COP Ch09 2024 default.pdf

COP Ch09 2024 default (0:00 - 4:48) Hello and welcome back. The purpose of this recording is to cover Chapter 9, The Eating Disorders, which is my other area of research and expertise, other along with dissociation and dissociative disorders, which we covered before the break. Learning objectives,...

COP Ch09 2024 default (0:00 - 4:48) Hello and welcome back. The purpose of this recording is to cover Chapter 9, The Eating Disorders, which is my other area of research and expertise, other along with dissociation and dissociative disorders, which we covered before the break. Learning objectives, I won't go through them other than just to say that they are, again, all worded slightly differently, but you can see we'll be focusing primarily on anorexia nervosa, bulimia nervosa, and binge eating disorder. I will say a few things about other things though, so obviously when I say it, remember it's something that is potentially important. So, in the DSM, the chapter relevant to eating disorders is actually called Feeding and Eating Disorders, and that's because it includes a wide variety of things that go beyond what we think of when we say the term eating disorder. This is a general definition though. All these things combined entail a persistent disturbance in eating or eating related behavior that results in altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. So, at least that's what they all have in common. This table is from your text, and as I've said before, these are good sort of summary tables just to use to review for just your own knowledge, particularly for the exam. I'm not going to go through it right now because we're going to go through quite a few of these in more detail. It's also worth noting that how we've classified these things has changed over time in several ways, and I'll just mention the most recent set of changes where the main thing is they used to have the sort of feeding disorders, the things there at the end, pica, rumination disorder, avoidant restrictive food intake disorder, those kinds of things were in a completely different section for disorders associated with childhood. In fact, the last one, avoidant restrictive food intake disorder, wasn't in there at all, but pica and rumination disorder were. They've now moved all of those over into the same chapter. They've also moved binge eating disorder into official status in the DSM. Prior to that, it was just classified as eating disorder, not otherwise specified, and I'll talk about all that when we get to them. Anorexia nervosa and bulimia nervosa were pretty similar. They didn't change a whole lot other than the subtypes of bulimia nervosa, getting rid of those in the DSM-5. So, the ones that are in there are basically on this list, and we're going to spend the majority of our time talking about the ones from anorexia nervosa on down. Again, those are the ones that are traditionally considered eating disorders. I will talk, though, a little bit about the first three, just so you know what they are at least. As I think I said a minute ago, the term often applied for these disorders isn't eating disorders, but feeding disorders. Particularly for the first two, the third one's a little bit different, but at this point, all I really want you to know is what these are. We're not going to go into great detail, as we will for the other eating disorders, but I'll say a few things about them here. PICA is basically the defining characteristic is eating of inedible objects. So, this would be like someone who eats anything that's inedible, but often it could be very dangerous things like dirt or glass or paint or whatever. And it can be, as you'd imagine, as I said, very dangerous. I mean, if someone ingests glass or needles and things like that, you'll find cases of this. (4:49 - 7:30) And this would not be—we had some discussions last week about factitious disorder and and malingering and things like that. And there are actually times when someone with a factitious disorder might ingest something to make themselves sick, but that's not what we're talking about here. They're doing it for some other kind of reason. And often these are children or people with developmental disabilities that are doing this. And you'll see it in the literature, like if you look at the literature on developmental intellectual disabilities, that sort of stuff, you'll sometimes see it. And there is a literature on the etiology of this, which I'm not really going to go into. I mean, some people have tried to come up with theories like it's some sort of attempt to deal with a nutritional imbalance, like if they're eating dirt and rocks and things like that. But we really don't know for sure. And again, for time's sake, I'm not really going to go into it much more than that. Similarly, with rumination disorder, this is sometimes called rumination disorder of infancy. So it's a disorder often occurring in— also occurring in young kids or sometimes, again, people with intellectual disabilities. When we're talking about rumination, this is not like cognitive rumination, like associated with depression. We're talking about rumination like a ruminant, like a cow or something does, where they swallow food and then they regurgitate the food into their mouth and chew it again and then either spit it out or swallow it again. And although this can occur associated with other eating disorders, like sometimes you hear about instances of someone with bulimia nervosa who will also do this, although it can occur that way, most often it does occur, again, with young kids or people with developmental or intellectual disabilities. And again, there's a literature on this, which we're not really going to go into. It would be more like if we were focusing on child psychopathology, we might go into it in more detail. Some of the theories have to do with like self-stimulation, like it's a way of sort of a soothing kind of behavior. But it can also be quite dangerous because the person can choke on it or the acids can damage their teeth or their throat and things like that, esophagus. (7:30 - 9:28) So there's also a whole literature in some of those journals on how to treat it, often sort of aversive treatment procedures. But for time's sake, again, I'm not going to go into that one too much. The third one there is a new disorder, at least by that name added to the DSM-5, which is probably not necessarily a unitary disorder as much as a disorder that would potentially explain or name that would be applied to a variety of different kinds of problems. The central idea is that the person, often a child, but not necessarily, the person is avoiding eating, but not for any of the reasons typically associated with an eating disorder. So nothing to do with body image, nothing to do with fear of fatness, which is allegedly at least the primary characteristics of anorexia nervosa and bulimia nervosa. They're avoiding it for some other reason, like it could be texture-related issues of the food, or it could be that they've had some sort of aversive experience choking on it or whatever. And there may be a long list of reasons, to be honest. And that's what I mean when I say this might be not necessarily a unitary kind of construct. It might be a variety of different sort of syndromes. If you read the childhood literature on disordered eating, you'll see there are some suggested typologies of a long list of reasons why kids might avoid eating. And again, these are not for the reasons associated with a typical eating disorder, so not associated with body image, fear of fatness, those kinds of things. And there is a developing literature on etiology and treatment of this disorder. (9:30 - 10:40) Sometimes it even goes by like an acronym, ARFID, you'll find that in the literature. But we're going to move on and talk about the ones that are more traditionally known as eating disorders and leave this for another time. So when I say the ones traditionally known as eating disorders, that's primarily those three, probably the first two, anorexia nervosa and bulimia nervosa. But binge eating disorder is something that was added in the fifth edition of the DSM and there's quite a bit of research on it now. And then with all of the disorders in the DSM, there are two categories of sort of residual disorders. They used to just be one, the not otherwise specified. And so you could have an eating disorder, not otherwise specified. You could have a depressive disorder, not otherwise specified or a psychotic disorder, not otherwise specified. Now, there are two, there's the specified and the unspecified. (10:41 - 11:53) So specified means like something that we have actually has been named in the literature and you could refer to it. So something like purging disorder, for example, you would see there'll be another specified feeding disorder. Unspecified basically means a person meets the criteria for an eating disorder, but not a specific one. So not anorexia, not bulimia nervosa, not binge eating disorder and not anything else that has a necessary name. And it might be that they basically don't meet those criteria because they meet, they go back and forth or they don't quite meet the duration criterion or the severity or something like that. I will come back to that, those categories in a while because they are actually very common among the eating disorders, probably. Well, a lot of research actually suggests that they are the most common. And for that reason, we need to spend some time on them. But the ones that we'll go through, again, the most are the three in red there, anorexia, bulimia nervosa, binge eating disorder. (11:55 - 13:59) And as always, I'll kind of go through general description, epidemiology, etiology, and treatment. When we get to etiology, I'll approach it in two different ways because we have sort of an individualized etiological literature on each disorder. But then there's also this idea of a transdiagnostic approach, both to etiology and treatment, and we'll try to look at it both ways. Now, one more thing I want to say before we get into these specific disorders is a bit about terminology that you'll see in the field. Like the terms anorexia and bulimia, what do they actually mean? I mean, do they mean what we think they mean? Like when you say someone has anorexia or anorexia nervosa, you tend to think of what you think of associated with the disorder, which would be, if it's anorexia, it would be someone who's losing a lot of weight, fear of weight gain, starving self, all that sort of stuff. With bulimia, you tend to think of, often people think of purging, but none of those names really are based on what these terms actually mean. The other thing to keep in mind is what does nervosa mean? So, nervosa basically means of nervous origin or of psychological origin. So, anorexia nervosa means anorexia of psychological origin. Bulimia nervosa means the same thing. But again, I haven't really told you what anorexia means, probably in the chapter, but it actually means loss of appetite. So, for example, if you look in some of the literature on anorectic or anorexic drugs, these are drugs that suppress appetite. And so, literally, anorexia nervosa means loss of appetite of nervous or psychological origin. (14:00 - 17:58) Bulimia nervosa, what does that one mean? I think that one's in the text somewhere. Bulimia basically refers to ox hunger or ravenous appetite. And so, it's sort of like the opposite of anorexia nervosa, an increase in appetite of nervous or psychological origin. But the question is, do those terms really explain what these disorders are about? Are people with anorexia nervosa, do they lose their appetite? And the answer is really probably no. I mean, people with anorexia may say that they may not eat, but they'll often say that they're obsessed with food and they may have pictures of it all over the house and their life revolves around food. So, it's not that they don't have an appetite, they just may not eat. Similarly, with bulimia nervosa, does that term really explain the disorder? Do they just have this ravenous appetite? Well, if you define it purely based on the amount they eat, maybe, but if you define it based on sort of a hunger, then no. I mean, in fact, one of the things these people will say that sort of drives them nuts is that they eat so