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Chapter 8

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PSYC 3140
Kendra Thomson

Chapter 8: Eating and Sleep Disorders - psychological disruption of eating and sleeping Eating Disorders (ED): An Overview - began to increase during 1950s/60s - Bulimia Nervosa: o Binges: out of control eating episodes o excessive use of laxatives (to purge = get rid of) food - Anorexia Nervosa o Minimial amts of food o Body weight drops dangerously - Both disorders: overwhelming desire to be thin o Study: 176 patients for eating disorder, 83% = high drive for thinness o Both Anorexia and Bulimia desire to be thin - up to 20% of ppl w/ anorexia die, 5% dying w/in 10 years - Anorexia nervosa – highest mortality rate of any psychological disorder (including depression) - 30% of anorexia related deaths – suicide o 50 times higher than risk of death from suicide in general pops - Eating disorders widespread, increased dramatically in Western countries 1960-1995 - Switzerland 1956-1958: # of new cases of anorexia nervosa among females under treatment b/w 12-25 yrs was 3.98 per 100,000 o 16.76 new causes per 100,000 1973-1975 (4X increase) o similar results found in Sweden, NA, (over 50 yr period), Denmark - Bulimia Nervosa: o 1975-1986 - referral rates for anorexia: rose slowly  bulimia: rose rapidly (from almost 0 to 140 per yr)  unknown reason for increase  similar results worldwide  Garfinkel/Dorian may relate to increased prevalence of dieting / preoccupation w/ body among young women (exposed to social pressures toward consumption) - sixfold increase in death rate for ppl w/ eating disorders vs general pop - mortality rate for eating disorders (specif. anorexia nervosa) = highest of all psychological disorders (even depression) - Eating problems not recognized as psychological disorders until recently o 1872 – Sir William Withey Gull (British physician) – first to use term anorexia nervosa o First Canadian description of anorexia in Maritime Medical Journal in 1895 o Recognition of bulimia nervosa as separate disorder came later - 1970s o Eating disorders included as separate group of disorders for 1 time st in DSM IV  Before – classified as disorders first diagnosed in infancy, childhood, adolescence b/c of typical onset in adolescence - increase in eating disorders = culturally specific o until recently – ED not found in developing countries (limited access to daily food)  higher in Western countries where food is rampant o this is changing: eating disorders are going global  eg. Prevalence rates of ED in Japan, Hong Kong are approaching those in Canada, USA - ED occur in small segment of pop o More than 90% of severe cases = young females, families w/ upper- middle/upper class SES, live in socially competitive environments o Eg. Princess Diana – bulimia nervosa, bingeing/vomiting 4+ times per day during honeymoon - in ED (unlike other disorders), strongest contributions to etiology = sociocultural rather than psycho/bio factors - Another category of ED – Binge eating disorder Bulimia Nervosa - one of most common psychological disorders on uni campuses Clinical Description - eating large amts of food (junk food) than normal o amount of food imp, eating is experienced as out of control o ind attempts to compensate for binge eating / weight gain by purging techniques: self-induced vomiting imm after eating, laxatives / diuretics  some ppl use both methods - Study – women w/ bulimia who use laxatives are more impulsive than those who don’t - Other ways to compensate: fast for long periods b/w binges, excessive exercise (rigorous exercise more characteristic of anorexia) - Study – 81% of a group w/ anorexia exercised excessively, only 57% of group w/ bulimia nervosa - Activity levels increase at least 1 yr prior to developmnt of anorexia o Excessive exercise may be early earning sign - Bulimia nervosa subtyped in DSM IV into purging type and nonpurging type (exercise/fasting) o Nonpurging type more rare, 6-8% of ppl w/ bulimia o Study – compared purging vs nonpurging bulimics  Ppl who purged developed their ED at younger age, had higher rates of comorbid depression, anxiety disorders, alcohol abuse, higher rates of earlier sexual abuse o Other studies found little difs b/w purging and nonpurging types  Is subtyping useful? - Purging not efficient at reducing caloric intake o Vomiting reduced 50% of calories that were just consumed (less if vomiting is delayed) o Laxatives have little effect o Addition to DSM