1. Eating Disorders Psychological and Clinical Perspectives: Assessment,
diagnosis, treatment and explanations.
A critical look- what has been ignored?
Devinder Rana BSc (Hons) Psychology LM40507 Psychopathology and Abnormal Psychology

2. Aims By the end of the session you will be able to do the following:
Describe how the DSM-IV-TR defines and distinguishes different eating disorders.
Describe and compare how the biological, psychological and sociocultural perspectives explain the aetiology of eating disorders.
Analyse the different treatments and perspectives and their legal and ethical implications.

3. Eating Disorders 1. Anorexia Nervosa 2. Bulimia Nervosa
3. Eating Disorder Not Otherwise Specified (EDNOS) Binge-eating disorder (proposed diagnosis requiring further study).

4. Anorexia Nervosa

5. Criteria DSM-IV-TR
Refusal to maintain a body weight that is normal for the person’s age and height (i.e., a reduction of body weight to about 85% of what would be normally expected).
Intense fear of gaining weight or becoming fat, even though underweight.
Distorted perception of body shape and size.
Absence of at least three consecutive menstrual cycles.
Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American Psychiatric Association.
In-text citation: APA (2000)

6. Sub-types (APA, 2000).

7. In Context DSM-VI-TR (2000) Criteria
A 5’11 adult weighing 11 stone (70 kilos) falls into the OK category.
A deviation of 15% results in the individual now weighing just over 9 stone and is subsequently classed as anorexic.

8. Epidemiology
80-90% of suffers are female with typical age onset between years old (Pike, 1998).
Weight control remains a long-term issue.
Links with Obsessive Compulsive Disorder
Occur in young children
Occur in boys

9. Ballet dancers (Gelsey Kirkland) and gymnasts (Christy Henrich)

10. Characteristics of Anorexia
Anorexic’s develop eating habits typical of bulimia nervosa (e.g. maintenance of ‘normal’ weight through abnormal eating habits).
Socio-economic and academic achievement link.
Pre-occupation with food- thoughts of eating, preparation of food or watching others eat.
High ‘calorie consumption’ behaviours e.g. gym, running or swimming.
Young, European American Women .

11. Distorted body image
Over estimation of body proportion and distorted body image (Gupta & Johnson, 2000).
Link with depression, anxiety and OCD.

12. Effects of Anorexia Amenorrhea (lack of menstruation).
Immune infections

14. High/low blood pressure

15. Cracked Skin

16. Brittle hair and bones

17. Cardiotoxicity (heart damage)

18. Consequences
Mortality rate is 12x higher than the mortality rate for females aged 15 to 24 in the general population (Sullivan et al 1995).
Death results from:
Physiological consequences from starvation
Intentional suicidal behaviour

19. Historical Account and Definition
Anorexic nervosa means:
“ lack of appetite induced by nervousness”.
(Butcher et al, 2007).
Lack of appetite is not the real problem.

20. “Self-starvation, resulting in a minimal weight for one's age and height or dangerously unhealthy weight”.
Hudson et al (2006).

21. “ without desire for food”
Greek
An: without
Orexis: a desire for
“ without desire for food”
Nevid et al (2008).

22. Central to anorexia nervosa
Fear of gaining weight or becoming fat
Refusal to maintain even a minimal low body weight.

23. Historical Accounts
Accounts in early religious literature (Vandereycken, 2002).
First medical account published in 1689 Richard Morton.
18 year old girl and 16 year old boy- described as having a:
“nervous consumption that
caused wasting of body tissue”.
1873 Sir William Gull in London & Charles Lasegue in Paris independently describe the clinical syndrome and receive its current name.

24. Gull (1888)
Described a 14 year old girl:
“Without apparent cause, to evidence a repugnance to food, and soon afterwards declined to take whatever, except half a cup of tea or coffee”.

25. Problems with the diagnostic tool: DSM-IV-TR
Women who continue to menstruate but meet all the other diagnostic criteria for anorexia nervosa are just as ill as those who have amenorrhea (Cachelin & Maher, 1998; Garfinkel, 2002).
For men, the equivalent of the menstruation criterion is diminished sexual appetite and lowered testosterone levels (Beaumont, 2002).

