Eating

DisordersPsychologicalPsychological

and Clinical Perspectives: Assessment,and Clinical Perspectives: Assessment,

diagnosis, treatment and explanations.diagnosis, treatment and explanations.

A critical look- what has been ignored?A critical look- what has been ignored?Devinder Rana BSc (Hons) Psychology LM40507 Psychopathology and Abnormal Psychology Devinder Rana BSc (Hons) Psychology LM40507 Psychopathology and Abnormal Psychology

Aims Aims

By the end of the session you will be able to By the end of the session you will be able to do the following:do the following:Describe how the DSM-IV-TR defines and Describe how the DSM-IV-TR defines and distinguishes different eating disorders.distinguishes different eating disorders.Describe and compare how the biological, Describe and compare how the biological, psychological and sociocultural perspectives psychological and sociocultural perspectives explain the aetiology of eating disorders.explain the aetiology of eating disorders.Analyse the different treatments and Analyse the different treatments and perspectives and their legal and ethical perspectives and their legal and ethical implications. implications.

Eating DisordersEating Disorders

1. Anorexia Nervosa1. Anorexia Nervosa2. Bulimia Nervosa 2. Bulimia Nervosa

3. Eating Disorder Not Otherwise Specified 3. Eating Disorder Not Otherwise Specified (EDNOS) Binge-eating disorder (proposed (EDNOS) Binge-eating disorder (proposed

diagnosis requiring further study). diagnosis requiring further study).

Anorexia NervosaAnorexia Nervosa

Criteria DSM-IV-TRCriteria DSM-IV-TR

Refusal to maintain a body weight that is normal Refusal to maintain a body weight that is normal for the person’s age and height (i.e., a reduction for the person’s age and height (i.e., a reduction of body weight to about 85% of what would be of body weight to about 85% of what would be normally expected).normally expected).Intense fear of gaining weight or becoming fat, Intense fear of gaining weight or becoming fat, even though underweight.even though underweight.Distorted perception of body shape and size.Distorted perception of body shape and size.Absence of at least three consecutive menstrual Absence of at least three consecutive menstrual cycles.cycles.Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American American Psychiatric Association. Psychiatric Association. In-text citation: APA (2000) In-text citation: APA (2000)

Sub-types (APA, 2000). Sub-types (APA, 2000).

2 sub-types – how they

maintain weight

Binge/eating, purging type

Out of control eating Food amounts far greater then

average consumption Followed by efforts to purge

Restrictive TypeCalorie in-take controlledLimit food in-takeAvoid eating in the presence of other peopleEat slowly, cut and play with food (Beaumont, 2002)

In Context DSM-VI-TR (2000) In Context DSM-VI-TR (2000) Criteria Criteria

A 5’11 adult weighing A 5’11 adult weighing 11 stone (70 kilos) 11 stone (70 kilos) falls into the OK falls into the OK category.category.A deviation of 15% A deviation of 15% results in the results in the individual now individual now weighing just over 9 weighing just over 9 stone and is stone and is subsequently classed subsequently classed as anorexic. as anorexic.

Epidemiology Epidemiology

80-90% of suffers are female with typical 80-90% of suffers are female with typical age onset between 14-18 years old (Pike, age onset between 14-18 years old (Pike, 1998). 1998).

Weight control remains a long-term issue.Weight control remains a long-term issue.

Links with Obsessive Compulsive DisorderLinks with Obsessive Compulsive Disorder

Occur in young children Occur in young children

Occur in boys Occur in boys

Ballet dancers (Gelsey Kirkland) Ballet dancers (Gelsey Kirkland) and gymnasts (Christy Henrich) and gymnasts (Christy Henrich)

Characteristics of AnorexiaCharacteristics of Anorexia

Anorexic’s develop eating habits typical of Anorexic’s develop eating habits typical of bulimia nervosa (e.g. maintenance of ‘normal’ bulimia nervosa (e.g. maintenance of ‘normal’ weight through abnormal eating habits).weight through abnormal eating habits).Socio-economic and academic achievement link.Socio-economic and academic achievement link.Pre-occupation with food- thoughts of eating, Pre-occupation with food- thoughts of eating, preparation of food or watching others eat.preparation of food or watching others eat.High ‘calorie consumption’ behaviours e.g. gym, High ‘calorie consumption’ behaviours e.g. gym, running or swimming.running or swimming.Young, European American Women .Young, European American Women .