IV criteria  “self-evaluation is unduly influenced by body shape and weight” – psychological characteristic : overconcern w/ body shape  Eg. Pheobe – despite popularity, felt that slef-esteem was deterined by weight / shape of body o Garfinkel Study  of 107 bulimics, only 3% did NOT share this attitude - problem with DSM IV criteria  “nonpurging” subtype is diff to define o may not be necessary in DSM V Medical Consequences - Chronic bulimia w/ purging: o 1. Salivary gland enlargement (caused by repeated vomiting)  makes face look chubby o 2. Repeated vomiting causes erosion fo dental enamel on front teeth o 3. Continued vomiting  upset chemical balance of body fluids (NA/K levels)  electrolyte imbalance: result in serious medical complications eg. cardiac arrhythmia (disrupted heartbeat), renal (kidney) failure – both can be fatal - young women w bulimia develop more body fat than age/weight-matched healthy controls IRONIC! o Normalization of eating habits reverses imalance - intensinal problems from laxabtive abuse o severe constipation, permanent colon dmage - Calluses on fingers / back of hands from friction w/ teeth/throat when sticking hand down throat to stimulate gag reflex Associated Psychological Disorders - additional psychological disorders for bulimia nervosa anxiety / mood disorders - Study: compared 20 ppl w/ bulimia nervosa to 20 ind w/ panic disorders and to 20 ppl w/ social phobia o 75% of ppl w/ bulimia also had anciety disorder eg. social phobia, GAD o patients w/ anxiety disorders did not have inc rate of ED - Mood disorders (depression) commonly co-occur w/ ED - Theory: ED are way of expressing depression o Evidence - depression follows bulimia (may be reaction to it) - High prevalence of borderline personality disorder w/ bulimia - Substance abuse frequent in patients w/ bulimia (and vice versa) o Study: studied 58 women in treatment for alcoholism  71% = binge eating  91% = severe binge eating patterns - Studies: ED associated w/ nicotine dependence in adolescent girls, alcohol abuse in adult women o Binge-purge types of ED smoke the most o Smoking related to impulsive personality traits o Bulimia may be related to other behaviours of poor impulse control (eg. compulsive shoplifting) - Summary o Bulimia related to anxiety disorders, mood disorders, substance use disorders, borderline personality and impulse control disorders o ***Ppl w/ bulimia are w/in 10 % of normal body weight Anorexia Nervosa = (“nervous loss of appetite” – incorrect def b/c appetite is healthy) - successful in losing weight (very dif from bulimia), put lives in danger - anorexia and bulimia  morbid fear of gaining weight / losing control over eating - Major difference  whether ind is successful at losing wehgt o Anorexia = proud of diets/extraordinary control, don’t see themselves as having illness (denial of illness) o Bulimia = ashamed of the problem and lack of control, secretive of bulimic symptoms (shame of illness) o Denial/shame of illness = ppl don’t seek treatment as early as they should - most ppl w/ anorexia crave food but learn to control cravings - exercise to point of exhaustion - extreme amounts of exercise for female athletes: Christy Henrich (died of kidney failure at 22) o physically restrained to prevent excessive exercise - consequences of anorexia of young celebratitiones / models publicized in media Clinical Description - bulimia more common than anorexia o overlap – many ppl w/ bulimia have history w/ anorexia (at one pt used fasting to reduce body weight) - decreased body weight not core of anorexia - many ppl lose weight b/c of medical condition  ppl w/ anorexia have intense fear of obesity, relentlessly pursue thinness - commonly begins in adolescence who is overweight/perceives oneself to be o starts diet  escalates to obsession w/ being thin o continues to see oneself as overweight despite weight loss o Study: ppl w/ anorexia tend to overreport body weight o Study – Caroline Davis  severe / punishing exercise common in anorexia o Dramatic weight loss achieved through severe caloric restriction/combining caloric restriction w/ purging - 2 types of anorexia in DSM IV: Restriction Type: diet to limit caloric intake, Binge-eating/purging type: rely on purging to limit caloric intake - binge-eating/ purging anorexics ginge on small amounts of food, purge more consistently (eg. each time they eat) (both dif from bulimia) - 50% of anorexics engage in binge eating / purging - Study: data collected over 8 years, 136 inds w/ anorexia  