Describe normal eating?
A pattern of eating behaviours which:
- Maintains normal weight
- Ensures adequate nutrition
- Conforms with cultural/religious requirements
- Enjoyable
1:14:50
What are some of the consequences of 'abnormal' eating?
-
Constant “dieting”
-
Morbid Obesity
-
Anorexia nervosa
-
Bulimia nervosa
-
Binge Eating Disorder
-
Eating disorders are not secondary to other disorders, they are primary disorders
How common are eating disorders?
-
one of most common disorders in western world
-
alongside depression & anxiety
-
one of the most common to result in death of a patient
What are some of the disorders not otherwise specified in the DSM-5?
-
pika - eating odd things
-
rumination - eating, vomiting & re-eating it
1:18ish
What is the DSM-5 Criteria for Anorexia Nervosa?
-
Restriction of energy intake relative to requirements, leading to significantly low body weight (for age, sex, etc)
-
Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain.
-
Disturbance in the way one’s body weight or shape is experienced.
slide7
1:18:50
What are the two sub-types of Anorexia Nervosa?
-
Restricting Type
-
Not regularly engaged in binge eating or purging behaviours
-
Purging Type
-
Regularly engaged in binge eating and purging behaviours.
- Not regularly engaged in binge eating or purging behaviours
- Regularly engaged in binge eating and purging behaviours.
slide7
120:30ish
What is the Anorexia Nervosa severity scale in DSM-5 based on?
-
Body Mass Index (BMI)
121:40
What are the 4 criteria on the Distorted Attitude Toward Eating Scales?
-
Current
-
Ideal
-
Attractive (what they think is attractive)
-
Other Attractive (what others think is attractive)
How would a person with anorexia most likely score on Zellner's Distorted Body Image Scale?
High on Distorted Attitude
What is the main difference between a high & a low scorer
in the visual appearance of the 4 scoring criteria on the Distorted Attitude Toward Eating Scale?
-
High: the criteria are spread out
-
i.e., the difference between current & ideal weight is greater
-
Low: the criteria are more clumped together
-
i.e., the difference between current & ideal weight is much closer
- i.e., the difference between current & ideal weight is greater
- i.e., the difference between current & ideal weight is much closer
Are there any gender similarities/differences on the 'Distorted Attitude Toward Eating Scale'?
-
No real gender difference between ideal distortions
-
Men tend to overestimate their current weight
What are some physical outcomes of the chronic starvation associated with in anorexia nervosa?
-
Basal rates slow significantly
-
Blood Pressure & Heart Rate
-
Kidney and Gastro-Intestinal problems
-
Bone mass reduced significantly
-
Skin dries out
-
Neurological impairments
-
Reduction of important electrolytes (e.g. Na+, K+) (dangerous)
-
can develop cardiac arythmia
-
Endorphins may be released (may act as reinforcers for disordered behaviours in relation to eating)
-
Tiredness, fatigue, cognitively impaired
-
May lead to death
-
because of extreme physical changes
- Blood Pressure & Heart Rate
- can develop cardiac arythmia
- because of extreme physical changes
123:10
What are the Psychological changes associated with anorexia
-
Patient is no longer rational
-
Personality changes
124:10
Who most typically suffers with anorexia nervosa?
What may be some early indicators in this demographic?
-
Typically a disease of young female adolescents (90%).
-
May start off as
-
extreme & rigid dietary control
-
obsession with
-
food
-
weight gain
-
some of these people will remit from these early behaviours & others will develop an eating disorder
- extreme & rigid dietary control
-
obsession with
- food
- weight gain
124:30
What is the prognosis for anorexia?
-
Approx. 70% recover to some extent
-
takes about 5 – 7 years.
-
not treatable overnight - recovery takes a long time
-
typically only 20% will show remission within first year
-
10-20% will never recover, may remit & then fall back into disorder
-
Death rate – from physical complications and suicide is high
-
1 - 8% death rate (too high)
-
3rd most common cause of death
- takes about 5 – 7 years.
- not treatable overnight - recovery takes a long time
- typically only 20% will show remission within first year
- 1 - 8% death rate (too high)
- 3rd most common cause of death
1:26
What is the prevalence of Anorexia In the overall poulation?
-
Rare disease – 1% or less of the population
-
(but 3rd most common disease in young girls)
- (but 3rd most common disease in young girls)
What other disorders/conditions are often comorbid with anorexia?
