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PSYC*3390 Ch 9.doc

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PSYC 3390
Mary Manson

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Friday, November 30, 2012 Chapter 9: Eating Disorders and Obesity Eating Disorders - characterized by a severe disturbance in eating behaviour Clinical Aspects of Eating Disorders Anorexia Nervosa - anorexia nervosa literally means “lack of appetite induced by nervousness” - at the heart of anorexia nervosa is an intense fear of gaining weight or becoming fat, combined with a refusal to maintain even a minimally low body weight - the first medical account was published in 1689 by Richard Morton - the disorder did not receive its current name until 1873 - many patients deny they have problems and may be quietly proud of their weight loss - there are 2 types of anorexia nervosa: the restricting type and the binge-eating/purging type - in the restricting type, every effort is made to limit how much food is eaten and caloric intake is tightly controlled, patentees often try to avoid eating in the presence of other people and may eat excessively slowly, cut food into very small pieces and dispose of it secretly - the binge-eating/purging type either binge, purge, or binge and purge - a binge involves out-of-control eating of amounts of food that are far greater than what most people would eat in the same amount of time - 30-50% of patents transition from the restricting type to the binge-eating/purging type - methods of purging commonly include self-induced vomiting or misuse of laxatives, di- uretics and enemas - ballet dancers are at especially high risk for eating disorders because the artistic stan- dards of their profession emphasize a slender physique - the mortality rate for females with anorexia nervosa is more than 12 times higher than the mortality rates for females in the general population - when death occurs it is usually a result of either the physiological consequences of starvation, or more intentionally, suicidal behaviour - this is one of the sharp contracts to bulimia nervosa, where death as a direct outcome of the disorder is rare Bulimia Nervosa - binge eating and efforts to prevent weight gain using self-induced vomiting and exces- sive exercise Friday, November 30, 2012 - the word bulimia comes from the Greek bous (ox) and limos (hunger) and is meant to denote a hunger of such proportions that the person “could eat an ox” - the clinical picture of binge-eating/purging type of anorexia has much in common with bulimia nervosa - the differences is weight, by definition, the person with anorexia nervosa is severely underweight, this is not true of the person with bulimia nervosa - if a person who binges or purges also meets criteria for anorexia nervosa, the diagno- sis is anorexia nervosa (binge-eating/purging type) - the anorexia nervosa diagnosis “trumps” the bulimia nervosa diagnosis because there is much greater mortality associated with anorexia nervosa - bulimia typically begins with restricted eating motivated by the desire to be slender - during these early stages, the person diets and eats low-calorie foods but over time the person starts to eat “forbidden foods” - during an average binge, someone with bulimia nervosa may consume as many as 4800 calories - after the binge, in an effort to manage the breakdown of self-control, the person begins to vomit, fast, exercise excessively, or abuse laxatives - bulimia is a costly disorder for many patients, high food bills can create financial diffi- culties, and patents sometimes resort to stealing food - there is a difference between purging and nonpurging types of bulimia nervosa on the basis of whether the person uses a purgative method of preventing weight gain (vomit- ing, use of laxatives) or if they just fast or exercise - the typical patient with anorexia nervosa often denies the seriousness of her disorder - in contrast, patients with bulimia preoccupied with shame, guilt, self-deprecation, and and efforts at concealment Age of Onset and Gender Differences - both are do not occur in appreciable numbers before adolescence - the average age of onset for anorexia nervosa is 18.9 years and bulimia nervosa be- gins at an average age of 19.7 years - do occur in males but are far more common in women (10 females for every male) Medical Complications of Anorexia Nervosa and Bulimia Nervosa - anorexia nervosa is one of the most lethal psychiatric disorders - many patients look extremely unwell, the hair on the scalp thing and becomes brittle as do the nails Friday, November 30, 2012 - the skin becomes very dry and downy hair starts to grow on the face, neck, arms, back and legs - may develop a yellowish tinge to their skin - have a difficult time dealing with the cold, their hands and feet are often cold to the touch and have a purplish-blue tinge due to problems with temperature regulation and lack of oxygen to the extremities - as a consequence of chronically low blood pressure, patients often fee l tired, weak, dizzy and faint - Thiamin (vitamin B1) deficiency may also be present which could account for some of the depression and cognitive changes - in adolescents, anorexia can affect patterns of growth and development of healthy bones and brain function - people with anorexia nervosa can die from heat arrhythmias (irregular heartbeats), sometimes this is cause by major imbalances in key electrolytes such as potassium - chronically low levels of potassium can also result in kidney damage and renal failure - bulimia nervosa is much less lethal but also causes a number of medical problems - purging can cause electrolyte imbalances and low potassium (hypokalemia) - damage to the heart muscle can be caused by using ipecac to induce vomiting - callouses on fingers and tears to the throat from toothbrushes from inducing vomiting - teeth is damaged form acid in stomach from throwing up - brushing teeth immediately after vomiting damages the teeth even more - mouth ulcers and dental cavities are a common consequences - small red dots around the eyes are caused by the pressure of throwing up - swollen parotid (salivary) glands from repeated vomiting, known as “puffy cheeks” or “chipmunk cheeks” Other Forms of Eating Disorders - the DSM-IV-TR also includes the diagnosis of eating disorder not otherwise specified (EDNOS), used for patterns of disorder eating that do not exactly fit the criteria for any of the more specific diagnoses e.g. a women who meets all the criteria for anorexia ner- vosa except disrupted menstrual periods - approximately 40% of patients have EDNOS, it is the most prevalent among females - EDNOS also includes binge-eating disorder (BED), although it is technically not an of- ficial disorder, it is included in the appendix