few difs b/w 2 subtypes on severity of symptoms / personality o 62% of restricting subtype had begun bingeing / purging o subtyping may not be useful in predicting future course of disorder  May reflect phase / stage of anorexia o DSM 5 – subtyping may then only refer to the last 3 months - Ind w/ anorexia – never satisfied w/ weight loss o Staying at same weight / gaining weight causes pain, anxiety, depression  Continued weight loss for weeks is satisfactory  DSM IV criteria – body weight 15% below expected  avg is 25-30% below normal by the time ind seeks treatment - Criteria – marked disturbance in body image o Dif ppl focus on dif parts of body that need weight loss - ppl w/ anorexia become good at saying what they think doctors want to hear o they agree that they are underweight and need to gain weight (don’t belive it – will still think they are fat – reason why few ppl w/ anorexia seek treatment – don’t belive they have an illness, believe they still need to lose weight) o pressure from family leads to initial treatment - some anorexics have interest in cooking / food o eg. haord food in rooms, look at it periodically Medical Consequences - cessation of mentruation (amenorrhea) – occurs often in bulimia too o can be objective physical index of degree of food restriction  but - inconsistent b/c doesn’t occur in all cases  inconsistency  likely to be dropped in DSM V - dry skin, brittle hair/nails, sensitivity/intolerance of cold temps - lanugo – downy hair on limbs/cheecks - Cardiovasuclar problems - low blood pressure / heart rate - if vomiting in anorexia, electrolyte imbalance likely  cardiac / kidney problems (like in bulimia) Associated Psychological Disorders - anxiety / mood disorders (like in bulimia) - OCD frequently co-occurs w/ anorexia - unpleasant htoughts focused on gaining weight - ind engages in behaviours (some ritualistic) to rid oneself of neg thoughts - Substance abuse - strong predictor of mortality eg. by suicide Binge-Eating Disorder - distress from binge eating, no extreme compensatory behaviours  cannot be diagnosed w/ bulimia o these ind have binge eating disorder (BED) o BED in appendix of DSM IV as potential new disorder o DSM V – will be included as own category  BED - different patterns of heritability than other ED  greater likelihood in males, later stage of onset  greater likelihood of remission  better response to treatment compared to other EDs - ppl who meet criteria BED often found in weight-control gorups o Study: mildly obese ppl in weight control program  18.8% met ccriteria for BED  other programs – almost 30% of ppl in program met criteria - Hudson  BED = disorder caused by separate factors form obesity w/o BED o Associated w/ severe obesity o Generally 20% of obese ppl in weight-loss programs binge eat  50% of ppl for bariatric surgery (to correct severe/morbid obesity) - Study: followed 40 ppl w/ BED for 5 years. Good prognosis for group, only 18% maitinag full criteria for BED after 5 yrs o % of obese ppl inc from 21 – 39% at 5 yr follow up - approx 50% of ppl w/ BED try dieting b4 binging - approx 50% begin bingeing first, and then try dieting o ppl who binge first become more severely affected by BED & more likely to have additional disorders - have same concers re: shape / weight as ppl w/ anoexia and bulimia o distinguishes them from obese ppl who dn’t have BED - 33% of ppl w/ BED binge to alleviate bad moods/neg affect o more psychology disturbed than 67% who don’t use bingeing to regulate mood Statistics - bulimia nervosa recog as distinct psychological disorder in 1970s o 90-95% of ind w/ bulimia are women  most white middle to upper-middle class o 5-10% are male w/ later age of onset  homosexual / bisexual orientation – specific risk factor for bails – especially in bulimia nervosa - men w/ EDs and women w/ EDs are similar - Difference b/w genders  personality risk factors (eg. perfectionism) - Possible explanation for high bulimia rate in women: Men’s lower levels of personality risk factors - Male athletes in sports w/ weight regulations (Eg. wresting)  large group of males w/ eating disorders - Gender difference in bulimia was not always the case o Most recorded cases of bulmia = males for hudnreds of years - Age of onset: 16-19 yrs old o Signs of impending bulimic behaviour can occur earlier - Study: b/w 6-8% of young women (especially on uni campuses), meet criteria for bulimia - 9% of high school girls would meet criteria o only 2% were purging at that age - most ppl who seek treatment