Week_9_Eating_Disorders_2024.pdf

Eating Disorders 2 May 2024 Psychopathology of Everyday Life PSYC30014 Dr. Vanja Rozenblat [email protected] 1  Goals of this lecture ❖ Become familiar with diagnostic criteria (DSM-5) and associated features of EDs ❖ Understand transdiagnost...

Eating Disorders 2 May 2024 Psychopathology of Everyday Life PSYC30014 Dr. Vanja Rozenblat [email protected] 1  Goals of this lecture ❖ Become familiar with diagnostic criteria (DSM-5) and associated features of EDs ❖ Understand transdiagnostic models and symptom-level models ❖ Learn common aetiology of EDs ❖ Gain overview of treatment approaches and outcomes 2  Addressing pre-conceptions… Commonly held (incorrect) pre-conceptions: You can tell if someone has an eating disorder by looking at them Someone with an eating disorder will not be in the ‘normal’ weight range Eating disorders are a choice – people should just eat more/less 3 What is ‘normal’ eating? Eat when you’re hungry and stop Use moderate when you’re constraint satisfied w/out being too restrictive Sometimes just Over-eating at eating because it times – or feels good wishing you’d had more Eating is only one important area in your life 4 Centre for Clinical Interventions (CCI) Eating pathology 5  Diagnostic criteria and associated features 6  DSM-5 Feeding and Eating Disorders Anorexia Nervosa (AN) Bulimia Nervosa (BN) Binge Eating Disorder (BED) Other Specified Feeding and Eating Disorder (OSFED) Other Unspecified Feeling and Eating Disorder Pica Rumination Disorder Avoidant/Restrictive Food Intake Disorder 7  Anorexia Nervosa Diagnostic criteria: Persistent restriction of energy intake leading to low body weight Intense fear of weight gain or persistent behaviour that interferes with weight gain Disturbance in how weight/shape is perceived, undue influence of weight/shape on self-evaluation, or lack of recognition of seriousness of current low weight Subtypes: Restricting type (AN-R) Binge eating/purging type (AN-BP) 8  Anorexia Nervosa Sex ratio: 10 females : 1 male Elevated in gender diverse populations Prevalence: 12 month 0.4 - 0.8% Onset: Adolescence to early 20s Varied Course: Recovery after single episode Fluctuation between weight restoration and relapse Chronic course over many years Crossover to other ED (espec. BN) Comorbidity Anxiety and depression (30 - 60%) OCD 9 APA, 2013; Hoek, 2006; Martinussen et al., 2017; Stice et al. 2013; Ulfvebrand et al., 2015  Anorexia Nervosa Psychological Factors (AN-R) Clinical Presentation Perfectionism Gradually eliminating food Harm Avoidance Food rituals Feelings of ineffectiveness Preoccupation with food Inflexible thinking Ignoring huger cues Socially inhibited Baggy clothes to hide body Overly restrained emotional expression Autistic features common ❖ AN-BP psychological factors more similar to Bulimia Nervosa APA, 2013 10  Physical changes Serious physical side effects associated with EDs 11  Anorexia Nervosa Health complications ❖ Cardiac, endocrine (inc. osteoporosis, amenorrhea), gastro-intestinal, and many more ❖ Frequent hospitalisation common ❖ Highest death rate of any mental health condition Cognitive changes ❖ Mild deficits in executive functioning, memory, verbal & visuospatial processing ❖ Can impede recovery – e.g. rigid thinking ❖ Mostly improves with weight restoration Cog + Health issues can severely impact adolescent development King et al., 2015; Mehler & Brown, 2015 12  Bulimia Nervosa Diagnostic criteria: A) Recurrent episodes of binge eating (size & time & loss of control) B) Recurrent inappropriate compensatory behaviour to prevent weight gain – (e.g., Purging, laxatives/diuretics, fasting, excessive exercise) C) Occurs at least once per week for 3 months D) Self-evaluation unduly influenced by body shape and weight E) Does not occur exclusively during AN episode ❖ Purging vs non-purging subtype 13  Bulimia Nervosa Sex ratio 10 females : 1 Male Also elevated in gender diverse populations Prevalence 1 – 1.5% Onset Late adolescence/early adulthood (later than AN) May be preceded by AN Frequently begins during or following an episode of dieting APA, 201314  Bulimia Nervosa Varied Course Chronic or intermittent For many, persists for several years Periods of remission often alternate with recurrences of binge eating Purging may become addictive Comorbidity Depression and anxiety Substance use 15 Bahji et al., 2019; Ulfvebrand et al., 2015  Bulimia Nervosa Clinical presentation Binge-purge cycle Preoccupation with food Recognise