what is the stigma that still persists around eating disorders today?
That people with eating disorders are self-destructive and responsible for their condition. Also seen as fragile and attention-seeking
What are the basic features required for a diagnosis of anorexia nervosa?
- restriction of behaviours that promote healthy body weight / refusal to eat
- Intense fear of gaining weight & being fat
- Distorted body image or sense of body shape
The ‘Eating Disorders Inventory’ is one assessment of anorexia nervosa. What is another?
people with anorexia nervosa are shown line drawings & asked to identify their own figure, identify & ideal body shapes
What is interesting about the body drawing assessment of anorexia nervosa?
- people overestimate their own body size & chose a thin figure as the ideal
- interestingly people with anorexia are fairly accurate at reporting their actual weight, perhaps because they weigh themselves so frequently
- Men with anorexia didn’t differ from males without when pointing to the ideal male figure.
- Men with anorexia did however considerably over estimate their own body size, thus demonstrating a distortion with their own body image
What are the 2 types of anorexia nervosa?
severely limiting food intake
regularly engage in binge-eating & purging
Why is there some debate about distinguishing between two types of anorexia nervosa?
- Nearly 2/3 of women who initially meet criteria for the restricting subtype had switched over to the binge-eating/purging type 8 years later.
- The subtypes are thought to have limited predictive validity even though clinicians find them useful
At what age does Anorexia Nervosa develop and what events usually precipitate its onset
- Anorexia Nervosa usually begins in the early to middle teenage years
- Often after an episode of dieting & the occurrence of a life stress
- Anorexia is 10 times more frequent in women than men
Which other disorders co-occur with eating disorders?
Depression, OCD, phobias, panic disorder, substance use disorder & personality disorders
Mood disorders, schizophrenia, substance use disorder
Suicide rates are quite high: 5% complete suicide & 20% attempt it
What are the physical consequences of anorexia nervosa?
Self starvation & laxative use lead to:
Low blood pressure, reduced heart rate, kidney & gastrointestinal problems, declining bone marrow, dry skin, brittle nails, changes in hormone levels, anemia. Hair loss, lanugo (a fine soft body hair) Changes in electrolyte levels (potassium & sodium) which are for neural transmission; lead to tiredness, weakness, cardiac arrhythmias, sudden death.
What’s the prognosis for people with anorexia nervosa?
- Between 50% & 70% do recover
- Recovery usually takes 6 - 7 years & relapses are common prior to developing a stable pattern of eating and weight maintenance
- Anorexia is life threatening: death rates are 10 times higher than the general population & twice as high as other psychological disorders
- Early death often comes from congestive heart failure & suicide
What are the key features of Bulimia Nervosa?
- episodes of rapid consumption of an excessive amount of food within a short amount of time (2 hours), then a feeling of losing control over eating, as if one cannot stop.
- This is followed by compensatory behaviour (vomiting, fasting, excessive exercise) to prevent weight gain
- Body shape & weight are extremely important for self-evaluation
What are the key differences between anorexia nervosa and bulimia nervosa?
- Bulimia is not diagnosed if the binging & purging occurs in the context of anorexia & it’s extreme weight loss.
- People with anorexia lose a tremendous amount of weight, whereas people with bulimia do not
When is a binge most likely to occur?
- Usually in secret
- morning or afternoon is most likely
- triggered by stress & negative emotions
- after a (perceived) negative social interaction
- avoiding a craved food on one day was associated with a binge episode the next morning
- they continue until the person feels uncomfortably full
What leads to the second step of bulimia nervosa - the compensatory behaviour?
- after a binge people report feeling discomfort, disgust, & fear of weight gain
- This leads to purging to attempt to undo the calorific effect of the binge
What types of purging behaviours do people with bulimia most often engage in?
- Stick fingers down throat to induce vomiting
- after a time, may just be able to do this without fingers
- laxative or diuretic abuse (which is not very successful)
- excessive exercise
When does bulimia nervosa typically develop?
- in late adolescence or early adulthood
* Many people are somewhat overweight to start with & the binge eating often starts during an episode of dieting.
What other conditions typically co-occur with bulimia nervosa?
