Eating Disorders: Diagnosis, Support, and Conditions

Eating Disorders: Diagnosis and Conditions

• Enrollment numbers suggest many students have a history of eating disorders or other issues.
• Problems come from a combination of genetic, environmental, and socio-cultural factors.
• Emotional difficulties don't make you a bad person.
• Emotional and financial support is available to trans people in crisis.
• National Eating Disorder Information Centre (NEDIC) provides information, resources and referrals to Canadians affected by eating disorders.
• Connect with trained support workers through confidential helpline and instant chat services.
• Ontario Crisis Line is available for all ages (1-866-531-2600), and for Ontario College & University Students: 1-866-925-5454.
• Eating disorders appeared in the DSM for the first time in 1980 as a subcategory of disorders beginning in childhood or adolescence.
• In DSM-IV, anorexia nervosa and bulimia nervosa formed a distinct category, showing increased attention from clinicians and researchers.
• Binge eating disorder is now a distinct diagnostic category in DSM-5.
• DSM-5 introduced improved criteria for anorexia nervosa and bulimia nervosa.
• Anorexia and bulimia are more common in females than males.
• Binge eating disorder is equally common in women and men.
• About 1 million Canadians have an eating disorder (Statistics Canada 2016).
• Many people have undiagnosed eating disorders.
• Eating disorders are associated with high mortality rates (10-15%).
• There are high rates of suicide and suicide attempts.
• High rates of dieting exists in children from ages 11-14, which puts children at risk of developing an eating disorder.
• 'Other specified' feeding or eating disorder applies to atypical, mixed, or subthreshold conditions, including subthreshold bulimia nervosa & binge eating disorder, night eating syndrome, and purging disorder.
• 'Unspecified' feeding or eating disorder is used with insufficient information like in hospital emergency rooms or when an eating-related disorder has significant distress/impairment, but doesn't meet criteria for another disorder.
• Orthorexia is not in the DSM, but may fall in the category of 'other specified' disorders.
• Orthorexia has similarities to OCD; those with orthorexia are preoccupied with eating healthy foods to the extent that behavior/feelings cause distress or impairment and can become extreme and lead to an extremely restricted diet with nutritional deficiencies.
• People with purging disorder have levels of disturbed eating and psychopathology comparable to other eating disorders and high impulsivity.
• Anorexia nervosa and bulimia nervosa share the clinical feature of the intense fear of being overweight.
• Indications suggest these could be two variants of a single disorder, where co-twins diagnosed with anorexia nervosa are more likely to have bulimia nervosa (Walters & Kendler, 1994).
• Anorexia means "loss of appetite", while nervosa means "appetite loss due to emotional reasons"

DSM Criteria For Anorexia Nervosa

• Restriction of energy intake leads to a significantly low body weight within the context of a person's age, sex, and physical health status.
• There's an intense fear of gaining weight and the fear is not reduced by weight loss.
• Distorted sense of body shape, where even when emaciated, people still maintain that they are overweight or that certain parts of their bodies are too fat.
• To check on body size, people will weigh themselves frequently, measure the size of parts of the body, and gaze critically at their reflections in mirrors.
• The self-esteem of people with anorexia nervosa is closely linked to maintaining thinness, which is known as over evaluation of appearance.
• Among people with acute anorexia nervosa, lower body weight is associated with increased self-esteem.
• Anorexia typically begins in the early to middle teenage years, often after an episode of dieting and exposure to life stress and the prevalence of anorexia among children and adolescents is increasing.
• Comorbidity is high.
• At-risk men and women are prone to depression, panic disorder, and social phobia.
• Women were at substantially greater risk for mania, agoraphobia, and substance dependence.
• There is a high rate of co-occurring eating disorders and substance use disorders.
• A Spanish meta-analysis found no link between anorexia nervosa and illicit drug use, but a clear link evident between bulimia nervosa and drug use (Calero-Elvira et al., 2009).
• Canadian researchers tied drug use to the binging and dieting cycle (Gadalla & Piran, 2007).
• Physical changes with anorexia include lower blood pressure, heart rate, bone mass, kidney problems, gastrointestinal problems, dry skin, brittle nails, hormone changes, and mild anemia.
• Prognosis: 70% of patients recover, but recovery often takes six or seven years and relapses are common.
• Death rates are ten times greater than general population.
• Death rates two times greater than patients with other psychological disorders.
• Longitudinal investigation found mortality rate for AN is five times higher than the rate for the general population (Fichter & Quadflieg, 2016).
• Predictors of death include lower BMI, older age at first presentation for treatment, and alcohol misuse (Arcelus et al., 2011).
• Death mostly results from physical complications or suicide (Birmingham et al., 2005; Katzman, 2005).
• A BC survival analysis found anorexia is associated with a 25-year reduction in life expectancy (Harbottle, Birmingham, & Sayani, 2008).
• A review found that suicide rates are not elevated in bulimia nervosa as they are in anorexia nervosa (Franko & Keel, 2006).
• People with bulimia nervosa report thoughts of suicide, but the rate is much lower than for those with anorexia; one in five deaths attributed to anorexia involved suicide (Arcelus et al., 2011).