are in purging subtype - Diff prevalence rates of bulimia in studies of entire pop rather than smll grps o Study: sampling 8000 ind  lifetime prevalence = 1.1 % females, 0.1% males  2.3% females showed partial syndromes (and had some symptoms of bulimia, but not enough to fit DSM IV criteria)  low prev rates for males consistent w/ earlier findings o Study: lifetime prev rates of women 18-44 yrs = 1.6%  higher rate among younger women  18-24 yrs – prev 4.5%  0.4% for women 45-64 yrs old  higher prev in urban areas - Study of Kendler: 2163 twins (more than 1000 pairs) interviewed, lifetime prev rate = 2.8% o 5.3% when bulimic symptoms not meeting criteria were considered o prev greatest in younger women  Figure 6.2: rate mich higher for females born after 1960 than b4 1960  BUT – estimates probs low b/c many inds w/ EDs refuse to participate in studies  %s of ppl rep only inds who consented to participate in survey - Bulmia = chronic if untreated o Study: “drive for thinness” still present in grp of women10 yrs after diagnosis o Fairburn Study: 102 females w/ bulimia, followed 92 of them for 5 yrs  1/3 improved  no longer met diagnostic criteria each yr  1/3 improved and relapsed  50-67% had serious ED symptoms each yr of 5-year study  disorder has poor prognosis  Follow up study: strongest predictor of ED persistence = history of childhood obesity, continuing overemphasis on imp of being thin  Ind tend to retain bulimic symptoms (instead of shifting to other ED symptoms)  validates bulimia nervosa as separate diagnostic category - 90-95% of ind w/ anorexia are females o onset in adolescence (around 13 yrs) - inc rates of anorexia in 1960s/1970s - Study: Analyze data from 2163 twins study (mentioned earlier) to determine prev of anorexia o 1.62% met criteria for lifetime prevalence  inc to 3.7% w/ inclusion of anorexic symptoms that didn’t meet full criteria for disorder  Bulimia = more common than anorexia - anorexia = chronic o more resistant to treatment than bulimia Cross Cultural Considerations - bulimia & anorexia = culturally specific - develop in immigrants who recently move to western countries - Nasser’s Study: 50 Egyptian women in London unis, 60 Egyptian women in Cairo unis o None of women in Cairo had EDs, but 12% of Egyptian women in England had developed an ED  Same results of Asian women living in NA - prevalence varies among minority pops in NA o black / Asian NA females = lower than Caucasion, higher than aboriginal women o black adlescent girls have less body dissatisfaction, fewer weight concerns, more positive self-image, perceive themselves to be thinner than actually are (compared to white girls) - Major risk factors of ED for all groups: being overweight, higher social class, acculturatin to Western majority - Culturally determined influence: traditional Chinese cultures  plump = highly valued, ideals of beauty focused on face not body o Acne most reported as precipitant for anorexia than fear of being fat, body image disturbance = rare o Patients refused to eat b/c of excuses of feeling full / pain  could have related food intake to skin conditions o Besides this unique trait, they met all criteria for anorexia  Challenge to this theory: Study: Miss Hong Kong Beuaty Pageant 1975-1999  winners – taller / thinner than avg Chinese woman  Challenges notion that plumpness is valued in Chinese culture - Japan: prev of anorexia in teen girls = lower than NA, but is increasing o Need to be thin / fear of gaining weight not as imp in Japan culture o Changing as cultures become more Westrnized o Body image distortion / denial of problem = present in Japanese patients - Gupta Study: compare weight-related body image concerns in women 18-24 yrs in Canada and India o cross cultural study o levels of drive for thinness and body dissatisfaction didn’t differ b/w two cultures o body image concerns presented differently in 2 samples  Canadian women, body dissatisfaction related to weight of abdomen, hips, thighs, legs  Indian women – bod y dissatisfaction related to weight of face, neck, shoulder, chest (upper torso) - Anorexia / bulimia = homogeneous o Until recently, associated w/ Western cultures o Frequency / pattern of occurrence in minority Western cultures associated w/ Caucasian middle – class values Developmental Considerations - anorexia / bulimia strongly related to development (begin in adolescence) - diff patterns of physical development in girls / boys interact w/ cultural influences to create eating disorders - puberty – girls