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Psychological Aspects of Eating Disorders Sally Schwab, Ph.D., MSW Director, Primary Care Faculty Development and Curriculum New York Medical College.

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Presentation on theme: "Psychological Aspects of Eating Disorders Sally Schwab, Ph.D., MSW Director, Primary Care Faculty Development and Curriculum New York Medical College."— Presentation transcript:

1 Psychological Aspects of Eating Disorders Sally Schwab, Ph.D., MSW Director, Primary Care Faculty Development and Curriculum New York Medical College

2 Eating Disorders b Affect between 5 to 10 million people in the US b Approximately 5 -10% of people with eating disorders will die b Untreated, % of people with AN will die within 20 years b EDs have one of the highest mortality rates of any psychiatric illness b Disorders of control not food

3 Pediatric Eating Disorders b Have been largely ignored b Pts with AN and BN often become symptomatic in childhood & adolescence b Largest increase in EDs seen in minorities, children and males b AN third most common chronic illness in adols after obesity & asthma

4 Infancy b Difficulties in feeding b Failure to thrive physical abnormalitiesphysical abnormalities developmental delay (cognitive or genetic disorders)developmental delay (cognitive or genetic disorders) parental mental illnessparental mental illness temperamental mismatchtemperamental mismatch

5 Toddlers b Transition between parental feeding and self -feeding continuum of normal, picky and anorectic eaterscontinuum of normal, picky and anorectic eaters separation issuesseparation issues anorectic toddlers have higher temperament ratings on difficulty, irregularity, negativity, dependenceanorectic toddlers have higher temperament ratings on difficulty, irregularity, negativity, dependence These mothers have greater attachment insecurityThese mothers have greater attachment insecurity

6 School-Aged Children b Kids compare themselves to others b AN can develop in childhood b BN usually develops after puberty b Pica in childhood related to BN b Picky eating related more to AN b Can see excess exercise, talk of dieting and desire to be thin and beautiful.

7 School-aged b Boys and girls rate obese children as; having fewer friendshaving fewer friends being less liked by parents,being less liked by parents, doing less well at schooldoing less well at school being lazierbeing lazier being less happybeing less happy being less attractivebeing less attractive

8 School-aged b Gender differences emerge between 8-10 b Body dissatisfaction, esp. for girls, becomes more pronounced with age b 1989 CDC study: desire to be thinner increased from 40% in grade 3 to 79% in grade 6

9 Role of parents b Parents concerns about own weight affect boys and girls b Maternal and paternal overeating, body dissatisfaction and bulimic symptoms predicted secretive eating in children b Maternal /paternal dieting and behavior predicted overeating in children

10 Anorexia Nervosa (AN) and Bulimia Nervosa (BN) b Inability to distinguish physiological sensations of hunger and fullness from emotional feelings b View body as something to be controlled by the mind I feel fat, therefore I am worthlessI feel fat, therefore I am worthless I feel thin, therefore I am goodI feel thin, therefore I am good

11 DSM-PC/DSM-IV criteria for AN: Dieting/Body Image Variation b Dieting may occur if child is overweight, but be realistic b Does not completely eliminate any food group, but decreases food intake b Child favors thin appearance but has realistic image b Child can stop dieting voluntarily

12 DSM-PC/DSM-IV criteria for AN: Dieting/body image problem b Dieting is more restrictive & results in weight loss during growth periods b Person starts to become obsessed with pursuit of thinness and has fears of gaining weight b Begins to develop a consistent disturbance in body perception and starts to deny weight loss is a problem

13 Anorexia Nervosa (DSM IV) b Refusal to maintain body weight at or above minimally normal weight b Body weight <85% of that expected b Intense fear of weight gain, becoming fat, even though underweight b Disturbance in way weight is experienced

14 Anorexia Nervosa (DSM IV) b Denial of the seriousness of low body weight b Undue influence of body weight on self-evaluation b Absence of at least 3 consecutive menstrual cycles Restricting type: no regular binge /purgeRestricting type: no regular binge /purge Bingeing/purge type: regular binge/purgeBingeing/purge type: regular binge/purge

15 Clinical Red Flags: AN b Ritualistic eating habits, such as cutting up meat in very small bites b Refusal to eat in front of others b Suddenly deciding to become a vegetarian, or eating low / no-fat foods b Continual exercising b Hypersensitivity to cold b Wearing layers of clothes

16 DSM-PC/DSM-IV criteria: Purging/Binge Eating- variation b Occasional overeating or perception of overeating, either objective /subjective binges occurs. b Intermittent concern about body image or getting fat when too much food is eaten. Not pervasive, doesnt change eating patterns b Normal weight gain is present

17 DSM-PC/DSM-IV criteria: Purging/ Binge-Eating problem b Experimentation with vomiting, laxatives, fasting, or exercise to prevent weight gain b Isolated episodes far apart in time b Increased episodes of uncontrolled eating & perception of body becomes more distorted b Not sufficient to qualify for bulimia

