Eating Disorders PDF

Abnormal Psychology Fourteenth Edition Ann M. Kring & Sheri L. Johnson Chapter 11 Eating Disorders Chapter Outline Clinical Description of Eating Disorders Etiology of Eating Disorders Treatment of Eating Disorders Copyright ©2018 John Wile...

Abnormal Psychology Fourteenth Edition Ann M. Kring & Sheri L. Johnson Chapter 11 Eating Disorders Chapter Outline Clinical Description of Eating Disorders Etiology of Eating Disorders Treatment of Eating Disorders Copyright ©2018 John Wiley & Sons, Inc. 2 DSM-5 Criteria: Anorexia Nervosa Restriction of food that leads to very low body weight; body weight is significantly below normal Intense fear of weight gain or repeated behaviours to interfere with weight gain Body image disturbance Copyright ©2018 John Wiley & Sons, Inc. 3 Anorexia Nervosa (1 of 2) Weight loss is typically achieved through dieting o Can also occur through purging and excessive exercise Fear of gaining weight is not reduced by weight loss Copyright ©2018 John Wiley & Sons, Inc. 4 Anorexia Nervosa (2 of 2) Even when emancipated, those with anorexia nervosa may believe they are overweight o They overestimate their body size o They will choose a thin figure as ideal Severity ratings are based on Body Mass Index (BMI) Copyright ©2018 John Wiley & Sons, Inc. 5 Figure 11.1: Assessment of Body Image (a) Ratings of women who scored high on a measure of distorted attitudes toward eating (b) Ratings of women who scored low Copyright ©2018 John Wiley & Sons, Inc. 6 Body Mass Index (BMI) Copyright ©2018 John Wiley & Sons, Inc. 7 Subtypes of Anorexia Nervosa Restricting type o Weight loss is achieved by severely limiting food intake Binge-eating/purging type o The person has also regularly engaged in binge eating and purging Longitudinal research suggests limited validity, yet clinical utility of subtypes Copyright ©2018 John Wiley & Sons, Inc. 8 Anorexia Nervosa: Prevalence (1 of 2) Onset: early to middle teenage years Usually triggered by dieting and stress At least 3x more frequent in woman than men Copyright ©2018 John Wiley & Sons, Inc. 9 Anorexia Nervosa: Prevalence (2 of 2) Often comorbid with depression, OCD, phobias, panic, personality disorders Suicide rates are high o 5% completing o 20% attempting Copyright ©2018 John Wiley & Sons, Inc. 10 Anorexia Nervosa: Physical Consequences (1 of 2) Low blood pressure, heart rate decrease Kidney and gastrointestinal problems Loss of bone mass Copyright ©2018 John Wiley & Sons, Inc. 11 Anorexia Nervosa: Physical Consequences (2 of 2) Brittle nails, dry skin, hair loss Lanugo (a fine, soft hair) may develop Altered levels of potassium and sodium electrolytes o Can cause tiredness, weakness, and sudden death Copyright ©2018 John Wiley & Sons, Inc. 12 Anorexia Nervosa: Prognosis (1 of 2) 50-70% eventually recover o May often take 6 or 7 years o Relapse common Difficult to modify distorted view of self, especially in cultures that highly value thinness Copyright ©2018 John Wiley & Sons, Inc. 13 Anorexia Nervosa: Prognosis (2 of 2) Anorexia is life-threatening o Death rates 10x higher than general population o Death rates 2x higher than other psychological disorders o Death often results from physical complications of the illness Copyright ©2018 John Wiley & Sons, Inc. 14 DSM-5 Criteria: Bulimia Nervosa Recurrent episodes of binge-eating Recurrent compensatory behaviours to prevent weight gain o E.g., purging (vomiting), fasting, excessive exercise, use of laxatives and/or diuretics Body shape and weight are extremely important in self- evaluation Copyright ©2018 John Wiley & Sons, Inc. 15 Bulimia Nervosa: Severity Ratings Based on number of compensatory behaviours/week Copyright ©2018 John Wiley & Sons, Inc. 16 Bulimia Nervosa: Binge Eating (1 of 2) A binge episode includes: o An excessive amount of food consumed in a short period of time o A feeling of losing control over eating Typically occurs in secret Copyright ©2018 John Wiley & Sons, Inc. 17 Bulimia Nervosa: Binge Eating (2 of 2) May be triggered by stress, negative emotions or negative social interactions o Typical food choices: Cakes, cookies, ice cream, other easily consumed, high- calorie foods o Avoiding a craved food can later increase likelihood of binge o Reports of losing awareness or dissociation o Shame and remorse often follow Copyright ©2018 John Wiley & Sons, Inc. 18 Bulimia Nervosa: Compensatory Behaviour Feelings of discomfort, disgust, and fear of weight gain lead to inappropriate compensatory behaviour o Attempt to undo the caloric effects of the binge Vomiting, laxative and diuretic abuse, fasting, excessive exercise are used to prevent weight gain Binge/purge episode must occur at least