-
Depression
-
Anxiety
-
Obsessive Compulsive Disorders
-
Phobias
125:25
Do patients swap between Anorexia & Bulimia?
i.e., cross-over disorders
-
Anorexia can develop into Bulimia
-
but rarely the other way around
- but rarely the other way around
1:27
What is the DSM-5 criteria for Bulimia Nervosa?
-
1. Recurrent episodes of binge eating
-
In 2 hours food intake > normal
-
Lack of control over eating during the period
-
2. Recurrent inappropriate compensatory behaviour to prevent weight gain.
-
Vomiting/laxatives/diuretics/excessive exercise
-
3. Symptoms at least once a week for 3 months
-
4. Self evaluation is unduly influenced by body shape and weight.
-
5. The disturbance does not occur exclusively during periods of Anorexia Nervosa.
- In 2 hours food intake > normal
- Lack of control over eating during the period
- Vomiting/laxatives/diuretics/excessive exercise
slide11
1:27:10
What feature distinguishes Bulimia from Anorexia?
-
People suffering from Bulimia are usually of 'normal' weight
slide11
Why would someone with Bulimia maintain 'normal' weight?
-
they are not restricting their calories
-
they take in too many calories & then purge
-
whereas anorexia (severe calorie restriction)
- they take in too many calories & then purge
128:00
Who is most typically develops Bulimia Nervosa?
-
Typically found in older adolescents/ young women.
-
90% of cases are female
-
Low incidence : 1-2% of the population
- 90% of cases are female
- Low incidence : 1-2% of the population
slide12
1:29:15
How does Bulimia Nervosa usually start?
-
similar to Anorexia
-
rigid control of diet & fear of gaining weight
-
very aware of intake
-
may meet criteria for Anorexia early on
-
but then bingeing/purging behaviour kicks in & end up moving into Bulimia
- very aware of intake
- may meet criteria for Anorexia early on
- but then bingeing/purging behaviour kicks in & end up moving into Bulimia
129:50
What are some secondary (comorbid) physical risks associated with Bulimia?
-
Suicide
-
rates are high but lower than with Anorexia Nervosa
-
Electrolyte imbalance/ depletion
-
-
from frequent purging
-
Severe dental problems
-
from frequent vomiting
-
(ph balance destroyed – excess acidic gastric secretions destroy enamel on teeth).
- rates are high but lower than with Anorexia Nervosa
- from frequent purging
- from frequent vomiting
- (ph balance destroyed – excess acidic gastric secretions destroy enamel on teeth).
slide12
130:30
How likely is recovery from Bulimia?
-
Prognosis is more optimistic than with Anorexia
-
about 70% recover
-
more successful treatment for Bulimia
-
Recovery Depends on stage of disorder where intervention begins.
-
Comorbity with other disorders.
- about 70% recover
- more successful treatment for Bulimia
Death rate: 0-2% (too high) but lower than Anorexia
slide12
131:10
What is the difference between the DSM-5 severity rating for
Anorexia Nervosa & Bulimia Nervosa
Anorexia: BMI
Bulimia: number of times purging during a week
mild: 1-3
extreme: >14
for exam dont think about the numbers - think about the concept
128:40
What is the DSM-5 criteria for Binge Eating Disorder?
-
1. Recurrent episodes of binge eating
-
> food intake in 2hours
-
Lack of control
-
2. The Binge eating episodes are associated with 3 or more of the following:
-
Eating more rapidly than normal
-
Eating until uncomfortably full
-
Eating large amounts when not hungry
-
Eating alone because of embarrassment
-
Feeling disgusted/guilty/upset afterwards
-
3. Marked distress regarding binge eating episode
-
4. Binge eating occurs 1/wk for > 3mths
-
5. NO compensatory behaviour.
- > food intake in 2hours
- Lack of control
- Eating more rapidly than normal
- Eating until uncomfortably full
- Eating large amounts when not hungry
- Eating alone because of embarrassment
- Feeling disgusted/guilty/upset afterwards
slide13
What is the main difference between Bulimia & Binge Eating Disorder?
-
No compensatory behaviour in Binge Eating Disorder
133:00
Are there any gender differences in the prevalence of Binge Eating Disorder?
If so, how does the gender disparity compare to Anorexia & Bulimia?
-
Women: more prevalent than men
-
Gender disparity is much closer than Anorexia & Bulimia
133:20
134:35
How does the prevalence of Binge Eating Disorder compare to the other eating disorders?
-
Binge Eating Disorder is more prevalent than Anorexia & Bulimia
133:00
How does a classification within DSM impact the literature on eating disorders?
Use Binge Eating Disorder as an example...