26. Bulimia Nervosa

27. Criteria DSM-IV-TR Recurrent episodes of binge eating.
binges in a fixed period of time, food far greater than normal circumstances.
Lack of control and unable to stop.
Recurrent and inappropriate efforts to compensate for the effects of binge eating.
self induced vomiting
laxatives
excessive exercise
thyroid medication
Self-evaluation is excessively influenced by weight and body shape.
Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American Psychiatric Association.
In-text citation: APA (2000)

28. Characteristics
Food is eaten rapidly, secretively, without pleasure in binges where in excess of 5000 calories can be consumed (2x the recommended daily male intake).
Bulimics demonstrate a fear of weight gain and consider themselves to be heavier than they actually are (McKenzie et al 1993)
Approximately 80-90% of individuals will vomit following a period of binging, one third adopt laxative use and others constantly exercise (Anderson et al, 2001).
Long-term problems include digestive issues, dehydration, damage to stomach lining and damage to the teeth.
Fairburn & Beglin (1994) estimate prevalence between 0.5-1%.

29. Anorexia Vs. Bulimia Anorexia Bulimia
Weight loss not driven by desire to appear feminine.
Social concept of femininity drives behaviour
High self-control
Impulsive and emotional instability
Body weight significantly (>15%) below age/height
Weight fluctuation (remains relatively close to norms)
Less likely to have been overweight
More likely to have been overweight
Underweight (severe)
Normal weight (slightly overweight)
Less likely to abuse drugs/alcohol
More likely to abuse drugs/alcohol

30. Bulimia and Purging anorexia nervosa
Meets the criteria for binging/purging, also meets the criteria for anorexia nervosa, anorexia nervosa will be diagnosed.
Common anxiety with fear of being fat.

31. 2 types

32. Explanations

33. Complex Interaction Psychological Biological Socio-cultural family
Individual

34. Biological Factors
Genetics

35. Genetics Runs in families (Bulik & Tozzi, 2004)
Risk of anorexia nervosa for relatives of people with anorexia nervosa was 11.4x more greater. Bulimia 3.7X higher, than relatives with healthy controls. (Strober et al, 2000).
Relatives of patients with eating disorders are more likely to suffer from other problems, especially mood disorders (Mangweth et al 2003).
However, eating disorders are not densely clustered as are mood disorders and schizophrenia.

36. Twin studies
Anorexia nervosa and bulimia nervosa are hereditable disorders (Bulik & Tozzi, 2004; Fairburn & Harrison, 2003).

37. Genes
Chromosome 1 linked to the susceptibility to the restrictive type of anorexia (Grice et al, 2002).
Bulimia (purging) linked to chromosome 10 (Bulik et al, 2003).
Eating disorders linked to chromosomes involved
Genes responsible for serotonin: low serotonin level (Kaye et al., 2005)

38. Brain: Hypothalamus and GLP-1
Regulates bodily functions
Lateral hypothalamus: produces hunger when activated
Ventromedial Hypothalamus: reduce hunger when activated
Each part electrically stimulated in animals they decrease/increase eating behaviour (Duggan & Booth, 1986)
Glucagon-like peptide-1 (GLP-1) natural appetite suppressant.
Inject rats they will not eat even after a 24hr fast
Block GLP-1 in the hypothalamus-double food intake (Turton et al., 1996).

39. Weight Set Point Theory
LH, VMH, GLP-1, work together comprise a weight thermostat
Weight set point theory (WSP) (Hallschmid et al., 2004).
Genetic inheritance and early eating patterns determine WSP.
Weight falls below the WSP, hunger increases and metabolic rate decrease.
Diet and fall below WSP, hypothalamic activity produces a preoccupation with food and desire to binge.
Trigger bodily changes- harder to lose weight however little is eaten (Spalter et al., 1993)
Restricting-type anorexia: shut down their inner thermostat and control their eating completely.
Binge-purge pattern: battle spirals (Pinel et al., 2000)