Bulimia Nervosa (BN)

• Bulimia is from a Greek word meaning "ox hunger".
• The disorder involves episodes of rapid consumption of a large amount of food (binge), followed by compensatory behaviors (purge).
• Binge = eating excessive amount of food in < 2 hours. Typically occur in secret and may be triggered by stress, and involves feeling a lack of control over the behavior.
• Purge = vomiting, fasting, misuse of diuretics, laxatives or enemas, or excessive exercise. DSM-5 stipulates that the binge eating and compensatory behavior must continue at least once a week for three months.
• Bulimia nervosa is not diagnosed if the binging and purging occur only in the context of anorexia nervosa and its extreme weight loss; the diagnosis in such a case is anorexia nervosa, binge eating-purging type.
• Binge episodes tend to be preceded by poorer than average social experiences, self-concepts, and moods.
• Stressors that involve negative social interactions may be particularly potent elicitors of binges.
• There are high levels of interpersonal sensitivity, as reflected in large increases in self-criticism following negative social interactions.
• Those engaged in a binge often feels a loss of control over the amount of food consumed and rapidly consumed foods, especially sweets like ice cream or cake, are usually part of a binge.
• People with bulimia are usually ashamed of their binges and try to conceal them.
• Garfinkel (2002) noted that “a morbid fear of fat" is an essential diagnostic criterion for bulimia nervosa because it covers what clinicians and researchers view as the "core psychopathology" of bulimia nervosa, makes the diagnosis more restrictive, and makes the syndrome more closely resemble the related disorder of anorexia nervosa.
• Bulimia nervosa typically begins in late adolescence or early adulthood.
• Extreme body dissatisfaction was found among 7-8% of both grade 5 girls and boys in Nova Scotia, suggesting that particularly at-risk children can be identified at a young age (Austin, Haines, & Veugelers, 2009).
• Fat talk refers to the tendency for friends, particularly female friends, to take turns disparaging their bodies to each other.
• Both average and overweight people were seen as more likeable if they were depicted engaging in fat talk (Barwick et al., 2012), and it seems to reflect a highly defensive and negative sense of self.
• The majority of people with bulimia nervosa are somewhat overweight before the onset of the disorder and the binge eating often starts during a dieting episode.
• Long-term follow-ups of bulimia nervosa clients reveal that about 70% recover, though about 10% remain fully symptomatic (Keel et al., 1999).
• Physical side effects include potassium depletion, diarrhea, changes in electrolytes, irregularities in the heartbeat, tearing of tissue in the stomach and throat, loss of dental enamel, and swollen salivary glands.

Binge Eating Disorder (BED)

• BED is a new DSM-5 formal diagnostic condition and includes recurrent binges, occurring at least once per week for at least three months.
• This disorder includes recurrent binges, lack of control during each binge, and distress about binge-eating, as well as other characteristics
• Binge eating episodes must involve at least three of following:
  • eating more rapidly than normal
  • eating until feeling uncomfortably full
  • eating alone due to feelings of embarrassment
  • eating large amounts of food when not feeling hungry
  • feeling disgusted with oneself or depressed or very guilty.
• BED is distinguished from anorexia by lacking weight loss and from bulimia by lacking compensatory behaviors such as purging, fasting, or excessive exercise.
• It is seems more treatment responsive than anorexia/bulimia nervosa.
• Risk factors include childhood obesity, critical comments regarding being overweight, low self-concept, depression, and childhood physical or sexual abuse (Fairburn et al., 1998).
• The average life-term duration of BED (14.4 years) may be greater than the duration of AN (5.9 years) or BN (5.8) years (Pope et al., 2006).

