chapter 9

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19 Jun 2011

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Chapter 9 Eating Disorders
- 0.5% of Canadians 15 years of age or older reported that they had been diagnosed wit an eating
disorder in the preceding 12 months
- women are more likely than men to report an eating disorder
- 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 range; rates are also high among those aged 10-14 and 20-24
Clinical Description
- anorexia nervosa and bulimia nervosa both share features; the most important being an intense fear of
being overweight
Anorexia Nervosa
anorexia nervosa (AN) a disorder in which a person refuses to eat or to retain any food or suffers a
prolonged and severe decrease of appetite; the individual has an intense fear of becoming obese, feels
fat even when emaciated, refuses to maintain a minimal body weight, and loses at least 25% of his/her
original weight
- anorexia refers to loss of appetite and nervosa indicates that this is for emotional reasons
- there are 4 features required for the diagnosis:
the person must refuse to maintain a normal body weight
this is usually taken to mean that the person weighs less than 85% of what is considered
normal for that person’s 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
the person has an intense fear of gaining weight
and the fear is not reduced by weight loss; they can never be thin enough
patients with AN have a distorted sense of their body shape
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
in females, the extreme emaciation causes amenorrhea, the loss of the menstrual period
of the 4 diagnostic criteria, amenorrhea seems least important to determining a diagnosis
of anorexia; comparisons conducted in Canada show few differences between women
who meet all 4 criteria and women who meet the other 3 but not amenorrhea;
amenorrhea occurs in a significant minority of women before any significant weight loss
and the symptom can persist after weight gain
amenorrhea loss of menstrual period that is sometimes caused by eating disorders
- the distorted body image that accompanies AN has been assessed in several ways, most frequently by
questionnaires such as the Eating Disorders Inventory (EDI)
- the EDI is one of the most widely used measures to assess self-reported aspects of eating disorders
- patients with AN overestimate their own body size and choose a thin figure as their ideal
- DSM-IV-TR distinguishes 2 types of AN
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- in the restricting 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
disorders, impulsive behavior, stealing, alcohol and drug abuse, social withdrawal, and suicide attempts
than do patients with the restricting type of anorexia
- also, relative to the restricting type, binging-purging patients tend to weigh more in childhood, come from
heavier families with greater familial obesity, and use more extreme weight-control methods
- AN typically begins in the early to middle teenage years, often after an episode of dieting and exposure
to life stress
- its about 3-10 times more frequent in women than in men, with a lifetime prevalence of 1% in women
- twas 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
- comorbidity is higher in clinical samples than community samples
Physical Changes in Anorexia Nervosa
- self-starvation and use of laxatives produce numerous undesirable biological consequences in patients
with 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 the bodies
- levels of electrolytes, such as K and Na are altered; these are essential for the process of neural
transmission, and lowered levels can lead to tiredness, weakness, cardiac arrhythmias, and even sudden
- brain size declines in patients with AN, and EEG abnormalities and neurological impairments are
- deficits in white matter volumes in the brain are restored upon recovery from AN, but deficits in grey-
matter volumes appear irreversible, at least in the short term
- about 70% of patients with AN eventually recover; recovery often takes 6-7 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 times higher among patients with the disorder
than among the general population and twice as high among patients with other psychological disorders
- suicide rates are not elevated in bulimia nervosa like they are in AN, though people with BN are more
likely to have suicide ideation
Bulimia Nervosa
bulimia nervosa (BN) a disorder characterized by episodic uncontrollable eating binges followed by
purging either by vomiting or by taking laxatives
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- this disorder involves episodes of rapid consumption of a large amount of food, followed by
compensatory behaviors, 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 2 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 a case is AN, binge eating-purging type
- binges typically occur in secret, may be triggered by stress and the negative emotions it arouses, and
continue until the person feels uncomfortably full
- 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, especially sweets such as ice cream or cake, are usually
part of a binge
- 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’re doing or 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 2nd step of
BN purging to undo the caloric effects of the binge
- purging can involve induced vomiting and excessive exercise; the use of laxatives and diuretics is
common, even though this does not actually result in weight loss
- although many people binge occasionally and some people also experiment with purging, the DSM
diagnosis of BN requires that the episodes of binging and purging occur at least twice a week for 3
- there is a continuum of severity rather than a sharp distinction with BN; there’s some people who
binge/purge less frequently with twice a week but they can still have BN
- like patients with AN, patients with BN are afraid of gaining weight, and their self-esteem depends
heavily on maintaining normal weight
- 2 subtypes of BN are distinguished: a purging type and a non-purging type in which the compensatory
behaviors are fasting or excessive exercise
- BN typically begins in late adolescence or early adulthood
- about 90% of cases are women, and prevalence among women is thought to be about 1-2% of the
- Canadian studies of rates of eating disorders in community samples find that lifetime rates for females
are about 1.1% of the population for BN and 0.5% of the population for AN
- research conducted in Canadian schools also suggests that bulimia is more common than anorexia
among adolescents
- comparisons across time suggest that the frequency of BN may be increasing
- BN is associated with numerous other diagnoses, notably depression, personality disorders (especially
borderline personality disorder), anxiety disorders, substance abuse, and conduct disorder
- suicide rates are much higher among people with BN than in the general population
- a twin study has found that BN and depression are genetically related; BN has been associated with
stealing and patients with BN who steal tend also to be illicit drug users and promiscuous
- like AN, BN is associated with several physical side effects; frequent purging can cause K depletion;
heavy use of laxatives induces diarrhea, which can also lead to changes in electrolytes and cause
irregularities in the heartbeat; recurrent vomiting may lead to tearing of tissue in the stomach and throat
and to loss of dental enamel as stomach acids eat away at the teeth, making them ragged; the salivary
glands may become swollen
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