gain wait as fat, boys gain more lean muscle tissue - ideal look in western countries  muscular for men, thin / prepubertal for women o natural physical development (puberty) brings boys closer to this ideal, brings girls further away Causes - bio, psycho, social factors contribute to developmnt of serious EDs o most dramatic factors = social and cultural Social Dimensions - anorexia / bulimia = most culturally specific psych disorders - for many young women in Western countries, living in middle to upper class competitive environments, self-worth, happiness and success = determined by body measurements / % of body fat (factors that have no correlation to success / personal happiness in long run) - cultural imperative for thinness leads to dieting = first step to anorexia / bulimia - standards of desireable body sizes change o Study: collected data from Playboy mag, contestants in beatufy pageants from 1959-1978  both Playboy models / beauty pageants became sig thinner  bust/hip measurements sig smaller, waist = larger  change in desirable body shape / weight - comparing beauty peagenat winners from 1922-1999 since 1970s, most winners = undernourished  69% of Playboy and 60% beauty pageant contestants weighed 15% or more below normal for age / height (meeting one criteria for anorexia) - “glorification of slenderness” in magazines / TV o most females = thinner than avg NA woman o overweight men = 2-5 times more common on TV than overweight women  messaged aimed to be thin from media aimed at women - strong relationship b/w exposure to media images of thin female bodies, and body image concerns in women - 12% of female characters in prime-time comedies were dieting / making neg comments about body image - strong relationship b/w amount of media exposure and eating disorder symptoms in uni women - Study: girls who watched 8+ hrs of TV / week = sig greater body dissatisfaction than girls who watched less - Study: risk for developing ED is directly related to extent that women internalize / “buy in” to media messages / images glorifying thinness - In 1920s, ideal female body = similar in shape to ideal body today o shape achieved through fashion (girdles), not dieting o no diet articles in magazines during period (today – dieting ads everywhere) - Today’s standards are difficult to achieve b/c size / weight of avg woman inc over yrs w/ improved nutrition o Size increased throughout history o Collision b/w culture and physiology  women no longer satisfied w/ their bodies - Dramatic inc of young women in dieting / exercise to achieve impossible goal o Inc in dieting since 1950s: 1969 – 80% of Grade 12 female students wanted to lose weight, 30% dieting  Males: less than 20% wanted to lose weight, 6% dieting - Study: 3632 students in Grade 8 and 10  60.6% of females, 28.4% males were dieting - Younger girls diet less than older girls - Fallon / Rozin Study: male and female undergraduates  men rated their size, ideal size and size that was most attractive of opposite sex as approx equal o rated their ideal body weight as heavier than weight females thought most attractive in men o Women rated current figures as heavier than the most attractive (rated heavier as the ideal body size) - Study: undergrad women are critical of women’s hip sizes when making evaluations of women’s PA - Fallon Rozin Study – women’s judgment of ideal female body weight was less than weight that men thought was most attractive o Conflict b/w reality and fashion - neg attitudes re: body image are socially transmitted in adolescent girls o influence of close friendson attitudes of body image, dietary restraint, extreme weight loss behaviours  Experiment: 79 friendship cliques in 523 adoles. girls  Friendhip cliques shared same attidues toward body image, dietary restraint, imp of losing weight  Friendship cliques contribute sig to formation of ind body image concerns / eating behaviours  If friends use extreme dieting (or other weight loss tech), greater chance that you will too - most ppl who diet don’t develop ED o adlesc girls who dieted, = 8X more likely to develop an ED 1 yr later than those who weren’t dieting o Study: inc in binge eating during / after intense dieting in 201 obese women  Attempts to lose weight can lead to ED b/c weight reduction efforts in adolesc. girls lead to weight gain than weight loss!  Study: 692 girls, initially same weight, followed for 4 years. Girls who tried dieting had 300% greater rsk forobesity
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