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Chapter 9.doc

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Professor Cottrel

Ch 9 eating disorders  These disorders only appeared in the DSM for the first time in 1980 as one subcategory of disorders beginning in childhood or adolescence  Stat Canada 2002, 0.5% of Canadians 15 yrs of age or older reported that they had been diagnosed with an eating disorder in the preceding 12 months.  Women were more likely than men to report an E.D ---0.8% vs 0.2%  Among young women aged 15-24 1.5% reported that they had an E.D  Eating disorders can cause long term psychological, social and health problems  Hospitalization is sometimes necessary. Hospitalization rates are highest among young women in the 15-24 age range. Rates are also highest among those ages 10-14 and 20-24 CLINICAL DESCRIPTION  The diagnoses of these two disorders share several clinical feautures the most imp being an intense fear of being overweight  Co-twins of patients diagnoses with A.N for ex are themselves more likely than average to have B.N Anorexia Nervosa  Ms. A had A.N. anorexia refers to loss of appetite and nervosa indicates that this is for emotional reasons  Most patients with A.N actually do not lose their appetite or interest in food. They are preoccupied with food  Ms. A met all the four features required for the diagnosis:  1) the person must refuse to maintain a normal body weight, that is usually taken to mean that the person weights less than 85% of what is considered normal for that persons age and height. Weight loss is typically achieved through dieting although purging (self induced vomiting, heavy use of laxatives or diuretics) and excessive exercise can also be part of the picture  2) the person has an intense fear of gaining weight and the fear is not reduced by weight loss. They can never be thin enough  3) Patients with AN have a distorted sense of their body shape. They maintain that even when emaciated they are overweight or that certain parts of their bodies esp the stomach, butt and thighs are too fat. To check on their body size they typically weight themselves frequently, measure the size of diff parts of the body and gaze critically at their reflections in the mirror. Their self esteem is closely linked to maintaining thinness. The tendency to link self esteem and self evaluation with thinness is known as over evaluation of appearance  4) in females the extreme emaciation causes amenorrhoea the loss of the menstrual period. Of the four diagnostic criteria amenorrhoea seems least imp to determining a diagnosis of anorexia. Moreover amenorrhoea occurs in a significantly minority of women before any significant weight lose and the symptoms can persist after weight gain  eating disorder inventory (EDI). Was developed in Canada and is one of the most widely used measured to assess self reported aspects of eating disorders  patients with AN overestimate their own body size and choose a thing figure as their ideal  DSM-IV-TR distinguishes two types of AN. In the restrictive type, weight loss is achieved by severely limiting food intake; in the binge eating purging type the person also regularly engages in binge eating and purging  The binging purging subtype appears to be more psychopathological; patients exhibit more personality dis, impulsive beh, stealing, alcohol and drug abuse, social withdrawal and suicide attempts than do patients with the restricting type of anorexia  Binging purging patients tend to weight more in childhood, come from heavier families with greater familial obesity and use more extreme weight control methods.  Canadian research suggests that the diff between the two subtypes are becoming less distinct  An increasing proportion of patients were diagnosed with AN, the binging purging subtype, during each period. Over time, participants in both groups appeared to weigh more and were less likely to report amenorrhoea. Patients from both groups reported higher frequencies of purging beh, impulsive beh, and associated affective symptoms in the later time periods  AN typically begins in early to middle teenage years often after an episode of dieting and exposure to life stress. It is about 3-10 x more frequent in women than in men with a lifetime prevalence about 1% in women  When AN does occur in men, symptomatology and other characteristics, such as family conflict, are generally similar to those reported by women with the disorder  Found that males had lower levels of drive for thinness and body dissatisfaction but there were many more similarities than differences between the males and females  Patients with AN are diagnosed frequently with depression, OCD, phobias, panic disorder, alcoholism, oppositional defiant disorder, and various personality disorders  Comborbidty is higher in clinical samples than community samples. A growing concern is the high rate of occurring eating disorders and substance use disorders Physical Changes In AN  Blood pressure often falls, heart rate slows, kidney and gastrointestinal problems develop, bone mass declines, the skin dries out, nails become brittle, hormone levels change and mild anemia may occur  Some patients lose hair from the scalp, and they may develop laguna, a fine, soft hair on their bodies. Levels of electrolytes such as potassium and sodium are altered. These ionized salts present in various bodily fluids are essential for the process of neural transmission and lowered levels can lead to tiredness, weakness, cardiac arrhythmias and even sudden death.  