that the behaviour is maladaptive Weight varies, often in ‘average’ range Psychological factors Low self-esteem and guilt Impulsivity 16  Binge Eating Disorder Diagnostic Criteria: A) Recurrent binge eating (size + time + loss of control) B) Three or more of the following: Eating more rapidly than normal Eating until uncomfortably full Eating large amount of food when not hungry Eating alone because embarrassed or disgusted Depressed or guilty after over-eating C) Marked distress regarding binge eating D) Occurs once per week, 3 months + E) No regular use of inappropriate compensatory behaviours 17  Binge Eating Disorder Prevalence 12-month prevalence 2-3% Sex differences less skewed Prevalence higher amongst those in larger bodies Clinical features Guilt and shame regarding binging behaviour, secrecy Eating when not hungry Eating for emotional control Associated with increased psychological distress and metabolic disturbance Cossrow et al., 2016 18  OSFED – Other Specified Feeding or Eating Disorder Clinically significant distress or impairment but do not meet full criteria for other disorder Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range Similar health consequences, impairment, and comorbidities to AN Harder to detect as person does not present as ‘underweight’ Purging Disorder: Recurrent purging behaviour to influence weight or shape in the absence of binge eating Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. 19 Subthreshold BN/Subthreshold BED Sawyer et al., 2016.  Unspecified Feeding and Eating Disorder Clinically significant distress or impairment but do not meet full criteria for other disorder, ❖ Used when clinician chooses not to specify why criteria are not met ❖ Or presentations where there may be insufficient information to make a more specific diagnosis (e.g. in emergency room settings). 20  Avoidant Restrictive Food Intake Disorder Diagnostic criteria A) Persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following: Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children) Significant nutritional deficiency Dependence on enteral feeding or oral nutritional supplements Marked interference with psychosocial functioning B) Not better explained by lack of available food or by an associated culturally sanctioned practice C) The behaviour does not occur exclusively during the course of AN or BN, and there is no evidence of a disturbance in the way one’s body weight or shape is experienced. D) The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder. 21  Avoidant Restrictive Food Intake Disorder ❖ Age of onset younger than AN/BN Associated with: Childhood picky eating Lack of appetite/interest in food Sensory sensitivities Generalized anxiety Gastrointestinal symptoms Comorbid medical conditions Less likely to have mood disorder than AN or BN 22 ❖ Slightly more common in males  Pica A) Persistent eating of non-food substances for a period of at least 1 month B) The eating of non-food substances is inappropriate to the developmental level of the individual C) The eating behaviour is not part of a culturally supported or socially normative practice D) If occurring in the presence of another mental health disorder, or during a medical condition (e.g. pregnancy), it is severe enough to warrant independent clinical attention ❖ Prevalence data yet to be established, appears to be more common in those with an intellectual disability ❖ Increased prevalence in pregnancy 23  Rumination Disorder A) Repeated regurgitation of food for a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out. B) The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition). C) The behaviour does not occur exclusively in the course of AN, BN, BED, or ARFID. D) If occurring in the presence of another mental health disorder (e.g.neuro- developmental disorder), it is severe enough to warrant independent clinical attention. ❖ Prevalence data yet to be established, appears to be more common in those with an intellectual disability 24  Also: Disordered Eating Subthreshold eating pathology (Not in DSM) Common in adolescence (e.g., 16.3% estimate in Aus sample) Associated with psychosocial impairment and comorbid psychopathology Precursor to a ‘full blown’ ED 25 Hay et al., 2015  Also: ‘Orthorexia’ Not an official DSM-5 diagnosis May start as ‘clean eating’, progresses to elimination of many food groups Inflexible eating behaviours aimed at ‘purity’ Emotional wellbeing overly dependent on eating ‘right’ foods ❖ Similarities with AN: Health