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Chapter 10

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Konstantine Zakzanis

Chapter 10: Eating Disorders - first appeared in DSM in 1980s - binge eating will be included in the DSM-5 - women more likely than men - lifetime prevalence in US for anorexia was 0.9% women, 0.3% men, while bulimia nervosa was 1.5% and 0.5%; binge eating - 3.5% women and 2.0% men - treatment is often obtained from the general medical sector CLINICAL DESCRIPTION: -great heterogeneity in eating disorders, and thus most common diagnosis (between 40 to 70% of patients is category called eating disorder not otherwise specified (EDNOS) Purging disorder: form of bulimia that involves self-induced vomiting or laxative use at least once a week for a minimum of 6 months have levels of disturbed eating and associated forms of psychopathology that are comparable with other eating disorders high impulsivity - 1 in 6 eating disorder patients had a diagnosable impulse control disorder  most common impulse control disorders among these women were compulsive buying disorde and kleptomania individual eats so much on purpose unlike bulimia where they don’t want to eat Anorexia Nervosa • Anorexia Nervosa (AN) (“loss of appetite due to emotional reasons”) is 3- 4x more common in females than men • They may enjoy thinking about food, preparing meals for others to consume, and hoarding food they don’t eat, but they have an intense fear of becoming obese • there are four diagnostic criteria: 1) person must refuse t maintain a normal body weight - person weighs less than 85% of what is considered normal  weight loss is achieved by purging and excessive exercise 2) person has intense fear of gaining weight, and the fear is not reduced by weight loss 3) patients with AN have a distorted sense of their body shape - believe that they are overweight even when they are emaciated - "overevaluation of appearance" 4) extreme emaciation causes amenorrhea, the loss of menstrual period (least important diagnostic criteria • Many reduce their weight by cycling, running, or constantly walking and pacing • typically diagnosed with questionnaires like Eating Disorder Inventory (EDI), which was developed in Canada and is one of most widely used diagnostic tools • DSM-4 distinguishes two types of AN:  restricted type: weight loss is achieved by severely limiting food intake binge eating-purging type: person regularly engages in binge eating and purging - appears to be more psychopathological: patients exhibit more personality disorders, impulsive behaviour, stealing, alcohol/drug abuse, social withdrawal, and suicide attempts • As many as 6% of people die from causes related to it • Typically begins in the early-middle teenage years, often after an episode of dieting and exposure to life stress • recent data suggests that prevalence of anorexia among children and teens is increasing • comorbidity is high - men and women at risk for eating disorders were also prone to depression, panic disorder and social phobia • growing concern is the high rate of co-occurring eating disorders and substance use disorders Physical changes in anorexia:  Blood pressure falls  Heart rate slows  Kidney and gastrointestinal problems develop  Bone mass declines  Skin dries out  Nails become brittle  Hormone levels change  Mild anemia may occur  Some lose hair from scalp  May develop laguna (fine, soft hair on their bodies)  Levels of electrolytes (potassium and sodium) are altered, which can lead to tiredness, weakness, cardiac arrhythmias, and even death  Brain size declines - deficits in white matter (that can be restored after recovery) and grey matter (which deficits are irreversible) • About 70% of patients recover, recovery takes 6 or 7 years • relapses are common before a stable pattern of eating and maintenance of weight is achieved • Death is often a result - death is among 10x higher in patients with AN than regular population • death often results due to physical complications of the disease, or suicide • suicide rates are not elevated in BN like they are in AN • predictors of suicide in AN include purging behaviours, depression, substance abuse, and history of physical or sexual abuse • intentional self-injury is also linked to eating disorders, including cutting, scratching and self-hitting • Nock model believes that people engage in self-harm for (1) interpersonal reasons, (2) to suppress unwanted social stimulus (3) to suppress negative emotion and (4) to generate feelings among those who need to feel emotion Bulimia Nervosa • bulimia nervosa - arises from Greek word meaning " ox hunger" • characterized by individuals undergoing episodes of rapid food intake with large amount of food, followed by compensatory behaviours, like vomiting, fasting or excessive exercise, to prevent weight gain • gorge themselves with food (especially desserts and snack foods) usually in the afternoon or evenings , followed by self-induced vomiting or the use of laxatives, accompanied by the feelings of depression and guilt • DSM defines a binge as eating an excessive amount of food within less than two hours • stressors that involve negative social actions may be potent elicitors of binges -binges tend to be preceded by poorer than average social experiences, self-concepts, moods and self perceptions • individual usually feels a loss of control over the amount of food being consumed; may reach a dissociative state during binge, loosing awareness of what they are doing or feeling • DSM requires episodes of binging and purging occur at least twice a week for three months • like AN, individuals self-esteem relies on maintaining normal weight • there are two subtypes - a purging type and non purging type, in which compensatory activities are fasting or excessive exercise • 19% of bulimics under eat, 37% eat a normal amount, and 44% overeat • It is not fatal, but it can result in poor health outcomes • typically begins in late adolescence or early adulthood - more common than anorexia in adolescents • temporal studies have found that many BN patients are somewhat overweight before the onset of the disorder, and that binge eating often starts during a dieting episode • about 70% recover and 10% remain fully symptomatic • associated with number other diagnoses, like depression, personality disorders (especially borderline personality disorder), anxiety disorder, substance abuse and conduct disorder • suicide rates in BN patients is much higher than regular population • Physical side effects:  Potassium depletion Heavy use of laxatives induces diarrhea, which leads to changes in electrolytes and cause irregularities in the heartbeat Recurrent vomiting may lead to tearing of tissue in the stomach and throat loss of dental enamel as stomach acids eat away at the teeth making the ragged salivary glands may become swollen Binge Eating Disorder: • binge eating disorder (BED): includes recurrent binges (two times a week for at least 6 months), lack of control during bingeing episode, and distress about bingeing • distinguished from AN by its absence of weight loss and from BN by absence of compensatory behaviour • in DSM-4, it is a diagnosis in need of study rather than a formal diagnosis, but BED will be included in DSM-5 • appears to be more prevalent than either AN or BN • occurs more in women and than men • associated with obesity and history of dieting • linked with impaired work and social functioning, depression, low self-esteem, substance abuse, and dissatisfaction of body shape • risk factors include: childhood obesity, depression, and childhood physical/sexual abuse • average life-term duration of BED(14.4 years) may be greater than duration of AN(5.9 years and BN(5.8 years) ETIOLOGY OF EATING DISORDERS - several research suggests that eating disorders result when several influences converge on a person's life 1) BIOLOGICAL
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