18 Bulimia Nervosa (DSM - IV) b Recurrent episodes of binge eating: Eating, in a discrete period of time (e.g. within 2 hr period), an amount of food that is definitely larger than most people would eat during that timeEating, in a discrete period of time (e.g. within 2 hr period), an amount of food that is definitely larger than most people would eat during that time Sense of lack of control over eating during the episode (feeling like one can not stop eating or control what or how much one is eatingSense of lack of control over eating during the episode (feeling like one can not stop eating or control what or how much one is eating

19 Bulimia Nervosa (DSM - IV) b Recurrent inappropriate compensatory behavior to prevent weight gain: self-induced vomitingself-induced vomiting misuse of laxatives, diuretics, enemas or other medications; fasting, excessive exercisemisuse of laxatives, diuretics, enemas or other medications; fasting, excessive exercise Binge /purge occurs, on average 2 x week for 3 monthsBinge /purge occurs, on average 2 x week for 3 months

20 Bulimia Nervosa (DSM - IV) b Self-evaluation is unduly influenced by body shape and weight b Does not occur exclusively during episodes of anorexia nervosa Purging typePurging type Non-purging typeNon-purging type

21 Clinical Red Flags: BN b Normal-weight adolescents often make excuses to go to the bathroom after meals b Mood swings b Buying large amount of food, which suddenly disappear (hoarding) b Unusual swelling around jaw b Eating large amounts of food on spur of moment b Laxatives or diuretic wrappers found in trash

22 Binge Eating Disorder (BED) b Patients binge but do NOT purge 2 x week for 6 months2 x week for 6 months b Frequent failed attempts at dieting b Eat alone due to embarrassment about weight/restricts activities due to shame b Often overweight b Feels tormented by eating habits b Failures attributed to weight

23 Characteristics of ED Patients b Severe disturbances in eating behavior b Intense fear of being fat b Distorted thinking b Disturbance in perception of shape b Self-esteem highly dependent on weight b Control of food = control of world b Way to manage anxiety; rigid and ritualistic b Secretive b Weight gain = bad, no control b Weight loss = good, in control; measure of achievement b As weight decreases, concern about weight increases b Collect recipes/ cook for others b Obsessively weigh themselves; exercise

24 Distorted thinking b Filtering: magnify the negative b Polarization: Things are good or bad b Expecting disaster b Personalization b Over generalizing b Control fallacies: you feel externally controlled b Shoulds: iron clad rules about how to act

25 Personality features AN BN Personality features AN BN b perfectionist b high achievers b intense neediness b emotionally inhibited b need for control b feel ineffective b lack of insight b fear maturity/ struggle for autonomy b fear separation sexuality b self-regulatory problems with anxiety b social discomfort b sensitivity to reflection / self critical b high academic expectations b self-mutilation b impulsive behaviors shop lifting, promiscuity

26 Gender Differences Girls Boys Gender Differences Girls Boys b Between 50-69% normal weight dissatisfied b 16% underweight want to be thinner b Parents focus on physical appearance b Decreased body satisfaction after puberty b Dislike of thighs, buttocks, stomach b 21% think they are underweight b 10% think overweight b Parents focus on physical functioning b Increased body satisfaction after puberty b Desire to be bigger and taller

27 Gender differences b Girls tend to use more social comparisons which increase body dissatisfaction and dieting behaviors b Boys are less influenced by socio- cultural pressures than girls b Girls tend to describe themselves more negatively

28 Gender differences b Physical attractiveness often predicts self- concept and self-esteem in girls b Physical effectiveness predicts self- concept in boys (strength, sports) b When girls are praised for attractiveness, they begin to overvalue their physical attributes and invest more self-worth in matters related to appearance b Physically attractive girls are more preoccupied with weight (beauty =curse)

29 Factors Affecting Body Image b Sociocultural b Gender b Puberty b Ethnicity b SES status b 2oth century ideal is thin and light b Intense focus on physical appearance of girls b Associated with increased body weight and fat b Subcultural differences b Desire for thinness correlated with higher ses

30 Cultural Issues b Western ideal = thin b Non-Western cultures - obesity is often admired b Women believe they are more attractive to men if thin b NOT substantiated by men b Studies show mens stated preference of female weight was significantly greater than the womens assessment of selves

31 Ethnic Differences b African American girls seem more satisfied with weight; prefer heavier ideal. b African American girls more affected by mothers influence, whereas whites more affected by peers. b Binge eating more frequent in Asians and less frequent in blacks. b Hispanics reported more use of laxatives and diuretics to lose weight