risks/malnutrition from cutting foods Rigid food rules and preoccupation with food Interfering with normal functioning 26  Also: ‘Orthorexia’ ❖ Reasonably recently detected Impact of media/culture on psychopathology? ❖ When does ‘clean eating’ become unhealthy? Impact on functioning ‘Healthy’ vs ‘unhealthy’ food 27  Also: Muscle dysmorphia ❖ Not an ED but substantial body image component Subtype of Body Dysmorphic Disorder ‘Bigorexia’ – comparable to AN body image disturbance Preoccupation re: subjective lack of muscularity Genuinely see self as smaller Can lead to disordered eating (e.g., ↑ protein, ↓ fats) Mostly affects males 28 Transdiagnostic and symptom- level models 29  Diagnostic overlap Classification of main ED subtypes according to DSM-5 criteria (APA, 2013) OSFED BN-BP BED AN-R AN-BP BN-NP 30  Diagnostic Instability (Krug et al., in prep) Stable ED=34.5% NO ED 18.7% OSFED 10.8% 23.4% BN-BP AN-R AN-BP 5.7% BN-NP 31  Dual pathway model of BN 1. Binge eating as a result of restriction 2. Binge eating as an emotional regulation technique 32 Stice, 2001 Transdiagnostic model of EDs Fairburn, 2003 33 Restriction often leads to binging Fairburn, 2003 34 DSM-5 categories are still important Research Treatment DSM-5 diagnoses 35 Aetiology of Eating Disorders 36  Risk factors & correlates for EDs Risk factors from cohort-based longitudinal studies: Risk factors for Eating Disorders Dieting - #1 risk factor Personality factors – neuroticism, negative affect, perfectionism (AN) Body dissatisfaction Thin-ideal internalisation & social pressure to be thin Perinatal factors, including premature birth and complications during delivery Parental psychiatric factors Genetic factors Numerous correlates (i.e. from cross-sectional studies) identified, inc. childhood abuse, certain family environments, weight-based criticism. Stice et al., 2016, 2017. 37  Sex & Gender ❖ Most research has not distinguished sex and gender, compared sex differences – females v males ❖ (Presumed cisgender) female big risk factor for EDs – but males likely under- represented ❖ Eating disorders in males (presumed cisgender): Average onset of EDs later than for females Associated with jobs requiring particular body look or exercise regiment Muscularity more likely to be a focus Dieting less common risk factor Many men with an ED identify as gay or bisexual. 38 Coelho et al., 2019; Murray et al., 2017; Rasmussen et al., 2023  Gender diverse populations ❖ Transgender, gender fluid, gender non-binary populations Emerging research suggests symptomatology highest in transgender individuals – particularly transgender men Body dissatisfaction ++ Restriction related to mitigating or supressing secondary sex characteristics Impact of stigma Some evidence of symptom reduction following gender-affirming treatment 39 Chephekar, 2022 ; Rasmussen et al., 2023  Insights from twin studies Traumas Non-Shared Genetics Cognitive & Style Environment Biochemistry Personality Shared environment additive genetic (a2) additive effects of genes of small effect shared environment (c2) religious preference, socio-economic factors Family characteristics individual specific environment (e2) traumatic experience 40  Role of genetics ❖ Eating disorders aggregate in families - heritability estimates 40% - 60% ❖ Candidate gene studies (e.g., serotonin transporter) ❖ Genome Wide Association Study (GWAS) ▪ Mostly AN ▪ Identified several risk loci, also associated with psychological traits/disorders (OCD) and metabolic factors ▪ Mostly in European populations ❖ Gene x environment interactions ▪ Combination of genetic susceptibility and environmental factors ▪ Suggests the environment is very important Watson et al., 2021; Rozenblat et al., 2017 41 Eating disorders around the world 42 + -  Media and social media Cultural pressures glorify idea of the ‘perfect’ body Placing value on people on the basis of physical appearance, not inner qualities & strengths Definitions of beauty are narrow for both men and women ‘Desired’ body type changing over time – reflected in eating pathology 43 Historic beauty ideals Beauty ideals change over time  G. I. Joe 1970 - GI Joe was 5 ft. 10 inches, 32 inch waist and 12 inch upper arms 2000 - 29 inch waist and 16 ½ inch arms  Thinspiration & Fitspiration Thinspiration (thin + inspiration) → Aimed to promote weight loss and glorify Disordered Eating (DE) e.g. Amanda et al., 2017; Groesz et al., 2002; Talbot et al., 2017 Fitspiration (fit + inspiration) → Aimed to promote