40. The average American woman is 5’4” and 140 pounds.
The average American model is 5’11” and 117 pounds.

41. Societal
Pressures

42. Current Western standards of female attractiveness have contributed to increases in eating disorders (Jambor, 2001).
Decline Miss America Pageant, average decline of 0.28 pound per year (Garner et al., 1980).
Fashion models, actors, dancers, certain athletes: more prone to eating disorders (Couturier & Lock, 2006).
20% of gymnast surveyed had an eating disorder (Johnson, 1995).
White upper socioeconomic expressed more concerns about thinness (Mrgo, 985)
Recent years increased in all classes and minority groups (Germer, 2005).
Double standard has made women more inclined to diet and more prone (Cole & Daniel, 2005)
Cruel jokes targeted as obesity are standard in the media (Gilbert et al., 2005)
Deep rooted (Grilo, 2006)
Parents more likely to rate a picture of a chubby child as less friendly, energetic, intelligent and desirable.
61% of secondary school girls are dieting (Hill, 2006)

43. Battle of Brittan's

44. Timeline
The Three Graces; Pieter Pauwel Rubens

45. 1887 - Pierre Auguste Renoir, The Bathers

46. 1920 - Thin, short haired flapper

47. Monroe (Size 14/16)

48. 1960 - Twiggy Lawson (Aka the beginning of the end
Twiggy Lawson (Aka the beginning of the end.) This was the first time in history that an under weight woman became the standard for the ideal body image.

49. Cosmopolitan

50. Harper’s Bazaar

51. Modern day Fashion Model

52. Family Environment
Important role in the development of eating disorders (Reich, 2005)
½ families: emphasise thinness, physical appearance and dieting.
Mothers diet frequently and be perfectionist (Woodside et al., 2002).
Abnormal interactions and communication (Reich, 2005)
Family systems theory: dysfunctional family, person with eating disorder is representative of a larger problem (Rowa et al., 2001)
Enmeshed family pattern (Minuchin et al., 1978): over involved with in each other’s affairs and over concerned with details of each other’s lives.
Teenagers push for independence which threaten the harmony of the family.
Family may subtly force the child to take on a sick role- develop eating disorder or other illness.
Enables the family to maintain its appearance of harmony.
Some case studies support this view (Wilson et al., 2003)
Systematic research fails to support this link .

53. Ego Deficiencies and Cognitive Disturbances
Bruch built on psychodynamic and cognitive notions.
Disturbed mother-child interactions lead to serious ego deficiencies in the child (poor sense of control and independence) serve cognitive disturbances (Bruch, 2001).
Effective parents: attend to their child’s biological and emotional needs
Ineffective parents: fail to attend to needs, misinterpreting i.e., being hungry rather than seeing the actual condition- grow up confused.
Not being control of their behaviour, not rely on internal signs, not self-reliant instead during adolescence when looking for independence seek control with weight and body image.
Pearlman (2005) eating disorder parents define children needs rather than the child.
Bruch (1973) interviewed 51 mothers of a child with an eating disorder, many recalled how they never allowed the child to feel hungry and anticipated their child’s needs.
Perceive internal cues inaccurately (Bydlowski et al., 2005)
Anxious or upset- think they are hungry so eat
Worry how others view them, seek approval, be conforming and feel lack of control over their lives (Button & Warren, 2001).

54. When do people seek junk food? When they feel bad. Lyman (1982)

55. Mood Disorders
Eating disorders, especially bulimia nervosa, experience symptoms of depression (Perinea et al, 2005)
Eating disorder also qualify for a clinical diagnosis of major depressive disorder (Duncan et al., 2005)
Close relatives of people with eating disorders seem to have a higher rate of mood disorders than do close relatives of people without such disorders (Moorhead et al., 2003).
Eating disorders, especially bulimia nervosa have low activity of serotonin, similar to serotonin abnormalities found in depressed people.
People with eating disorders are helped by some of the same antidepressant drugs that reduce depression.

56. Treatments for Anorexia Nervosa

57. How is proper weight and normal eating restored?
Past in hospitals, today in outpatient settings (Vitousek & Gray, 2006)
Life-threatening cases: force tube and intravenous feedings on a patient who refuses to eat (Tyre, 2005)
Can result in distrust in the patient (Robb et al., 2002).
Weight restoration approaches: clinicians use rewards whenever patients eat properly or gain weight (Tacon & Caldera, 2001)
Combination of supportive nursing care, nutritional counselling & high calorie diet (no more than 2,500 calories a day). Herzog, et al., 2004).
Help them to recognise that the weight gain is under control and will not lead to obesity..
Gain the necessary weight in 8-12 weeks.

