Eating

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• Eating
• Disorders
• Psychological
• and Clinical Perspectives Assessment,
• diagnosis, treatment and explanations.
• A critical look- what has been ignored?
• Devinder Rana BSc (Hons) Psychology LM40507
  Psychopathology and Abnormal Psychology

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Aims

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

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Eating Disorders

• 1. Anorexia Nervosa
• 2. Bulimia Nervosa
• 3. Eating Disorder Not Otherwise Specified
  (EDNOS) Binge-eating disorder (proposed diagnosis
  requiring further study).

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Anorexia Nervosa
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Criteria DSM-IV-TR

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

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Sub-types (APA, 2000).
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In Context DSM-VI-TR (2000) Criteria

• A 511 adult weighing 11 stone (70 kilos) falls
  into the OK category.
• A deviation of 15 results in the individual now
  weighing just over 9 stone and is subsequently
  classed as anorexic.

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Epidemiology

• 80-90 of suffers are female with typical age
  onset between 14-18 years old (Pike, 1998).
• Weight control remains a long-term issue.
• Links with Obsessive Compulsive Disorder
• Occur in young children
• Occur in boys

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Ballet dancers (Gelsey Kirkland) and gymnasts
(Christy Henrich)
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Characteristics of Anorexia

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

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Distorted body image

• Over estimation of body proportion and distorted
  body image (Gupta Johnson, 2000).
• Link with depression, anxiety and OCD.

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Effects of Anorexia

• Amenorrhea (lack of menstruation).
• Immune infections

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(No Transcript)
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High/low blood pressure
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Cracked Skin
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Brittle hair and bones
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Cardiotoxicity (heart damage)
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Consequences

• Mortality rate is 12x higher than the mortality
  rate for females aged 15 to 24 in the general
  population (Sullivan et al 1995).
• Death results from
• Physiological consequences from starvation
• Intentional suicidal behaviour

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Historical Account and Definition

• Anorexic nervosa means
• lack of appetite induced by nervousness.
• (Butcher et al, 2007).
• Lack of appetite is not the real problem.

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• Self-starvation, resulting in a minimal weight
  for one's age and height or dangerously unhealthy
  weight.
• Hudson et al (2006).

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• Greek
• An without
• Orexis a desire for
• without desire for food
• Nevid et al (2008).

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Central to anorexia nervosa

• Fear of gaining weight or becoming fat
• Refusal to maintain even a minimal low body
  weight.

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Historical Accounts

• Accounts in early religious literature
  (Vandereycken, 2002).
• First medical account published in 1689 Richard
  Morton.
• 18 year old girl and 16 year old boy- described
  as having a
• nervous consumption that
• caused wasting of body tissue.
• 1873 Sir William Gull in London Charles Lasegue
  in Paris independently describe the clinical
  syndrome and receive its current name.

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• Gull (1888)
• Described a 14 year old girl
• Without apparent cause, to evidence a repugnance
  to food, and soon afterwards declined to take
  whatever, except half a cup of tea or coffee.

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Problems with the diagnostic tool DSM-IV-TR

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

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Bulimia Nervosa
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Criteria DSM-IV-TR

• Recurrent episodes of binge eating.
• binges in a fixed period of time, food far
  greater than normal circumstances.
• Lack of control and unable to stop.
• Recurrent and inappropriate efforts to compensate
  for the effects of binge eating.
• self induced vomiting
• laxatives
• excessive exercise
• thyroid medication
• Self-evaluation is excessively influenced by
  weight and body shape.

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Characteristics

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

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Anorexia Vs. Bulimia
Anorexia Bulimia
Weight loss not driven by desire to appear feminine. Social concept of femininity drives behaviour
High self-control Impulsive and emotional instability
Body weight significantly (gt15) below age/height Weight fluctuation (remains relatively close to norms)
Less likely to have been overweight More likely to have been overweight
Underweight (severe) Normal weight (slightly overweight)
Less likely to abuse drugs/alcohol More likely to abuse drugs/alcohol
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Bulimia and Purging anorexia nervosa

• Meets the criteria for binging/purging, also
  meets the criteria for anorexia nervosa, anorexia
  nervosa will be diagnosed.
• Common anxiety with fear of being fat.