healthy and fit lifestyles e.g. Boepple & Thompson, 2016; Talbot et al., 2017, Carrotte, et al., 2015; 2017 BUT, fitspiration also idealizing the extremely thin body, with an additional emphasis on 47 muscle tone → related to body dissatisfaction, negative mood & DE  Experimental EMA Design to assess Fitspiration Random Post-image ratings assignment to 1. Pressures to change body image view fitspiration 2. Satisfaction variables or neutral image 3. Disordered Eating 60 images (30 fitspiration and 30 neutral) were piloted amongst 60 male participants. Highest scoring 15 fitspiration images & 15 neutral images (furniture, plants, art) from Instagram were selected from the pilot phase to be included into the instant survey app. Signalling at random intervals 5 times per day, every day for 7 days. → total of 35 assessments over the entire Phase 2 period  Male Fitspo/Thinspo study – Quick overview of findings State based data BEFORE & AFTER image ↑ Body fat dissatisfaction (d = 0.12***) ↑ Muscularity dissatisfaction (d = 0.14***) ↑ Negative mood (d = 0.11***) Viewing fitspiration ↑ Urge to engage in behaviours to reduce body fat (d = images 0.06***) ↑ Urge to engage in behaviours to increase muscularity (d = 0.11***) ↓ Body fat dissatisfaction (d = -0.05***) ↓ Muscularity dissatisfaction (d = -0.09***) ↑ Negative mood (d = 0.05***) Viewing thinspiration – Urge to engage in behaviours to reduce body fat (d = images 0.00, ns) ↑ Urge to engage in behaviours to increase muscularity (d = 0.05) Yee, Z. W., Griffiths, S., Fuller-Tyszkiewicz, M., Richardson, B., Blake, K., & Krug, I. (2020). Differential Impacts of Viewing Fitspiration and Thinspiration on Male Body Image: An Ecological Momentary Assessment Study. Body Image 49 https://doi.org/10.1016/j.bodyim.2020.08.008 Thankfully, there is EVER growing resistance… 50 E.g. on my insta feed this week 51  An aetiological model of EDs GENETICS PREDISPOSING FACTORS BIOLOGICAL SOCIOCULTURAL FACTORS FACTORS Trauma Stress PRECIPITATING FACTORS Life transition Vulnerability to ED Life change Family problems/ tension Ongoing stress Ongoing trauma/ abuse Ongoing family tension PERPETUATING FACTORS EATING DISORDER Treatment outcomes and approaches 54  Evidence-based treatment ❖ Gradually increasing evidence for specific treatments Family based treatment for anorexia nervosa in adolescents CBT/CBT-E and guided self-help for bulimia nervosa and binge eating ❖ Early symptom improvement predictive of better outcomes long term – important to get into treatment quickly ❖ ED research still in its infancy (like most mental health) – does not mean that treatment doesn’t work EDs unlikely to spontaneously recover w/out treatment Can involve inpatient, day program, or weekly individual therapy 55 Nazar et al., 2017; NICE 2021 Guidelines  Barriers in recovery from EDs ❖ Many don’t seek treatment Don’t recognise seriousness of condition May be encouraged by friends and family – but often secrecy Fearful of change Egosyntonic ❖ Very low BMI often requires inpatient admission ❖ Behaviours can become deeply ingrained ❖ EBP often involves targeting behaviours early, followed by addressing body image and related factors Gregertsen et al., 2017 56  Emerging approaches ‘Health at every size’ movement We have limited control of our body shape/weight in the long term Being ‘overweight’ does not necessarily equate to ‘unhealthy’ Addressing weight stigma in medical field Body positivity Embracing diversity + uniqueness of your body Fighting against ‘thin ideal’ Body neutrality Ulian et al., 2018 57  Poodle science (video non-examinable) https://www.youtube.com/watch?v=H89QQfXtc-k 58  Resources Butterfly Foundation Helpline: 1800 33 4673 (8am until midnight, 7 days per week) Website: thebutterflyfoundation.org.au Eating Disorders Victoria Helpline: 1300 550 236 (9:30am – 5pm, Mon-Fri) Website: eatingdisorders.org.au 59  References Bahji, A., Mazhar, M. N., Hawken, E., Hudson, C. C., Nadkarni, P., & MacNeil, B. A. (2019). Prevalence of Substance Use Disorder Comorbidity among Individuals with Eating Disorders: A Systematic Review and Meta-Analysis. Psychiatry Research. Baenas, I., Etxandi, M., Munguía, L., Granero, R., Mestre-Bach, G., Sánchez, I.,... & Fernández-Aranda, F. (2022). Impact of COVID-19 Lockdown in Eating Disorders: A Multicentre Collaborative International Study. Nutrients, 14(1), 100. