abnormal PSYCHOLOGY

Fourth Canadian Edition

Chapter 10Chapter 10Eating Disorders

Prepared by: Tracy Vaillancourt, Ph.D.

Modified by: Réjeanne Dupuis, M.A.

Chapter Outline

• Clinical Description

• Etiology of Eating Disorders

• Treatments of Eating Disorders

Prevalence • Lifetime prevalence in the U.S. in 2001 and 2003

– Anorexia nervosa (women 0.9%; men 0.3%); Bulimia nervosa (women 1.5%; men 0.5%); Binge eating disorder (women 3.5%; men 2.0%)

• One-year prevalence in Canada in 2002– 0.5% of Canadians reported an eating disorder diagnosis

(women 0.8%; men 0.2%)– Women ages 15-24 reporting an eating disorder: 1.5% – 1.7% of Canadians meet criteria for an eating attitude

problem

• Eating disorders can cause long-term psychological, social and health problems

Types of Eating Disorders

• Anorexia Nervosa (AN)

• Bulimia Nervosa (BN)

• Binge Eating Disorder

• Eating Disorder not otherwise specified (EDNOS)

Anorexia Nervosa (AN)• Anorexia—loss of appetite• Nervosa—appetite loss due to emotional reasons

– Term a misnomer because most patients do not lose their appetite or interest in food

• Four features required for the diagnosis:1. Refusal to maintain a normal body weight

• < 85% of what is considered normal for age and height2. Intense fear of gaining weight; fear not reduced by weight loss

• Overevaluation of appearance

3. Distorted sense of body shape4. Amenorrhea in post-pubertal females

Types of AN• Restricting type

– Weight loss is achieved by severely limiting food intake

• Binge eating-purging type– Person regularly engages in binge eating and purging

• Binge eating-purging type is more psychologically impaired that restricting type

– More psychopathological, more personality disorders, impulsive behaviour, stealing, alcohol and drug abuse, social withdrawal, and suicide attempts

• They also tend to weigh more in childhood; come from heavier families with greater familial obesity; and use more extreme weight-control methods

Features of AN• Typically begins in the early to middle

adolescence

• Often after an episode of dieting and exposure to life stress

• Lifetime prevalence 1% (in women)– 3 to 10 X > more frequent in women than men

• Comorbid with depression, obsessive-compulsive disorder, phobias, panic disorder, alcoholism, oppositional defiant disorder, and various personality disorders

Physical Changes with AN blood pressure heart rate slows bone mass • Kidney and

gastrointestinal problems dry skin

• Nails become brittle• Hormone levels change• Mild anemia

• Hair loss • Laguna• Altered levels of

electrolytes, such as potassium and sodium

• Tiredness• Weakness• Cardiac arrhythmias• Sudden death. in brain size

– White and grey matter

Prognosis of AN

• 70% of patients recover

• Relapses are common

• Death rates are 10 X > than general population

• Death rates 2X > than patients with other psychological disorders

Eating Disorders and Intentional Self-harm

• Self-harm is associated with impulsivity • 16.9% of Canadian youth (ages 14-21) engaged non-

suicidal self-injury • 3/10 first-year undergraduate students admitted

intentionally engaging in at least one act of self-harm, cutting for women and reckless driving for men – These behaviours were related to history of emotional abuse,

illicit drug use, depression, various personality factors

• Reasons for engaging in self-harm: (1) interpersonal reasons; (2) to suppress an unwanted social stimulus; (3) to suppress negative emotions; (4) to generate feelings

Bulimia Nervosa (BN)

• Involves episodes of rapid consumption of a large amount of food (binge), followed by compensatory behaviours (purge).– Binge = eating excessive amount of food in < 2 hours

• Typically occur in secret

• May be triggered by stress

– Purge= vomiting, fasting, or excessive exercise

• Note. If binging and purging occur only in the context of AN then BN not diagnosed

BN (cont.) • People with BN are afraid of gaining weight

– “A morbid fear of fat”

• 2 subtypes of bulimia nervosa:1. Purging type 2. Non-purging type

• Compensatory behaviours are fasting or excessive exercise

• Typically begins in late adolescence or early adulthood

Other Features of BN• Comorbid with depression, personality disorders,

anxiety disorders, substance abuse, and conduct disorder

• Physical side effects– Potassium depletion– Diarrhea– Changes in electrolytes – Irregularities in the heartbeat– Tearing of tissue in the stomach and throat – Loss of dental enamel – Swollen salivary glands

Binge Eating Disorder• Recurrent binges (2X / week for at least six months) + lack

of control during the binging episode + distress about binging– + rapid eating and eating alone.