much even when they're not hungry. And so, it's really not that they're eating so much because of an appetite, it's for other reasons. So, in general, those terms are misnomers and we keep encountering disorders where the name doesn't really capture the disorder very well. Dissociative identity disorder was formerly multiple personality disorder. I remember saying that was a misnomer. I say schizophrenia is a bit of a misnomer, but the same thing here applies to anorexia and bulimia nervosa. And I haven't heard anyone suggest we should change the names, even though they did change the name, remember, of multiple personality disorder to dissociative identity disorder. So, anyways, that's terminology. Now, let's get in and start talking about the disorders. And we have to start somewhere. So, let's start with anorexia nervosa. These pictures, somewhat gruesome, I guess, but the idea is that these are depictions of two people at different stages, but of the same disorder. Anorexia doesn't always look like the one on the right. It may be someone in the early stages, maybe more like the person on the left. And if not caught or treated in time, may end up looking like the person on the right. General clinical description, really, we're talking about three features that are primary to anorexia nervosa. Persistent energy intake restrictions. In other words, person's just not eating enough to the point that it is affecting the person's weight, either through weight loss or failure to gain weight. Exactly how you define that is changed over time. And it's even less clear now in the DSM than it was in the past. It used to be defined based on percentage underweight. So, someone had to be, in earlier editions of the DSM, like 20 percent underweight. Then they change it to 15 percent below weight. Or you could base it on a body mass index. In earlier editions of the DSM, it was around less than 17.5. Now they're more vague, exactly what the cutoff is, because it's hard to compare those numbers sometimes. The percentage underweights notoriously difficult to figure out what someone's normal weight actually would be. (17:59 - 18:46) A BMI you can calculate, but it depends on how much is lean body mass and how much is body fat. So, that's not exact either. And this is allegedly a psychological disorder, right? So, it's not supposed to be defined purely based on a physical factor. The physical factor is supposed to be an indicator, really, of the psychological factor. So, the point is someone is restricting exactly where you draw the line. It's not extremely clear these days. But in extreme cases, it's quite obvious. And they actually do have criteria for like what's considered mild, moderate, severe. And I'll get to those in just a minute. (18:47 - 19:12) But anyways, all that is sort of in the first major criterion. Second one, you have intense fears of gaining weight. So, it's not just that someone's underweight. They're also afraid of gaining weight, losing control of eating. And then there's some kind of body image disturbance. And exactly what that is, the conceptualization of that has changed over time. (19:12 - 19:36) But it's in there. It's worded in there in a particular way now, which I'll show you next, I believe. Yeah. So, here are the official criteria. I've just sort of paraphrased them to make them clearer. But the first one, again, the restriction that is vague, as you can see. (19:36 - 21:25) Second one, fear of gaining weight, even though significantly underweight. So, that's the key. I mean, even though the person is below a normal weight, they still have a fear of being overweight or gaining weight. The body image criterion, notice this is the third one there. It's kind of vague. Disturbance in which one's body, in the way in which one's body weight or shape is experienced. That's one possibility. Or undue influence of body weight or shape on self evaluation. That's another possibility. So, that's like when someone says their worth as a human being is dependent upon their body size. Or persistent lack of recognition of the seriousness. So, you have someone who's dying of anorexia and they don't seem to recognize the seriousness of the weight. And I knew someone, probably one of the worst cases I remember was around 5 foot 11. I'm doing this in feet and inches. And weight was around 70 pounds. Which you can figure out the body mass or the weight in kilograms. Bottom line, extremely underweight. And so bad that her, basically, her body was sort of eating her heart to survive. And so, that would show up on medical tests of her cardiac functioning. But if you tell her that, she would say, well, but if I gain weight, my clothes won't fit. So, in other words, that's a classic example of not really taking seriously the seriousness of the current low body weight. (21:25 - 26:36) Oh, no. There's one thing on that previous slide I forgot to say. I'll come back to it in a minute about the two different subtypes of anorexia nervosa. And I have another slide where I'll talk about that. Remember I said earlier that the SM-5 is vague with regards to the actual cutoff for when you would diagnose anorexia nervosa. But they do have these guidelines for what's considered mild, moderate, severe, or extreme. So, this is based on a body mass index. So, if it was greater than or equal to 17, but still meeting the criteria for anorexia, you'd say that that was mild. If it was 16 to 17, moderate, and so forth. So, below 15, that would be extreme. Now, I did say earlier about the subtypes. I just didn't mention it on that slide. But there have historically been two subtypes diagnostically. First is the restricting type or restricting subtype. This is someone who, one way to think about it is the person's primary weight control method is starvation. So, the person does not engage in purging behavior. And they also don't engage in binging behavior. The thing about the subtypology is that for it to be meaningful, it needs to tell us something else about the individual, not just that they do what I just said. And there is evidence that it does tell us something different about the personality. So, people with the restricting type, as noted there, also tend to have some personality characteristics. So, more obsessive compulsive personality, they may be more inflexible, strict about rules, rigidity, that sort of stuff. In contrast, you have the binge eating purging type. These are people who they still meet the criteria for anorexia nervosa, but they may engage in binge eating or purging. And we'll talk more about exactly what binge eating and purging are when we talk about bulimia nervosa. The key here is that they actually only have to do one or the other, but often they do both. So, you'll have people that report binging and purging, but yet they meet the weight criterion for anorexia. In other words, they're really underweight, which really makes the distinction between anorexia nervosa, binge eating purging subtype, and bulimia nervosa more complicated. It's really just body weight. So, if someone's normal weight and they're engaging in binging or purging, you end up diagnosing bulimia nervosa. If they're overweight, then it would be anorexia nervosa, binge eating purging subtype, with a couple exceptions about the binging and purging. Again, they don't have to do both. And the definition of binging is slightly different than it is for bulimia nervosa, which I'll get to when I talk about bulimia nervosa. As with the restricting type, though, there are sort of personality characteristics associated with this subtype. So, as noted there, tend toward impulsiveness, substance abuse. So, they may engage in a variety of sort of impulsive kind of behaviors. Binging and purging may be one of them. And at least my reading of the literature, the validity of this distinction is fairly well established. So, let's watch a little video clip, and then we'll talk about it with the next slide. Yeah, basically, it's, I don't want to eat because it seems like as soon as I eat, I just gain weight, get fat, look bulgy to me anyway, so that only makes it worse. But then there's sometimes where, you know, I can't stop it. I have to. And then, and then once I eat, regardless of the amount, there's a strong urge to either purge or take laxatives or something along those lines. Is it a particular number of pounds that you're aware of when you say that you're worried about your weight? No. I guess you could say that the only problem is that it never stops. You know, you start at a weight, it becomes very obsessive where you're getting on the scale 10 times a day. (26:36 - 27:31) How much do you weigh? Well, I weigh 96 pounds now. Are you aware of, for your height and build, what your so-called ideal weight might be? No, not really. There was a time where I thought that I had it under control, and I wasn't getting on the scale at all and eating regular meals. And I know that at that point I was 118 pounds, and that's probably a good weight for me. I remember feeling okay there when I was there. And do you notice that as you lose more weight, does your concern lessen about the weight, or does it grow larger? It grows larger. (27:32 - 28:30) So the lower down you go in terms of your weight, your concern about it and the drive to lose even more actually increases. Is that what I'm understanding? That's right. How is it that you come to gain weight from time to time? Most of the time it has to do with some sort of social situation where I actually draw more attention to myself if I don't eat, like a birthday weekend that I just had a couple of weekends ago. And I'm a chocolate freak, so that's what they do. And they fix you your favorite foods, and they just give you all this stuff. And then you almost have to eat it, because if you don't, you're drawing more attention to yourself, so it becomes out of control. (28:32 - 28:52) And it's almost like, since I can't monitor and not eat it, I eat it all. And then I have to take care of it somehow later. When you gain weight like that, what feeling does that give you? Frustrated, angry, feeling worthless. (28:53 - 29:05) I guess that comes from a lot of things. Number one, just because you're allowing, all of a sudden you realize that you gave control to someone else. And you gave up control, you couldn't even monitor it. (29:05 - 29:27) I want to go back and ask again about another detail. You said that you have to get rid of weight when you gain it. How do you do that? Usually I try and throw up. And sometimes I'm successful at that, and I feel better, and it's fine. Sometimes I can't throw it up for whatever reason, I don't know. So then it's, if I can, it can be exercise. (29:28 - 30:38) Like on a weekend, if I don't have anything planned, I'll probably work out for two hours. But if it's like a work situation where I'm at work and we had a birthday party and I can't, then it's a laxative. In what way does your body not feel right? It feels fat. And when I look in the mirror, especially around the stomach and the hips and the back end and around up here, it just looks fat. It hangs, almost like I'm pregnant. What's the lowest weight you've ever gotten down to? I got down to 87 pounds in the early 20s. That's when it was the worst. That was probably the worst bout of it that I had. How about your periods? Are they regular, or is that, does that stop when you lose weight? Do they stop? Yeah, it has. And I'm real frustrated that it hasn't stopped this time yet, because that tells me that I'm not, I need to lose more weight still. Because there's some sort of connection there with if you lose enough weight and have enough, that your body fat is so low, you don't have a period. Well, if I'm still having a period, that means that I have enough body fat, obviously. (30:38 - 30:53) So I still need to lose some. So there's quite a few things we could talk about there. A lot of what she said was fairly illustrative in terms of anorexia nervosa. (30:53 - 31:14) I did look up the weights in terms of kilograms. She said she was 96 pounds, which would be around 44 kilograms. Her lowest weight, I think she said 87 pounds, would have been like 39.5. And I also looked up what I said earlier about the person that weighed 70 pounds. (31:14 - 31:29) That would be about 31.8 kilograms. And she was also very tall, that woman. So she would have