once a week for 3 months Copyright ©2018 John Wiley & Sons, Inc. 19 Bulimia Nervosa: Prevalence (1 of 2) Onset late adolescence or early adulthood 90% of people with bulimia nervosa are women Prevalence among women: 1 – 2% Copyright ©2018 John Wiley & Sons, Inc. 20 Bulimia Nervosa: Prevalence (2 of 2) Typically overweight before onset and symptoms begin while dieting Comorbid with depression, personality disorders, anxiety, substance use disorders, conduct disorder Suicide rates are higher than in general population o But much lower than in anorexia nervosa Copyright ©2018 John Wiley & Sons, Inc. 21 Bulimia Nervosa: Physical Consequences (1 of 2) Potassium depletion from purging Laxative use depletes electrolytes, which can cause cardiac irregularities Vomiting may lead to tearing of the tissue in the stomach and throat Copyright ©2018 John Wiley & Sons, Inc. 22 Bulimia Nervosa: Physical Consequences (2 of 2) Loss of dental enamel from stomach acids in vomit Mortality rate higher than other disorders Copyright ©2018 John Wiley & Sons, Inc. 23 Bulimia Nervosa: Prognosis ~75% recover 10-20% remain fully symptomatic Early intervention linked with improved outcomes Poorer prognosis when depression and substance abuse are comorbid or when more severe symptomatology Copyright ©2018 John Wiley & Sons, Inc. 24 Bulimia vs. Anorexia The key difference is weight loss: o People with anorexia nervosa lose a tremendous amount of weight o People with bulimia nervosa do not Copyright ©2018 John Wiley & Sons, Inc. 25 DSM-5 Criteria: Binge Eating Disorder (1 of 2) Binge eating episodes include at least three of the following: o Eating more quickly than usual o Eating until over full o Eating large amounts even if not hungry o Eating alone due to embarrassment about large food quantity o Feeling bad (e.g., disgusted, guilty, or depressed) after the binge Copyright ©2018 John Wiley & Sons, Inc. 26 DSM-5 Criteria: Binge Eating Disorder (2 of 2) Recurrent binge eating episodes No compensatory behaviour is present Copyright ©2018 John Wiley & Sons, Inc. 27 Binge Eating Disorder: Severity Ratings Based on number of binges/week Copyright ©2018 John Wiley & Sons, Inc. 28 Binge Eating Disorder: Prevalence (1 of 3) Associated with obesity and history of dieting o BMI > 30 Comorbid with mood disorders, anxiety disorders, ADHD, conduct disorder, and substance use disorders Copyright ©2018 John Wiley & Sons, Inc. 29 Binge Eating Disorder: Prevalence (2 of 3) Risk factors include: o Childhood obesity, critical comments about being overweight, weight-loss attempts in childhood, low self- concept, depression, and childhood physical or sexual abuse Copyright ©2018 John Wiley & Sons, Inc. 30 Binge Eating Disorder: Prevalence (3 of 3) More prevalent in women More prevalent than anorexia or bulimia Equally prevalent among Euro-, African-, Asian-, and Hispanic-Americans Copyright ©2018 John Wiley & Sons, Inc. 31 Binge Eating Disorder: Physical Consequences (1 of 2) Problems associated with obesity: o Increased risk of type 2 diabetes o Cardiovascular problems o Chronic back pain o Headaches Copyright ©2018 John Wiley & Sons, Inc. 32 Binge Eating Disorder: Physical Consequences (2 of 2) Problems independent of obesity: o Sleep problems o Anxiety/depression o Irritable bowel syndrome o Early onset of menstruation in women Copyright ©2018 John Wiley & Sons, Inc. 33 Binge Eating Disorder: Prognosis This is a relatively new diagnosis o New to DSM-5 o Few studies have assessed prognosis Research so far suggests between 25-82% recover Duration of just over 4 years Copyright ©2018 John Wiley & Sons, Inc. 34 Binge Eating Disorder vs. Anorexia and Bulimia Binge Eating Disorder vs. Anorexia Nervosa: o Absence of weight loss in binge eating disorder Binge Eating Disorder vs. Bulimia Nervosa: o Absence of compensatory behaviours (purging, fasting, or excessive exercise) in binge eating disorder Copyright ©2018 John Wiley & Sons, Inc. 35 Genetics (1 of 2) First-degree relatives of women with: o Anorexia nervosa are 10x more likely to have the disorder o Bulimia nervosa are 4x more likely to have the disorder First-degree relatives of women with eating disorders appear to be at higher risk for anorexia or bulimia Copyright ©2018 John Wiley & Sons, Inc. 36 Genetics (2 of 2) Higher MZ concordance rates for both anorexia and bulimia Nonshared/unique environmental factors also contribute to the development of eating disorders Key features of eating disorders, body dissatisfaction, desire for thinness, binge eating and weight preoccupation, are heritable Copyright ©2018 John Wiley & Sons, Inc. 37 Neurobiological Factors (1 of 4) Hypothalamus o Regulates hunger and eating o However, it