PSY_183 Feeding and Eating Disorders 2024 PDF

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2018, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloading Is for Private Use Only by Students Currently Registered in UCSB Psych 183. For-P...

Introduction to Psychopathology Alan J. Fridlund, Ph.D. NOTICE: These Lecture Notes © Copyright 2014, 2018, 2020, 2023, 2024, by Alan J. Fridlund, Ph.D. All Rights Reserved. They May Be Downloading Is for Private Use Only by Students Currently Registered in UCSB Psych 183. For-Profit Reproduction in Whole or In Part Without Written Permission of the Instructor Is a Violation of U.C. Regulations and the DMCA and Is Expressly Prohibited.  Notice All Course materials (class lectures and discussions, handouts, examinations, Web materials) and the intellectual content of the Course itself are protected by United States Federal Copyright Law, and the California Civil Code. UC Policy 102.23 expressly prohibits students (and all other persons) from recording lectures or discussions and from distributing or selling lectures notes and all other course materials without the prior written permission of the Instructor (See http://policy.ucop.edu/doc/2710530/PACAOS-100). Students are permitted to make notes solely for their own private educational use. Exceptions to accommodate students with disabilities may be granted with appropriate documentation. To be clear, in this class students are forbidden from completing study guides and selling them to any person or organization. The text has been approved by UC General Counsel. You are granted permission in Psych 183 to download and retain personal copies of these slides solely for your own use. Feeding and Eating Disorders DSM-5-TR Main Feeding and Eating Disorders Avoidant/Restrictive Food Intake Disorder (ARFID) – picky eating or disinterest in food leading to significant weight loss. Anorexia nervosa – significantly low body weight with intense fear of gaining weight of becoming fat, and body image distortion. Bulimia nervosa – recurrent binge eating with a loss of control over bingeing, and compensatory behaviors to prevent weight gain. Binge Eating Disorder - recurrent binge eating with a loss of control over bingeing, but without compensatory behavior.  Avoidant/Restrictive Food Intake Disorder (ARFID) Commonly develops in infancy or early childhood and may persist into adulthood; no apparent sex difference in diagnosis. Disinterest in food, or “picky eating” due to extreme sensitivity to sensory qualities of food (e.g., appearance, color, smell, texture, temperature, taste). Note: there is a normal period of food neophobia in 1 to 3 year olds. Eating pattern results in significant weight loss, nutritional deficiency, dependence on tube feeding or required supplements. Sustained nutritional deficiencies with ARFID may lead to eventual physical deterioration and death. Unlike other eating disorders, there is little concern with body image or appearance. Can occur after prior incidents of choking or vomiting, and may accompany a variety of medical conditions and other mental disorders. May be more common in children with learning difficulties, ADHD, and/ or Autism Spectrum Disorder. Treatment involves nutritional counseling, CBT, appetite stimulants, and anti-anxiety meds.  Except for ARFID, Most Eating Disorders Are: overwhelmingly female. co-morbid among family members at rates greater than general population. frequently accompanied by anxiety and substance use disorders. overwhelmingly found in Western countries. apparently related to Western cultural conceptions about food and femininity. increasing in non-Western countries as they Westernize; with Westernization: – more females join the workforce. – thin-ness replaces obesity as a sign of wealth and status. – disordered eating in non-Western cultures has been associated with exposure to Western movies and television. Relative Prevalences of DSM-5-TR Eating Disorders in Males vs. Females  Why Are Eating Disorders Overwhelmingly Female? Across Western cultures, males are likelier to be obese, but are less likely than females to care about their physical appearance. Women’s magazines and Web sites emphasize physical attractiveness and, ironically, both food preparation and dieting. Men’s magazines emphasize fitness and body-building. Weight- loss ads are 10X as frequent in women’s magazines. Males in sports that emphasize thin-ness or weight control (wrestling, boxing, crew, jockeying), or in competitive body- building, rather than agility or strength, show rates of disordered eating comparable to females. Males active in the gay social scene are often subject to many of the same physical attractiveness pressures as heterosexual females, and they appear to have elevated rates of eating disorders. With the 1990’s onset of “metrosexuality,” rates of eating disorders may be increasing among males generally.  