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Anorexia nervosa DSM Criteria?
- ~ Refusal to maintain minimally normal body weight
- ~ Intense fear of becoming fat
- ~ Disturbance in body perception - perceive themselves to be fat
- ~ Amenorrhoea
Subtypes: restricting, binge-eating/purging
What are the critical criteria for AN?
- ~ Intense fear of becoming fat
- ~ Disturbance in body perception
- Amenorrhea is a physical by-product of the disease, not an actual symptom.
- There is a lack of consensus as to what the minimally normal body weight should be, and failure to meet this criteria does not indicate less sever psychopathology.
Subtyping is also not useful in predicting course - rather indicates current stage so should be applied only to the previous 3 months.
What is the typical family of an AN?
Successful, hard-driving, concerned about appearances, eager to maintain harmony. Often ignore/deny conflict and attribute problems to other rather then engaging in healthy communication.
Mothers are often dieting themselves and want their daughters to be thin ("society's messengers"). Generally perfectionistic.
What is the difference in psyche between AN and BN?
AN = proud of diets and self control
BN = ashamed of eating issues and lack of control
What are some features associated with AN?
Severe exercise is common.
Dry skin, brittle/thinning hair, sensitivity to cold, lanugo.
Mortality rate as high as 20% (highest mortality rate of any psychological disorder). 30% are suicides.
Ego-syntonic - behaviour consistent with the way they view the world - seldom seek treatment on their own.
Personality characteristics: high neuroticism, perfectionist, obedient, shy.
What are eating disorders often comorbid with?
AN: anxiety, OCD, depression, substance abuse (a strong predictor of mortality, esp suicide)
BN: anxiety (80%), depression (evidence suggests depression follows BN - may be a reaction to it), substance abuse (laxatives and elevated rates of alcohol/drugs), borderline personality disorder.
Treatment of AN?
Very difficult to treat due to ego-syntonicity.
In general drug treatment is not effective. Anti-psychotics may have a desirable weight gain effect.
First goal is weight restoration - important for health/survival, also cognitive impairments when severely underweight.
Initial weight gain is a poor predictor of long term outcome. Need to address underlying dysfunctional attitudes and interpersonal disruptions or will almost always relapse.
- Family based therapy, e.g. Maudsley approach for teenagers.
- ~ 15-20 sessions. Outpatient treatment with parents in key role.
- ~ Phase 1: restore weight - family playing a supportive role and helping patient eat/gain weight.
- ~ Phase 2: give control of eating back to the child.
- ~ Phase 3: establish healthy adolescent identity.
Motivational interviewing: resolving ambivalence and developing a motivation to change.
- Include the family to accomplish 2 goals:
- ~ Negative and dysfunctional communication re: food and eating is eliminated
- ~ Attitudes toward body shape and image distortion addressed.
What is a predictor of an eating disorder?
Early concern about being overweight is the most powerful predictive factor.
Screen for high risk individuals and provide with a preventative program, e.g. education about body changes and being healthy.
Bulimia nervosa DSM criteria?
- ~ Binge eating: large amount in a discrete period of time, lack of control over eating.
- ~ Inappropriate compensatory behaviours.
- ~ Binge eating and compensatory behaviours 2x per week for 3 months
- ~ Self evaluation influenced by weight/shape.
- ~ Does not occur exclusively during periods of AN (AN trumps BN)
Sub types: purging, non-purging type.
What are the critical criteria for BN?
- ~ Binge eating
- ~ Inappropriate compensatory behaviours
- ~ Self evaluation influenced by weight/shape
Proposed to relax criteria about binge frequency and duration - does not influence severity of psychopathology.
Suggested to remove subtypes - no differences in terms of psychopathology, frequency, or prevalence of comorbid disorders.
What are some features associated with BN?
Physiological complications include: swollen salivary glands, calluses on fingers, eroded dental enamel, severe constipation/colon damage (laxative abuse), tearing of the oesophagus, ruptured stomach, electrolyte imbalance.
Personality features: high neuroticism, novelty seeking, emotional instability, impulsivity.