32 Epidemiology b More than 50% of women in U.S. diet b 15% of all women medical students have lifelong hx of ED b > 90% are women b > 95% are white b > 75% are adolescents when first dx b 2/3 of high school students report being on a diet when only 20% were overweight b Most from mid - upper SES

33 Epidemiology b Third most common chronic illness in adolescent women is AN b Mortality is reported to be about 6% b 1997 Youth Risk Behavior Study by CDC reports: 30% of high school students are dieting30% of high school students are dieting 4.9% use diet pills4.9% use diet pills 4.5% induced vomiting or use laxatives4.5% induced vomiting or use laxatives

34 Prevalence in Males b Of AN patients, 5% - 10% are men b One study of Navy men reports 2.5% prevalence of AN, 6.8% of BN and 40% of binge eating b A study of civilian men report of those with ED, 42% are homosexual or bisexual while 58% with AN are asexual

35 Epidemiology b Occurs in.5% - 3% of all teenagers b Prevalence in U.S. of AN is.5% - 1% b 1/3 of insulin dependent females with diabetes suffer from an ED b Peak onset of AN: : puberty : puberty and : leaving home / identity formationand : leaving home / identity formation

36 Prevalence of bulimia b Up to 25% of adolescents have at some time engaged in purging to control weight b Between 4% - 10% of older adolescents and college age women develop BN b Mean age of onset: 18.4 years of age peak of sexual maturity and body image dissatisfaction.peak of sexual maturity and body image dissatisfaction.

37 Who may be at risk? b Physically active people: competitive athletes: skaters, gymnasts, dancers, runners 15%-60% estimated prevalence15%-60% estimated prevalence b Male wrestlers and rowers 1/3 of high school wrestlers use method of weight-cutting: food restriction, fluid depletion using steam rooms, saunas, diuretics (often resume normal eating off season but maintain up to only 3% body fat)1/3 of high school wrestlers use method of weight-cutting: food restriction, fluid depletion using steam rooms, saunas, diuretics (often resume normal eating off season but maintain up to only 3% body fat)

38 Female Athlete b Female athlete triad Menstrual dysfunctionMenstrual dysfunction Eating disordersEating disorders OsteoporosisOsteoporosis

39 At risk... b Higher incidence for men and women in military b Greater risk for girls who undergo early puberty b Patients with a family history of ED b Vegetarians among adolescents: twice as likely to diet frequentlytwice as likely to diet frequently four times as likely to intensively dietfour times as likely to intensively diet eight times as likely to use laxatives as their non-vegetarian peerseight times as likely to use laxatives as their non-vegetarian peers

40 Body Image Disturbance b Body image disturbance gets WORSE with weight loss b As the typical teenage girl loses weight, she becomes more satisfied b As teenage girl developing AN loses weight, she becomes less satisfied and resets her initial goal

41 Body Image b The way one experiences ones body b Girls who have greater self-confidence and positive self-esteem more likely to have secure, healthy body image b Two basic dimensions Body satisfactionBody satisfaction Body size perceptionBody size perception

42 Body Satisfaction Body Size Perception (Affective)(Cognitive) b How a person feels and acts about their size and appearance b Personal meaning and feeling are associated with the body b Im inferior because Im fat b Estimation of ones size, but also distorted perception that the body is far from the idealized standard b The way one sees themselves and the way they think others see them

43 Displacement of Feelings b I am depressed and I really feel fat b No boy asked me out because I am fat b Bad things happen to me because I am fat b Goal: separate body image issues from other emotional aspects of ones life b Correlation between weight loss and happiness is illusory

44 Dangers for Future b Never learn how to cope with real issues b Will always blame body when relationships fail b Unrealistic expectations get set up b Always tries hard to please others; overlook own needs

45 Precipitating Factors b dieting prompted by plumpness b being teased about weight b depression or seasonal onset b feeling lack of control in ones life b interpersonal conflict /first sexual experience b developmental tasks of transition b separations

46 Inadequate coping skills in response to: b Puberty b separation - leaving home to college b stress b pressure for high achievement b regulation of tension / anxiety b sexual trauma

47 Characteristics of a binge b ingestion of between 5, ,000 calories per episode (within 2 hours) b continual snacking on small amounts during day is NOT a binge b food often is high caloric and carbos b usually occurs in secret b continues until uncomfortably full, is interrupted or run out of food

48 Bingeing and Purging b 80-90% of bulimics induce vomiting b vomiting often a goal in itself b induce with fingers or instruments first eat marker food, so when purge will know all is gonefirst eat marker food, so when purge will know all is gone b develop ability to vomit at will b could use up to 100 laxatives/diuretics per day

49 Binges triggered by: b dysphoric mood states b interpersonal stressors b intense hunger following dietary restraint b negative feelings related to weight

50 During a Binge... b Feel lack of control b In a dissociative state b Feeling of frenzied b Feeling of relief b Average binge/purge episodes - 14 times a week b Most dont want to give it up