Changed Standards of Female Attractiveness Kate Moss for Calvin Klein, ~2002 - “Heroin Chic” The Three Graces Pieter Pauwel Rubens, 1639 Hourglass Shape: Female Beauty Ideal?  Changed Standards of Male Attractiveness Creation of Adam Michelangelo, 1510 Tom of Finland ~1970 BTS, 2023 Portrait of Henry VIII Hans Holbein, 1540  General Fallacy Underlying Most Eating Disorders: That Dieting Works In Western societies, females go on diets much more than males. Going on diets may be a gateway to eating disorders. BUT - about 95% of diets fail as a means of weight loss. They can produce transient weight losses, but the weight is almost always quickly regained -- and more (due to resetting of metabolic rate). The only long-term successful weight-loss method is a lifelong pattern of healthy food selection, meal planning, good sleep, and consistent exercise. Anorexia Nervosa  Anorexia Nervosa (DSM-5-TR) (Greek for “nervous loss of appetite”) Limiting food intake to below normative requirements for age, sex, development, and physical health, leading to a significantly low body weight, as calculated by one’s body mass index (BMI), with BMI’s < 17 kg/m2 considered “significantly low” by the WHO. Intense fear of weight gain or “becoming fat,” and relentless dietary and other habits that prevent weight gain. Body-image distortion: person “feels fat” and believes he/she is fat even when obviously underweight (confirmed with trick- lens studies), overvalues weight and body image, and/or denies the significance of low body weight. Common but not criterial: in females, amenorrhea (cessation of menstruation, due to loss of body fat, which secretes estrogen); in males, loss of sexual desire. Images of Anorexia Nervosa  Who Develops Anorexia Nervosa? Lifetime prevalence of.9% to 1.4% in the general female population (in males, about 1/10 as prevalent). About 5% of young females exhibit partial criteria for Anorexia nervosa. Occurs across diverse cultures and populations, but more common in post-industrialized, high-income countries (e.g., U.S. and many European countries, Australia, New Zealand, and Japan) May be more frequent (prevalence from 15% to 60%) in female athletes and dancers (e.g. ballet), among gay or bisexual males, and in male wrestlers, jockeys, runners, or models who must “make weight.” Most cases begin in adolescence (peak ages 13 to 18) Runs in families: – MZ / DZ concordances: 44% vs. 12%. Many cases of twins and triplets with Anorexia nervosa. – Relatives of family members with Anorexia nervosa have a 10-12X chance of developing the disorder themselves. – Elevated prevalences of both Anorexia nervosa and Bulimia nervosa are found in affected families. – The heritability of Anorexia nervosa (variance due to genetics) may be as high as 0.5-0.8, about the same as for Bipolar Disorder and Schizophrenia.  How Does Anorexia Nervosa Begin? Often develops in adolescents who, as children, were “picky eaters” (but not sufficient for ARFID diagnosis). Adolescents with Anorexia nervosa often display: desires for perfection and academic success, social avoidance, disinterest in sex, and the denial of hunger in the face of starvation. Typically begins with a period of dietary restriction after a period of weight gain and negative comments about the person’s weight (e.g., by peers, mother). Mothers with “food issues” or who have histories of eating disorders themselves often criticize their children’s weights and “enable” the development of eating disorders. Sometimes, Anorexia nervosa begins after a stressful life event accompanied by stress-related loss of appetite, such as leaving home for college, followed by compliments by parents and peers on new “thinness.”  