Distorted body image Distorted body image

Over estimation Over estimation of body of body proportion and proportion and distorted body distorted body image (Gupta & image (Gupta & Johnson, 2000). Johnson, 2000).

Link with Link with depression, depression, anxiety and OCD. anxiety and OCD.

Effects of Anorexia Effects of Anorexia

Amenorrhea (lack of menstruation). Amenorrhea (lack of menstruation).

Immune infectionsImmune infections

High/low blood pressure High/low blood pressure

Cracked SkinCracked Skin

Brittle hair and bonesBrittle hair and bones

Cardiotoxicity (heart damage)Cardiotoxicity (heart damage)

Consequences Consequences

Mortality rate is 12x higher than the Mortality rate is 12x higher than the mortality rate for females aged 15 to 24 in mortality rate for females aged 15 to 24 in the general population (Sullivan et al the general population (Sullivan et al 1995). 1995).

Death results from:Death results from:Physiological consequences from starvationPhysiological consequences from starvation

Intentional suicidal behaviour Intentional suicidal behaviour

Historical Account and DefinitionHistorical Account and Definition

Anorexic nervosa means: Anorexic nervosa means:

“ “ lack of appetite induced by lack of appetite induced by nervousness”.nervousness”.

(Butcher et al, 2007). (Butcher et al, 2007).

Lack of appetite is not the real problem. Lack of appetite is not the real problem.

““Self-starvation, resulting in a minimal Self-starvation, resulting in a minimal weight for one's age and height or weight for one's age and height or dangerously unhealthy weight”.dangerously unhealthy weight”.

Hudson et al (2006). Hudson et al (2006).

GreekGreek

An:An: without without

Orexis:Orexis: a desire for a desire for

“ “ without desire for food” without desire for food”

Nevid et al (2008). Nevid et al (2008).

Central to anorexia nervosaCentral to anorexia nervosa

Fear of gaining weight Fear of gaining weight or becoming fator becoming fat

Refusal to maintain Refusal to maintain even a minimal low even a minimal low body weight. body weight.

Historical AccountsHistorical Accounts

Accounts in early religious literature Accounts in early religious literature (Vandereycken, 2002). (Vandereycken, 2002). First medical account published in 1689 Richard First medical account published in 1689 Richard Morton.Morton.18 year old girl and 16 year old boy- described 18 year old girl and 16 year old boy- described as having a:as having a:

““nervous consumption thatnervous consumption that caused wasting of body tissue”. caused wasting of body tissue”.

1873 Sir William Gull in London & Charles 1873 Sir William Gull in London & Charles Lasegue in Paris independently describe the Lasegue in Paris independently describe the clinical syndrome and receive its current name. clinical syndrome and receive its current name.

Gull (1888)Gull (1888)

Described a 14 year old girl: Described a 14 year old girl:

““Without apparent cause, to evidence a Without apparent cause, to evidence a repugnance to food, and soon afterwards repugnance to food, and soon afterwards declined to take whatever, except half a declined to take whatever, except half a

cup of tea or coffee”. cup of tea or coffee”.

Problems with the diagnostic tool: Problems with the diagnostic tool: DSM-IV-TRDSM-IV-TR

Women who continue to menstruateWomen who continue to menstruate but but meet all the other diagnostic criteria for meet all the other diagnostic criteria for anorexia nervosa are just as ill as those anorexia nervosa are just as ill as those who have amenorrhea (Cachelin & Maher, who have amenorrhea (Cachelin & Maher, 1998; Garfinkel, 2002).1998; Garfinkel, 2002).For menFor men, the equivalent of the , the equivalent of the menstruation criterion is diminished sexual menstruation criterion is diminished sexual appetite and lowered testosterone levels appetite and lowered testosterone levels (Beaumont, 2002). (Beaumont, 2002).