- Depression, Personality Disorders, Substance use disorders, conduct disorder
- NB: Bulimia symptoms can predict onset of depression & vice versa - thus each disorder is a risk factor for the other
- Suicide rates are higher than with the general population but considerably lower than for those with anorexia
Even though people with bulimia tend to have a normal BMI, there are still physical consequences for people with bulimia. What are these?
- menstrual irregularities, amenorrhea, potassium depletion,
- laxative use can lead to electrolyte depletion which causes irregular heart beat
- vomiting can lead to menstrual problems, tearing of tissue in the stomach & throat, loss of dental enamel, swollen salivary glands
- death is about 4% of people with bulimia
What is the prognosis for people with bulimia nervosa?
- 75% recover
- approx 10% - 20% remain fully symptomatic
- early intervention is linked to better outcomes
- Those who binge & vomit more & have comorbid substance use or depression have poorer outcomes
What are the key features of binge-eating disorder?
- Reported binge eating episodes (1/week for at least 3 months)
- Lack of control during the episodes
- DIstress about the binging
- Binge eating episodes includes at least 3 of the following:
- eating more quickly than usual
- eating until overfull
- eating large amounts even if not hungry
- eating alone due to embarrassment about large quantities of food
- feeling bad (disgusted, guilty or depressed) after the binge
- no compensatory behaviour is present
What distinguishes binge eating disorder from Anorexia or bulimia nervosa?
*The absence of weight loss
*The absence of compensatory behaviour (purging, fasting, excessive exercise)
*Most often people with binge eating disorder are obese (BMI over 30)
NB: not all obese people binge eat
*about 2%-25% of obese people might qualify for a diagnosis of binge eating disorder
What is binge eating disorder associated with?
Binge eating disorder is associated with obesity and a history of dieting
- impaired work and social functioning
- depression, low self-esteem, substance use disorder & dissatisfaction with body shape
What are the risk factors for Binge Eating Disorder?
- childhood obesity, critical comments about weight, weight-loss attempts in childhood, low self-concept, depression, and childhood physical &/or sexual abuse
- Relatives of obese people with binge eating disorders are more likely to have binge eating disorders (20%) than were relatives of people without binge eating disorders (9%)
What is the prevalence of Binge Eating Disorder?
- Binge eating disorder appears to be more prevalent than either anorexia or bulimia nervosa
- Prevalence rates of 3.5% for women & 2% for men
- It is more common with women (although less gender difference than with AN & BN)
- Binge eating disorder is equally prevalent in European, African, Asian & Hispanic Americans
- It is comorbid with depression & anxiety disorders
What are the physical consequences of Binge Eating Disorder?
*Many are a function of obesity: increased risk for type 2 diabetes, cardiovascular problems, breathing problems, insomnia, joint/muscle problems
Other problems independent of obesity include:
*sleeping problems, anxiety, depression, irritable bowel syndrome, early onset menstruation
What is the prognosis for people with binge eating disorder?
- 25%-82% of people recover
* people often have binge eating disorder for 14.4 years - far longer than anorexia or bulimia
What factors contribute to the development of an eating disorder?
- sociocultural pressure to be thin
- the role of the family
- the role of environmental stress
Both anorexia and bulimia run in families. What’s the likelihood of developing AN or BN if you have a first degree relative with an eating disorder?
*10 x more likely to develop anorexia nervosa
*4 x more likely to develop bulimia nervosa
1st degree relatives of women with eating disorder are at higher risk for AN or BN
*1st degree relatives of people with eating disorders are more likely than average to have symptoms of eating disorders that do not meet criteria for a diagnosis
*1st degree relatives of men with AN are at greater risk for developing AN - this is not the case for relatives with BN
Which key features of eating disorders have been found to be heritable?
- dissatisfaction with one’s body
- a strong desire to be thin
- binge eating
- preoccupation with weight
Aside from genetic factors what other factors have been found that influences the development of an eating disorder?
- unique nonshared environmental factors
- eg. different interactions with parents or different peer groups
- additionally, certain personality characteristics: negative emotionality & constraint
Why is it not surprising that the hypothalamus has been proposed as playing a role in anorexia?
research on animals with legions to the lateral hypothalamus is associated with weight loss and reduced appetite
What hormonal abnormalities occur in the hypothalamus as a result of self-starvation?