Altered Eating Habits in Anorexia Nervosa Restrictive type: Development of obsessive thinking about food (how much did I eat, how much can I let myself eat) Establishing irrational rules about food (eat only green foods, eat only X% of what’s on my plate, eat only the insides of fruits or vegetables and leave the outsides) Food rituals (sipping water between bites, chewing X times before swallowing) Binge-eating/ Purging Type: ½ of all people with Anorexia nervosa binge and “purge,” although the binges are usually small, and the “purging” is most often via excessive exercise. Comorbidity: Up to 70% of patients with Anorexia nervosa also have OCD, and some researchers consider it an OCD Spectrum Disorder.  What Goes Wrong in Anorexia Nervosa? Old psychoanalytic view: food is symbolic impregnation; rejecting food is rejecting one’s sexuality. (No longer believed.) Suspected risk factors (apart from genetics): – Hypothalamic and pituitary abnormalities – Abnormalities in brain serotonin that may inhibit eating – It is unclear whether these brain findings are part of the etiology or the results of the disorder. – Neuroadaptive changes involving metabolically-related protein ANGPTL6 (angiopoietin-like protein 6) occur in the brain that lead starvation to persist. – Emotional reactivity and obsessive personality traits may give rise to the “Two P‘s of Anorexia Nervosa”: Powerlessness & Perfectionism “If can control my body, then I can have a “perfect body” and a “perfect life.” As with all disorders and illnesses, the etiology is complex.  Other Signs/Sx of Anorexia Nervosa Behavioral: Falling off the growth curve (losing weight needlessly). Going on a diet needlessly. Going to the bathroom regularly just after eating. No longer eating with the family. Saying things like “I hate my body” or “I feel fat.” Being very anxious or depressed but guarded about why. Physiological / Neurological: Dry skin, thinning hair, patchy hair loss, brittle nails, always feeling cold. Cyanosis (blueing) of toes and fingernails. Chronic constipation. Enlarged parotid salivary glands (“chipmunk cheeks”) and tooth erosion if there is induced vomiting Chest pain and palpitations. Muscle wasting and osteoporosis (loss of bone density) Loss of brain volume due to cerebral atrophy.  Course and Prognosis of Anorexia Nervosa 40 % - Complete recovery (takes 4-7 years) 30 % - Partial recovery with relapses 30 % - Persistent anorexia nervosa – Poor social and occupational functioning – 10-25% mortality rate, usually from cardiac complications or suicide – Sufferers of anorexia nervosa die by suicide at rates 18X as high as non-anorexic comparison groups. Poor prognosis is associated with longer duration of illness, older age at onset, existing relationship problems, and binge-purge subtype  How is Anorexia Nervosa Treated? Patient’s denial of illness is a major impediment, and patients may resist re-gaining of weight. Medical management of any physical illnesses that may have resulted from starvation. Hospital re-feeding if necessary (intravenous or nasogastric tube at first, then progressing to feeding my mouth with social reinforcement). Hospitalization indicated if individual falls below 75% of body weight. Note: rapid re-feeding can be fatal. Residential treatment center Inpatient → Outpatient family therapy – Reassert parents’ control of eating. – Begin a program of slow re-feeding. – Most kinds of outpatient longterm psychotherapy are helpful. Medication? – Weak effectiveness so far, but most helpful have been the SSRI Prozac and the major tranquilizer Zyprexa, used to treat any accompanying depression, anxiety, etc. Bulimia Nervosa  Bulimia Nervosa (DSM-5-TR) (Greek for “ox appetite”) Recurrent “binge eating” (eating much more than most people would in a 2-hour period) – at least once weekly for 3 months is required for diagnosis, although patients with bulimia nervosa typically binge-eat much more, an average about 14 episodes of bingeing per week. A sense of loss of control over one’s eating during a binge; sometimes people experience dissociation during a binge. Compensatory behavior to maintain or lose weight (frequency of such behavior is used to score the severity of the disorder): – Purging: Self-induced vomiting (manual or with emetic medications), laxatives, Synthroid (thyroid medication), diet pills, or diuretics; also seen in people with diabetes who stop using prescribed insulin, which results in very damaging weight loss. – Non-purging: extreme exercise and/or temporary fasting. Because of constant purging, most patients with Bulimia nervosa maintain a roughly normal weight or are overweight. Preoccupation with body size, weight as critical to one’s self- evaluation.  