been, again, one of the most underweight anorexia nervosa patients I ever worked with. (31:29 - 31:54) But the woman in this video, that would be her current weight. And she would, by DSM criteria, at least based on what she said, would meet the criteria for the binge eating purging subtype, right? Because she talked about needing to purge either. She said purge, actually. (31:54 - 32:05) That could mean a variety of things. But I think she meant self-induced vomiting or laxatives, which actually counts as purging. I don't think she said too much about binging. (32:05 - 32:18) But it wouldn't necessarily matter to meet the binge eating purging subtype, because you only have to do one or the other. She said a few other things. He asked her about menstrual irregularities. (32:18 - 32:33) And she said she currently was not irregular. And that illustrates one of the problems with that criterion for anorexia that is no longer there. Remember, we didn't mention it, or I didn't mention it when we were talking about the criteria. (32:33 - 32:49) But it used to be a criterion. And it's really, it was not a very sensitive or specific one. Because people like her could actually meet all the other criteria, but not meet that criterion. (32:50 - 33:12) And, or you could have people that were actually like normal weight, who would have amenorrhea, because they were losing weight very quickly. I mean, basically, it's your body way of saying, currently, you're not stable enough to conceive a child. And so, it's shutting down your reproductive system. (33:13 - 33:37) And it could be because you're really below weight, but it could also be because you're losing weight too quickly. But they did get rid of it as a diagnostic criteria for that reason, plus the fact that it obviously only applies to women and not men. And you can be diagnosed having anorexia if you're male. (33:37 - 33:57) So, that's why it's not there. Anyways, what else did she say? The part about, as you lose weight, does the obsession get more or less? She said it actually gets more. I mean, if it was just someone had sort of a goal to be very thin, you would think that the closer you got to that goal, the better you would feel. (33:58 - 34:23) But that's one of the sort of mysteries of anorexia nervosa, that the less you weigh, the more obsessed with it you often become. And often people will say that there's a time when they were at a higher weight and they felt comfortable with that weight, as she said. So, for now, let's move on and talk about the next disorder. (34:23 - 34:34) At this point, I'm just going through, remember the sort of description of the disorders. We'll come back to epidemiology, etiology, and treatment shortly. Bulimia nervosa. (34:35 - 34:54) So, here there are three primary features, at least in the DSM. Binge eating, exactly what that means depends on what definition you use. But at least in terms of the DSM criteria, it really has two components. (34:54 - 35:09) Has to be a lot of food and the person has to feel out of control while doing it. I'll talk more about that in just a few minutes. The second component, compensatory behaviors. (35:09 - 35:23) So, doing something to undo what you've just done in terms of the binge eating. And that could be a variety of things. Prototypically, it's like self-induced vomiting, which is often referred to as purging. (35:23 - 35:41) The woman in the video used the term purging to refer to that, I believe. Although, laxatives is sort of viewed as a form of purging too. The DSM has actually changed a bit in terms of how they've used the term purging. (35:41 - 36:01) Currently, they refer to all the compensatory behaviors as purging. Previously, they referred to purging specifically referring to like vomiting and laxatives. And then there were other kinds of compensatory behaviors like excessive exercise or fasting that they didn't call purging. (36:02 - 36:15) In fact, they used to have a purging and a non-purging type of bulimia nervosa. They've gotten rid of those changes or those distinctions in the DSM-5. And they just basically used the term compensatory to make it a little bit clearer. (36:16 - 36:43) The third feature is similar to what we saw for anorexia nervosa, but actually more vague and just referring to self-esteem being determined by weight, body shape. So, as worded, here are the official criteria. And as I said, the binge eating has a specific definition. (36:45 - 36:52) And that's it right there. Eating in a discrete period of time. An amount of food that is definitely larger than what most individuals would eat. (36:52 - 37:01) So, it has to be a lot of food. And again, the person has to feel out of control. If they just eat a lot, but they don't feel out of control, that's not binge eating. (37:02 - 37:26) Now, the questionable situation is when they do feel out of control, but it's not a lot of food. That is often called like a subjective binge, subjective binge eating, whereas the large amounts of food are considered objective binge eating. And to meet the DSM criteria, for bulimia nervosa, they need to be objectively large. (37:27 - 37:57) So, if someone has these subjective episodes of binge eating, where they say they just felt terribly out of control and they binged. And then you say, what did you eat? They go, oh, I had an M&M, which I've heard before. I mean, you hear the other extreme too, where they say, I ate, I had two pizzas, then I had two large sandwiches, then I had two quarts of ice cream, then I had two, which I've also heard. (37:58 - 38:23) That would technically be considered as objectively large, so an objective binge eating. The person who says the one M&M was a binge, to that person it is, but it doesn't meet the DSM criteria for bulimia nervosa. Now, it could meet the criteria for anorexia nervosa binge eating purging type. (38:23 - 38:37) That was more vague. And as long as someone engages in one of those, they can meet the subtype criteria, but not for bulimia nervosa. So, anyways, that's the A criterion. (38:38 - 39:05) The B is the compensatory behaviors, and notice there's a variety of things listed there. How often does this have to happen? I mean, if somebody does this once or twice, do you diagnose them with an eating disorder? No, that's not a good thing, but it has to occur at least once a month for three months. And it used to be, in earlier editions of the DSM, it was twice a week for, I believe, six months. (39:06 - 39:20) And so, we've made it easier to make this diagnosis. One of the criticisms of the DSM-5, they lowered the thresholds. But anybody doing it at least once a week for three months, that's not a fairly normal thing to do. (39:20 - 39:46) So, to me, lowering that threshold was a reasonable thing to do. And then, again, the self-evaluation criteria, the sort of body image criterion, that it's not, that self-evaluation is unduly influenced by body shape and weight. So, I believe we saw that in the video, too, where the person said, you put on weight, you feel worthless. (39:46 - 40:00) I mean, that's basically what we're talking about. She met the criteria for anorexia, but that criterion is part of both of them. The last one here does not occur exclusively during episodes of anorexia. (40:00 - 40:22) So, if someone meets the full criteria for anorexia and bulimia nervosa, then you would basically just call it anorexia nervosa, the binge purge subtype. So, remember I said with anorexia nervosa, there are subtypes. You've got the restricting subtype and the binge eating purging subtype. (40:23 - 40:35) With bulimia nervosa, there used to be subtypes. At least in the DSM-IV, there was a purging subtype and non-purging. This is where they define purging slightly differently. (40:35 - 40:54) So, non-purging would be people that did not engage in self-induced vomiting or laxatives, things like that. But they could do things like exercise or strict dieting. And still, it was defined as compensatory but not purging, which again is a little bit different than how they define it now. (40:54 - 41:12) It's really only a small subset of people with bulimia nervosa at that time would have met the non-purging criteria. And there was questionable validity of this distinction. The non- purging type seemed actually more similar to binge eating disorder. (41:13 - 41:22) And so, in the DSM-V, they have eliminated the subtypes for bulimia nervosa. But again, not for anorexia nervosa. They still exist. (41:24 - 41:41) Now, let's talk more about the body image issue with bulimia nervosa. As we looked at a minute ago, there is a criterion that's quite vague. And it just talks about self-evaluation being based on body size and shape. (41:41 - 42:00) If you think historically about body image and eating disorders, often in the past, what you often thought of or saw was like the old picture of someone looking in a mirror. The person would be very thin. But what the reflection would look larger than the person actually was. (42:00 - 42:20) And so, it was the issue of sort of body size overestimation, which the field has sort of gotten away from that construct and has focused on other aspects of body image. But there has been some interesting research on it, even that some that I've done or my advisor had done. So, I want to talk briefly about that. (42:21 - 42:40) If you look at these cards, they're kind of crude looking. But it's a measure of body image where you present these to people. And not all in a row like that, but nine separate cards ranging from small to large. (42:40 - 42:53) You put them in like random order. And you can ask a lot of different questions. You can ask them which one is closest to your current body size and which one is closest to your ideal body size. (42:53 - 43:08) You can ask them other things. But the way it's been typically studied, you ask those two questions. And by the way, there's another version of this for measurement of body image associated with obesity that has 18 cards. (43:08 - 43:15) But this was the original one that had nine cards. And again, this was developed by my advisor. And it's something that I've used quite a bit. (43:15 - 43:43) My students have used it. And they did a study, my advisor and some of his colleagues did a study a while back where they administered this test, if you want to call it that, to a group of women diagnosed as having bulimia nervosa. And also a comparison group of basically women similar age, but no eating disorder diagnosis. (43:44 - 44:08) And again, they asked them those two questions, which one's closest to your current body size and which one is closest to your ideal body size. And they found something quite interesting. This is a basically a regression line of weight predicting current body size scores. (44:09 - 44:32) And it was in pounds, but it doesn't matter if you use kilograms. It also doesn't matter if you use body mass index, which is actually works a little bit better because body mass index takes height into consideration. But what you can see is that as weight went up, the current body size that the person chose went up, which makes sense. (44:32 - 45:06) But if you look at the two lines, one's for the women diagnosed with bulimia nervosa and the other one, not the best term there, but that's the comparison group of women not diagnosed with bulimia nervosa. Basically, the point is that at every weight level, the women diagnosed with bulimia nervosa were reporting a larger body size. Now, even when you're controlling for body size, so this doesn't mean necessarily that they are picking a card that's larger than they are. (45:06 - 45:18) It could be that the other group is picking a card that's smaller than they are. But at least compared to someone the same size, they are saying they are larger. That's the first question. (45:18 - 45:41) They then asked them the other question about ideal body size. And if you take a close look here, you'll see the lines are basically switched where the bulimia nervosa group is lower. And what this means is there's still a relationship between actual body size and ideal body size, and that some people tend to be a little bit realistic. (45:41 - 45:59) The larger you are, the larger your ideal. But, again, there was a difference between those with bulimia nervosa and those without. And in this case, the ones bulimia nervosa wanting to be much smaller