Strongly related to anxiety disorders
Treatment for BN?
- SSRIs (antidepressants) and anxiolytics:
- ~ Addressing the fact that low serotonin is linked to binge-eating and impulsivity.
- ~ Do not have long-lasting effects.
- ~ Short term treatment, semi-structured approach, problem oriented.
- ~ Collaborative skill learning model.
- ~ Stage 1 (sessions 1-8): present CBT, take history, behavioural strategies to stabilise eating (e.g. scheduled eating), weighing, introduce self-monitoring, stabilise eating through education (e.g. physical consequences, ineffectiveness of purging/dieting)
- ~ Stage 2 (sessions 9-16): eliminate dieting, address concerns about weight/shape, strategies to modify cognitions attitudes and beliefs (challenge cognitive distortions and irrational thoughts), challenge societal standards and values regarding attractiveness, work on other issues (e.g. low self-esteem, depression), develop coping strategies (resisting urge to binge/purge).
- ~ Stage 3 (sessions 17-20): maintenance and relapse prevention, consolidate gains, prepare for termination, distinguish between a lapse and a relapse.
Self help programs using CBT principles seem effective for less severe cases.
- ~ Focuses exclusively on interpersonal relationships
- ~ Manualised treatment - strict protocol that are followed
- ~ Foal areas (pick 1): interpersonal disputes, role transitions, grief, interpersonal deficits.
CBT is the most common treatment (better because it gets you there faster). But IPT catches up and in some cases does better long term.
Our best treatment works for just over half the people with BN. 1/3 will recovery, 1/3 will be functioning but still struggle with BN, 1/3 won't be helped.
What are the causes of eating disorders?
- Social factors:
- ~ Societal trends for the "thin ideal"
- ~ Strong relationship between media exposure and body image concerns in women.
- Cultural factors:
- ~ African Americans and Hispanics are less likely to internalise the thin ideal.
- ~ Developing nations have emphasis on larger shape.
- Psychological factors:
- ~ Low self esteem: lack of sense of control, lack of confidence in abilities, unstable identity.
- ~ Perfectionism: dieting may be an attempt to exert control.
- ~ Distorted body perception: inaccurate perception of own body, thought-shape fusion.
- ~ Escape theory: difficulty tolerating negative emotion.
- Biological factors:
- ~ Genetics: relatives of ED have 5x greater risk. Might be inheriting a set of personality traits that predispose you to an ED. But no adoption studies so can't rule out sociocultural factors.
- ~ Neuroendocrine dysfunction: hunger controlled by the hypothalamus. Low levels of serotonin linked to impulsivity and binge eating. OR, are these abnormalities caused by starvation/binge-purge?
What are EDNOS?
- Eating disorders not otherwise specified:
- ~ Do not meet criteria for any specific ED
- ~ Unusual pattern of eating behaviour
- ~ Do not meet full criteria for AN or BN.
- ~ Newly emerging disorders, e.g. BED, purging disorder
What is the problem with the current EDNOS?
Currently 40-70% of eating disorders are diagnosed as EDNOS.
- Proposals to deal with this:
- ~ Relaxing criteria for AN/BN
- ~ Identifying new disorders
- ~ Just have the one diagnosis of "eating disorder" and specify traits.
- ~ Conceptualise along a multi-dimensional axis, e.g. Big 5.
Recommend relaxing criteria and identifying new disorders.
What is BED?
- Binge eating disorder:
- ~ Binge eating: eating a large amount in a discrete period, lack of control over eating.
- ~ Distress about binge eating
- ~ Binge eating 2x per week for 6 months
- ~ Binge eating not associated with compensatory behaviours
Treatment for BED?
CBT or IPT (equally effective).
Self help procedures may be useful.
More severe cases may require more intensive treatments, especially if comorbid disorders.
Is obesity an eating disorder?
There is an argument obesity is like a food addiction. In which case pathological overeating could belong in the DSM, but obesity itself probably doesn't.
In most cases obesity is a physical state, not a psychological one.