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2 types
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Explanations
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Complex Interaction
Psychological
Biological
Socio-cultural
family
Individual
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Biological Factors

• Genetics

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Genetics

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

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Twin studies

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

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Genes

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

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Brain Hypothalamus and GLP-1

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

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Weight Set Point Theory

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

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The average American woman is 54 and 140 pounds.
The average American model is 511 and 117
pounds.
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• Societal
• Pressures

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

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Battle of Brittan's
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Timeline

• 1639 - The Three Graces Pieter Pauwel Rubens

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• 1887 - Pierre Auguste Renoir, The Bathers

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• 1920 - Thin, short haired flapper

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• 1950 - Monroe (Size 14/16)

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• 1960 - Twiggy Lawson (Aka the beginning of the
  end.) This was the first time in history that an
  under weight woman became the standard for the
  ideal body image.

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• 1988 - Cosmopolitan

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• 2002 - Harpers Bazaar

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• Modern day Fashion Model

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Family Environment

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

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Ego Deficiencies and Cognitive Disturbances

• Bruch built on psychodynamic and cognitive
  notions.
• Disturbed mother-child interactions lead to
  serious ego deficiencies in the child (poor sense
  of control and independence) serve cognitive
  disturbances (Bruch, 2001).
• Effective parents attend to their childs
  biological and emotional needs
• Ineffective parents fail to attend to needs,
  misinterpreting i.e., being hungry rather than
  seeing the actual condition- grow up confused.
• Not being control of their behaviour, not rely on
  internal signs, not self-reliant instead during
  adolescence when looking for independence seek
  control with weight and body image.
• Pearlman (2005) eating disorder parents define
  children needs rather than the child.
• 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 childs needs.
• Perceive internal cues inaccurately (Bydlowski
  et al., 2005)
• Anxious or upset- think they are hungry so eat
• Worry how others view them, seek approval, be
  conforming and feel lack of control over their
  lives (Button Warren, 2001).

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

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

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Treatments for Anorexia Nervosa
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How is proper weight and normal eating restored?

• Past in hospitals, today in outpatient settings
  (Vitousek Gray, 2006)
• Life-threatening cases force tube and
  intravenous feedings on a patient who refuses to
  eat (Tyre, 2005)
• Can result in distrust in the patient (Robb et
  al., 2002).
• Weight restoration approaches clinicians use
  rewards whenever patients eat properly or gain
  weight (Tacon Caldera, 2001)
• Combination of supportive nursing care,
  nutritional counselling high calorie diet (no
  more than 2,500 calories a day). Herzog, et al.,
  2004).
• Help them to recognise that the weight gain is
  under control and will not lead to obesity..
• Gain the necessary weight in 8-12 weeks.

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How are lasting changes achieved

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

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Aftermath of Anorexia Nervosa

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

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Treatment Bulimia Nervosa
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Treatments

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

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Aftermath

• Treated successfully, relapse is a common problem
  triggered by new life stresses.
• 1/3 treated relapse 6months later (Olmsted et
  al., 1994)
• Former patients less depressed then time of
  diagnosis (Halmi, 1995)
• Depends on history, length and frequency of
  vomiting.

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Karen Carpenter 1970s
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Reading Seminar

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

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• Petrie, T., Greenleaf, C., Reel, J., Carter, J.
  (2008, October). Prevalence of eating disorders
  and disordered eating behaviors among male
  collegiate athletes. Psychology of Men
  Masculinity, 9(4), 267-277. Retrieved January 22,
  2009, doi10.1037/a0013178
• Tibon, S., Rothschild, L. (2009, January).
  Dissociative states in eating disorders An
  empirical Rorschach study. Psychoanalytic
  Psychology, 26(1), 69-82. Retrieved January 22,
  2009, doi10.1037/a0014675
• Hepworth, J., Griffin, C. (1995). Conflicting
  opinions? 'Anorexia nervosa,' medicine and
  feminism. Feminism and discourse Psychological
  perspectives (pp. 68-85). Thousand Oaks, CA US
  Sage Publications, Inc. Retrieved January 22,
  2009, from PsycINFO database.

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• Wu, K. (2008, December). Eating disorders and
  obsessive-compulsive disorder A dimensional
  approach to purported relations. Journal of
  Anxiety Disorders, 22(8), 1412-1420. Retrieved
  January 22, 2009, doi10.1016/j.janxdis.2008.02.00
  3

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Reading

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

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End