than a same size person without the eating disorder. (46:00 - 46:22) And if you overlay those two like this, you can basically think of body dissatisfaction as being the difference between the top line and the bottom line, the curved line and the straight line. I realize they cross towards the end, but that's really the regression lines. It probably, in reality, didn't act that way. (46:23 - 46:45) And the top one, by the way, is curved probably because of a ceiling effect that the cards only went up to number nine in this particular study. And if you go up higher, it's probably more of a straight line. But the point here is really just the big difference between current and ideal, which is larger for the women with the eating disorder than those without. (46:45 - 47:00) And this is, again, the eating disorder bulimia nervosa. We found similar results when comparing women with anorexia nervosa, except that the lines really don't cross down there. They look very similar to bulimia nervosa. (47:01 - 47:28) And so at least by what they're saying, they actually do report seeing themselves as larger than a same-size person without an eating disorder. Now, whether they really see themselves that way or whether it's more of an affective sort of thing, an attentional bias, like people that are afraid of certain things tend to overestimate the risk of whatever that is. And that's another way people have interpreted it. (47:28 - 47:57) But there still does seem to be something associated with size that has sort of been not really included in the DSM in recent years when defining the body image component of these disorders. And we'll come back to some other body image research later when we're talking about etiology of eating disorders in general. Now, the last disorder, at least with an actual name that we're going to talk about here, is binge eating disorder. (47:58 - 48:24) We will talk about the other specified in a moment, but let's talk about binge eating disorder first. So the primary features of this disorder are food binges, but no compensatory behaviors. So that would be the primary feature distinguishing them from people with bulimia nervosa that people with binge eating disorder don't engage in compensatory behaviors. (48:24 - 48:53) There's also not really a body image criterion, and I'll talk about that more in just a second. This is, it does have an interesting history, although I said it's only added in the DSM-5. If we go way back to the DSM-3, this is when the disorder called bulimia was first added to the DSM, and it was just called bulimia. (48:53 - 49:25) It wasn't called bulimia nervosa, and it was defined more broadly, where people had to engage in binge eating, but they then had to engage in a bunch of other behaviors, and there was a list of them that you could pick. Some of them were things like self-induced vomiting, but it was also other things not including self-induced vomiting. So you could meet the criteria for bulimia even if you did not engage in any of the compensatory sort of stuff. (49:25 - 49:58) And so what we realized soon after that is that that group of people in the bulimia group, the group's kind of heterogeneous. In other words, there was people that were thin or normal weight and engaged in binging and purging, and then there was another group of people that were typically overweight, engaged in binging, but not purging. And at that point in time, they began to go by a variety of different names. (49:59 - 50:32) Sometimes this group was considered compulsive overeaters or things like that. And with the next edition of the DSM, they redefined bulimia to call it bulimia nervosa, which then did require you to engage in purging behavior. So if you had previously been diagnosed with bulimia, but you weren't purging, then you no longer had a diagnosis in the DSM-3R, and then it was the same in the four. (50:33 - 50:55) And so with the four TR, they added what was called binging disorder as an experimental diagnostic category. So the TR, by the way, is just mean text revision. They revised the DSM-4 before they came out with a completely new system. (50:56 - 51:22) And I thought actually that binging disorder was going to be in the DSM-4 as a standalone category, but it again appeared in the appendix, and there's been much more research on it. So with the DSM-5, it achieved full diagnostic status. For some reason, there are people that criticize that move. (51:22 - 51:57) Like critics of the DSM-5 say that adding binging disorder didn't make a whole lot of sense because they're defining just basic overeating as a disorder. One of the former developers of the DSM claims he would have it if they defined it that way. But the truth of the matter is it has been studied a lot going, as I was saying, all the way back to the DSM-3, and there was this whole subgroup of people that had previously been diagnosed as having a disorder who then did not have a disorder when it was redefined. (51:58 - 52:08) And there has been a lot of research on it. So I don't agree with the argument that it doesn't belong in the DSM. These are the actual criteria. (52:09 - 52:26) You see, it's not just overeating. It's doing a lot of things that really cause a person a lot of distress about the overeating. The first criterion, the A criterion, is really more or less the same as for bulimia nervosa. (52:26 - 52:53) So the person engages in binge eating that's a large amount of food and also feels out of control. But then the B criterion there has a bunch of things that might occur, and you only have to have three of them. But there are things like eating more rapidly, eating until uncomfortably full, large amounts of food when not hungry, eating alone, feeling embarrassed, feeling disgusted with yourself. (52:54 - 53:17) And often when you, even though they say three, you interview people with this problem, they will report having all of those. And there's the general criterion of it has to cause a lot of distress regarding the binge eating. How often does it have to occur? On average, at least once a week for three months. (53:18 - 53:55) And again, you'll talk to people who will say that they've been doing this for a long time. In fact, often going back to childhood, I'll get to that in a minute, which leads to sort of a different interpretation of the etiology of this one compared to, for example, anorexia and bulimia nervosa. Now that last criterion there is just basically what separates it from bulimia nervosa that notice the binge eating is not associated with the current use of inappropriate compensatory behaviors as in bulimia nervosa. (53:56 - 54:05) So, that's at least how you define it. That's the difference. Notice there's no mentioning of body image at all. (54:06 - 54:32) There's no reference to someone's self-worth being based on that or anything. And that's one of the issues that's been studied. The general assumption is that people with this disorder, they may not be really happy with the way they look, but it's often based on the fact that they are overweight, which is different than people that are normal weight or underweight being unhappy with how they look. (54:32 - 54:46) So, the general assumption is that the body image concern is a little bit more sort of realistic if you want to use that term. And for that reason, they're not here. They're not listed as criteria. (54:46 - 55:09) Now, there has been more recent research questioning that. And it's something that we may revise in the future, but at least for now, it's just not listed at all. So, the last disorder or disorders that we're going to talk about in general at this point are the ones listed here, other specified and unspecified feeding disorder. (55:10 - 55:43) And as I said at the beginning, all of the disorders that we've talked about have these sort of residual categories. And we haven't spent much time on any of the other ones. So, you may go, well, why are we going to spend time on the eating ones? And it's because at least historically, they have been so common, at least with the research I'm aware of, the most common disorders, at least in clinical practice, are basically these residual category disorders, which a lot of people don't necessarily realize. (55:45 - 56:06) The only distinction between these two categories, and I mentioned this earlier in the lecture, is just that with the first one, you specify a name as you're actually listing it. So, there's a few that have sort of been studied in the literature. Purging disorder is one that I mentioned, and you'll see some research on that. (56:06 - 56:28) So, you could say someone, that would be someone who engages in purging, but not binging at all. So, you could call that the other specified feeding or eating disorder. If they just met some broad criteria for an eating disorder, but it wasn't something that you could really put a name to, you would just call it unspecified feeding or eating disorder. (56:29 - 56:45) In the past, it was just called eating disorder, not otherwise specified. And that sort of took on a life of its own. You would hear people talking about EDNOS in terms of sort of an acronym from that term. (56:46 - 57:09) And there's a lot of research on it, as I was saying. Here is a, from a review article, looking at the prevalence of various eating disorders in clinical settings, so outpatient. So, these would be people in treatment for an eating disorder, but not necessarily a hospital, it would be outpatient. (57:10 - 57:43) And as you can see, in each of the studies, the prevalence of EDNOS was larger than either anorexia nervosa or bulimia nervosa. And now remember also that I said, prior to the DSM-5 binge eating disorder would have been counted as eating disorder, not otherwise specified. So, there's a, those comments out there are pointing out that that didn't explain why EDNOS was so much more prevalent. (57:43 - 58:15) So, like in the first study, it had 57% EDNOS, binge eating disorder was 9.7%. In the second one, it was 8.5. In the third study, where 70% of the sample met the criteria for EDNOS, people with binge eating disorder weren't even included in the study. So, or they were excluded from those numbers. So, clearly it wasn't just due to binge eating disorder. (58:16 - 58:37) Why is it so high? It's a couple of reasons. One, people go back and forth between these things and don't have the criteria for a particular disorder for a long enough period of time to meet the overall criteria. Because they might spend some time appearing to meet the criteria for anorexia and then bulimia and going back and forth. (58:38 - 59:01) Or it might be thresholds that they just don't quite meet the duration or the severity criterion, but it's still a pretty serious sort of problem. And so, you don't want to say they don't have a disorder. They have an eating disorder, but it just didn't meet the criteria for either anorexia or bulimia nervosa. (59:02 - 59:29) Some of them going back prior to the DSM-IV for anorexia might have been EDNOS because, remember, it had the amenorrhea criterion. So, if they met all the criteria for anorexia except the amenorrhea criterion, then you'd have to call them EDNOS. And some of the changes for the DSM-V were really designed to try to make that EDNOS category smaller. (59:29 - 59:49) So, by getting rid of the amenorrhea criterion, that was one way. By slightly reducing the severity and the duration criteria for both bulimia nervosa and anorexia nervosa, that was one way. By adding binge eating disorder, that was another way. (59:50 - 1:00:19) Have the numbers actually gone down? Apparently some, but still, it's a very common presentation to have people who just don't neatly fall into these categories. Now, I'm going to show you another video, and this video is about EDNOS, but I'm showing it to you also because it has some other useful information about eating disorders in general and about treatment. It was also filmed at a place where I used to work, so I found that a little bit interesting. (1:00:19 - 1:00:49) I do believe there's one mistake in the video, but I'll show it to you and then we'll talk about it afterwards. Now, I've shown this video before, but for some reason this year you get a warning saying this video is age restricted and only available on YouTube, but we're watching it on YouTube, so I'm not sure why that's a