Bulimia NervosaBulimia Nervosa

Criteria DSM-IV-TRCriteria DSM-IV-TRRecurrent episodes of binge eating. Recurrent episodes of binge eating. binges in a fixed period of time, food far greater than normal circumstances.binges in a fixed period of time, food far greater than normal circumstances.Lack of control and unable to stop.Lack of control and unable to stop.

Recurrent and inappropriate efforts to compensate for the effects of Recurrent and inappropriate efforts to compensate for the effects of binge eatingbinge eating..

self induced vomitingself induced vomitinglaxativeslaxativesexcessive exercise excessive exercise thyroid medicationthyroid medication

Self-evaluation is excessively influenced by weight and body shape.Self-evaluation is excessively influenced by weight and body shape.

Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American Psychiatric Association. American Psychiatric Association. In-text citation: APA (2000) In-text citation: APA (2000)

Characteristics Characteristics

Food is eaten rapidly, secretively, without pleasure in Food is eaten rapidly, secretively, without pleasure in binges where in excess of 5000 calories can be binges where in excess of 5000 calories can be consumed (2x the recommended daily male intake).consumed (2x the recommended daily male intake).Bulimics demonstrate a fear of weight gain and consider Bulimics demonstrate a fear of weight gain and consider themselves to be heavier than they actually are themselves to be heavier than they actually are (McKenzie et al 1993)(McKenzie et al 1993)Approximately 80-90% of individuals will vomit following Approximately 80-90% of individuals will vomit following a period of binging, one third adopt laxative use and a period of binging, one third adopt laxative use and others constantly exercise (Anderson et al, 2001).others constantly exercise (Anderson et al, 2001).Long-term problems include digestive issues, Long-term problems include digestive issues, dehydration, damage to stomach lining and damage to dehydration, damage to stomach lining and damage to the teeth.the teeth.Fairburn & Beglin (1994) estimate prevalence between Fairburn & Beglin (1994) estimate prevalence between 0.5-1%. 0.5-1%.

Anorexia Vs. BulimiaAnorexia Vs. BulimiaAnorexiaAnorexia BulimiaBulimia Weight loss not driven by Weight loss not driven by desire to appear feminine. desire to appear feminine.

Social concept of femininity Social concept of femininity drives behaviour drives behaviour

High self-control High self-control Impulsive and emotional Impulsive and emotional instability instability

Body weight significantly Body weight significantly (>15%) below age/height(>15%) below age/height

Weight fluctuation (remains Weight fluctuation (remains relatively close to norms)relatively close to norms)

Less likely to have been Less likely to have been overweight overweight

More likely to have been More likely to have been overweight overweight

Underweight (severe)Underweight (severe) Normal weight (slightly Normal weight (slightly overweight)overweight)

Less likely to abuse Less likely to abuse drugs/alcohol drugs/alcohol

More likely to abuse More likely to abuse drugs/alcohol drugs/alcohol

Bulimia and Purging anorexia Bulimia and Purging anorexia nervosa nervosa

Meets the criteria for binging/purging, also Meets the criteria for binging/purging, also meets the criteria for anorexia nervosa, meets the criteria for anorexia nervosa, anorexia nervosa will be diagnosed. anorexia nervosa will be diagnosed.

Common anxiety with fear of being fat.Common anxiety with fear of being fat.

2 types 2 types

Bulimia

Purging (80%)Vomiting

Use of laxatives

Non-purgingFast/exercise

ExplanationsExplanations

Complex InteractionComplex Interaction

Biological Socio-cultural

family

Psychological

Individual

Biological FactorsBiological Factors

GeneticsGenetics

GeneticsGenetics

Runs in families (Bulik & Tozzi, 2004)Runs in families (Bulik & Tozzi, 2004)Risk of anorexia nervosa for relatives of people Risk of anorexia nervosa for relatives of people with anorexia nervosa was 11.4x more greater. with anorexia nervosa was 11.4x more greater. Bulimia 3.7X higher, than relatives with healthy Bulimia 3.7X higher, than relatives with healthy controls. (Strober et al, 2000). controls. (Strober et al, 2000). Relatives of patients with eating disorders are Relatives of patients with eating disorders are more likely to suffer from other problems, more likely to suffer from other problems, especially mood disorders (Mangweth et al especially mood disorders (Mangweth et al 2003). 2003). However, eating disorders are not densely However, eating disorders are not densely clustered as are mood disorders and clustered as are mood disorders and schizophrenia. schizophrenia.