Brain size declines in patients with anorexia and EED abnormalities and neurological impairments are frequent  Deficits in white matter volumes in the brain are restored upon recovery from anorexia nervosa but deficits in grey matter volumes appear irreversible at least in the short term.  These consequences may be especially problematic for adolescents with AN Prognosis  About 70% of patients with AN eventually recover. However recovery often takes 6 or 7 years and relapses are common before a stable pattern of eating and maintenance of weight is achieved.  AN is a life threatening illness, death rates are about 10 x higher among patients with the disorder than among the general population and twice as high as among patients with other psychological disorders  Death most often results from physical complications of the illness or from suicide  The standardized mortality rate for the 326 patients with AN was very high (10.5). standardized mortality rate is defined as the ratio of observed deaths relative to expected deaths. Among the 17 AN patients who had died the leading cause was suicide followed by pneumonia, hypoglycemia and live disease  Found that suicide rates are not elevated in B.N like they are in AN though ppl with BN are more likely to have suicide ideation. Predictors of suicide in AN patients include purging beh, depression, substance abuse and a history of physical or sexual abuse Bulimia Nervosa  Ms Bs beh is BN. Bulimia from a Greek word means ox hunger.  This disorder involves episodes of rapid consumption of a large amount of food, followed by compensatory beh such as vomiting, fasting or excessive exercise to prevent weight gain  The DSM defines a binge as eating an excessive amount of food within less than two hours. BN is not diagnosed if the binging and purging occur only in the context of AN and its extreme weight loss; the diagnosis in such as case is AN binge eating purging subtype  Binges typically occur in secret may be triggered by stress and the negative emotions it arouses and continue until the person is uncomfortably full.  Stressors that involve negative social interactions may be particularly potent elicitors of binges.  Bulimics have high levels of interpersonal sensitivity, as reflected in large increases in self- criticism following negative social interactions.  Further binge episodes tend to be preceded by poorer than average social experiences, self concepts and moods  Also reported that the binge episodes are followed by deterioration in self concept, mood state and social perception  The person who is engaged in a binge often feels a loss of control over the amount of food being consumed. Foods that can be rapidly consumed, esp sweets such as ice cream or cake are usually part of a binge. Although research suggests that patients with BN sometimes ingest an enormous quantity of food during a binge.  Binges are not always as large as the DSM implies and there may be wide variation in the caloric content consumed by individuals with BN during binges. Patients are usually ashamed of their binges and try to conceal them. They report that they lose control during a binge even to the point of experiencing something akin to a dissociative state perhaps losing awareness of what they are doing of feeling that it is not really they who are binging  After the binge is over disgust, feelings of discomfort and fear of weight gain lead to the 2 step of BN—[urging to undo the caloric effects of the binge. As seen with Ms. B purging can involve induced vomiting and excessive exercise. The use of laxatives and diuretics is common even though this odes not actually result in weight loss  The DSM diagnoses of BN requires that the episodes of binging and purging occur at least twice a week for three months  Suggesting that there is a continuum of severity rather than a sharp distinction  Like patients with AN patients with BN are afraid of gaining weight and their self esteem depends heavily on maintaining normal weight.  Observed that a morbid fear of fat is an essential diagnostic criterion for BN cuz 1) it covers what clinicians and researchers view as the core psychopathology of BN 2) it makes the diagnosis more restrictive and 3) it makes the syndrome more closely resemble the related disorder or AN  as with anorexia two subtypes of BN are distinguished: a purging type and a non purging type in which the compensatory beh are fasting or excessive exercise. And recent evidence does not strongly support the validity of this distinction  BN typically begins in late adolescence or early adulthood. About 90% of cases are women and prevalence among women is thought to be about 1 to 2% of the population.  Find tat lifetime rates for females are approx 1.1% of the population for BN and 0.5% of the population for AN  Suggests that bulimia is more common than anorexia among adolescents  One study found that by age 18 80% of young women in BC with normal height and weight indicate that they would like to weight less.  