problem. But if you click on watch on YouTube, it should work. (1:00:49 - 1:01:03) At least it does when you view it on a computer. I'm not sure about another device, but hopefully that will work. So, let's talk about the video. (1:01:05 - 1:01:16) As I said, I used to actually work at the Renfrew Center. There's several of them in the U.S. I'm not sure which one this one was, but good experience. I mean, I was both working in research and clinically. (1:01:16 - 1:01:39) I used to eat meals with them like they were illustrating there, and I showed you the video because, as I said, it wasn't just about EDNOS. It's about eating disorders in general. So, a lot of what we saw in terms of treatment and the issues being discussed are not specific to EDNOS. (1:01:40 - 1:01:53) They are things that apply to people with eating disorders in general. They're sort of transdiagnostic factors, which is something we'll come back to shortly. And I did want to clarify what I believe was a mistake. (1:01:53 - 1:02:11) It was the comment about EDNOS being the most deadly disorder. All I can figure is that they misunderstood what the psychologist said. I believe that when he was quoted as talking about these disorders being the most deadly, I believe he was talking about eating disorders in general. (1:02:12 - 1:02:24) And specifically, anorexia nervosa has the highest mortality rate. So, I don't think he was talking about EDNOS. Other than that, as I said, it's an interesting video. (1:02:24 - 1:03:01) We saw two different women that would obviously not meet specific criteria for anorexia nervosa or bulimia nervosa, but it's pretty clear that they had an eating-related problem. In Taylor's case, talking about passing out and having to drop out of a dance team or club, whatever it was, which was a big thing for her, and the obsession, you know, weighing herself 7 to 14 times a day, which actually doesn't make any sense. But, you know, clear that this was an eating-related problem. (1:03:01 - 1:03:18) She did talk about purging too. Perhaps she didn't do it often enough or for a long enough period of time to meet the bulimia nervosa criteria, I'm not sure. And they described her sort of rollercoaster life and probably ups and downs with her weight. (1:03:19 - 1:03:49) The other woman, Allie, was less typical, but still obviously had eating-related problems. She almost could have been described as something you see this day and age called orthorexia nervosa, which is where people basically get very, very strict about health food diets to the point that it becomes unhealthy. It's something that I've actually done some research in, and some of my students have looked into. (1:03:49 - 1:04:10) It's not an officially recognized disorder. Some people argue it's nothing other than a variant of anorexia nervosa. But if you think about the motivation for her doing it, it wasn't about looking a particular way or even really being thin. (1:04:10 - 1:04:37) It was about being healthy, which seems like it's a good thing, right? But when it gets to the point that it negatively affects your health, then something has gone wrong. But again, those are some of the general things that I wanted to talk about. What we saw them doing in terms of the eating, that's pretty typical for, at least for many treatments of eating disorders, because it's basically an exposure therapy. (1:04:37 - 1:04:55) People are afraid of these foods. Often they're considered their fear foods for a couple reasons. One, because they feel like they can't eat them without binging on them, or they think that they can't eat them without having to purge afterwards. (1:04:56 - 1:05:11) And as the guy said, these are not necessarily always healthy foods. And so it's not like you're encouraging people to have an unhealthy diet. But the irony of fear foods is that people end up binging on them anyway. (1:05:11 - 1:05:35) So when they're trying to restrict them from their diet, they end up eating probably more of them than when you try to encourage them to eat normal amounts of them. So that is a fairly typical part of most, at least more behavioral or cognitive behavioral approaches to treatment of eating disorders, getting them to face their fears. So we'll come back and talk about treatment in a little while. (1:05:36 - 1:06:08) But I did want to show you that one because I thought it illustrated some important points. Let's move on now, though, and talk about epidemiology of the disorders that we've been talking about. Starting with anorexia nervosa, I have some question marks for some of these because it's the sort of, it's the assumption, and there is a lot of evidence supporting it, but there's also some reasons to question some of these things. (1:06:09 - 1:06:36) So I believe to affect mainly adolescent girls, young women, there are groups of people that might sort of be missed, particularly men, often afraid to come forward with a disorder that is believed to be primarily among women. Also, older people when the disorder is believed to be mainly among younger people. So at least we know the rates are higher in these groups. (1:06:36 - 1:07:04) That doesn't mean that they don't occur in those other groups, too. Prevalence rates somewhere around 1% less, slightly less, but somewhere around there. Mortality rate, this is the disorder, as I was saying earlier, that does seem to have the highest mortality rate of all psychiatric disorders. (1:07:04 - 1:07:15) So it's not EDNOS, it's anorexia nervosa. And this can be for a variety of reasons. It can be for the effects of starvation, or it can be suicide. (1:07:16 - 1:07:34) But when you put them together, it does seem to have the highest psychiatric, excuse me, the highest mortality rate of all psychiatric disorders. Age of onset's probably about right, early to late adolescence. It's probably the earlier onset of the eating disorders. (1:07:35 - 1:07:47) Bulimia nervosa would be a little bit later. Binge eating disorder is, we know less about it, but its pattern of onset would be a little bit different. I'll come to that one in a moment, too. (1:07:49 - 1:07:58) Recovery from anorexia, typically a lengthy process. And there's a subgroup who don't recover. I mean, it's almost like you have sort of three groups. (1:07:58 - 1:08:31) One that seems to sort of make a full recovery, another group that are sort of in the middle where they have ups and downs for probably the rest of their life, and another third that deteriorate and eventually do not survive it. It's associated with a variety of both medical and psychological complications. Sometimes the psychological complications are related to the medical complications. (1:08:31 - 1:08:52) Like if you starve yourself and get in a physiological state of starvation, it affects you psychologically, too. So, and I'll come to some of the specifics here in just a minute. And as I said, it's both medical and psychological complications. (1:08:53 - 1:09:19) This table is from your text and is just a sort of a summary of the effects of anorexia nervosa. Again, the vast majority of these would be from the effect of starvation. Some of them might be from the effects of purging and or taking laxatives. (1:09:19 - 1:09:46) You notice under there like fluids and electrolytes, dehydration associated with purging, low potassium from vomiting, kidney failure. I mean, I've seen one woman was taking so many laxatives that it basically destroyed her, one of her kidneys and like half of the other one had like half functioning. And she would take like 150 of them a day. (1:09:46 - 1:10:08) I mean, we're talking about just amounts that your body is not prepared to be able to deal with. This is just a table that I had come up with independent of your text and mentioning some of the consequences. Again, amenorrhea used to be a criterion, but it is really an effect of the starvation. (1:10:08 - 1:10:42) And the rest of those pretty much similar either starvation related or electrolyte imbalance would be more like from purging or perhaps taking laxatives. The lanugo, I don't know if anybody knows what that is, but that's like a real sort of fine type of hair that might grow over one's body, probably to help keep in warmth. Like if you have no body fat, then it's hard for your body to keep itself warm. (1:10:42 - 1:11:02) So, it does that as a way of trying to conserve heat. And it's not a very attractive sort of thing. If someone's actually doing this to look attractive, having like the layer of, it's almost like fur, like hair on your body would not be viewed as a very attractive sort of thing. (1:11:02 - 1:11:23) Although I think that's a misconception to say that people with this disorder are doing purely to look attractive. Psychological disorders, a variety of things, but primarily some of the things mentioned there. Anxiety, obsessive compulsive disorder and anxiety related disorder. (1:11:24 - 1:11:53) Mood disorders are quite common as are substance abuse. Some of these vary a bit depending on whether if you're talking about the binge purge subtype or the restricting subtype, like substance abuse would be more commonly associated with the binge purge subtype. OCD would be more associated probably with the restricting subtype. (1:11:55 - 1:12:21) And again, suicide's on there because as I've said, the mortality rate is probably the highest of all psychiatric disorders. So, that's a summary of some of the epidemiological data of anorexia nervosa. What about bulimia nervosa? Some question marks there too, believed to primarily affect females, women. (1:12:22 - 1:12:45) Perhaps those estimates are a little bit off as are the racial ethnicity data. Particularly for this one, like with regard to men, it's harder to hide when you have anorexia nervosa because you're so thin. But with bulimia nervosa, it's fairly easy to conceal it. (1:12:46 - 1:13:02) And I mean, I have worked with men before who just say, you know, it's no one would have any idea that they're doing this. Prevalence rate, slightly more than anorexia nervosa. It depends on the sample you're looking at. (1:13:03 - 1:13:26) So, in females or women overall, maybe 1.1%. If you look at college or university sample, whatever term we want to use, they would be quite a bit higher. And the age of onset, as I said, anorexia is probably the earliest. So, here, it would be a little bit later. (1:13:26 - 1:13:39) Sometimes, sort of developmentally, a person starts off trying to be anorexic, basically. And they get to the point where they can't. And they start binging, they start putting on weight. (1:13:40 - 1:14:10) And so, the anorexia sort of turns into bulimia nervosa. Medical complications, there are probably not as many as anorexia nervosa, but there still are some. And in addition to the starvation-related side effects, which you may have for bulimia nervosa also, you've got a lot of complications due to the purging, self-induced vomiting. (1:14:10 - 1:14:30) So, if you look at the list there, most of those would be related to purging. Permanent colon damage could be related to abuse of laxatives. Like, remember the woman I was saying taking 150 or so, she was actually diagnosed with anorexia. (1:14:32 - 1:14:52) But the same kind of thing, it would have sort of lasting effects on you. You might then have to depend on laxatives or something like that for the rest of your life. Associated psychological factors or disorders, many of them are somewhat similar to anorexia nervosa. (1:14:52 - 1:15:21) Some of them are perhaps even higher. Personality disorders, particularly borderline personality disorder, although there's sort of an overlap in terms of how the disorders are defined because one of the criteria for borderline personality disorder refers to impulsive behaviors and binge eating can be an example. So, if you engage in binge eating, you may automatically meet one of the criteria for borderline. (1:15:22 - 1:15:47) But anyways, there is quite a bit of research on the overlap there, as well as some of the other ones. Anxiety, social anxiety, social phobia. I remember in one of the clinics where I worked when I was in graduate school, we would screen these eating disorder clients with a variety of measures, not just eating-related tests, but all these other ones too. (1:15:47 - 1:16:11) And we started giving a social anxiety test, the fear of negative evaluation