58. How are lasting changes achieved
Overcome their underlying psychological problems in order to achieve lasting improvement
Therapy and education: individual, group and family approaches (Hechler et al., 2005).
Recognise need for independence and teach them more appropriate ways to exercise control (Dare & Crowther, 1995).
Trust their internal sensations and feelings (Kaplan & Garfinkel, 1999)
Correcting disturbed cognitions: change attitudes about eating and weight (McFarlane et al., 2005).
Identify, challenge and change maladaptive assumptions (Lask et al., 2000)
Changing family interactions: meet with the family, point out troublesome family patterns, separate feelings and needs from those of other family members (Couturier & Lock, 2006).

59. Aftermath of Anorexia Nervosa
Use of combined approaches has improved the outlook but the road to recovery is difficult (Fairburn, 2005)
Positive
Weight is often restored once treatment begins (McDermott & Jaffa, 2005)
83% improvement, several years later, 33% fully recovered and 50% partially improved (Herzog et al., 1999)
Menstruate again (Fombonne, 1995)
Death rates are decreasing (Neumarker, 1997).
Negative
20% remain seriously troubled for years (Haliburn, 2005)
When recovery occurs it is not always permanent
1/3 triggered again by new stresses (Fennig et al., 2002)
½ continue to experience emotional problems- depression, social anxiety, obsessive which are common when reaching normal weight (Steinhausen, 2002)

60. Treatment Bulimia Nervosa

61. Treatments Eating disorder clinics
Eliminate binge-purge patterns and establish god eating patterns,
Education as much as therapy (Davis et al 1997)
Individual insight therapy: cognitive-recognise and change maladaptive attitudes (Cooper, 2006)
Not respond then use interpersonal psychotherapy- improve interpersonal functioning.
Psychodynamic therapy- limited support.
Behavioural therapy: supplement with cognitive
Dairies- note sensations of fullness etc
Exposure and response prevention
Anti-depressant medication: Prozac help 40%
Group therapy: self-help groups- helpful to 75% when combined with individual sight therapy

62. Aftermath
Treated successfully, relapse is a common problem triggered by new life stresses.
1/3 treated relapse 6months later (Olmsted et al., 1994)
Former patients less depressed then time of diagnosis (Halmi, 1995)
Depends on history, length and frequency of vomiting.

63. Karen Carpenter: 1970’s

64. Reading Seminar
Should individuals with Anorexia Nervosa Have the Right to Refuse Life-Sustaining Treatment?
Yes: Heather Draper from “Anorexia Nervosa and Respecting a Refusal of Life-Prolonging Therapy: A Limited Justification”, Bioethics (April 1, 2000)
No: J.L. Werth, Jr., Kimberly S. Wright, Rita J. Archambault, and Rebekah J. Bardash, from “When Does the ‘Duty to Protect’ Apply with a Client Who Has Anorexia Nervosa?” The Counselling Psychologist (July, 2003).

65. Petrie, T. , Greenleaf, C. , Reel, J. , & Carter, J. (2008, October)
Petrie, T., Greenleaf, C., Reel, J., & Carter, J. (2008, October). Prevalence of eating disorders and disordered eating behaviors among male collegiate athletes. Psychology of Men & Masculinity, 9(4), Retrieved January 22, 2009, doi: /a
Tibon, S., & Rothschild, L. (2009, January). Dissociative states in eating disorders: An empirical Rorschach study. Psychoanalytic Psychology, 26(1), Retrieved January 22, 2009, doi: /a
Hepworth, J., & Griffin, C. (1995). Conflicting opinions? 'Anorexia nervosa,' medicine and feminism. Feminism and discourse: Psychological perspectives (pp ). Thousand Oaks, CA US: Sage Publications, Inc. Retrieved January 22, 2009, from PsycINFO database.

66. Wu, K. (2008, December). Eating disorders and obsessive-compulsive disorder: A dimensional approach to purported relations. Journal of Anxiety Disorders, 22(8), Retrieved January 22, 2009, doi: /j.janxdis

67. Reading
Nevid, J.S., Rathus, S.A., & Greene, B. (2008). Abnormal Psychology In A Changing World. (7th ed.). Pearson Prentice Hall: London. Chapter 10, pp

69. End