Etiology of Eating Disorders

• The role of genetics has been largely ignored, relative to other types of disorders, because of a prevailing emphasis on socio-cultural factors.
• Both anorexia nervosa and bulimia nervosa run in families.
• First-degree relatives of young women with anorexia nervosa are about four times more likely than average to have the disorder themselves (Strober et al., 1990).
• Twin studies of eating disorders also suggest a genetic influence.
• Most studies of both anorexia and bulimia report higher identical than fraternal concordance rates.
• The hypothalamus is a key brain center in regulating hunger and eating (de Krom et al., 2009). Animals with lesions to the lateral hypothalamus lose weight and lose/have no appetite (Hoebel & Teitelbaum, 1966).
• Ghrelin is a hormone that is associated with hunger, and leptin is linked to satiation/fullness.
• Levels of some hormones regulated by the hypothalamus, such as cortisol, are chronically elevated in those with anorexia and bulimia.
• These abnormalities occur as a result of self-starvation, and levels return to normal following weight gain (Doerr et al., 1980).
• Weight loss of animals with hypothalamic lesions does not parallel anorexia.
• Lesioned animals appear to have have no hunger; anorexia clients continue to starve themselves despite being hungry since the hypothalamic model doesn't account for body-image disturbance or fear of becoming fat.
• Endogenous opioids are produced by the body and reduce pain sensations, enhance mood, and suppress appetite, at least among those with low body weight.
• Starvation may increase the levels of endogenous opioids, resulting in a positively reinforcing euphoric state (Marrazzi & Luby, 1986), while excessive exercise increases opioids and is thus reinforcing (Davis, 1996; Epling & Pierce, 1992).
• Hardy and Waller (1988) hypothesized that bulimia is mediated by low levels of endogenous opioids, which promote craving; a euphoric state stems from food ingestion, reinforcing bingeing.s

Neurotransmitters Related To Eating Disorders

• Low levels of serotonin metabolites and serotonin in people with bulimia.
• Serotonin metabolites have been linked with the negative mood and self-concept changes that precipitate binge episodes. (Steiger et al., 2005).
• Hildebrandt et al. (2010) advanced a development model that links serotonin and estrogen in bulimia nervosa which states that there are genetic polymorphisms at birth that limit the serotonergic system and associated genes may be further impacted by harsh environments in the form of maladaptive parenting styles.
• Subsequent environmental estrogens predispose female adolescents to weight gain, increasing the perceived need to engage in dieting that may become excessive.

Sociocultural Factors and Eating Disorders

• Standards society has set for the ideal body in history has varied greatly.
• Under current standards, the famous nudes painted by Rubens in the seventeenth century are overweight.
• Playboy models became thinner between 1959-1978 (Garner, Garfinkel, Schwartz, & Thompson, 1980).
• A follow-up study of Playboy centerfolds found the trend of increasing thinness leveled off and then began reversing.
• When it comes to unrealistic images, females consistently feel more pressure than males.
• Average women would have to increase her bust by 12 inches, reduce her waist by 10, and grow to over seven feet in height to achieve the same figure as the Barbie doll (Moser, 1989).
• The insidious effects of exposing young girls to Barbie dolls with unrealistic body images are shown in experiment (Dittmar, Halliwell, & Ive, 2006).