scale. And one thing that struck me is often the women, and occasionally men, we just didn't have many, the clients with eating disorders would sometimes score the maximum possible score on the fear of negative evaluation scale. So, a lot of social anxiety. (1:16:12 - 1:16:32) And again, if you're doing stuff to change your appearance because you're worried about what people will think about you, you can see the overlap with social anxiety. The mood disorders, substance use, that's a bit, it's definitely there, and there's different theories about why it is. Some people have argued that these disorders are actually a variant of mood disorders. (1:16:33 - 1:17:07) Other people would argue that the eating itself is actually affecting your neurochemistry and might lead to problems with mood. We do know, again, when people are seriously biologically deprived, anorexia or something similar, that it basically will cause a variety of these sort of psychological problems that would get better when you sort of normalize the person's eating and body weight. Now, I've mentioned men a couple times, and there is some literature specifically on bulimia nervosa in men. (1:17:07 - 1:17:55) We don't know the exact prevalence rates, but somewhere around what I have listed there. And possibly, again, related to those sort of racial ethnic sort of factors, do seem to see higher rates in a couple groups based on sexuality is one, and also based on like athletes that, particularly athletes in certain types of sports where there are weight regulations and they often have to lose weight or gain weight quite quickly. The one that would come to mind most quickly for me for that would be like wrestling. (1:17:55 - 1:18:14) I don't mean like WWE wrestling. I mean like real wrestling where they have these particular weight classes. Gymnasts or, excuse me, wrestlers will tell you that they've had coaches tell them you have to lose this by tomorrow or whatever, and they would do all these extreme things to try to lose weight. (1:18:15 - 1:18:39) I said gymnasts by mistake, but I was going to mention gymnasts too, because that's another one where you'll see high rates of these things, not just among men, but among women too. The other one, which could also be men or women, but there's just more of them that are men, would be jockeys, because they have to keep their weight off. Otherwise, it's harder on the horse. (1:18:39 - 1:19:15) But if you'll talk to jockeys, they'll tell you that there's a whole lore among them about how to eat a lot and throw it up, and they have terms for it and all sorts of stuff. You definitely do see these things among groups where there's a particular reason why they have to maintain their weight. Just interestingly, I'll point out here that although we think of the rates of eating disorders increasing, in some ways they are. (1:19:16 - 1:19:44) There is some evidence that the prevalence of bulimia or bulimia nervosa may have decreased in recent years, at least going back to like the 80s. You'll notice this study ends around the turn of the most recent century, and I haven't seen a follow-up. I mean, someone needs to do a follow-up, but at least from the 80s, the 90s to around 2000, the numbers seem to be going down a bit. (1:19:45 - 1:20:05) And why is that? I mean, maybe it's education, maybe it's treatment. There was a lot of this going on in like sororities and stuff, particularly in the US, maybe in the 80s, and they sort of got control of it a bit. But again, interestingly, there is some evidence that some of these things are going down. (1:20:06 - 1:20:36) The top one is prevalence of bulimia nervosa, and that was based on earlier criteria, but the criteria are about the same. But some of these, if you look, like for example, the body image criterion, criterion C, that's still extremely common. We're talking about 67% of women meeting the body image criterion for an eating disorder, and 31% of men meeting that criterion. (1:20:37 - 1:20:57) So, those are still high, even though the overall numbers may be going down. Binge eating disorder, this one we know less about just because we haven't studied it as long as the other two disorders. But it's probably more common, and it also depends on sort of the sample that you're looking at. (1:20:57 - 1:21:41) Talking about the general population, the number I have there at the top, but if you start looking at the obese population, it's going to be higher. And if you go into places where people are seeking help for weight loss, weight loss centers, you'll find really high rates among them of people meeting the criteria for binge eating disorder. I remember my master's research, my thesis when I was in undergrad, many years ago, I went into some of these weight loss centers and was measuring eating disorder symptomatology, and they were similar to the eating disorder clinic where I was working at the time, too. (1:21:45 - 1:22:04) We talk about gender differences for eating disorders, and, you know, we've seen numbers like 9 to 1 and things like that. Binge eating disorder is quite different. It does seem to affect more females than males, but the difference is much closer. (1:22:04 - 1:22:30) So, we're talking about maybe instead of 9 to 1, something like 1.5 to 1. And that relates to some of the ideological theories, too, that we'll talk about at some point here. Age of onset, a little bit later than anorexia, probably similar with bulimia nervosa. This is quite interesting, too. (1:22:31 - 1:23:03) If you talk to people with, particularly like bulimia nervosa, and you ask them, which started first? Because they're going to be engaging in binging and also dieting. You say, which started first? People with bulimia nervosa will say the dieting started first, and then they just basically gave in and started binging, and then they learned to purge and all that. With anorexia nervosa, almost by definition, the dieting starts first because the disorder is really based on not eating enough. (1:23:05 - 1:23:17) With binge eating disorder, though, it's not necessarily that way. About half of the people with it will say, yes, dieting preceded the binging. But about the other half will not say it. (1:23:17 - 1:23:46) They'll say, I have always been like this in terms of having issues with emotional eating. So, they'll say they eat in response to negative emotions, and the dieting that they do has really been just to try to counteract the effects of the binging. So, perhaps there's, that tells us one thing, that binge eating disorder is a little bit different than these other disorders in terms of relationship with dieting. (1:23:47 - 1:24:16) And also, perhaps there's different subtypes of people with binge eating disorder. In terms of other things, mood disorders, substance abuse, anxiety are common. Probably not as common as anorexia nervosa and bulimia nervosa, but still much more common, particularly like if you compare them to a non-eating disordered obese sample, the rates of these things are much higher. (1:24:18 - 1:24:37) All right, so now let's talk about etiology. And to do that, there's really two approaches we could take. We could do a sort of disorder specific approach where we talk about the etiology of anorexia, then the etiology of bulimia nervosa, and other disorders. (1:24:37 - 1:25:06) Or we could take what's called a transdiagnostic approach, which basically means looking at them collectively, sort of what they have in common. This is a term you'll see in the literature quite a bit associated with other disorders too, but particularly associated with eating disorders. The researcher most associated with it would be Christopher Fairburn, who's known for other research in the eating disorder field too. (1:25:07 - 1:25:39) I mean, he's done a lot of, he's one of the developers of cognitive behavioral approaches treatment of eating disorders. But again, you see him associated with the transdiagnostic model, which basically is summarized on the slide here, sort of viewing the, again, what they have in common, the overvaluation of eating shape and weight as the core pathology underlying all eating disorders. Although, as I'll get to in a second, it underlies some of them better than others. (1:25:39 - 1:26:05) According to the model, it hypothesizes that overvaluation leads to restrictive eating, dieting, then that in turn leads to disordered eating. And the model's been sort of updated in recent years too, to include some other factors too. So, what's the plus of the transdiagnostic model? Well, it may explain the high rate of diagnostic crossover. (1:26:05 - 1:26:38) I talked about in the context of EDNOS that a lot of the people end up with that diagnosis because they cross over and don't seem to meet the specific criteria for one disorder long enough, or they do, but they still cross over. So, it does explain that. A downside though, or a limitation of the transdiagnostic model, I've alluded to this already, is that it doesn't seem to work quite as well for binge eating disorders. (1:26:39 - 1:27:06) So, as I noted just a few minutes ago, many people with binge eating disorder report the binge eating started before the weight concerns and dieting started. So, that whole idea sort of expressed in that second bullet point above doesn't really hold for people with binge eating disorder, at least as well. It's not that all of them report that, but a sizable number of them report that. (1:27:08 - 1:27:40) So, what I'm going to try to do is take both approaches and talk a little bit eating disorder specific, but then also talk about transdiagnostic approaches. And to make sure I have enough time for the second part, I'm not going to spend too much time on the first part, but let's go through some of the sort of highlights. So, with all disorders, we've talked about the biopsychosocial model, which includes biological, psychological, and social or sociocultural factors. (1:27:41 - 1:28:23) So, we'll try to do the same here, although you could say collectively the eating disorders are a category where sociocultural factors may play more of a role, at least than they did for other disorders. And some people would argue that sociocultural factors are overemphasized, and eating disorders and biological factors are under-emphasized, but at least it would be probably correct to say that sociocultural factors, again, play more of a role for these disorders than they do for other disorders that we've talked about. And most of the sociocultural factors are really more of the transdiagnostic stuff. (1:28:23 - 1:28:52) So, I'll talk about them in the context of that, but we'll talk more about some biological factors and some psychological things here. So, biological factors associated with anorexia nervosa, there's some degree of heritability, but it may depend on what aspect of the disorder is being studied. And it's probably the case that there's some sort of interaction between genetic factors in the environment. (1:28:52 - 1:29:07) That's really the case for all disorders in terms of the genetic influence. It's not just genetic per se. It's how someone's genetic makeup interacts with the environment that matters. (1:29:09 - 1:29:32) Neurotransmitters have been studied. Serotonin may play some kind of role with anorexia and perhaps bulimia nervosa. Exactly how is it clear? And the complicating factor with eating disorders more so than with things like depressive disorders or psychotic disorders is that these things are actually reactive to diet. (1:29:32 - 1:29:56) So, you can alter your diet significantly. You can affect serotonin levels. So, when we start talking about the serotonin activity perhaps being somehow playing a role, we're not sure that it's actually causal as opposed to being an effect of the out-of-control sort of eating behavior. (1:29:56 - 1:30:21) Other things, though, that have been at least studied may have something to do with hormonal systems like the neuroendocrine system, particularly involved in the regulation of hunger and fullness. Psychological factors, these things you've seen in the literature, at least to be associated with anorexia. But it looks similar to the list of what I gave you earlier of effects of anorexia. (1:30:21 - 1:30:53) So, again, some of the challenge is knowing what's cause and what's effect. But at least the things that have been