Week 4 Lecture 4b - Eating Disorders (112:50) (DN)

Question 1

Describe normal eating?

Answer 1

A pattern of eating behaviours which:

• Maintains normal weight
• Ensures adequate nutrition
• Conforms with cultural/religious requirements
• Enjoyable

1:14:50

Question 2

What are some of the consequences of ‘abnormal’ eating?

Answer 2

• Constant “dieting”
• Morbid Obesity
• Anorexia nervosa
• Bulimia nervosa
• Binge Eating Disorder
• Eating disorders are not secondary to other disorders, they are primary disorders

Question 3

How common are eating disorders?

Answer 3

• one of most common disorders in western world
• alongside depression & anxiety
• one of the most common to result in death of a patient

Question 4

What are some of the disorders not otherwise specified in the DSM-5?

Answer 4

• pika - eating odd things
• rumination - eating, vomiting & re-eating it

1:18ish

Question 5

What is the DSM-5 Criteria for Anorexia Nervosa?

Answer 5

• 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.

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1:18:50

Question 6

What are the two sub-types of Anorexia Nervosa?

Answer 6

• Restricting Type
  
  • Not regularly engaged in binge eating or purging behaviours
• Purging Type
  
  • Regularly engaged in binge eating and purging behaviours.

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120:30ish

Question 7

What is the Anorexia Nervosa severity scale in DSM-5 based on?

Answer 7

• Body Mass Index (BMI)
  121: 40

Question 8

What are the 4 criteria on the Distorted Attitude Toward Eating Scales?

Answer 8

1. Current
2. Ideal
3. Attractive (what they think is attractive)
4. Other Attractive (what others think is attractive)

Question 9

How would a person with anorexia most likely score on Zellner’s Distorted Body Image Scale?

Answer 9

High on Distorted Attitude

Question 10

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?

Answer 10

• **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

Question 11

Are there any gender similarities/differences on the ‘Distorted Attitude Toward Eating Scale’?

Answer 11

• No real gender difference between ideal distortions
• Men tend to overestimate their current weight

Question 12

What are some physical outcomes of the chronic starvation associated with in anorexia nervosa?

Answer 12

• 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

123:10

Question 13

What are the Psychological changes associated with anorexia

Answer 13

• Patient is no longer rational
• Personality changes

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Question 14

Who most typically suffers with anorexia nervosa?

What may be some early indicators in this demographic?

Answer 14

• 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

124:30

Question 15

What is the prognosis for anorexia?

Answer 15

• 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

1:26

Question 16

What is the prevalence of Anorexia In the overall poulation?

Answer 16

• Rare disease – 1% or less of the population
  
  • (but 3rd most common disease in young girls)

Question 17

What other disorders/conditions are often comorbid with anorexia?

Answer 17

• Depression
• Anxiety
• Obsessive Compulsive Disorders
• Phobias

125:25

Question 18

Do patients swap between Anorexia & Bulimia?

i.e., cross-over disorders

Answer 18

• Anorexia can develop into Bulimia
  
  • but rarely the other way around

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Question 19

What is the DSM-5 criteria for Bulimia Nervosa?

Answer 19

• 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.

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1:27:10

Question 20

What feature distinguishes Bulimia from Anorexia?

Answer 20

• People suffering from Bulimia are usually of ‘normal’ weight

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Question 21

Why would someone with Bulimia maintain ‘normal’ weight?

Answer 21

• they are not restricting their calories
  
  • they take in too many calories & then purge
• whereas anorexia (severe calorie restriction)

128:00

Question 22

Who is most typically develops Bulimia Nervosa?

Answer 22

• Typically found in older adolescents/ young women.
  
  • 90% of cases are female
  • Low incidence : 1-2% of the population

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1:29:15

Question 23

How does Bulimia Nervosa usually start?

Answer 23

• 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

129:50

Question 24

What are some secondary (comorbid) physical risks associated with Bulimia?

Answer 24

• 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).

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130:30

Question 25

How likely is **recovery** from **Bulimia**?

Answer 25

* 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. Death rate: 0-2% (too high) but lower than Anorexia slide12 131:10

Question 26

What is the **difference** between the DSM-5 **severity rating** for Anorexia Nervosa & Bulimia Nervosa

Answer 26

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

Question 27

What is the **DSM-5** criteria for **Binge Eating Disorder**?

Answer 27

* 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.** slide13

Question 28

What is the **main difference** between **Bulimia & Binge Eating Disorder**?