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Coelho, J. S., Suen, J., Clark, B. A., Marshall, S. K., Geller, J., & Lam, P. Y. (2019). Eating disorder diagnoses and symptom presentation in transgender youth: a scoping review. Current Psychiatry Reports, 21(11), 1-10. Cossrow, N., Pawaskar, M., Witt, E. A., Ming, E. E., Victor, T. W., Herman, B. K.,... Erder, M. H. (2016). Estimating the prevalence of binge eating disorder in a community sample from the United States: Comparing DSM-IV-TR and DSM-5 criteria. The Journal of Clinical Psychiatry, 77(8), e968-974. Fairburn, C., & Harrison, P.J. (2003). Eating Disorders. The Lancet; 361: 407-416. Garner, D. M., & Garfinkel, P. E. (Eds.). (1997). Handbook of treatment for eating disorders. Guilford Press. Gregertsen, E. C., Mandy, W., & Serpell, L. (2017). The Egosyntonic Nature of Anorexia: An Impediment to Recovery in Anorexia Nervosa Treatment. Frontiers in Psychology, 8, 2273. Hay, P., Girosi, F., & Mond, J. (2015). Prevalence and sociodemographic correlates of DSM-5 eating disorders in the Australian population. Journal of Eating Disorders, 3(1), 19. Holland, G., & Tiggemann, M. (2017). “Strong beats skinny every time”: Disordered eating and compulsive exercise in women who post fitspiration on Instagram. International Journal of Eating Disorders, 50(1), 76-79. King, J. A., Geisler, D., Ritschel, F., Boehm, I., Seidel, M., Roschinski, B.,... & Roessner, V. (2015). Global cortical thinning in acute anorexia nervosa normalizes following long-term weight restoration. Biological Psychiatry, 77(7), 624-632. Martinussen, M., Friborg, O., Schmierer, P., Kaiser, S., Øvergård, K. T., Neunhoeffer, A. L.,... & Rosenvinge, J. H. (2017). The comorbidity of personality disorders in eating disorders: a meta-analysis. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 22(2), 201-209. 60  References Mehler, P. S., & Brown, C. (2015). Anorexia nervosa–medical complications. Journal of Eating Disorders, 3(1), 11. Murray, S. B., Nagata, J. M., Griffiths, S., Calzo, J. P., Brown, T. A., Mitchison, D.,... & Mond, J. M. (2017). The enigma of male eating disorders: A critical review and synthesis. Clinical Psychology Review, 57, 1-11. Nazar, B. P., Gregor, L. K., Albano, G., Marchica, A., Coco, G. L., Cardi, V., & Treasure, J. (2017). Early response to treatment in eating disorders: A systematic review and a diagnostic test accuracy meta‐analysis. European Eating Disorders Review, 25(2), 67-79. Rasmussen, S. M., Dalgaard, M. K., Roloff, M., Pinholt, M., Skrubbeltrang, C., Clausen, L., & Kjaersdam Telléus, G. (2023). Eating disorder symptomatology among transgender individuals: a systematic review and meta-analysis. Journal of Eating Disorders, 11(1), 84. Rozenblat, V., Ong, D., Fuller-Tyszkiewicz, M., Akkermann, K., Collier, D., Engels, R. C.,... & Krug, I. (2017). A systematic review and secondary data analysis of the interactions between the serotonin transporter 5-HTTLPR polymorphism and environmental and psychological factors in eating disorders. Journal of Psychiatric Research, 84, 62-72. Sawyer, S. M., Whitelaw, M., Le Grange, D., Yeo, M., & Hughes, E. K. (2016). Physical and psychological morbidity in adolescents with atypical anorexia nervosa. Pediatrics, 137(4). Sideli, L., Lo Coco, G., Bonfanti, R. C., Borsarini, B., Fortunato, L., Sechi, C., & Micali, N. (2021). Effects of COVID‐19 lockdown on eating disorders and obesity: A systematic review and meta‐analysis. European Eating Disorders Review, 29(6), 826-841. Stice, E. (2001). A prospective test of the dual-pathway model of bulimic pathology: Mediating effects of dieting and negative affect. Journal of Abnormal Psychology, 110(1), 124. Stice, E. (2016). Interactive and mediational etiologic models of eating disorder onset: Evidence from prospective studies. Annual Review of Clinical Psychology, 12, 359-381. Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk factors that predict future onset of each DSM–5 eating disorder: Predictive specificity in high-risk adolescent females. Journal of Abnormal Psychology, 126(1), 38. Ulfvebrand, S., Birgegård, A., Norring, C., Högdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299. Ulian, M. D., Aburad, L., da Silva Oliveira, M. S., Poppe, A. C. M., Sabatini, F., Perez, I.,... & Vessoni, A. (2018). Effects of health at every size® interventions on health‐related outcomes of people with overweight and obesity: a systematic review. Obesity Reviews, 19(12), 1659-1666. 61 Watson, H. J., Palmos, A. B., Hunjan, A., Baker, J. H., Yilmaz, Z., & Davies, H. L. (2021). Genetics of eating disorders in the genome-wide era. Psychological Medicine, 1-11.