Twin studies Twin studies

Anorexia nervosa and Anorexia nervosa and bulimia nervosa are bulimia nervosa are hereditable disorders hereditable disorders (Bulik & Tozzi, 2004; (Bulik & Tozzi, 2004; Fairburn & Harrison, Fairburn & Harrison, 2003). 2003).

GenesGenes

Chromosome 1Chromosome 1 linked to linked to the susceptibility to the the susceptibility to the restrictive type of restrictive type of anorexia anorexia (Grice et al, (Grice et al, 2002). 2002). Bulimia Bulimia (purging) linked (purging) linked to to chromosome 10chromosome 10 (Bulik et al, 2003). (Bulik et al, 2003). Eating disorders linked to Eating disorders linked to chromosomes involved chromosomes involved Genes responsible for Genes responsible for serotonin: low serotonin serotonin: low serotonin level (Kaye et al., 2005)level (Kaye et al., 2005)

Brain: Hypothalamus and GLP-1 Brain: Hypothalamus and GLP-1

Regulates bodily functionsRegulates bodily functionsLateral hypothalamus: produces Lateral hypothalamus: produces hunger when activatedhunger when activatedVentromedial Hypothalamus: Ventromedial Hypothalamus: reduce hunger when activatedreduce hunger when activatedEach part electrically stimulated in Each part electrically stimulated in animals they decrease/increase animals they decrease/increase eating behaviour (Duggan & eating behaviour (Duggan & Booth, 1986)Booth, 1986)Glucagon-like peptide-1 (GLP-1) Glucagon-like peptide-1 (GLP-1) natural appetite suppressant.natural appetite suppressant.Inject rats they will not eat even Inject rats they will not eat even after a 24hr fastafter a 24hr fastBlock GLP-1 in the hypothalamus-Block GLP-1 in the hypothalamus-double food intake (Turton et al., double food intake (Turton et al., 1996).1996).

Weight Set Point Theory Weight Set Point Theory LH, VMH, GLP-1, work together LH, VMH, GLP-1, work together comprise a comprise a weight thermostatweight thermostatWeight set point theory (WSP) Weight set point theory (WSP) (Hallschmid et al., 2004).(Hallschmid et al., 2004).Genetic inheritance and early eating Genetic inheritance and early eating patterns determine WSP.patterns determine WSP.Weight falls below the WSP, hunger Weight falls below the WSP, hunger increases and metabolic rate increases and metabolic rate decrease. decrease. Diet and fall below WSP, hypothalamic Diet and fall below WSP, hypothalamic activity produces a preoccupation with activity produces a preoccupation with food and desire to binge. food and desire to binge. Trigger bodily changes- harder to lose Trigger bodily changes- harder to lose weight however little is eaten (Spalter weight however little is eaten (Spalter et al., 1993)et al., 1993)Restricting-type anorexia: shut down Restricting-type anorexia: shut down their inner thermostat and control their their inner thermostat and control their eating completely. eating completely. Binge-purge pattern: battle spirals Binge-purge pattern: battle spirals (Pinel et al., 2000)(Pinel et al., 2000)

The average American woman is 5’4” and 140

pounds.

The average American model is 5’11” and 117

pounds.