Another study of more than 1,800 females from Ottawa, Hamilton, and T,O between the ages of 12 and 18 found that 27% has disordered eating attitudes and beh and approx 1 in 7 participants engaged in binge eating with associated loss of control  Comparisons across time suggest that the frequency of BN may be increasing.  Cohort effect- with rates being higher among ppl born after 1960 who alsp tend to have younger ages of onset  BN patients are somewhat overweight before the onset of the disorder and that the binge eating often starts during an episode of dieting.  Long term follow up of BN patients reveal that about 70% recover although about 10% remain fully symptomatic  BN is associated with numerous other diagnoses, notably depression, personality disorders ( esp borderline person disorder) anxiety dis, substance abuse and conduct disorder  Suicide rates are much higher among ppl with BN than in the general population. A twin study had found that bulimia and depression are genetically related  Somewhat curiously BN has been associated with stealing. Patients with bulimia who steal tend also to be illicit drug users and promiscuous. This combination of beh may reflect impulsivity or lack of self control, characteristics that may be relevant to the beh of binge eating  Like anorexia bulimia is associated with several psychical side effects. Frequent purging can cause potassium depletion. Heavy use of laxatives includes diarrhoea which can also lead to changes in electrolytes and cause irregularities in the heart beat. Recurrent vomiting may lead to dental enamel as stomach acids eat away at the teeth, making them ragged. The salivary glands may become swollen. However mortality appears to be much less common in BN than in AN Binge Eating Disorder  DSM-IV-TR includes binge eating disorder (BED) as a diagnosis in need of further study rather than a formal diagnosis. This disorder includes recurrent binges (2 x per week for at least 6 months), lack of control during the binging episode, and distress about binging as well as other characteritcs such as rapid eating and eaing alone.  It is distinguished from AN by the absence of weight loss from BN by the absence of compensatory beh (purging, fasting or excessive exercise)  Binge eating disorder appears to be more prevalent than either AN or BN  One advantage of including BED as a diagnosis is that it would apply to many patients who are now given the vague diagnosis of eating disorder not otherwise specified since they do not meet criteria for anorexia or bulimia  BED has several features that support its validity. It occurs more often in women than in men and is associated with obesisty and a history of dieting.  Its linked with impaired work and social functioning, depression, low self esteem, substance abuse and dissatisfaction with body shape  Risk factors for developing BED include childhood obesity, critical comments regarding being overweight, low self concept, depression, and childhood physical or sexual abuse  Recent data also indicate that the average life time duration of BED (14.4 yrs) may be greater than the duration of AN (5.9 yrs) or BN (5.8 yrs)  Reported that only about half of the women with an apparent binge eating disorder reported feeling “out of control”  Do not view binge easting disorder as a discrete diagnostic category seeing it instead as a less severe version of BN.  Found few differences between patients with binge eating disorder and the non purging form of BN but the preponderance of evidence seems to support the distinction between these disorders ETIOLOGY OF EATING DISORDERS  A single factor is unlikely to cause an eating disorder  including genetics, the role of the brain, socio-cultural pressures to be thin, the role of the family and the role of the environment  table 9.1 pg 257 and table 9.2 pg 261 Biological Factors Genetics  both AN and BN run in families. 1 degree relatives of young women with AN are about 4 x more likely than average to have the disorder themselves  twin studies of eating disorders also suggest a genetic influence. Most studies of both anorexia and bulimia report higher identical than fraternal concordance rates  a strong genetic component was found with a herabtability estimate of 56%  research has also shown that key features of the eating disorders such as dissatisfaction with ones body and a strong desire to be thin appear to be heritable eating disorders and the brain  the hypothalamus is a key brain centre in regulating hunger and eating. Research on animals with lesions to the lateral hypothalamus indicates that they lose weight and have no appetite thus its not surprising that the hypothamlus has been proposed to play a role in anorexia. The paraventicular nucleus has also been implicated.  The level of some hormones regulated by the hypothalamus such as cortisol are indeed abnormal in patients with anorexia; rather than causing the disorder however these hormonal abnormalities occur as a reulst of self starvation and levels return to normal following weight gain  Animals appear to have no hunger and become indifferent to food, whereas patients with anorexia continue to starve themselves despite being hungry and having an interest in food. Nor does the hypothalamic model account for body images disturbances or fear of becoming fat.  A dysfunctional hypothalamus thus does not seem a high likely factor in anorexia nervosa  Endogenous opiods- are substances produced by the body that reduce pain sensations, enhance mood and suppress appetite at least among those with low body weight.  