Friday, November 30, 2012 - an individual with BED binges at a level comparable to a patient with bulimia nervosa but does not regularly engage in any form of compensatory behaviour to limit weight gain, most patients are older and it is not uncommon in men Distinguishing among Diagnoses - the distinction between normal and disordered eating is a fuzzy one - the distinction between anorexia nervosa and bulimia nervosa is often not clear - the clinical features of eating disorders seem to evolve, one common pattern is anorex- ia nervosa morphing into bulimia nervosa Association of Eating Disorder with Other Forms of Psychopathology - there is a great deal of comorbidity with eating disorders, 2/3 of patients with anorexia or bulimia are also diagnosed with depression - OCD is often found in patents with eating disorders especially anorexia - comorbid personality disorders are also frequently diagnosed - more than a third of patients with eating disorders have engaged in self-harm - one problem with examinations of personality disorders is that some of the distur- bances could reflect the consequences of malnourishment - starvation can increase both irritability and obsessionally Prevalence of Eating Disorders - the lifetime prevalence of anorexia, bulimia, and binge-eating disorder are 0.9%, 1.5% and 3.5% for women and 0.3%, 0.5% and 2% for men - this is only clinically diagnosable eating disorder though, many people, particularly young women in their teens and 20s have disordered eating patterns Eating Disorders across Cultures - the majority of research is conducted in North America and Europe but eating disor- ders have been found in South Africa, Japan, Hong Kong, Taiwan, Singapore, India, Africa, Iran - being white appears to be associated with having the kinds of subclinical problems that may put people at high risk e.g. body dissatisfaction, dietary restraint and a drive for thinness - asian women exhibit levels of pathological eating similar to white women Friday, November 30, 2012 - an important factor is how assimilated into white culture minority women are, black adolescent girls seem less inclined to use weight and appearance to fuel their sense of identity and self-worth - some of the clinical features of diagnosed forms of eating disorders may also vary ac- cording to culture e.g. in Hong Kong they are not concerned about getting gat but fear their stomach bloating Course and Outcome - eating disorders are notoriously difficult to treat, and relapse rates are high - in a study looking 21 years after patients with anorexia nervosa had first sought treat- ment, 16% of patients (all women) were no longer alive, 10% were still sugaring, 21% had partially recovered and 51% were fully recovered - with bulimia nervosa, the long-term mortality rate is much lower, around 0.5% - in a long-term study which the length of follow-up was 11 years, 70% were in remission and no longer met diagnostic criteria and 30% had problems with their eating Risk and Causal Factors in Eating Disorders Biological Factors Genetics - the tendency to develop an eating disorder runs in families - relatives of patients with eaten disorders are more likely to suffer from other problems, especially mood disorders - there are presently no adoption studies and a small number of twin studies - these suggest that both anorexia and bulimia are heritable disorders - there is also provocative evidence from a number of studies for a gene or genes on chromosome 1 that might be linked to susceptibility to restrictive anorexia nervosa - susceptibility to bulimia nervosa may be linked to chromosome 10 - eating disorders have been linked to genes that are involved in the regulation of the neurotransmitter serotonin - serotonin is known to play in the regulation of eating behaviour and mood - it is interesting that mood and eating disorders often cluster together in families - since bulimia and anorexia often overlap, it is possible that they may have some genet- ic factors in common Set Points - there is a tendency for our bodies to “resist” marked variation from some sort of biolog- ically determined “set point” Friday, November 30, 2012 - trying to achieve and maintain a significant decrease in body mass below your individ- ual set point may be trying to do this in the face of internal physiological opposition, es- pecially hunger - as we lose more and more weight, hunger may rise to extreme levels, encouraging eating, weight gain, and a return to a state of equilibrium Serotonin - a neurotransmitter that has been implicated in obsessionality, mood disorders, and im- pulsivity, appetite and feeding behaviour - some researchers have concluded that eating disorders involve a disruption in the serotonin system - it is not clear if serotonin is the cause of the problem or a result of malnourishment Sociocultural Factors Peer and Media Influences - models are getting thinner and thinner - thinness became deeply rooted as a cultural ideal in the 1960s - Twiggy was the first super-thin supermodel - in Fiji, being fat used to be associated with being strong, being able to work and being kind and generous, being thing was regarded negatively and was thought to reflect be- ing sickly, incompetent and receiving poor treatment - there was an absence of anything that could be considered an eating disorder - when television came to Fiji, girls saw western program and started expressing con- cerns about their weight and dislike about their bodies Family Influences - certain problems seem to characterize the families of patients - more than 1/3 of patients with anorexia reported that family dysfunction was a factor - rigidity, parental overprotectiveness, excessive control and marital discord are common factors - many parents have long-standing preoccupations regarding the desirability of thinness, dieting and good physical appearance and perfectionist tendencies - with bulimia nervosa, risk factors are high parental expectations, other family mem- bers’ dieting and degree of critical comments from other family members Friday, November 30, 2012 - the largest predictor of bulimic symptoms was the extent to which family members made disparaging comments about the woman’s appearance and focused on her need to diet Individual Risk Factors Internalizing the Thin Ideal - buying into the notion that being thin is highly desirable is associated with a range of problems that are thought to be risk factors for eating disorders including body dissatis- faction, dieting and negative affect Body Dissatisfaction - highly intrusive and pervasive perceptual biases regarding how “fat” they are - girls and women believe men prefer more slender shapes than they in fact do - many women feel evaluated by other women - the
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