Bingeing Binge eating involves consuming amounts of food that are larger than average portions within a two-hour period. The binge is associated with a feeling of “loss of control,” and ends: – when the person develops stomach pain, becomes tired, gets interrupted, or – when the food runs out. People with Bulimia nervosa tend to binge on high-calorie (high-fat or high-carb) foods, e.g., fast foods and junk foods, that they would otherwise avoid when not bingeing. Typically, a single binge can contain 2000-3000 calories, with the individual eating in 1 hour what the average adult eats in 1 day.  Social or Solitary Bingeing with Secret Purging During a binge, the initial pleasure turns to guilt and shame. Images of Bulimia Nervosa  Who Gets Bulimia Nervosa? Adolescents and young adults, 80% female. Peak ages 15 to 18 in females, and 18 to 26 years for males. Up to 50% of people with Bulimia nervosa report histories of Anorexia nervosa. Point prevalence in general population of ~1% for full Bulimia nervosa syndrome, to 5% for partial Bulimia nervosa syndrome. Among college students, point prevalence of Bulimia nervosa may be 10% (or even higher). High prevalence may relate to the “Freshman 15,” the unwanted weight gain seen when starting college. Actually, on average: – Students gain about 4 lb during their first 3 months of freshman yr, a rate 11X higher than typical for their age. – BUT most don’t gain 15 lb. During the first yr, males gain ~6 lb and females gain ~4.5 lb. Brain studies suggest numerous abnormalities in multiple brain systems, but it is unclear whether these changes are causes or effects (true for Anorexia nervosa as well).  Emotionality and Bulimia Nervosa Some studies find associations between Bulimia nervosa and early sexual abuse (but this fits only some Bulimia nervosa sufferers), chaotic childhoods, and a family history of eating disorders. A risk factor is pressure to maintain a stereotypically attractive weight, as required by one’s profession or social milieu. People with Bulimia nervosa are likelier to be emotionally impulsive and unstable, and diagnosable with Borderline, Histrionic or Narcissistic personality disorders. Up to 33% of people with Bulimia nervosa also have OCD, and like Anorexia nervosa, it is sometimes considered to be an OCD spectrum disorder.  How Does Bulimia Nervosa Start? Bulimia nervosa is often triggered when person attempts restrictive diets, fails, and reacts by binge eating. In response to the binges, patients compensate, usually by purging, by vomiting, by using enemas, or by taking laxatives, diet pills, or drugs to reduce fluids. In a 2006 5-year study of female adolescents, by age 20 nearly 20% had used diet pills (appetite suppressants, laxatives, or stimulants) to help curb their appetites. Going off the diet pills nearly always results in bingeing. Patients then revert to severe dieting, excessive exercise, or both. (Some patients with Bulimia nervosa follow bingeing only with fasting and exercise. They are then considered to have non- purging bulimia nervosa.) The cycle then swings back to bingeing and then to purging again. The binge-purge cycling in Bulimia nervosa may partly be explained by Pavlovian conditioning, i.e., being full becomes a conditional stimulus for purging.  Self-Injurious Behavior In severe Bulimia nervosa, the low self-esteem and impulsivity may result in self-injurious behavior such as: – cutting – burning – punching or slapping – hitting oneself with an object – eye-pushing – biting and head-banging – less commonly, bone breaking, or amputation As in other disorders (e.g., Borderline Personality Disorder), these behaviors are often enacted as attempts to “ward off feelings,” -- technically, to induce dissociation.  