Opiods are released during starvation and have been viewed as playing a role in both anorexia and bulimia.  Starvation among patients with anorexia may increase the levels of endogenous opiods resulting in positively reinforcing euphoric state  The excessive exercise seen among some patients with eating disorders would increase opiods and thus be reinforcing  Hypothesized that bulimia is medicated by low levels of endogenous opiods which are though to promote craving; a euphoric state is then produced by the ingestion of food thus reinforcing binging  Some data support the theory that endogenous opiods do play a role in eating disorder at least in bulimia  Found low levels of the endogenous opiod beta endorphin in patienst with bulimia; they also observed that the more severe cases of bulimia had the lowest levels of beta endorphin  Patients with bulimia have decreased regional mu-opiod receptor binding in the insular cortex and this is inversely correlated with fasting beh  Animal research has shown that serotonin promotes satiety (Feeling full) therefore it could be that the binges patients with bulimia result from a serotonin deficit which would cause them not to feel satisfied as they eat  Have identified low levels of serotonin metabolites in patients with bulimia and serotonin metabolites have been linked with the negative mood and self concept changes that precipitate binge episodes.  Patients with bulimia also show smaller responses to serotonin agonists (Chemicals that combine with receptors to initiate a reaction) again suggesting an under active serotonin system  When patients who had recovered from BN had their serotonin levels reduced they showed an increase in cognitions related to eating disorders such as feeling fat.  These data all suggest that a serotonin deficit may well be related to BN  This work focuses principally on brain mechanisms, relevant to hunger, eating and satiety and does little to account for other key features of both disorders particularly the intense fear or becoming fat Socio-cultural variables  Playboy magazine centrefolds became thinner between 1959 and 1978  Although one study found that the trend toward portrayals of increasing thinness was levelling off an analysis of playboy centrefolds were becoming even thinner. This study showed that models shown on the internet have unhealthy levels of thinness  The findings for female body size showed increasing thinness in keeping with unrealistic cultural pressures; in contrast the body size of the male Playgirl models had grown due to increases in muscularity and the body sizes of typical males had also grown but cuz of increases in body fat  Females still feel more pressure than males  Barbie look- increase bust by 12 inches, reduce waits by 10 and grow to over 7 feet in height  5 and 6 year olds exposed to Barbie images suffered lower body esteem and greater desire to achieve the thin ideal  confirmed that women who are portrayed as eating heavily are indeed seen as more masculine and less feminine than women who are portrayed ad eating light meals  the scarlet O’Hara effect refers to this phenomenon of eating lightly to project femininity  In gone with the wind mammy admonishes scarlet to eat a meal prior to going to a barbeque so that she would appear dainty by eating very little  Prevalence of obesity has doubled since 1990; currently 20-30% of north Americans are overweight, perhaps cuz of an abundance of food and a sedentary lifestyle  Increasing prevalence of obesity to an evolutionary tendency for humans to eat to excess to store energy in their bodies for a time when food may be less plentiful  Found that weight dissatisfaction was associated negatively with age among women (younger women were more dissatisfies with their weight) but this association was not evident among men  This study also found that women were more likely than men to wish they weighed less and were actually doing something to try and lose weight; this tendency was found regardless of whether their actual weight was in the acceptable range as prescribed by body mass index tables  Women place greater importance on appearance than men do and that this diff exots across the lifespan and can even be detected among the elderly  There are diff among females and males in the extent of their internalization and acceptance of prescribed body image standards  Standards as a key component of risk for eating disorder and related dysfunctional behaviours  31% of Canadian young women from grades 6-10 thought that they were too fat. The proportion increased with age and by grade 10, 44 % indicated that they were too fat  dieters increased from 7% of men and 14% of women in 1950 to 29% of men and 44% of women in 1999.  A new study in southern Ontario found that in more than 2,000 girls aged 10 to 14, 29.3% were dieting and 1 in 10 had maladaptive eating attitudes suggesting the presence of an eating disorder  By grades 9 and 10 more than 25% of young women in Canada were on a diet when the survey was conducted  The diet industry is valued at more than 50$ billion per year.  Also liposuction (vacuuming out fat deposits just under the skin) is a very common.  