-
Once a disorder has its own classification - an abundance of research is normally done
-
Binge Eating Disorder has only just received a separate classification in DSM
-
and there is very little research in literature
-
this is likely to change with its separate classification in DSM-5 (2013)
- and there is very little research in literature
- this is likely to change with its separate classification in DSM-5 (2013)
133:40
What is an important distinction when considering obesity and Binge Eating Disorder (BED)?
-
People with Binge Eating Disorder are likley to be obese
-
but all obese people do not necessarily have BED
- but all obese people do not necessarily have BED
slide14
133:45
What are some factors that may lead to BED?
-
Factors leading to BED:
-
Childhood obesity
-
Negative weight comments
-
Depression
-
Childhood abuse
- Childhood obesity
- Negative weight comments
- Depression
- Childhood abuse
What are Outcomes of Binge Eating Disorder?
Outcomes are less severe than other eating disorders
Largely Psychological issues
-
impairments in
- social functioning
- work
- self esteem
- more likely to engage in substance abuse
Health impacts are very different to Anorexia & Bulimia
-
Directly related to the weight gain of the disorder
- Type 2 Diabetes
- Cardiovascular disease
- Breathing problems
- Sleep Apnoea
- Joint & muscular problems
not much in the literature likely to increase over the next 5-10 years with its inclusion in the DSM-5 as a stand alone disorder
135:15
What factors are considered in the aetiology of eating disorders?
-
Genetic factors
-
Neurobiological factors
-
Psychodynamic/Environmental factors
-
Cognitive Behavioural factors
Genetic factors
-
Both major disorders are familial
-
Anorexic Patients – 1st degree relatives 10 times more likely to have the same disorder.
-
Bulimic Patients – 1st degree relatives 4 times more likely to have the same disorder
1:36:00
What have twin studies shown with regard to eating disorders? Nature or Nurture?
-
Monozygotic - from same embryo
-
Dizygotic - share 50% genetic
-
Monozygotic twins ↑ concordance rate for eating disorders than dizygotic twins.
-
this is evidence for a genetic component to eating disorders
- this is evidence for a genetic component to eating disorders
1:36:35
Why is much more work needed in the area of genetic contribution?
-
Mostly a social & psychological focus in the literature.
-
Some genetic factors have been identified but low power
-
further work required.
1:37:15
Neurobiological factors
-
Role of the hypothalamus?
-
animal studies lesioned - led to decreased appetite
-
but accompanied by an indifference to food
-
(different to eating disorders where focus is on food)
-
Endogenous opioids
-
enhances mood, suppresses appetite.
-
↑ during starvation & exercise
-
Reinforcing state?
-
Most severe Bulimia cases had lowest beta- endorphin
- animal studies lesioned - led to decreased appetite
-
but accompanied by an indifference to food
- (different to eating disorders where focus is on food)
- enhances mood, suppresses appetite.
- ↑ during starvation & exercise
- Reinforcing state?
1:37:30
What role might serotonin play in eating disorders?
-
Serotonin promotes satiety thus are binges due to serotonin deficit?
-
AN and BN ↓ serotonin metabolites
-
AN who recover less well respond worse to serotonin agonists.
-
suggests serotonin may be playing a role in eating disorders
-
SSRIs effective for eating disorder treatment
-
question is - are you treating the disorder or symptoms e.g., depression, anxiety
- suggests serotonin may be playing a role in eating disorders
- question is - are you treating the disorder or symptoms e.g., depression, anxiety
1:39:35
Psychodynamic factors: what is the underlying thought in the literature?
idea is that the core cause is a disturbed parent-child relationship.
1:41:40
What elements of a parent-child relationship may be 'disturbed' when considering the psychodynamic factors in eating disorders?
-
Children raised as ineffectual
-
so do not develop behaviour to gain competence, respect and effectiveness
-
Failure to develop sense of self because of conflicting mother- daughter relationship
-
Food symbol of relationship
-
Binging/Purging is the conflict
- so do not develop behaviour to gain competence, respect and effectiveness
What environmental factors may contribute to eating disorders?
-
Early menarche
-
Stress in mothers during pregnancy
-
Premature birth or cephalhematoma in newborn babies
Cognitive Behavioural factors of Bulimia Nervosa...