does not seem a likely causal factor in anorexia nervosa Copyright ©2018 John Wiley & Sons, Inc. 38 Neurobiological Factors (2 of 4) Low levels of endogenous opioids o Substances that reduce pain, enhance mood, and suppress appetite o Released during starvation May reinforce restricted eating of anorexia o Excessive exercise also increases opioids Copyright ©2018 John Wiley & Sons, Inc. 39 Neurobiological Factors (3 of 4) Serotonin o Related to feelings of satiety (feeling full) o Low levels of serotonin metabolites among people with anorexia and bulimia suggests underactive serotonin activity o Antidepressants that increase serotonin often effective in treatment of eating disorders May be linked to comorbid depression Copyright ©2018 John Wiley & Sons, Inc. 40 Neurobiological Factors (4 of 4) Dopamine o Related to feelings of pleasure and motivation o Key role in “liking” of food and the “wanting” or craving for food Copyright ©2018 John Wiley & Sons, Inc. 41 Cognitive Behavioural Factors: Anorexia Nervosa (1 of 2) Body-image disturbance powerfully reinforces weight loss Behaviours that achieve or maintain thinness: o Negatively reinforced by the reduction of anxiety about gaining weight o Positively reinforced by comments from others o Positively reinforced by the sense of mastery or self- control Copyright ©2018 John Wiley & Sons, Inc. 42 Cognitive Behavioural Factors: Anorexia Nervosa (2 of 2) Perfectionism and personal inadequacy lead to excessive concern about weight Criticism from family and peers regarding weight related to strong drive for thinness and disturbed body image Copyright ©2018 John Wiley & Sons, Inc. 43 Cognitive Behavioural Factors: Bulimia Nervosa (1 of 2) Self-worth strongly influenced by weight and shape Lapses in rigid restrictive eating rules escalates into a binge After binging, disgust with oneself and fear of gaining weight lead to compensatory behaviour Copyright ©2018 John Wiley & Sons, Inc. 44 Cognitive Behavioural Factors: Bulimia Nervosa (2 of 2) Purging temporarily reduces anxiety about weight gain This cycle lowers a person’s self-esteem, which triggers further bingeing and purging Copyright ©2018 John Wiley & Sons, Inc. 45 Figure 11.3 Schematic of Cognitive Behaviour Theory of Bulimia Nervosa Copyright ©2018 John Wiley & Sons, Inc. 46 Cognitive Behavioural Factors: Binge Eating People with bulimia nervosa and binge eating disorder: o Typically binge when under stress or experience negative emotions o Propensity to experience negative emotions predicts the onset of eating disorders o Binging may function as a way to regulate negative emotion o However, people with these disorders often feel more negative after a binge Copyright ©2018 John Wiley & Sons, Inc. 47 Sociocultural Factors (1 of 2) The American cultural ideal has progressed steadily toward increasing thinness Dieting, especially among women, has become more prevalent o Often precedes onset Higher BMI and body dissatisfaction is related to higher risk for developing eating disorders Copyright ©2018 John Wiley & Sons, Inc. 48 Sociocultural Factors (2 of 2) Unrealistic media portrayals o Women may feel shame when they don’t match the ideal o “Pro-eating disorder” websites Stigma associated with being overweight Copyright ©2018 John Wiley & Sons, Inc. 49 Gender Influences (1 of 2) Objectification of women’s bodies o Women defined by their bodies; men defined by their accomplishments o Societal objectification of women leads to “self- objectification” Women see their own bodies through the eyes of others Leads to more shame when they fall short of cultural ideals Copyright ©2018 John Wiley & Sons, Inc. 50 Gender Influences (2 of 2) Aging and changes in life roles (having a life partner or having children) associated with decreases in eating disorder symptoms Copyright ©2018 John Wiley & Sons, Inc. 51 Cross-Cultural Factors Anorexia found in many cultures o Even those with little Western cultural influence o May not include fears of getting fat As countries become more like Western cultures, eating disorders increase Bulimia more common in industrialized societies than non-industrialized ones Copyright ©2018 John Wiley & Sons, Inc. 52 Racial and Ethnic Differences (1 of 2) Greater incidence of eating disturbances and body dissatisfaction among white women No differences in actual eating disorders, particularly bulimia o Differences most pronounced in college women White and Hispanic women report greater body dissatisfaction than African American women Copyright ©2018 John Wiley & Sons, Inc. 53 Racial and Ethnic Differences (2 of 2) White compared to African American teenage girls o Diet more frequently o More likely to be dissatisfied with