UNDERSTANDING PSYCHOPATHOLOGY

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UNDERSTANDING PSYCHOPATHOLOGY

• Eating Disorders

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OVERVIEW

• Definitions
• Myths about eating disorders
• Eating Disorders and Obesity -- how are they
  related?
• Advocacy

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KEY FEATURES

• Disturbance of eating
• Under eating
• Over eating
• Eating at inappropriate times (NES)
• Eating the wrong things
• Disturbance of body image
• Feeling fat
• Fear of fatness
• Over valuation of weight or shape

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EATING DISORDERS IN THE DSM IV
ANOREXIA NERVOSA

• Refusal to maintain minimum weight for height
• Body image disturbance
• Amenorrhea (in females)

BULIMIA NERVOSA

• Recurrent episodes of binge eating
• Over valuation of weight/shape
• Recurrent extreme compensatory
• behaviors (purging or
• nonpurging type)

EATING DISORDERS NOS

• Binge Eating Disorder
• Other eating disturbances

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BODY DYSMORPHIC DISORDER
A. Preoccupation with an imagined defect in
appearance. If a slight physical anomaly is
present, the persons concern is markedly
excessive. B. The preoccupation causes
clinically significant distress or impairment
on social, occupational, or other important
areas of functioning. C. The preoccupation is
not better accounted for by another mental
disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa).
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EPIDEMIOLOGY OF EATING DISORDERS

• Syndromes are relatively uncommon
• Symptoms are highly prevalent
• Female to male ratio 10 to 1
• Ethnic minority representation unknown
• Onset occurs typically between ages 12 - 20
• Complex association with socioeconomic status

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BODY DYSMORPHIC DISORDER

• Described by Janet (1903) and Kraepelin (1909)
• Introduced into the ICD-10 (1992) requires
  duration of more than 6 months.
• DSM-III (1980) as an example of an atypical
  somatoform disorder (no criteria).
• DSM III-R (1987) separate disorder --
  distinguishes delusional vs. non-delusional.
• DSM IV drops this distinction

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EPIDEMIOLOGY OF BODY DYSMORPHIC DISORDER

• Prevalence is unknown, but BDD is thought to be
  common
• Malefemale ration is thought to be 11
• Mean age of onset 14 years

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EPIDEMIOLOGY OF OBESITY

• Female to male ratio varies across age and ethnic
  groups
• Ethnic minority women have substantially higher
  rates than white women
• Onset occurs from childhood through adulthood
• Inverse association with socioeconomic status

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DEFINING NORMAL BODY IMAGE AND EATING BEHAVIOR
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BODY IMAGE AND EATING BEHAVIOR VARIABLES

• BODY IMAGE
• Perception
• Evaluation
• Importance

• EATING BEHAVIOR
• Food selection
• Food quantities
• Meal patterns
• Subjective experience of control

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BODY IMAGE AND EATING BEHAVIOR VARIABLES

• BODY IMAGE
• Perception
• distortion
• Evaluation
• dissatisfaction
• Importance
• undue influence on sense of self-worth

• EATING BEHAVIOR
• Food selection
• not specified
• Food quantities
• overeating
• Meal patterns
• night eating
• Control over eating

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THE ROLE OF CULTURE

• Body ideals
• Gender roles
• Toxic environment

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THE CHANGING FEMALE BEAUTY IDEAL 1965
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THE CHANGING FEMALE BEAUTY IDEAL 1985
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MALE BEAUTY IDEAL
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CULTURAL MILIEU

• Masculinity is often defined in active terms

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McDonalds or McBinge?

• Standard Meal (870 calories)
• Hamburger 270 calories
• Medium French Fries 450 calories
• Small Coke 150 calories
• Super Size Meal (1,870 calories)
• Big Xtra! 810 calories
• Super French Fries 610 calories
• Super Size Coke 450 calories

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MYTHS EATING DISORDERS ARE...

• Disorders of vanity
• Disorders of white women
• Disorders of minimal clinical significance

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FACTS ABOUT EATING DISORDERS

• In the United States, we have no current,
  nationally representative epidemiologic data on
  eating disorders consequently, we cannot answer
  with certainty the question of how common eating
  disorders are in general or among specific
  demographic groups in particular.

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FACTS ABOUT EATING DISORDERS

• Among adolescent girls, prevalence rate estimates
  range from gt 1 to 5.
• Among adult women, estimates range from 2 to
  10.
• Eating disorders are estimated to be 10 fold more
  common among females compared to males however,
  some data suggest that eating disorders are
  increasing among men.

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DIVERSITY OF EATING DISORDERS

• Recent studies have shown that women of color are
  far from being immune to developing eating
  disorders. However,
• Just how common eating disorders are among girls
  or women of color is yet to be established.

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CHANGING ATTITUDES

• The female body ideal has become unrealistically
  thin
• Women used to think that the ideal was attainable
  only for a rare group of women
• Women used to feel sorry for those who had to be
  ultra slim--now women believe that everyone can
  attain the ideal

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ACCESS TO CARE

• It is estimated that only 25 of women with an
  eating disorder seek or receive treatment for
  their eating disorder.
• Access to care is even more limited among males
  or members of ethnic minority groups.

