined as the likelihood that a behavior will be elicited by a particular stimulus or context (i.e., cue). It was measured using the Self-Report Habit Index (SRHI), a 12-item self-report questionnaire.
97
What were the four principal components of the Regulating Emotions and Changing Habits (REaCH) intervention?
1. cue-awareness,
2. creation of new behavioral routines,
3. suppression of maladaptive habits, and
4. emotion regulation.
98
Explain the concept of "habit reversal" as used in the REaCH intervention.
involves implementing motoric counteractions that are incompatible with the target habit and can be performed until the urge subsides.
99
What is "stimulus control" and how was it applied as a habit change strategy in REaCH?
Stimulus control interventions involve altering the environment to either discourage the maladaptive behavior or encourage an alternate behavior.
100
What were the three main categories of self-reported habits measured by the Self-Report Habit Index (SRHI) that showed a significant treatment type effect in the REaCH group compared to Supportive Psychotherapy (SPT)?
1. restrictive food intake,
2. compensatory behaviors, and
3. delay of eating.
101
Beyond habit strength, what other clinically meaningful measures showed improvement or a trend toward improvement in the REaCH group compared to SPT?
The REaCH group showed a significant reduction in Eating Disorder Examination-Questionnaire (EDE-Q) global scores and a trend toward greater caloric intake in the laboratory meal.
102
What limitation of the study related to the inpatient setting was acknowledged by the authors?
he interventions were administered on an inpatient unit alongside other treatments, making it difficult to isolate the specific effects of REaCH.