studied, low self-esteem, negative affect, negative emotions, dysfunctional thinking, perfectionism, that one is at least probably more evidence that it's not just a result of the anorexia and it may play some sort of a causal role. Social factors, again, the cultural stuff I'll come back to. (1:30:53 - 1:31:19) But more social, like family stuff we're talking about here. And people with anorexia do report high levels of criticism and lower levels of care from parents. There is probably some degree of direct influence from parents in terms of modeling, in terms of their own behavior, or comments made about people's eating behavior or weight. (1:31:21 - 1:31:40) And peer pressure, cultural values play a role. I'll come back to more of the sociocultural stuff, but at least mentioning it here. And there's actually, on the internet, things like pro-anorexia websites, where, which is slightly different than the Thinspiration. (1:31:40 - 1:32:09) That's, at least Thinspiration, the goal is to inspire people to exercise for healthy reasons. That may be a problem also, but the pro-anocytes are more explicitly just sort of for emphasizing the merits of having anorexia and sharing secrets about being anorexic and pictures and all sorts of stuff. So, that's definitely a concern. (1:32:10 - 1:32:32) So, with bulimia nervosa, there may also be biological factors, similarly a moderate heritability. Interestingly, perhaps a heritability towards some other things too, like obesity, along with substance use and mood disorders. Serotonin comes up here also. (1:32:32 - 1:32:57) In fact, there, you can find in literature, the sort of serotonin theories of eating disorders. And they use the fact that SSRI medications work sometimes as evidence that these disorders might be based on a serotonin sort of imbalance or serotonin mechanism. And there is some support for that. (1:32:57 - 1:33:24) But as I said, with anorexia, the problem is that serotonin and other neurotransmitter levels are actually reactive to diet. And particularly if you engage in a diet where you restrict carbohydrate intake, that may affect serotonin levels. So, doing exactly what people with bulimia nervosa do could actually cause the same thing that some people are hypothesizing to be a causal factor. (1:33:26 - 1:33:56) Another model into the psychological factors, a model specific to bulimia nervosa is the dual pathway model by a researcher named Stice. Basically, the idea that there are two pathways that may lead one to binge eating, and it may be one or the other or both. The two pathways being dietary restriction and negative affect. (1:33:57 - 1:34:08) So, some people starve themselves and end up binging a result. Other people binge and result of negative affect. And for some people, it's the combination of both. (1:34:10 - 1:34:55) In terms of some social factors, people with bulimia nervosa talk about a history of weight related teasing, so higher levels of critical comments about their eating shape and weight. They may also report a history of poor family functioning, at least relative to people without an eating disorder. And looking at individual episodes of binge eating, often negative interpersonal interactions may trigger those, which makes sense why then we'll come back in a little while that interpersonal therapies that target interpersonal sort of factors may be useful for people with bulimia nervosa. (1:34:57 - 1:35:21) And for binge eating disorder, notice that even when we're talking about the disorder specific etiological level, a lot of these are very similar. So, moderate degree of heritability. Again, the serotonin system has been implicated, but again, there's a limitation of the effect of diet on serotonin levels. (1:35:22 - 1:35:44) And some research on possible roles of hormonal disturbances that would may be a little bit more unique to binge eating disorder. Psychological factors. This is one where I've mentioned negative affect associated with bulimia nervosa, the dual pathway model. (1:35:44 - 1:36:14) But there's probably stronger support for the role of negative affect associated with binge eating disorder. Remember, I talked about a large number of people report that they started binge eating before they started dieting and largely relation to negative affect. People talk about being emotional eaters from way back, even sometimes when they were kids. (1:36:15 - 1:36:45) And also, as noted there, a high percentage of people will report a major depressive episode in the period before they developed the disorder. So, suggesting that the mood- related issues may have led to the disordered eating as opposed to the other way around. And a few things related to social functioning, binge eating disorder, seem to be associated with overall poor family functioning. (1:36:47 - 1:37:00) Elevated levels of criticism again. Reduced levels of affection. Some people talk about sort of turning to food for the affection they don't get from relationships, including families. (1:37:02 - 1:37:35) And the one other issue that because a lot of these people are obese and there are stigma associated with obesity, that some of these negative attitudes may affect people with this disorder in a negative way, but then lead to more problems with binge eating. So, now that we've talked a little bit about disorder-specific ideological factors, let's talk now about the sort of trans-diagnostic factors. These are things that sort of apply to most of the eating disorders. (1:37:35 - 1:38:06) Although, as I said before, a little bit less to binge eating disorder than to the rest. And what we're talking about here are a variety of things, but some of the social-cultural dimensions, for example, the sort of teaching young people that being thin equals being successful and happy. Also, we're talking about like research on ideal body size standards that change rapidly. (1:38:06 - 1:38:17) They've changed rapidly over time. Like people don't realize that they talk about like the thin ideal being a recent thing. It's actually changed over time. (1:38:17 - 1:38:45) There were other times in history, certain cultures where there was a very thin ideal and people, particularly women, would do things to try to meet that thin ideal. Like there was times in the past when, you know, women wore corsets and had ribs removed to make their waist look smaller. Go back in time, we talk about people vomiting and taking laxes and you think that sounds kind of extreme. (1:38:46 - 1:39:11) There's been times in the past when women would eat tapeworms as a way of trying to consume calories. So, the point is when the standards change, the frequency of extreme weight control behaviors change. And a lot of this comes through the media, particularly more recently where we have all sorts of media platforms where you can look at all sorts of different body sizes. (1:39:11 - 1:39:28) And also, like different standards for men and women, which I'll come to in just a minute. It's also cross-cultural considerations. So, you can sort of look at this from a variety of perspectives. (1:39:29 - 1:39:46) Like, for example, some North American minority groups have different standards for body image. So, they have different rates of disordered eating. Immigrants to Western cultures, people coming from places where they don't have these kind of standards. (1:39:46 - 1:40:05) When they move to places that do, you see an increase in eating disorders, also an increase in obesity. And again, just different cultural values associated with different cultural groups and how that relates to standards of body image. That's the kind of stuff we're talking about. (1:40:07 - 1:40:18) Regarding that, but back to the issue more of men and women, this has been studied for years. It's a fairly famous study. I mean, it's fairly dated, but it's quite meaningful. (1:40:19 - 1:40:50) Years ago, remember I showed you the body image cards from the bulimia nervosa study? That was one that, as I said, some of, well, actually my advisor had done that particular study. This was done with not people with disordered eating, but just average college or university students, I believe. And they had men and women in the study, and they used cards sort of similar to what I showed you, a little bit different. (1:40:50 - 1:41:31) But they had them for men and women, and they asked both men and women three questions about the cards that looked like them. So they would show women cards of women, and they would say, what is your current body size? What do you view as most attractive? And what do you view as your ideal? They would also show them the opposite sex or gender and say, which one do you view as most attractive? So that's why there's four numbers associated with both men and women. So they did the same thing for men. (1:41:31 - 1:41:54) They would show them the male cards and say, what's your ideal? What do you view as most attractive? And what is your current? And then they would show them the female cards and say, which one do you think is most attractive? And so the findings are pretty interesting. I mean, look at the women. First of all, several things jump out at you. (1:41:54 - 1:42:21) First, the distinction between current and ideal is quite large. Also, notice that the men's attractive was actually larger than what women said was attractive. So if women are saying they're doing it just to look the way men want them to, they actually want to be thinner than men say is attractive, at least according to this study. (1:42:21 - 1:42:36) And interestingly, their own ideal was less than what they said was attractive. So they wanted to be thinner than what they said was attractive. If you look at the men's, the most striking point is that all three of their ratings were basically the same. (1:42:37 - 1:42:49) They thought they looked the way they wanted to, and they thought they looked attractive. I mean, that's the best way to interpret that. And they wanted to be larger than what women thought was attractive. (1:42:49 - 1:43:10) So obviously, this to some degree relates to the higher rate of disordered eating and eating disorders among women than men. Now, the downside of this study is that it was focusing purely on like body fat, adiposity. It wasn't focusing on muscularity. (1:43:10 - 1:43:44) And if you do ask men questions about muscularity, and you use measures that include muscularity, you do find much more body dissatisfaction than you would in a measure like this, which does explain why men may be more likely to have things like muscle dysmorphia than women, although women can have it too. But clearly, it relates to disordered eating. And follow-up studies have also looked at the relationship between disorder. (1:43:44 - 1:44:03) And this was just a blow up of the women's slide. But this study was a follow-up study where they did the same sort of measure. But they broke the women down in terms of those who scored high or low on a distorted eating attitudes test. (1:44:03 - 1:44:20) And so this was what they looked like when they scored high on the disordered eating attitudes test, distorted attitudes towards eating. The eating attitudes test is the actual test. And you can see the distinction is quite large, particularly between current and ideal. (1:44:21 - 1:44:40) This is what the group looked like when they scored low on the same measure. So, not only are there gender differences, but these ratings do relate to actual eating behavior, at least attitudes towards eating. So, clearly, something is going on that can be measured there. (1:44:41 - 1:45:19) This is just the same slide showing the difference between the group high and low on distorted eating attitudes. Other things, you know, body's beauty standards, like, they're not so big in Australia, but the US, these pageants, you know, Miss America, Miss Universe. And what has been found is that the BMIs for winners of the Miss America competition have gradually gone down since, like, the 20s, other than, I guess, there was an outlier around 1940. (1:45:21 - 1:45:30) But they've consistently gone down. I think a follow-up study, this one ended, you know, before the turn of the century. I think follow-up studies have shown they've continued to go down. (1:45:30 - 1:45:45) Maybe not as on the same curve, because then they would be around 15 by the year 2020. But they are quite low. I