51 Goals of Purge Effects of purge Goals of Purge Effects of purge b prevent weight gain b feel in control b feel relief from physical discomfort b reduce fear of gaining weight b purge bad feelings b reduce dysphoria b reduce anxiety b eradicate fear of weight gain b disparaging self- criticism b depressed mood b guilt /shame b exhaustion

52 Associated Mental Disorders AN BN b 50% -75% depression b up to 69% have OCD b 43% anxiety disorders b 49% substance abuse b 12% bipolar b 40% personality disorders b 20%-50% history of sexual abuse

53 State of Starvation b depressed mood ; poor concentration b social withdrawal / apathy b decreased ability to make decisions b irritability/ insomnia b decreased libido b food obsessionality hoarding; preoccupation; abnormal tasteshoarding; preoccupation; abnormal tastes

54 Theories of Etiology b Problems in separation / autonomy; control b Conflicts in sexuality b History of sexual abuse b Family conflicts (over involved parent in AN / detached parent in BN) b Family and personal hx of depression b In BN more likely to have obese parent b Neurotransmitter imbalances

55 Family Influences b Dysfunctional families create vulnerable individuals - look at content of what is expressed as link to symptom b ED families have the following: concern for weight/ shape/ appearancesconcern for weight/ shape/ appearances concern for achievement/ reputationconcern for achievement/ reputation need to modulate depressive affectneed to modulate depressive affect low self-esteemlow self-esteem difficulty with impulse regulationdifficulty with impulse regulation

56 Prognosis b 30% of pts with AN will be chronically ill b After RX, 50% continue with persistent social impairment and 50% will relapse b 10% will die of the illness

57 Prognostic indicators Good Bad Prognostic indicators Good Bad b pt admits to feeling hungry b positive self-esteem b mature developmentally b has attained some autonomy b Being ill >6 yrs b premorbid obesity b bulimic behavior b unstable personality b excessive somatic concerns b lower minimum weight b ambivalence to recovery

58 Issues leading to rx problems Patient Clinician Issues leading to rx problems Patient Clinician b Denial of illness b Shame for BN and secretiveness b pathologic pursuit of thinness b Inability to trust adults b co-morbid disorders b nutritional chaos b substance abuse b distorted thinking b Pt evokes intense feelings of hostility; helplessness and stress b lack of experience increases frustration b more experience gives long term perspective b Female clinicians may evoke jealousy b Hard to hear about details of purge - lead to revulsion

59 Treatment difficulties b Patients dont want to get well b Denial of symptoms b Pts fear you want to make them fat b Fear dependency b Rejection sensitivity

60 Assessment of Body Image b Is there anything about your body that you wish you could change? b How important is your body size to how you feel about yourself as a person? b Do you spend a lot of time thinking about your body? b Are there things you intentionally avoid because of the way you feel about your body? b Do you try to do something about your weight? Are you trying now? b What are you doing to control your weight?

61 Screening for EDs b How do you feel about exercise? Avoids humiliation if pt doesnt exerciseAvoids humiliation if pt doesnt exercise Lets you understand why person exercisesLets you understand why person exercises b If I walked into your house, what kinds of foods would I find? b What would you like to have in your house, but dont have? b Are there any restrictions on what you eat?

62 Strategies b Be open, honest, firm; non-judgmental b Set realistic goals b Attempt to build trust b Be sensitive to the shame and humiliation the patient feels b Understand the intensity of the denial and ambivalence to recovery b Depersonalize pts poor compliance b Appreciate pts mistrust of doctors

63 Strategies b Do not insist on rapid weight gain and threaten hospitalization - will lead to binge eating to meet goal then purge b Beware of refeeding syndrome b Weigh pts when completely disrobed and after empty bladder pts wear layers of clothing to add weightpts wear layers of clothing to add weight pts load up on water before being weighedpts load up on water before being weighed b DO NOT TREAT ALONE

64 Treatment modalities b Inpatient Vs outpatient b Medication b Nutritional counseling b Group or family therapy b Psychoeducational approach b Individual psychotherapy cognitive / behavioral/ psychodynamiccognitive / behavioral/ psychodynamic

65 Cognitive Behavioral Therapy b Best proven approach to ED b Focus on restructuring thinking errors b Focus on present not past b Help pt to recognize the distorted reactions to food b Discovers false attitudes / become less self-critical

66 Goals of Treatment b Short term Nutritional rehabilitation: restore healthy weight; medically stable stateNutritional rehabilitation: restore healthy weight; medically stable state Restore to non-suicidal stateRestore to non-suicidal state b Long Term Restore to normal eating patternRestore to normal eating pattern Dx and treat long term social, psych and behav. ProblemsDx and treat long term social, psych and behav. Problems Restructure dysfunctional thinkingRestructure dysfunctional thinking

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