SocietalSocietal

PressuresPressures

Current Western standards of female attractiveness have contributed Current Western standards of female attractiveness have contributed to increases in eating disorders (Jambor, 2001). to increases in eating disorders (Jambor, 2001). Decline Miss America Pageant, average decline of 0.28 pound per Decline Miss America Pageant, average decline of 0.28 pound per year (Garner et al., 1980).year (Garner et al., 1980).Fashion models, actors, dancers, certain athletes: more prone to Fashion models, actors, dancers, certain athletes: more prone to eating disorders (Couturier & Lock, 2006). eating disorders (Couturier & Lock, 2006). 20% of gymnast surveyed had an eating disorder (Johnson, 1995). 20% of gymnast surveyed had an eating disorder (Johnson, 1995). White upper socioeconomic expressed more concerns about thinness White upper socioeconomic expressed more concerns about thinness (Mrgo, 985)(Mrgo, 985)Recent years increased in all classes and minority groups (Germer, Recent years increased in all classes and minority groups (Germer, 2005). 2005). Double standard has made women more inclined to diet and more Double standard has made women more inclined to diet and more prone (Cole & Daniel, 2005)prone (Cole & Daniel, 2005)Cruel jokes targeted as obesity are standard in the media (Gilbert et Cruel jokes targeted as obesity are standard in the media (Gilbert et al., 2005)al., 2005)Deep rooted (Grilo, 2006)Deep rooted (Grilo, 2006)Parents more likely to rate a picture of a chubby child as less friendly, Parents more likely to rate a picture of a chubby child as less friendly, energetic, intelligent and desirable. energetic, intelligent and desirable. 61% of secondary school girls are dieting (Hill, 2006)61% of secondary school girls are dieting (Hill, 2006)

Battle of Brittan's Battle of Brittan's

Timeline Timeline

16391639 - - The Three GracesThe Three Graces; Pieter Pauwel Rubens ; Pieter Pauwel Rubens

18871887 - Pierre Auguste Renoir, - Pierre Auguste Renoir, The BathersThe Bathers

1920 - 1920 - Thin, short haired flapper Thin, short haired flapper

19501950 - Monroe (Size 14/16) - Monroe (Size 14/16)

19601960 - Twiggy Lawson (Aka the beginning of the end.) This was the first - Twiggy Lawson (Aka the beginning of the end.) This was the first time in history that an time in history that an under under weight woman became the standard for the weight woman became the standard for the ideal body image. ideal body image.

19881988 - Cosmopolitan - Cosmopolitan

20022002 - Harper’s Bazaar - Harper’s Bazaar

Modern day Fashion ModelModern day Fashion Model

Family Environment Family Environment Important role in the development of eating disorders Important role in the development of eating disorders (Reich, 2005)(Reich, 2005)½ families: emphasise thinness, physical appearance and ½ families: emphasise thinness, physical appearance and dieting. dieting. Mothers diet frequently and be perfectionist (Woodside et Mothers diet frequently and be perfectionist (Woodside et al., 2002). al., 2002). Abnormal interactions and communication (Reich, 2005)Abnormal interactions and communication (Reich, 2005)Family systems theory: dysfunctional family, person with Family systems theory: dysfunctional family, person with eating disorder is representative of a larger problem eating disorder is representative of a larger problem (Rowa et al., 2001)(Rowa et al., 2001)Enmeshed family pattern (Minuchin et al., 1978): over Enmeshed family pattern (Minuchin et al., 1978): over involved with in each other’s affairs and over concerned involved with in each other’s affairs and over concerned with details of each other’s lives. with details of each other’s lives. Teenagers push for independence which threaten the Teenagers push for independence which threaten the harmony of the family. harmony of the family. Family may subtly force the child to take on a sick role- Family may subtly force the child to take on a sick role- develop eating disorder or other illness. develop eating disorder or other illness. Enables the family to maintain its appearance of harmony.Enables the family to maintain its appearance of harmony.Some case studies support this view (Wilson et al., 2003)Some case studies support this view (Wilson et al., 2003)Systematic research fails to support this link .Systematic research fails to support this link .