mean, look at the, look at some of those, if you look at the BMI values, again, around 17. (1:45:46 - 1:46:10) I mean, that's in the anorexic range. And this doesn't mean that the women did have anorexia, but it means that what is being shown to people as an ideal, at least one variant of an ideal, is the range that is basically what anorexia nervosa is. The other area where we see this is like in the modeling industry. (1:46:11 - 1:46:36) And by the way, the reason I have this picture up there, if you can't guess, it's just to illustrate that what's been considered sort of beautiful over time, beauty standard has changed. And there were times, as I was saying earlier, when it was much larger. And those times, although we didn't have probably the science that we have now, it was not believed that there were higher rates of disorder eating. (1:46:36 - 1:46:58) Whereas when you have models that are supposed to look like anorexics, then you have much higher rates, not just among people in general, but also among the models themselves. So, there's a whole issue about disordered eating in the modeling industry. And I'm going to show you a couple clips now. (1:46:58 - 1:47:16) I'll show you the first one, and then we'll talk briefly about it. And then I'll show you the second one, and we'll talk briefly about it. So, I've actually never seen that show. (1:47:16 - 1:47:33) Perhaps it's a good show, but what I just saw there isn't very good. And it illustrates clearly the problems associated with the modeling industry. I mean, the one woman they talked about said things like, I'm not bulimic because I don't vomit after everything I eat. (1:47:34 - 1:47:47) We know that you don't have to do it after everything you eat to meet the criteria for the disorder. She even said something like, I'm obsessed with my weight, but I don't have an eating disorder. I guess she said, I'm not bulimic. (1:47:48 - 1:48:05) But the whole point of the transdiagnostic model is that being obsessed with your weight really is the problem. And the behaviors are simply a way of dealing with the problem. Although, if someone doesn't engage in any of the behaviors, I mean, you wouldn't meet the criteria for an eating disorder. (1:48:05 - 1:48:23) But clearly, people like her and many models have to. And you can see why they have to. Because the guy who's measuring her basically says, your thighs are too big, your waist too big, whatever he was saying. (1:48:23 - 1:48:45) Your hips are too big. When obviously, she was already very thin. So there's no question that the modeling industry contributes to this, both for the women that are in it and for people that see it as a sort of guide for what the standard is, particularly young girls growing up looking at this. (1:48:45 - 1:49:03) But it's not all that way. So I'm going to show you a second video that shows that in some places within the modeling industry, they've decided to do something about it. So I like that video a little bit more. (1:49:03 - 1:49:15) I used to have a longer one about the same guy. It's just no longer available on YouTube. And he would talk about how he was part of the problem for years. (1:49:15 - 1:49:51) And it was really when the young woman that he knew died that he began to realize what a problem it was. And so what they've done in Israel, as noted in the video, is they've just banned people below a certain body mass, which is somewhere around what the cutoff for anorexia would be, even though the DSM is vague about exactly what it is. And some people argue that that's discrimination, that you're discriminating against very thin people, because not everyone who's very thin has an eating disorder. (1:49:52 - 1:50:00) But that is what they've done. And some other countries are following suit, too. I think we've seen models die. (1:50:01 - 1:50:17) There was one in Brazil that died, I believe, on the catwalk. And I believe they've taken action, too. I was once asked when I was in New Zealand to do a debate on the radio about this issue. (1:50:17 - 1:50:42) We had someone from the fashion industry, the modeling industry, and they had a psychiatrist, and they had me. And they thought we were going to argue about the whole thing, but we actually all agreed that it was probably a good thing, at least to have some sort of control over this issue. And what's happening, certainly in the US in that first example, is not good. (1:50:44 - 1:51:18) So, there's good and there's bad in the modeling industry. Let's keep going. So, if dieting is related to eating disorders, why is that? And what's some of the evidence or research associated with that? Well, if you do sort of cross-sectional research where you ask people about the past and you say, people with eating disorders, which came first, the dieting or the disordered eating? People with bulimia nervosa will almost always say the dieting came first. (1:51:18 - 1:51:28) With anorexia, they almost have to say the dieting because that is the disorder. Less so with binge eating disorder. Maybe, as I've said, maybe half of them say that. (1:51:28 - 1:52:08) If you look at perspective studies, in other words, you measure people's dieting status at time one and follow them on to time two, you find a fairly similar sort of thing that dieting at time one predicts other eating disturbance to binge eating at time two. The experimental research is sort of mixed. If you bring people into the laboratory and sort of deprive them and subject them to various experimental manipulations, you do sometimes see the overeating or binging sort of effect. (1:52:09 - 1:52:34) You don't necessarily see it though in experimental weight loss research. So, in other words, if you randomly assign people to a dieting condition and a control group, then it's not necessarily the case that those who diet go on to increase their binge eating also. Problem with that though is most experimental research these days would be on diets that are healthy. (1:52:35 - 1:53:06) Very extreme dieting is hard to do ethically. Years ago, there was a study in the US where they did study a bunch of conscientious objectors in the war, I believe it was the Vietnam War, who agreed basically to be research subjects instead of going into the military. But what they did or the researchers did was they deprived the research participants or they basically restricted their intake for an extended period of time. (1:53:06 - 1:53:33) And they ended up developing all sorts of symptoms very similar to people with eating disorders, both eating-related but also mood-related and even things like engaging in self-injurious behaviors and things like that. So, when you take it to the extreme, the research or when you take the dieting to the extreme, it does seem to have the effect that we see in people with eating disorders. There's also animal research. (1:53:34 - 1:53:53) A lot of times, it's really sort of ignored. People don't seem to pay much attention to it. But in particular, there's a paradigm where if you study rats and you deprive them of food, then you stress them and then you offer them very highly palatable food. (1:53:54 - 1:54:06) Apparently, rats have certain things they like more than other things. If you have all three of those ingredients, they end up binge eating sort of in the same way that humans do. And you have to have all three ingredients. (1:54:06 - 1:54:15) If you just stress them or you just deprive them, you don't really get the effect. You have to have all three of them. But that is quite consistent with what humans say. (1:54:15 - 1:54:33) When they're deprived, when they're stressed, and when the food's available, the foods that they like are available, that's when they tend to binge. So, overall, the conclusions aren't completely clear. But we know that the dieting does play a role, particularly when taken to the extreme. (1:54:33 - 1:54:48) And we also know that it really doesn't work. This is just a slide showing that you follow people over time. And one thing that distinguishes them is that the dieters tend to actually gain weight relative to ones that are non-dieters. (1:54:50 - 1:55:04) So, another thing that we need to talk about while talking about the etiology is this addiction model of eating disorders. We'll talk about addictions. I think it's actually next week. (1:55:04 - 1:55:19) And many people have argued that eating disorders are a variant of an addiction. I've actually written a book chapter on eating addiction. But in the chapter, I said, I don't believe in eating addictions, which I guess is giving away what I'm about to say. (1:55:19 - 1:55:35) But the argument is typically that they share a lot of similarities. So, for example, they both involve... When I say both, I mean disordered eating and addictions like drugs or alcohol. They both involve severe craving, loss of control. (1:55:37 - 1:55:47) They both involve using the substance to cope with negative feelings. People become preoccupied with both of them. They have unsuccessful attempts to quit. (1:55:49 - 1:56:07) They deny the seriousness of the problem. And they have many adverse psychosocial consequences, both for people, again, with other kinds of addictions and with eating disorders. But the problem is that it becomes an issue of partial similarity at some point. (1:56:07 - 1:56:21) In other words, you can abstain from alcohol. You can abstain from cocaine, heroin, anything, any of the drugs that people become addicted to. You can't abstain from food. (1:56:22 - 1:56:42) In fact, if you try to abstain from food, that's called an eating disorder. And some people then say, well, it's not food, it's certain foods like sugar or refined foods or whatever, that people are addicted to those and they need to avoid those specific kinds of foods. And often, it's the foods that people binge on. (1:56:43 - 1:57:19) Now, the problem with that logic is it's basically runs the exact opposite to what you would recommend from this more behavioral, cognitive behavioral model of eating disorders, where people basically have these rigid rules that when they then violate the rules, it leads to the binging. So, those rules are actually viewed as part of the problem. And so, the addiction model, even though there are things like Ovary is Anonymous that may have helped people, it's not viewed as really consistent with our understanding of eating disorders. (1:57:20 - 1:57:40) It's not very viewed positively as a treatment for people with disordered eating. And on that topic, let's talk about treatment for eating disorders. So, there are several treatments that have been studied for bulimia nervosa. (1:57:41 - 1:58:05) Some of these are, at least, these are all mentioned in your text, I believe. Things like motivation enhancement therapy, self-help approaches typically based on CBT, cognitive behavioral therapy itself, and interpersonal therapy. And then there are also pharmacological approaches, typically antidepressants, often SSRIs. (1:58:06 - 1:58:19) For time's sake, I'm going to talk about a couple of these where there seems to be the most empirical support. That would be cognitive behavioral therapy and interpersonal psychotherapy. This is a little table from your text. (1:58:20 - 1:58:36) The table says content of Fairburn's manual for bulimia nervosa. I'm not actually sure if that's from bulimia nervosa or binge eating disorder because it's from a book on binge eating, which sort of deals with both. But a lot of that would be the same. (1:58:36 - 1:58:59) There's a few other things that you do in cognitive behavioral therapy for bulimia nervosa. And you'd have to sort of say this day and age, it would be the treatment of choice. It doesn't work for everybody, but you sort of want to start with the thing with the most empirical support, which is probably cognitive behavioral therapy. (1:59:00 - 1:59:39) As the name implies, it targets both cognitions and behaviors. So you're targeting the eating behaviors, trying to get the eating normalized, the reduction of purging, the reduction of dieting, but also targeting dysfunctional thinking, that all or nothing sort of thinking that we were talking about earlier, and the sort of equating self-worth with body size and shape, all of that sort of stuff. There's more recently an enhanced CBT, which is basically trying to target some of the other sort of personality features a