Scarlett O'Hara Effect

• Women respond to socio-cultural pressures by eating lightly in an attempt to project images of femininity.
• Research confirmed that women portrayed as eating heavily are less feminine and more masculine than women portrayed as eating light meals.
• Pliner and Chaiken coined the term 'Scarlett O'Hara effect' to refer to this phenomenon of eating lightly to project femininity.
• While cultural standards and pressures to be thin increased, people became more overweight.
• Between 1900 and the present day, obesity in Canada has doubled, so that 25% of Canadians are overweight.
• Pinel, Assanand, and Lehman (2000) attribute the rise of obesity to an evolutionary tendency for humans to eat too much in order to store energy for a time when food may be scarce.
• Excessive body fat has negative connotations, such as being unsuccessful and less controlled.
• Obese people are seen as less intelligent / lazier.
• Investigations suggest negative attitudes towards fat are pervasive so obese people endorse these views; however, the bias is more unconscious in those who are thinner (Schwartz et al., 2006).
• The media promotes these stereotypes.
• A content analysis of 18 primetime television situation comedies conducted by researchers in Calgary found that females with below average weights are overrepresented in these shows, and the heavier the female character, the more likely they were to have negative comments directed toward her (Fouts & Burggraf, 2000).
• "Pro-ana” websites glorify starvation and reinforce irrational beliefs about the importance of thinness/benefits of being dangerously thin and those in desperation seek them out, or find diet tips there. A common theme views thinness as happiness (Rodgers, Skowron, & Chabrol, 2012).
• Appearance pressures are growing on young males, which can be seen in a heightened drive for muscularity, which can take the extreme form of muscle dysmorphia.

Cross-Cultural Studies

• Eating disorders are more common in industrialized societies than in non-industrialized nations, but this gap is closing, and levels of research interests & publications around this topic are increasing (So & Walter, 2013).
• Young women immigrating to Westernized cultures may be prone to developing eating disorders because of rapid cultural changes and pressures (Geller & Thomas, 1999).
• Anorexia theories emphasize the fear of fatness/distorted body image as motivating factors which make self-starvation and weight loss powerful reinforcers.
• Behaviours that achieve or maintain thinness are negatively reinforced by less anxiety about becoming fat.
• Dieting and weight loss may be positively reinforced by the sense of mastery/self-control (Fairburn, Shafran, & Cooper, 1999; Garner, Vitousek, & Pike, 1997).
• Exposure to media can cause those that see thinness as ideal and compare themselves to those they see as attractive to have low body satisfaction (Stormer & Thompson, 1996).
• Brief exposure to fashion models can instill negative moods in young women, and they're especially vulnerable when exposed (Pinhas et al., 1999).
• Binging occurs when diets are broken (Polivy & Herman, 1985) and small mistakes in diet can lead those with anorexia to a binge.
• Purging after binging again shows the fear of gaining weight.
• Anorexia clients without episodes of bingeing/purging may have a more intense obsession with and fear of weight gain (Schlundt & Johnson, 1990) or be better able to exercise self-control.
• Those who have disturbed parent-child relationships can have low self-esteem + perfectionism, which are common in those with the eating disorder; symptoms may fulfill the need to increase personal effectiveness.

Psychodynamic Views

• Hilde Bruch (1980) posits that anorexia nervosa is an attempt by children who have been raised ineffectually who seek competence/respect and ward off feelings of helplessness, ineffectiveness, and powerlessness.
• This ineffectiveness is created by parenting style in which the parents' wishes are imposed on the child rather than the child's.
• Children do not learn to identify their own internal states/become self-reliant through this method.
• When faced with the tasks of adolescence, the child can turn to societal pressure of thinness/dieting as a means of gaining control and proving their identity.
• Self-reports show high level of conflict in the family among people with eating disorders (e.g., Hodges, Cochrane, & Brewerton, 1998), but parent reports do not necessarily indicate high problems of family problems.
• Disturbed relationships are still part of the issue, and support for the family is low so it may be difficult to fit the family into system based theory; it is possible these results stem from the ED in its nature.
• Studies indicate higher self-reports of childhood abuse in people with eating disorders, especially those with bulimia nervosa (Steiger & Zanko, 1990).
• A Toronto study found that 25% of women with eating disorders reported experiencing previous sexual abuse.
• Relative to normal eaters, bulimic women had higher levels of childhood abuse
• Level of abuse predicted high degree of psychopathology (Leonard, Steiger, & Kao, 2003).
• Physical/Abuse are large predictor for the development of an ED, which lines of with 2012 Community Health Survey (Afifi et al., 2014).