Ego Deficiencies and Cognitive Ego Deficiencies and Cognitive Disturbances Disturbances

Bruch built on psychodynamic and cognitive notions. Bruch built on psychodynamic and cognitive notions. Disturbed mother-child interactions lead to serious Disturbed mother-child interactions lead to serious ego deficienciesego deficiencies in the in the child (poor sense of control and independence) serve cognitive disturbances child (poor sense of control and independence) serve cognitive disturbances (Bruch, 2001).(Bruch, 2001).Effective parents: attend to their child’s biological and emotional needsEffective parents: attend to their child’s biological and emotional needsIneffective parents: fail to attend to needs, misinterpreting i.e., being hungry Ineffective parents: fail to attend to needs, misinterpreting i.e., being hungry rather than seeing the actual condition- grow up confused. rather than seeing the actual condition- grow up confused. Not being control of their behaviour, not rely on internal signs, not self-reliant Not being control of their behaviour, not rely on internal signs, not self-reliant instead during adolescence when looking for independence seek control with instead during adolescence when looking for independence seek control with weight and body image. weight and body image. Pearlman (2005) eating disorder parents define children needs rather than the Pearlman (2005) eating disorder parents define children needs rather than the child. child. Bruch (1973) interviewed 51 mothers of a child with an eating disorder, many Bruch (1973) interviewed 51 mothers of a child with an eating disorder, many recalled how they never allowed the child to feel hungry and anticipated their recalled how they never allowed the child to feel hungry and anticipated their child’s needs. child’s needs. Perceive internal cues inaccurately (Bydlowski et al., 2005)Perceive internal cues inaccurately (Bydlowski et al., 2005)Anxious or upset- think they are hungry so eatAnxious or upset- think they are hungry so eatWorry how others view them, seek approval, be conforming and feel lack of Worry how others view them, seek approval, be conforming and feel lack of control over their lives (Button & Warren, 2001).control over their lives (Button & Warren, 2001).

When do people seek junk food? When they feel bad. When do people seek junk food? When they feel bad. Lyman (1982)Lyman (1982)

0 20 40 60 80 100

self-confidence

happiness

love

anxiety

depression

boredom

nurition

junk food

Mood DisordersMood Disorders

Eating disorders, especially bulimia nervosa, Eating disorders, especially bulimia nervosa, experience symptoms of depression (Perinea et al, experience symptoms of depression (Perinea et al, 2005)2005)Eating disorder also qualify for a clinical diagnosis of Eating disorder also qualify for a clinical diagnosis of major depressive disorder (Duncan et al., 2005)major depressive disorder (Duncan et al., 2005)Close relatives of people with eating disorders seem to Close relatives of people with eating disorders seem to have a higher rate of mood disorders than do close have a higher rate of mood disorders than do close relatives of people without such disorders (Moorhead relatives of people without such disorders (Moorhead et al., 2003).et al., 2003).Eating disorders, especially bulimia nervosa have low Eating disorders, especially bulimia nervosa have low activity of serotonin, similar to serotonin abnormalities activity of serotonin, similar to serotonin abnormalities found in depressed people.found in depressed people.People with eating disorders are helped by some of People with eating disorders are helped by some of the same antidepressant drugs that reduce the same antidepressant drugs that reduce depression. depression.

Treatments for Anorexia Treatments for Anorexia NervosaNervosa

How is proper weight and normal How is proper weight and normal eating restored? eating restored?

Past in hospitals, today in outpatient settings (Vitousek & Past in hospitals, today in outpatient settings (Vitousek & Gray, 2006)Gray, 2006)Life-threatening cases: force tube and intravenous Life-threatening cases: force tube and intravenous feedings on a patient who refuses to eat (Tyre, 2005) feedings on a patient who refuses to eat (Tyre, 2005) Can result in distrust in the patient (Robb et al., 2002).Can result in distrust in the patient (Robb et al., 2002).Weight restoration approaches: Weight restoration approaches: clinicians use rewards clinicians use rewards whenever patients eat properly or gain weight (Tacon & whenever patients eat properly or gain weight (Tacon & Caldera, 2001)Caldera, 2001)– Combination of supportive nursing care, nutritional counselling & Combination of supportive nursing care, nutritional counselling &

high calorie diet (no more than 2,500 calories a day). Herzog, et high calorie diet (no more than 2,500 calories a day). Herzog, et al., 2004). al., 2004).