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ADVOCACY
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SERVICE UTILIZATION

• Specifically, we analyzed an insurance consortium
  database that included almost 4 million
  individuals with health insurance
• to determine how many individuals had received
  treatment within a given year and
• to describe treatment along basic parameters.

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SERVICE UTILIZATION

• The main results were threefold
• Health services use data suggest that only 1 in
  10 patients with an eating disorder receive
  treatment for their disorder.
• Men with Bulimia Nervosa are significantly
  underrepresented among those who had received
  treatment.
• Regardless of gender, the intensity of treatment
  provided was less than intensity recommended by
  clinical guidelines.

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SERVICE UTILIZATION

• The average length of care for females with AN
  was 17 days per year
• Less than 40 of female patients with BN received
  at least 15 days of treatment (evidence based
  medicine suggests that at least 15 sessions are
  required for an initial course of treatment)
• Men received an average of 9 days of care

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ACCESS TO CARE

• This study illustrates that eating disorders go
  untreated or under-treated in a large number of
  individuals.
• Although clearly all individuals with and eating
  disorder are likely to receive insufficient care,
  problems with access to care are even worse for
  girls or women of color and for males with an
  eating disorder.

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INSUFFICIENT ACCESS TO CARE LIKELY REASONS

• Stigma
• Lack of knowledge about treatment resources
• Lack of trained professionals
• Insufficient resources to support adequate
  treatment

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WHY SHOULD WE FOCUS ON ETHNIC MINORITY GROUPS?

• Half the human experience
• Monitor ethnic inequalities in health
• Identify protective factors
• Determine group-specific service needs

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RACE IN THE U.S. CENSUS 2000

• Five principal race categories
• White
• Black or African American
• American Indian or Alaska Native
• Asian
• Native Hawaiian or Other Pacific Islander
• Residual category (Some other race)
• Checking two or more races was possible

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RACE AND ETHNICITY IN THE UNITED STATES (U.S.)
CENSUS

• Race and Hispanic (Latino) origin are two
  separate and distinct concepts
• Hispanic is defined as a person of Cuban,
  Mexican, Puerto Rican, South or Central American,
  or other Spanish culture or origin regardless of
  race.
• U.S. federal agencies must use at least two
  ethnicity categories Hispanic-Not Hispanic

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U.S. POPULATION BY RACE AND ETHNICITY CENSUS 2000
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RACE AND ETHNICITY IN SELECT STATES CENSUS 2000
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RACE A SOCIOPOLITICAL CONCEPT

• There is no genetic foundation to race
• Objections to using race as a variable (Am J
  Public Health, 2000, Vol. 90 New England J.
  Medicine, 2001, Vol. 344, 18)
• Concern Reification of race as a biological
  construct (i.e., race differences reflect innate,
  biological differences)
• Indifference People are people
• Hostility Reverse racisms

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NATIONAL GROWTH AND HEALTH STUDY, WAVE II DESIGN

• Epidemiological sample, three sites
• Berkeley, CA
• Cincinnati, OH
• Washington, DC
• Two-stage assessment of eating disorders and
  other DSM IV Axis I disorders
• Screen
• SCID EDE

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NATIONAL GROWTH AND HEALTH STUDY, WAVE II SAMPLE

• 1061 Black women (response rate 87.5)
• 985 White women (response rate 84.5)
• Mean age Black women 21.46 (SD 0.7) White
  women 21.26 (SD 0.7)

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EATING DISORDERS IN BLACK WOMEN AND WHITE WOMEN
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COMPENSATORY BEHAVIORS IN BLACK AND WHITE WOMEN
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WEIGHT CONTROL BEHAVIORS IN BLACK AND WHITE
WOMEN, BY LOCATION DC VERSUS CA

• In Berkeley, but not in DC, Black and White women
  differed significantly.

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AGE OF ONSET OF THE EATING DISORDER
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ONSET AGE OF EATING DISORDER IN BLACK AND WHITE
GIRLS

• Mean age of onset of the eating disorder is
  significantly earlier in White women compared to
  Black women (p lt .05).
• Likely, our study has not yet captured the full
  window of risk for Black women

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TREATMENT FOR BN OR BED

• Of the 61 women with Bulimia Nervosa (BN) or
  Binge Eating Disorder (BED), 11 White women
  (26) and 1 Black woman (5) reported having
  received treatment for the eating disorder.

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EATING DISORDERS IN ETHNIC MINORITY GROUPS

• Myth the Golden Girl
• Smolak Striegel-Moore, 2001
• Under-utilization of mental health services
• Cachelin et al., 2000 2001
• Pike et al., 2001
• Wilfley et al., 2001
• Cultural competence of service providers
• Pathways to Health (Research Strategic Plan for
  the NIMH fiscal years 2000-2001)

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MOST COMMON BARRIERS TO SEEKING TREATMENT

• Financial difficulties (59)
• No or inadequate health insurance (48)
• Belief that treatment wont help (38)
• Fear of stigma (35)
• Lack of knowledge about treatment resources
  (35) Source Cachelin, Rebek, Veisel,
  Striegel-Moore, Int. Journal of Eating Disorders,
  2001.