-
Fear of fatness reinforced through successful dieting
-
Media representations of “ideal”
-
+ being overweight + comparison of self to other = body dissatisfaction
-
Troubled family/personal relationships
-
Difficulty expressing emotions
-
History of bullying/being teased/ridiculed for weight
-
Teased > body dissatisfaction > eating disorder
-
History of physical and/or sexual abuse
-
Family history of depression
-
Weight loss Positively Reinforced by positive comments about weight loss
- + being overweight + comparison of self to other = body dissatisfaction
- Teased > body dissatisfaction > eating disorder
1:42:00
What were the findings of Polivy et al., 1976; 1988; 1994?
-
Individuals who score high on restraint scale ate more.
-
Even when preload was perceived as fattenting
-
Even when food unpleasant
Briefly describe the experimental design Polivy et al., employed?
Low Restraint Pre-load No pre-load Rate Amount Measured High Restraint Pre-load No pre-load Rate Amount Measured 
Briefly describe the cycle of bulimia nervosa?
-
Low self-esteem & high negative affect
-
dieting to feel better about self
-
food intake is restricted too severley
-
diet is broken
-
binge
-
Compensatory behaviours to reduce fears of weight gain
-
(e.g., vomiting, laxatives)
- (e.g., vomiting, laxatives)
When restrained from purging, what physical symptoms are seen in a person with Bulimia?
-
When restrained from purging
-
↑ anxiety and skin conductance when eating
- ↑ anxiety and skin conductance when eating
How does society impact the way women see themselves?
Are Socio-Cultural Influences vulnerable to the passing of time?
-
Women are socialized to look ‘nice’
-
pressure accompanied with that combined with other contributory factors may lead to an eating disorder
-
Definition of ‘nice’ varies dramatically over time if visual records are used as a guide.
-
Changes very marked during 20th and early 21st century,
-
last 25 years popular culture has settled on an ideal of very thin women.
- pressure accompanied with that combined with other contributory factors may lead to an eating disorder
- last 25 years popular culture has settled on an ideal of very thin women.
Are Socio-Cultural Influences vulnerable to the passing of time?
If so, how have these influences changes, and is there an impact on eating disorders?
-
Yes
-
Definition of ‘nice’ varies dramatically over time if visual records are used as a guide.
-
Changes very marked during 20th and early 21st century,
-
Circumstantial evidence suggested Rubens’ concept of beauty (full figured women) was common among his contemporaries
-
Dieting is now more common
-
(1950 vs. 1999: Men - 7% - 29%; women - 14% - 44%)
-
Eating disorders often preceded by periods of dieting
-
Body dissatisfaction
-
(for whatever reason – overweight; exposure to societal “norms” in media) are risk factors for eating disorders.
-
not causal
-
last 25 years popular culture has settled on an ideal of very thin women.
- (for whatever reason – overweight; exposure to societal “norms” in media) are risk factors for eating disorders.
- not causal
What pharmacological interventions have been used in the treatment of eating disorders?
What are the problems with these interventions?
-
Anti-Depressants
-
Fluoxetine ↓ binge eating and vomiting in BN compared to placebo.
-
Also ↓ depression and distorted view toward eating.
-
Problem = drop-out rate.
-
1/3 of women dropped out of study (side effects)
-
Relapse when medication withdrawn
-
AN does not respond well to anti- depressant medication
- Fluoxetine ↓ binge eating and vomiting in BN compared to placebo.
- Also ↓ depression and distorted view toward eating.
-
Problem = drop-out rate.
- 1/3 of women dropped out of study (side effects)
- Relapse when medication withdrawn
- AN does not respond well to anti- depressant medication
What Psychological Interventions are used in the treatment of Anorexia Nervosa?
Anorexia
-
Two tiered process:
- 1) Hospitalization immediate weight gain
- 2) Operant conditioning to achieve healthy weight
- CBT + Hospitalization = ↓ of anorexic symptoms after 1yr
- Family therapy
-
Lunch meetings to
- 1. Change patient role of anorexic
- 2. Redefine issue as an interpersonal issue (not personal)
- 3. Prevent parents using the disorder to prevent conflict
- Preliminary data suggest this is effective
What Psychological Interventions are used in the treatment of Bulimia Nervosa?
Bulimia
-
CBT most valid and current gold-standard
- Cognition–i.e.challenge perception of “thin”
- Behaviour–i.e.being taught assertiveness skills
- CBT better than anti-depressants at 1, 6 and 10-y follow up
- Purging decreases by 70-90%
- However, LARGE individual differences.
- Interpersonal therapy and family therapy options.
What Psychological Interventions are used in the treatment of Binge Eating Disorder?
-
Newly formed so data scarce.
-
CBT and IPT most effective
-
More work required!
Lecture Summary