Abnormal cortisol levels occur in the hypothalamus as a result of self starvation and return to normal after weight gain
What are the limitations with the hypothalamic model of anorexia?
- Animals with hypothalamic lesions appear to have no hunger & become indifferent to food whereas people with anorexia starve themselves despite being hungry & thinking about food.
- The hypothalamic model does not account for the fear of becoming fat or for body image disturbance
What evidence is there to support endogenous opioids playing a role in eating disorders?
Endogenous opioids are substances produced by the body to reduce pain sensations, enhance mood & suppress appetite
- Opioids are released during starvation which may positively reinforce a euphoric state for people with anorexia or bulimia
- excessive exercise also increases opioids and so further exacerbates the situation
- we don’t yet know however if the low levels of opioids are a cause of bulimia or an effect of the changes in food intake or purging
What evidence is there to support serotonin playing a role in feeling satiety (feeling full) for people with eating disorders?
- Serotonin promotes feelings of satiety (fullness)
- people with bulimia may have a serotonin deficit that causes them not to feel full as they eat
- food restriction also interferes with serotonin synthesis in the brain - for people with anorexia, the severe food restrictions could interfere with the serotonin system
What evidence is there to support serotonin metabolites & an underactive neurotransmitter playing a role in eating disorders?
*Low levels of serotonin metabolites have been reported in people with anorexia and bulimia
*People with anorexia that have not returned to a normal weight range show a poorer response to serotonin agonists than people with anorexia who have returned to normal weight
*People with bulimia have smaller responses to serotonin agonists
these all contribute to the neurotransmitter being under active
What evidence is there to support the neurotransmitter dopamine playing a role in eating disorders?
- Dopamine is linked to the pleasurable aspect of food that compel animals to go after food
- restrained eaters appear to be more sensitive to food cues
- women with anorexia showed greater activation in the ventral striatum (a brain area linked to reward & dopamine activation) than women without Anorexia when viewing pictures of underweight women
- women with An or BN have a greater expression of dopamine transporter gene DAT which regulates the reuptake of dopamine
What do the cognitive behavioural theories of eating disorders focus on understanding in relation to eating disorders?
Understanding thoughts, feelings, behaviours that contribute to distorted body image, fear of fat, and loss of control over eating.
People with eating disorders have maladaptive schemata that narrow their attention towards thoughts & images related to body shape, weight, and food
Cognitive Behavioural Theories of anorexia nervosa emphasise fear of fatness and body-image disturbance as the motivating factors that powerfully reinforce weight loss.
Why is this?
Behaviours that achieve or maintain thinness reduce anxiety about becoming fat and are negatively reinforced by the sense of mastery or self-control they create
How do cognitive behavioural theorists explain body image in the context of anorexia nervosa eating disorder?
Perfectionism and a sense of personal inadequacy may lead a person to becoming especially concerned with their appearance
- portrayals in the media of thinness as an ideal, being overweight, & a tendency to compare oneself with especially attractive others all contribute to dissatisfaction with one’s body
- criticism from parents and peers about being overweight also produces a strong drive
How do cognitive behavioural theorists explain body image in the context of bulimia nervosa eating disorder?
- self worth is judged by their weight & shape
- they have low self-esteem & as they are more able to control their weight & shape than other aspects of themselves, this becomes the focus
- They set strict rules of diet, which are evitably broken, this lapse then escalates into a binge, the binge leads to disgust, which leads to compensatory behaviour, lowering self esteem further, which starts the cycle again
- negative mood state (depression & anxiety) also further increase the cycle
- stress & negative affect are relieved by purging
What sociocultural factors influence attitudes to body weight?
The standards society sets for ideal body weight has greatly reduced over the past 50 years
- thinness is highly valued by society
- paradoxically, obesity has more than doubled in this period
- dieting to lose weight is more common
- liposuction & other surgical procedures are now available
- body dissatisfaction has grown - leading to fear of being fat
- exposure to media portrayals of unrealistically thin models also influences body dissatisfaction
- there are websites promoting anorexia and bulimia encouraging people to become seriously underweight
What sociocultural factors influence attitudes towards people who are overweight?