Unethical Research Examples

• An experiment of hunger/malnutrition was conducted in aboriginal (First Nations) communities, Canada by Nutrition experts put in place by the government
• Controlled Experiment were taken place unethically by Mosby (2013) because they were not told about what was going. Cree People of Manitoba were included.
• It is said that Researchers sought after those both, young and old, did not give enough foods/nutrition so that it they could better analyze them
• A thousand child were affected by keeping them starve and at times malnourish, mainly so that the research objectives could thrive.
• Retrospective research has described clients with anorexia as having been perfectionistic, shy, and compliant before the eating disorder's onset.
• People with bulimia have additional characteristics of histrionic features, affective instability, and an outgoing social disposition (Vitousek & Manke, 1994).
• Those with anorexia/bulimia are high in neuroticism/anxiety, low in self-esteem (Bulik et al., 2000) and their neuroticism can predict AN onset (Bulik et al., 2006) since traditional family value are high for the two.
• Those that are anorexic clients have a great level of narcissism which carry on to post eating habits and eating has now increased.
• The "poor me" style has great implications because it has can lead to higher degrees of the rate at which they withdraw from programs (Campbell, Waller, & Pistrang, 2009).
• Eating is greatly correlated with the ideal of perfection (Hewitt & Flett (1991b).
• Hewitt and Flett (1991b) created a multidimensional perfectionism scale, and two are included : self-oriented and socially.
• Post weight restored / unweight had show great score for “Self".
• Unrestored score high in perfection both forms. Anorexic person will have will show high indication of (Self oriented)

The Three Factor Interactive Model of Bulimia

• Can explain Bulimics: (Ideal) body image, and a loss if Self values
• A certain amount of individuals try and seem to have an image of perfection and in the process forget to realize there are error (Hewitt, Flett, & Ediger, 1995; Hewitt et al., 2003).
• People respond to great measure of stresses at Stanford and expectations by acting clam but their anxiety and stress.is high. They're know to be in front the public but act with pressure to not show their true colors.
• Role of causal dimension have been test to the fullest in the world, has show many prospective dimensions have high rating on onset of disorder, research is in need.

Treatments Of Eating Disorders

• Typically deny and can find that its a hard time for one to enter a patient
• Majority have an eating disorder which can range up to 90% , this is a high sign that the program is too resentful (Fairburn et al., 1996)
• Those with Anorexia require to a hospital due to that they don’t take/eat properly, so the nutrients is low when there in the hospital there ingestion is tracked
• Intravenous help to secure those with low body weight can use the nutrients to be better and have the proper nutrition.
• Dentist will check the gum decay , many with bulimia have problems where there gum get the rode or even the tooth get decayed. and this is a result people that purge from the mouth to remove all the access eating so that the body does not store that food and cause that person to gain weight.
• The number shows some to time increase for relapse of Eating disorder .
• A current survey in Toronto for patient of Anorexia to discover some will back lash. Carter et al. (

2012. discovery in their survey to those those those those

Relapse will increase for whom whom the patient has:

• Those that binge and purge
• Those that are obsessive in character
• Those that are not really motivated and have not put dedication which has resulted in relapse.
• Antidepressants drugs is very helpful towards bulimia
• Medication are really hard to to help those with these these mental problem because it leads to the increase of those dropping form the treatment and only a select can can follow through (Fairburn, Agras, & Wilson, 1992).
• Has at the moment there are no effective method to secure Anorexia Neravosa.
• Those with Anoxeria requires certain amount of stage to help overcome the situations. First goal, the individual has to maintain a certain number of mass weight to keep the process stable and save
• Secondly Long has to have dedication and maintain of goal weight Meta data showns some the families and individual therapy to better assess there degree after eating disorder/treatment The individual those 6-10 have some sort of improvement. The two show that their can be improvement those one of the two. CBT-E is one of the the top methods to help those who have a history of Burmia and even BED
• (CBT-E) This help to show that some to the treatment to to secure them and have shown is needed.
• Mood /Perfection/Self esteem the biggest problem where those who are in perfection and want that (image) to to be (self) and and are un satisfied.
• Binge and ED has seen the big problems where treatment through these method have been secured by some to the top researcher. The use by interpersonal skills to create secure people that love one another was created.

More facts CBT

• Those people with CBT those who have come in with the disorder to the half is difficult because most some to the studies don't indicate fully whether it is that to have a hard time
• These are some of the many reasons that many have to have many factor (anxeity/ depression) etc.
• These individuals have many difficulty to stay in touch with themselves in the process that the body needs more and wants to be better/ secure.
• These problem continue and more time can be shown because of the individuals negative to be better and need to be that person.