What Is the Damage in Bulimia Nervosa? (and other disorders with purging, e.g., in some cases of Anorexia nervosa) Most of the damage is from repeated vomiting: – Rupture of stomach or esophagus; blood in vomitus. – Heart damage from loss of electrolytes (mainly, potassium) – Osteoporosis (weakening of bones from Ca++ loss) – Erosion of teeth, gums and fingernails – Broken blood vessels in the eyes – Swollen parotid (cheek/jaw salivary) glands (“chipmunk cheeks”) – Females: Menstrual irregularities (amenorrhea in 50%, irregular periods in remainder) and higher risk of pregnancy complications. Also associated with: – high (30 to 70%) rates of ETOH and/or drug use disorders – smoking (in order to maintain weight) – other impulsive behavior (sexual promiscuity, cutting, kleptomania).  How Is Bulimia Nervosa Treated? Unlike Anorexia nervosa, Bulimia nervosa usually responds well to treatment. 1st line treatment: high doses of SSRI’s (such as Prozac), which have been shown to reduce bingeing by up to 70% and vomiting by up to 60%. Therapy is also indicated: – Support groups – Cognitive-behavior therapy involving reducing ideation about need to be thin – Diary-keeping for binge-purge “triggers” – Focus is on resisting impulses to binge or purge, healthy eating w/ established mealtimes (“nutritional rehabilitation”), and developing positive alternatives to food-centered behavior. Treatment over several years is usually successful (70-90%), but relapse is common, and people with histories of Bulimia nervosa should not expect cures. Binge-Eating Disorder  Binge-Eating Disorder (DSM-5-TR) Most common distinct eating disorder: – Point prevalence > 2% of all adults (~3.5% females, 2% males); some surveys report 50:50. – Among mildly obese people in weight-loss programs, 10-15% may have binge-eating disorder. – Occurrence rising amid the current “obesity epidemic.” Binge-eating at least once a week for 3 months without compensatory behavior. Loss of control about what or how much is eaten. Risk factors: childhood obesity, familial (esp. maternal) focus on food, with parental history of restricting food Most people with binge-eating disorder are medically obese (>20% over ideal body weight), and many have morbid obesity (>100 lb over ideal body weight).  How Is Binge-Eating Disorder Handled? Dieting, as expected, usually worsens binge-eating disorder and increases weight. Costs of binge-eating disorder are the costs of obesity: – Hypertension, coronary artery disease, stroke – Type 2 Diabetes (poor glucose sugar regulation leading to organ damage from sugar buildup) – Obstructive sleep apnea (snoring/choking that interrupts breathing during sleep) – Acid reflux (persistent heartburn) – Joint pain, arthritis, fatigue, immobility – Early mortality Psychological costs – Shame, guilt at bingeing behavior – Social avoidance in order to binge, and embarrassment at appearance – Depression and anxiety Treatment is similar to that for Bulimia Nervosa (SSRI’s*, therapy for healthy eating & impulse control), but people with Binge-Eating Disorder may also need treatment for obesity, e.g., medication (semaglutide for appetite reduction) and/or bariatric (weight-loss) surgery. *SSRI’s may increase appetite, though.  Semaglutide / Tirzepatide Sold as Wegovy, or Ozempic (weekly injection), and Rybelsus (by tablet, multiple times per day). Mounjaro (tirzepatide) works similarly. Classified as a “glucagon-like peptide-1” (GLP1) agonist. It mimics the actions of a natural peptide made in the brain and intestines. It lowers blood sugar and reduces appetite. Brand-name semaglutide and tirzepatide were FDA- approved only for treatment of diabetes, but for several years individuals have been using a loophole to purchase generic versions on the Internet for weight loss. But Wegovy was approved for weight loss by the FDA in January, 2023, and approvals for the other medications are expected soon. The largest clinical trial shows that semaglutide causes people to lose an average of 15 % of their body weight. Potential side effects are nausea, vomiting, diarrhea, abdominal pain, constipation, and headaches. Already, semaglutide is being incorporated into traditional weight-loss programs, and it is expected to become a blockbuster medication. It may revolutionize the treatment of obesity and other disorders (e.g., diabetes, stroke, heart attacks, even alcohol-use disorder and Alzheimer’s-type dementia). End