– Help them to recognise that the weight gain is under control and Help them to recognise that the weight gain is under control and will not lead to obesity..will not lead to obesity..

– Gain the necessary weight in 8-12 weeks. Gain the necessary weight in 8-12 weeks.

How are lasting changes achievedHow are lasting changes achievedOvercome their underlying psychological Overcome their underlying psychological problems in order to achieve lasting problems in order to achieve lasting improvement improvement Therapy and education: individual, group Therapy and education: individual, group and family approaches (Hechler et al., and family approaches (Hechler et al., 2005).2005).Recognise need for independence and Recognise need for independence and teach them more appropriate ways to teach them more appropriate ways to exercise control (Dare & Crowther, exercise control (Dare & Crowther, 1995).1995).Trust their internal sensations and Trust their internal sensations and feelings (Kaplan & Garfinkel, 1999) feelings (Kaplan & Garfinkel, 1999) Correcting disturbed cognitions: change Correcting disturbed cognitions: change attitudes about eating and weight attitudes about eating and weight (McFarlane et al., 2005).(McFarlane et al., 2005).Identify, challenge and change Identify, challenge and change maladaptive assumptions (Lask et al., maladaptive assumptions (Lask et al., 2000)2000)Changing family interactions: meet with Changing family interactions: meet with the family, point out troublesome family the family, point out troublesome family patterns, separate feelings and needs patterns, separate feelings and needs from those of other family members from those of other family members (Couturier & Lock, 2006). (Couturier & Lock, 2006).

Aftermath of Anorexia Nervosa Aftermath of Anorexia Nervosa Use of combined approaches has improved the outlook but the road to Use of combined approaches has improved the outlook but the road to recovery is difficult (Fairburn, 2005)recovery is difficult (Fairburn, 2005)PositivePositiveWeight is often restored once treatment begins (McDermott & Jaffa, 2005)Weight is often restored once treatment begins (McDermott & Jaffa, 2005)83% improvement, several years later, 33% fully recovered and 50% 83% improvement, several years later, 33% fully recovered and 50% partially improved (Herzog et al., 1999)partially improved (Herzog et al., 1999)Menstruate again (Fombonne, 1995)Menstruate again (Fombonne, 1995)Death rates are decreasing (Neumarker, 1997).Death rates are decreasing (Neumarker, 1997).NegativeNegative20% remain seriously troubled for years (Haliburn, 2005)20% remain seriously troubled for years (Haliburn, 2005)When recovery occurs it is not always permanentWhen recovery occurs it is not always permanent1/3 triggered again by new stresses (Fennig et al., 2002)1/3 triggered again by new stresses (Fennig et al., 2002)½ continue to experience emotional problems- depression, social anxiety, ½ continue to experience emotional problems- depression, social anxiety, obsessive which are common when reaching normal weight (Steinhausen, obsessive which are common when reaching normal weight (Steinhausen, 2002)2002)

Treatment Bulimia Nervosa Treatment Bulimia Nervosa

Treatments Treatments

Eating disorder clinics Eating disorder clinics Eliminate binge-purge patterns and establish god eating patterns, Eliminate binge-purge patterns and establish god eating patterns, Education as much as therapy (Davis et al 1997)Education as much as therapy (Davis et al 1997)Individual insight therapy: cognitive-recognise and change Individual insight therapy: cognitive-recognise and change maladaptive attitudes (Cooper, 2006)maladaptive attitudes (Cooper, 2006)Not respond then use interpersonal psychotherapy- improve Not respond then use interpersonal psychotherapy- improve interpersonal functioning. interpersonal functioning. Psychodynamic therapy- limited support. Psychodynamic therapy- limited support. Behavioural therapy: supplement with cognitiveBehavioural therapy: supplement with cognitiveDairies- note sensations of fullness etcDairies- note sensations of fullness etcExposure and response prevention Exposure and response prevention Anti-depressant medication: Prozac help 40%Anti-depressant medication: Prozac help 40%Group therapy: self-help groups- helpful to 75% when combined Group therapy: self-help groups- helpful to 75% when combined with individual sight therapywith individual sight therapy

AftermathAftermath

Treated successfully, relapse is a common Treated successfully, relapse is a common problem triggered by new life stresses. problem triggered by new life stresses.