Answer 28

* **No compensatory behaviour** in Binge Eating Disorder 133: 00

Question 29

Are there any **gender differences** in the prevalence of **Binge Eating Disorder**? If so, how does the gender disparity compare to Anorexia & Bulimia?

Answer 29

* Women: more prevalent than men * Gender disparity is much closer than Anorexia & Bulimia 133: 20 134: 35

Question 30

How does the prevalence of Binge Eating Disorder compare to the other eating disorders?

Answer 30

* Binge Eating Disorder is more prevalent than Anorexia & Bulimia 133: 00

Question 31

How does a classification within DSM impact the literature on eating disorders? Use Binge Eating Disorder as an example...

Answer 31

* 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) 133:40

Question 32

What is an **important distinction** when considering obesity and Binge Eating Disorder (BED)?

Answer 32

* People with Binge Eating Disorder are likley to be obese * but all obese people **do not necessarily** have BED slide14 133:45

Question 33

What are some factors that may lead to BED?

Answer 33

* Factors leading to BED: * Childhood obesity * Negative weight comments * Depression * Childhood abuse

Question 34

What are Outcomes of Binge Eating Disorder?

Answer 34

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

Question 35

What **factors** are considered in the **aetiology** of **eating disorders**?

Answer 35

* Genetic factors * Neurobiological factors * Psychodynamic/Environmental factors * Cognitive Behavioural factors

Question 36

Genetic factors

Answer 36

* 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

Question 37

What have **twin studies** shown with regard to eating disorders? Nature or Nurture?

Answer 37

* 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 1:36:35

Question 38

Why is much more work needed in the area of genetic contribution?

Answer 38

* Mostly a social & psychological focus in the literature. * Some genetic factors have been identified but low power * further work required. 1:37:15

Question 39

Neurobiological factors

Answer 39

* **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 1:37:30

Question 40

What role might **serotonin** play in eating disorders?

Answer 40

* 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 1:39:35

Question 41

Psychodynamic factors: what is the underlying thought in the literature?

Answer 41

idea is that the core cause is a disturbed parent-child relationship. 1:41:40

Question 42

What elements of a **parent-child relationship** may be 'disturbed' when considering the psychodynamic factors in eating disorders?

Answer 42

* 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

Question 43

What **environmental factors** may contribute to eating disorders?

Answer 43

* Early menarche * Stress in mothers during pregnancy * Premature birth or cephalhematoma in newborn babies

Question 44

Cognitive Behavioural factors of Bulimia Nervosa...

Answer 44

* 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 1:42:00

Question 45

What were the findings of Polivy et al., 1976; 1988; 1994?

Answer 45

* Individuals who score high on restraint scale ate more. * Even when preload was perceived as fattenting * Even when food unpleasant

Question 46

Briefly describe the experimental design Polivy et al., employed?

Answer 46

Low Restraint Pre-load No pre-load Rate Amount Measured High Restraint Pre-load No pre-load Rate Amount Measured 

Question 47

Briefly describe the **cycle** of **bulimia nervosa**?

Answer 47

* 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)

Question 48

When **restrained from purging**, what **physical symptoms** are seen in a person with Bulimia?

Answer 48

* When restrained from purging * ↑ anxiety and skin conductance when eating

Question 49

How does society impact the way women see themselves? Are Socio-Cultural Influences vulnerable to the passing of time?

Answer 49

* 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.**

Question 50

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?

Answer 50

* 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.

Question 51

What **pharmacological interventions** have been used in the treatment of eating disorders? What are the **problems** with these interventions?

Answer 51

* **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

Question 52

What **Psychological Interventions** are used in the treatment of **Anorexia Nervosa**?

Answer 52

**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

Question 53

What **Psychological Interventions** are used in the treatment of **Bulimia Nervosa?**

Answer 53

**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.

Question 54

What **Psychological Interventions** are used in the treatment of **Binge Eating Disorder**?

Answer 54

* Newly formed so data scarce. * CBT and IPT most effective * More work required!

Question 55

**Lecture Summary**

Answer 55

* Anorexia nervosa and Bulimia nervosa, separate but related eating disorders of low incidence in population * Bulimia more amenable to intervention and treatment * Anorexia nervosa has life-threatening consequences in end stages of wasting that results * Binge Eating Disorder – new classification in 2013. * Aetiologies are speculative, at best, and this impedes treatment and prognosis for both groups * Some treatment programmes report good recovery rates after one-year post-treatment, but relapses occur