How has ED’s been in the DSM
- anorexia and Bulimia started in the DSM in part of a category grouped with childhood presentation
- Chapter was added (Feeding and Eating Disorder Chapter)
Define the Feeding and Eating Disorder Chapter
Characterised by persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning
What are the 6 conditions in the Feeding and Eating Disorder Chapter
- Pica: persistent eating of non-nutritive substances (e.g.,
dirt, hair) - Rumination Disorder: repeated regurgitation of food
- Avoidant/Restrictive Food Intake Disorder [ARFID]:
persistent failure to meet appropriate nutritional and/or
energy needs - Anorexia Nervosa [AN]*
- Bulimia Nervosa [BN]*
- Binge-Eating Disorder [BED]*
- Other / Unspecified
Diagnostic criteria of Anorexia
A. Restriction of energy intake leading to significantly low body weight
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight on self-evaluation, or persistent lack of recognition of seriousness of low body weight
Specifiers:
* Restricting Type or Binge-eating/purging type
* Partial or full remission
How below weight is the average person with Anorexia?
*Average person with AN is 25 – 30% below normal body weight per BMI
What is the Diagnostic criteria for Bulimia
A. Recurrent episodes of binge eating
* Eating amount of food definitely larger than most individuals would eat in a similar time period, under similar circumstances
- Sense of lack of control over eating during the episode
B. Recurrent compensatory behaviours (e.g. vomiting, laxatives, exercise, fasting)
C. Both behaviours occur, on avg., at least once a week for 3 months
D. Self-evaluation is unduly influenced by body shape and weight
E. Does not occur exclusively during episodes of AN
What are the specifiers of bulimia?
- In partial or full remission
- Severity based on average number of inappropriate compensatory behaviours per week
- Mild: 1 - 3 episodes
- Moderate: 4 - 7 episodes
- Severe: 8 - 13 episodes
- Extreme: 14 or more episodes
Similarities/differences with AN and BN
Anorexia:
Extreme dieting → very low weight
Denies problem, feels in control
Comforted by strict self-control
Bulimia:
Binge eats, then compensates (vomit, exercise, etc.)
Normal weight
Aware of problem, feels ashamed
Upset by lack of control
Both:
Obsessed with body shape and weight
Low self-esteem tied to appearance
Common in young women, high SES
Can overlap — some binge/purge in both
Key idea:
Anorexia = control
Bulimia = loss of control
What is BED
- BED involves recurrent episodes of binge eating
- Large amount of food in 2 hrs & loss of control (see Bulimia, Criteria A)
- ≥ 3 associated symptoms (e.g. eating more rapidly, eating until uncomfortably full, eating when not hungry, embarrassed by how much eaten, feeling disgusted, depressed, or guilty afterward),
- Marked distress about binge eating
- Occurs once a week for ≥ 3 months
- Does not involve compensatory behaviour
Specifiers: in partial/full remission and severity
How do ED’s happen? (Epidemiology)
BED the most common eating disorder in Aust and overseas (2-3.5% of general population, higher in people with obesity).
AN – initially considered a culturally specific disorder? Previously thought to occur in Western or more economically developed countries only. Now, some evidence occurring in other countries.
Most at risk: young females from high SES groups,
people who participate in sports that emphases
weight (e.g., gymnastic, dance, jockeys
Trends of AN and BN
BN incidence is declining and AN incidence is stable, but AN is being diagnosed earlier than before (increased incidence in younger age groups < 15 years).
ED and Sex
- ED 10 times more common in women than men
but - Documented risk factor for men in subgroups including
- Wrestlers (pressure to “make weight”)
- Athletes
- Some sexual orientations
- Age of onset of eating disorders in men & women similar
Age and ED
*Both AN and BN have onset in adolescence and early adulthood
- Weight and dieting (and the presence of EDs) decreases as adolescent girls become women (esp. following marriage &
parenthood)
Medical complications of AD
- Amenorrhea
- Dry skin, brittle hair & nails
- Increased sensitivity to cold
- Downy hair growth on face and limbs
- Cardiovascular problems (e.g., low blood pressure)
- If purging – electrolyte imbalance; dehydration, dental problems; sensitised gag reflex
- Osteopenia (low bone density) leading to osteoporosis/stress fractures
- Death, due to starvation; suicide risk
Medical problems of BN
- Many purging-related complications
- Enlarged salivary gland – gives face a chubby appearance
- Damage to dental enamel (dependent on compensatory method)
- Risk of electrolyte imbalance (-> cardiac arrhythmia, renal failure)
- Callusing on fingers and back of hand from contact with teeth and throat to stimulate gag reflex
- Intestinal problems (e.g., colon damage) if laxative abuse
Comorbidy of ED
- high diagnostic crossover
- Comborditiy of ED with other disorders esp anxiety, mood, substance use, personality disorders. Between 50- 70% of people with AN, BN, or BED will also qualify for another DSM diagnosis
- In AN and BN: OCD
Cause of ED (biological)
- Possible genetic component though complex to interpret (ABC news)
- Role of neurotransmitters that normally regulate eating
- Preliminary data suggests abnormalities in serotonin levels
- Hypothalamic function
- Dopaminergic systems & reward- sensitivity.
- Biological disruption to Body’s attempt to maintain “set point”
psychological cause of ED`
- Cognitive factors (distorted perception of body size/weight)
- Lack of interoceptive awareness
- Perfectionism, control
- Dysphoria, low self-esteem, depression
- Anxiety associated appearance of self to others
- Association between weight/appearance and self-worth, success etc
Social causes of ED
Eating disorders - possibly the most culturally specific psychological disorder currently in DSM
- Perceptions of attractiveness
- Acceptance of dietary restraint, particularly in some occupations/cultures
- Religious and cultural reasons for dietary restraint are prominent in some cultures.
- Family influences (ongoing area of investigation). Suggestion that mothers were dieters/ those with AN avoid conflict but like control. Upbringing may play a role.
Family and individual influences on the cause of ED
- An affected parent may increase the risk
- “family dysfunction” – families that are more
rigid, less cohesive, and poor communication
The family environment may be a factor in EDs but the relations still require further study.
Individual risk factors the demographic factors already discussed and factors such as low mood (negative affectivity) and perfectionism.
Risk factors for ED
- Physical size
- Eating patterns
- Pubertal status
- Personality characteristics
- Attitudes about eating & self
- Family dynamics/functioning
- Family history
- Interoceptive awareness (recognition of internal cues
including various emotional states as well as hunger)
An integrative model: eating disorders (link between biological, social, psychological risk of developing and ED)
Eating disorders result from biological vulnerability, psychological distress, and social pressure, which together influence eating behaviors and maintain the cycle through temporary relief from anxiety.
Some treatment differences in S AN, BN, & BED
- AN may require force feeding/hospitalisation; BN rarely
does - BN and BED may be more amenable to successful psychological treatment than AN
- BN and BED may be treated with weight loss drugs
Anorexia - treatment approaches vary but most
aim to
- Enhance self-esteem, tying this to internal rather than external evaluations
- Provide education about “normal body weight” & address maladaptive cognitions regarding loss of control
- May involve family therapy
- Promote weight gain (sometimes using behaviour therapy programs; or the Maudsley method – assuming control over eating until it can be returned to the client