1/3 treated relapse 6months later 1/3 treated relapse 6months later (Olmsted et al., 1994)(Olmsted et al., 1994)

Former patients less depressed then time Former patients less depressed then time of diagnosis (Halmi, 1995)of diagnosis (Halmi, 1995)

Depends on history, length and frequency Depends on history, length and frequency of vomiting. of vomiting.

Karen Carpenter: 1970’s Karen Carpenter: 1970’s

Reading Seminar Reading Seminar

Should individuals with Anorexia Should individuals with Anorexia Nervosa Have the Right to Refuse Life-Nervosa Have the Right to Refuse Life-Sustaining Treatment?Sustaining Treatment? Yes: Heather Draper from “Anorexia Nervosa Yes: Heather Draper from “Anorexia Nervosa and Respecting a Refusal of Life-Prolonging and Respecting a Refusal of Life-Prolonging Therapy: A Limited Justification”, Therapy: A Limited Justification”, Bioethics Bioethics (April (April 1, 2000)1, 2000)No: J.L. Werth, Jr., Kimberly S. Wright, Rita J. No: J.L. Werth, Jr., Kimberly S. Wright, Rita J. Archambault, and Rebekah J. Bardash, from Archambault, and Rebekah J. Bardash, from “When Does the ‘Duty to Protect’ Apply with a “When Does the ‘Duty to Protect’ Apply with a Client Who Has Anorexia Nervosa?” Client Who Has Anorexia Nervosa?” The The Counselling Psychologist Counselling Psychologist (July, 2003).(July, 2003).

Petrie, T., Greenleaf, C., Reel, J., & Carter, J. (2008, Petrie, T., Greenleaf, C., Reel, J., & Carter, J. (2008, October). Prevalence of eating disorders and disordered October). Prevalence of eating disorders and disordered eating behaviors among male collegiate athletes. eating behaviors among male collegiate athletes. Psychology of Men & MasculinityPsychology of Men & Masculinity, , 99(4), 267-277. (4), 267-277. Retrieved January 22, 2009, doi:10.1037/a0013178Retrieved January 22, 2009, doi:10.1037/a0013178Tibon, S., & Rothschild, L. (2009, January). Dissociative Tibon, S., & Rothschild, L. (2009, January). Dissociative states in eating disorders: An empirical Rorschach study. states in eating disorders: An empirical Rorschach study. Psychoanalytic PsychologyPsychoanalytic Psychology, , 2626(1), 69-82. Retrieved (1), 69-82. Retrieved January 22, 2009, doi:10.1037/a0014675January 22, 2009, doi:10.1037/a0014675Hepworth, J., & Griffin, C. (1995). Conflicting opinions? Hepworth, J., & Griffin, C. (1995). Conflicting opinions? 'Anorexia nervosa,' medicine and feminism. 'Anorexia nervosa,' medicine and feminism. Feminism Feminism and discourse: Psychological perspectivesand discourse: Psychological perspectives (pp. 68-85). (pp. 68-85). Thousand Oaks, CA US: Sage Publications, Inc. Thousand Oaks, CA US: Sage Publications, Inc. Retrieved January 22, 2009, from PsycINFO database.Retrieved January 22, 2009, from PsycINFO database.

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Reading Reading

Nevid, J.S., Rathus, S.A., & Greene, B. Nevid, J.S., Rathus, S.A., & Greene, B. (2008). (2008). Abnormal Psychology In A Abnormal Psychology In A Changing World. Changing World. (7(7thth ed.). Pearson ed.). Pearson Prentice Hall: London. Chapter 10, pp. Prentice Hall: London. Chapter 10, pp. 330-357. 330-357.

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