*people are seen as having little self control
*stereotyped as lonely, shy, greedy, attention seeking and stupid
Health professionals even regard overweight people as lazy, stupid, or worthless
There is a huge stigma associated with being overweight
What are the gender related sociocultural factors that influence eating disorders?
- One primary reason for more women than men developing an eating disorder is that western standards reinforce the desirability of being thin for women more than men
- the objectification of the female body leads women to be defined by their bodies far more than men
- this leads to self-objectification - seeing their body through the eyes of others leading to greater shame about their bodies
- as we get older women & men tend to be less concerned about the ideal body shape
What have cross-cultural studies found in regard to eating disorders?
- Even though anorexia is found across a variety of cultures, there is a variation of the presentation of anorexia across cultures (e.g. not all have the fear of becoming fat)
- Bulimia appears more common in industrialised societies (rarely seen in non westernised cultures)
What ethnic differences have been found in regard to eating disorders?
- Anorexia used to be 8 x greater among whites than among women of colour in the USA
- differences in bulimia does not seem so great
- the relationship between BMI and body dissatisfaction differs across ethnicity (whites are more dissatisfied)
- socioeconomic status is also important - more upper & middle class people have eating disorders
How do personality factors influence the development of eating disorders?
- perfectionistic, shy, and compliant personality styles tend to predict the onset of eating disorders
- perfectionism can be self-oriented, other-oriented or socially-oriented: people with anorexia had higher levels of self & other oriented perfectionism than those without anorexia
*body dissatisfaction, poor interoceptive awareness (the extent people can distinguish different biological states of their bodies), propensity to experience negative emotions
How do family characteristics influence the development of eating disorders?
- High levels of family conflict, which is related to perception of family discord by the person with the eating disorder
- it is not known if childhood sexual assault plays a role in the development of eating disorders
What are the major treatments for people with eating disorders?
- Hospitalisation (intravenous feeding)
- Medications: antidepressants (prozac)
- Psychological therapies
What are the major medication
treatments for people with eating disorders?
*antidepressant medications, particularly prozac is used to treat eating disorders
*Prozac has been shown as superior to placebo in reducing binge eating and vomiting
however people with bulimia often drop out of medication treatment (1/3 before the end of 8 week treatment programs) due to side effects of medication
*when antidepressant medications are withdrawn, relapse often occurs
*some anti-obesity drugs have been helpful at reducing binge eating behaviours
What are the major psychological treatments for people with anorexia nervosa?
Therapy for anorexia nervosa is two-tiered
*immediate goal is weight gain to avoid medical complications and possible death
*Hospital treatment is normally imperative
*operant conditioning behavioural therapy programs (reinforcement for weight gain) have been somewhat successful in the short term
*2nd goal is long-term maintenance of weight gain - this is harder to achieve
CBT can improve anorexia symptoms up to a year after treatment
*family therapy is principle form of psychological treatment for anorexia:
-change the patient role of the person with anorexia
-redefining the eating problem as interpersonal
-preventing the parents from using their child’s anorexia as a means of avoiding conflict
What are the major psychological treatments for people with bulimia nervosa?
CBT is the best validated & current standard treatment of bulimia nervosa
- people are encouraged to question societies standard for physical attractiveness
- they must uncover and change beliefs that encourage them to starve themselves to avoid being overweight
- they need to learn that they can achieve a normal body weight without severe dieting & that unrealistic restriction of food can trigger a binge
- and that one bite of high calorie food is not a disaster - altering all-or-nothing thinking to help them eat more moderately
- assertiveness skills are also taught
- Overall goal is to develop normal eating patterns without binging and purging
- CBT is quite promising in its outcomes
What are the major psychological treatments for people with binge eating disorder?
CBT appears to have some success as a treatment for binge eating disorder
What are the major programs aimed to prevent the development of eating disorders?
- Psychoeducational approaches
education to prevent the development
- De-emphasising sociocultural influences
teaching to resist or reject sociocultural pressures to be thin
- Risk factor approach
identifying those with known risk factors and intervening to alter these factors