• Distinguished from AN by absence of weight loss

• Distinguished from BN by the absence of compensatory behaviours (e.g., vomiting)

• More prevalent than either AN or BN– 6% of successful dieters – 19% of unsuccessful dieters – Risk factors for developing BED include:

• Childhood obesity, critical comments regarding being overweight, low self-concept, depression, and childhood physical or sexual abuse

Etiology of Eating Disorders

Etiology: Biological Factors

Genetics• AN and BN run in families• First-degree relatives of young women with AN 4 X > likely to

have the disorder themselves • AN and BN in identical twins than fraternal twins• heritability estimate of 56%

Eating Disorders and the Brain• Hypothalamus proposed to play a role in AN • Paraventricular nucleus also implicated• Abnormal cortisol endogenous opioids due to starvation regional mu-opioid receptor binding in the insular cortex in

BN levels of serotonin metabolites in BN

Socio-Cultural Variables• Steady progression toward increasing thinness as the

ideal– Unrealistic cultural pressures

• Scarlett O’Hara effect Body dissatisfaction• Activity Anorexia• Gender Influences • Cross-Cultural Influences

– Eating disorders more common in industrialized societies, such as the United States, Canada, Japan, Australia, and Europe, than in non-industrialized nations

To Diet or Not to Diet?

• The diet industry is a multi-billion dollar a year business

• Hedonic system • Heredity: 20-50% of variability is genetic • Psychological factors

– Stress, motivation for thinness – Dieting appears to be a predictor of ED – False hope syndrome

• Dieting tends to lead to weight fluctuation and is a health risk factor

Etiology: Psychological Views

Cognitive-Behavioural Views on AN• Emphasize fear of fatness and body-image disturbance

as the motivating factors that make self-starvation and weight loss powerful reinforcers – Behaviours that achieve or maintain thinness are negat-

ively reinforced by the of anxiety about becoming fat. – Dieting and weight loss may be + reinforced by the sense

of mastery or self-control they create • see the thinspiration effect

• Criticism from peers and parents about being overweight may also contribute to ED

Etiology: Psychological Views (cont.)

Psychodynamic View• Disturbed parent-child relationships • Symptoms of eating disorder fulfill some need or to avoid

growing up sexually

Family Systems Theory• Relationship between patient and how the symptoms are

embedded in a dysfunctional family structure than may exhibit the following characteristics:– Enmeshment– Overprotectiveness – Rigidity– Lack of conflict resolution

Child Abuse

Etiology: Psychological Views (cont.)

Personality Factors In AN• Perfectionistic, shy, and compliant before the onset of

the disorder

In BN• Histrionic features, affective instability, and an outgoing

social disposition

BN and AN • High in neuroticism and anxiety and low in self-esteem • High on traditionalism, indicating strong endorsement• Narcissism

Cognitive-Behavioural Theory of BN

Treatment of EDUp to 90% of people with ED are not in treatment and

those who are in treatment are often resentful

Biological Treatments• SSRIs in particular fluoxetine (Prozac)

– Frequently used to treat bulimia – Helps reduce depression, distorted attitudes toward food

and eating • Unfortunately, SSRIs not consistently effective • More drop-outs of studies in biological and cognitive-

behavioural treatments • Currently, there is no empirical basis for using

antidepressants to treat AN

Treatment of ED (cont.)Psychological Treatment of AN

– Two-tiered process• Immediate goal is to help the patient gain weight• 2nd goal of treatment is long-term maintenance of weight gain

– Not yet reliably achieved

– CBT of the maintenance of AN • Based on an extreme need to control eating • Tendency to judge self-worth in terms of shape and weight • Treatment has shown

– Schema-Focused Cognitive Behaviour Therapy, Family Systems Therapy, and Interpersonal Therapy used to treat EDs

Psychological Treatment of BN– CBT: treatment of choice for BN and binge eating disorder

Treatment of ED (cont.)Psychological Treatment of BN

– CBT: treatment of choice for BN and binge eating disorder– Goal: to develop normal eating patterns – Clients:

• Question society’s standards for physical attractiveness• Uncover and challenge detrimental beliefs about starving and

becoming overweight • Learn that normal can be maintained with dieting • Learn assertion skills

– Outcome has its limitations• Fewer binges and purges , but clients to not feel much better • Half tend to relapse

Prevention of ED in Canada

• Preventive efforts show reduction of prevalence of ED, especially for high-risk participants

• The Piran Study – Ongoing study at an international ballet school in Toronto– Prevalence of ED: From 50% in 1987 to 15% in 1991, 1996– Based on participation and changing the ballet school culture

• McVey and Devy Program – Reduce the impact of media portrayals of unrealistic body

images

• School-based peer support group • Web-based training program for teachers

Treatment of ED in Canada

• B.C. Children’s Hospital Eating Disorders Program– Services: Intake, Day Treatment, Outpatient Services,

Inpatient Unit, Residence, Parent-Child Group, Outreach Provincial Services

• Sheena’s Place, non-profit organization – Perceived as ‘waiting-rooms’ for hospital-based programs

– Currently offers 50 groups, e.g., University and college studetns, Unlocking emotional eating

• Obesity is also receiving attention

Copyright

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