their bodies Role of acculturation o More common in women living in US longer Stereotyped beliefs about race and eating disorders shape of people perceive disorders eating behaviours Copyright ©2018 John Wiley & Sons, Inc. 54 Personality Influences (1 of 2) Severe restriction of food intake can have powerful effects on personality and behaviour o Preoccupation with food, fatigue, poor concentration, lack of sexual interest, irritability, moodiness, and insomnia Copyright ©2018 John Wiley & Sons, Inc. 55 Personality Influences (2 of 2) Personality characteristics before an eating disorder o Body dissatisfaction, poor Interoceptive awareness, and negative affect predicted disordered eating o Perfectionism high among women with anorexia and remains high after successful treatment Copyright ©2018 John Wiley & Sons, Inc. 56 Family characteristics Self-reports of people with eating disorders indicate high levels of family conflict o Parental reports don’t always indicate family problems One observational study: o No difference in frequency of positive and negative message among parents with and without a child with an eating disorder More observational studies needed Copyright ©2018 John Wiley & Sons, Inc. 57 Medications (1 of 2) Bulimia nervosa o Often treated with antidepressants Likely because it is often comorbid with depression o Dropout and relapse rates high Anorexia nervosa o Medications have been used with little success in improving weight or other core features of anorexia Copyright ©2018 John Wiley & Sons, Inc. 58 Medications (2 of 2) Binge eating disorder o Limited research suggests that antidepressant medications are not effective in reducing binges or increasing weight loss Copyright ©2018 John Wiley & Sons, Inc. 59 Psychological Treatment: Anorexia Nervosa (1 of 2) Immediate goal is to increase weight to avoid medical complications and avoid death Second goal is long-term maintenance of weight gain CBT o Reductions in symptoms through 1 year Copyright ©2018 John Wiley & Sons, Inc. 60 Psychological Treatment: Anorexia Nervosa (2 of 2) Family-based therapy (FBT) o Interactions among family members can play a role in treating the disorder o Helps parents support child’s healthy weight while building family functioning o Early results show improved outcomes over individual therapy o Early weight gain may be an important predictor of a good outcome Copyright ©2018 John Wiley & Sons, Inc. 61 Psychological Treatment: CBT for Bulimia Nervosa (1 of 4) Best-validated and most current standard for treatment Challenge societal standards for physical attractiveness Challenge beliefs about weight and dieting Copyright ©2018 John Wiley & Sons, Inc. 62 Psychological Treatment: CBT for Bulimia Nervosa (2 of 4) Challenge all-or-nothing beliefs about food o One bite of high-calorie food does not need to trigger a binge Increase self-assertiveness skills Increase regular eating patterns (three meals per day) Copyright ©2018 John Wiley & Sons, Inc. 63 Psychological Treatment: CBT for Bulimia Nervosa (3 of 4) CBT more effective than medication o Adding medication may help alleviate depression o Adding exposure and ritual prevention (ERP) may not add much beyond CBT alone Copyright ©2018 John Wiley & Sons, Inc. 64 Psychological Treatment: CBT for Bulimia Nervosa (4 of 4) Guided self-help CBT o Use of self-help books on topics such as perfectionism, body image, negative thinking, and food and health o Meet for small number of sessions with a therapist to guide them through self-help material Interpersonal therapy o Not as effective in the short-term as CBT Copyright ©2018 John Wiley & Sons, Inc. 65 Psychological Treatment: Binge Eating Disorder (1 of 2) CBT shown to be effective o Targets binge eating through self-monitoring, self- control, and problem-solving skills CBT more effective than medication Copyright ©2018 John Wiley & Sons, Inc. 66 Psychological Treatment: Binge Eating Disorder (2 of 2) Interpersonal therapy equally as effective as CBT and guided self-help CBT o All three are more effective than behavioural weight- loss programs o Behavioural weight-loss programs promote weight loss, but do not curb binge eating Copyright ©2018 John Wiley & Sons, Inc. 67 Prevention of Eating Disorders Psychoeducational approaches o Early education about eating disorders Deemphasize sociocultural influences o Help resist or reject sociocultural pressures to be thin Risk-factor approach o Identify people at risk (e.g., weight and body-image concern, restricting food) and intervene to alter these factors Copyright ©2018 John Wiley & Sons, Inc. 68 Copyright Copyright © 2018 John Wiley & Sons, Inc. 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