There are some indications that this preoccupation with being thin moderated somewhat at least in the 1980s  Found that the # if articles on dieting increased steadult during the period when centrefolds were becoming thinner  Analyzed the content of three women’s magazines to 1991 and found the # of articles on weight lose has decreased in cosmopolitan and Ms. Over this period  Shifted from the degree of content to an analysis of the relative impact of various media  Found that increases in eating disorder symptoms were associated with increased exposure to fashion magazines and these increases were not associated with amount of television viewed  Also found that amount of t.v watched was unrelated to body image variables for either girls or boys  However watching soap operas was associated with increased drive for thinness in girls and boys. Also the reasons for watching tv mattered; there was a negative impact on body image variables if tv was watched for reasons of social learning or as a diversion from negative mood states.  The socio cultural ideal of thinness- ppl learn to fear being or even feeling fat  In addition to creating an undesired physical shape, fat has negative connotations such as being unsuccessful and having little self control.  Obese ppl are viewed by others as less smart and are stereotypes as being lazy.  A new study suggests that this anti fat bias exists across the age spectrum so that even the most obese ppl tend to endorse these views; however the bias seems more automatic among thinner ppl  Found that females with below average weights were over presented in these shows and that the heavier the female character the more likely she was to have negative comments directed towards her. These negative comments were especially likely to be reinforced by audience laughter  Even worse than the medias promotion of thinness is the proliferation in the last 5 years of pro-anorexia websites  These websites glorify starvation and reinforce irrational beliefs about the importance of thinness  That some ppl become anorexic cuz of a pursuit of fitness rather than a pursuit of thinness  Activity anorexia- this concept refers to the loss of appetite when engaged in physical activity  Found that dancers, relative tro models, had higher rates of anorexia and more disturbed eating attitudes  But dancers also engage in much more strenuous physical activity.  Suggest that the two interrelated motivational factors account for activity anorexia: food deprivation increases the reinforcement effectiveness of physical activity and physical activity decreases the reinforcement effectiveness of food  Hypothesizes that anorexics often display great interest in food and are sometimes obsesses with food but lack positive incentives for actually eating the food Gender Influences  Women appear to have been more heavily influenced by the cultural ideal of thinness  Women are typically valued more for their appearance whereas men gain esteem more for their accomplishments  Women apparently are more concerned than men about being thin, are more likely to diet and are thus more vulnerable to eating disorders.  The risk for eating disorders among groups of women who might be expected to be particularly concerned with their weight such as models, dancers and gymnasts appears to be especially high.  Cuz the onset of eating disorders is typically preceded by dieting and other concerns about weight Cross cultural studies  Eating disorders appear to be far more common in industrialized societies such as the US, Canada, Japan, Australia, and Europe than in non-industrialized nations and it is also generally accepted that eating disorders are more evident in western cultures  Young women who immigrate to industrialized western cultures may be especially prone to developing eating disorders owing to the experience of rapid cultural changes and pressures  The wide variation in the prevalence of eating disorders across cultures suggest the importance of culture in establishing realistic vs potentially disordered views of ones body.  In one study of 369 adolescent girls in Pakistan none met diagnostic criteria for AN and only one met criteria for bulimia  Its difficult to compare prevalence rates across cultures accurately  The effects of introducing tv (and exposure to body shape ideals via tv) to a rural area of Fiji that had never had tv. This study showed that within three years there was a noticeable increase in preoccupation with weight and body shape, purging beh, and negative evaluations of body characteristics. Interview data also indicated that the Fijian girls acknowledged social learning and wished to emulate ppl they had seen on tv  A disorder similar to AN that exists in several non industrialized Asian countries (India, Malaysia, the Philippines). This disorder involves severe emaciation, food refusal and amenorrgea but not a fear of becoming fat  BN is a culture bound syndrome while AN is not. Thus AN may be much more common across cultures and the genetic heratability of AN relative to BN may show less variability across cultures PSYCHODYANMIC VIEWS (imp one)  Most propose that the core cause lies in disturbed parent-child relationships and agree that certain core personality traits such as low self esteem and perfectionism, are found among individuals with eating disorders  Symptoms of an eating dis
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