Transcript abnormal PSYCHOLOGY Third Canadian Edition

abnormal
PSYCHOLOGY
Fourth Canadian Edition
Chapter 10
Eating Disorders
Prepared by:
Tracy Vaillancourt, Ph.D.
Modified by: Réjeanne Dupuis, M.A.
Chapter Outline
• Clinical Description
• Etiology of Eating Disorders
• Treatments of Eating Disorders
Prevalence
• Lifetime prevalence in the U.S. in 2001 and 2003
– Anorexia nervosa (women 0.9%; men 0.3%); Bulimia nervosa
(women 1.5%; men 0.5%); Binge eating disorder (women
3.5%; men 2.0%)
• One-year prevalence in Canada in 2002
– 0.5% of Canadians reported an eating disorder diagnosis
(women 0.8%; men 0.2%)
– Women ages 15-24 reporting an eating disorder: 1.5%
– 1.7% of Canadians meet criteria for an eating attitude
problem
• Eating disorders can cause long-term psychological,
social and health problems
Types of Eating Disorders
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Anorexia Nervosa (AN)
Bulimia Nervosa (BN)
Binge Eating Disorder
Eating Disorder not otherwise specified
(EDNOS)
Anorexia Nervosa (AN)
• Anorexia—loss of appetite
• Nervosa—appetite loss due to emotional reasons
– Term a misnomer because most patients do not lose their
appetite or interest in food
• Four features required for the diagnosis:
1. Refusal to maintain a normal body weight
• < 85% of what is considered normal for age and height
2. Intense fear of gaining weight; fear not reduced by weight loss
• Overevaluation of appearance
3. Distorted sense of body shape
4. Amenorrhea in post-pubertal females
Types of AN
• Restricting type
– Weight loss is achieved by severely limiting food
intake
• Binge eating-purging type
– Person regularly engages in binge eating and purging
• Binge eating-purging type is more psychologically
impaired that restricting type
– More psychopathological, more personality disorders,
impulsive behaviour, stealing, alcohol and drug abuse,
social withdrawal, and suicide attempts
• They also tend to weigh more in childhood; come from
heavier families with greater familial obesity; and use
more extreme weight-control methods
Features of AN
• Typically begins in the early to middle
adolescence
• Often after an episode of dieting and exposure
to life stress
• Lifetime prevalence 1% (in women)
– 3 to 10 X > more frequent in women than men
• Comorbid with depression, obsessivecompulsive disorder, phobias, panic disorder,
alcoholism, oppositional defiant disorder, and
various personality disorders
Physical Changes with AN
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 blood pressure
 heart rate slows
 bone mass
Kidney and
gastrointestinal problems
dry skin
• Nails become brittle
• Hormone levels change
• Mild anemia
• Hair loss
• Laguna
• Altered levels of
electrolytes, such as
potassium and sodium
• Tiredness
• Weakness
• Cardiac arrhythmias
• Sudden death.
•  in brain size
– White and grey matter
Prognosis of AN
• 70% of patients recover
• Relapses are common
• Death rates are 10 X > than general
population
• Death rates 2X > than patients with other
psychological disorders
Eating Disorders and
Intentional Self-harm
• Self-harm is associated with impulsivity
• 16.9% of Canadian youth (ages 14-21) engaged nonsuicidal self-injury
• 3/10 first-year undergraduate students admitted
intentionally engaging in at least one act of self-harm,
cutting for women and reckless driving for men
– These behaviours were related to history of emotional abuse,
illicit drug use, depression, various personality factors
• Reasons for engaging in self-harm: (1) interpersonal
reasons; (2) to suppress an unwanted social stimulus;
(3) to suppress negative emotions; (4) to generate
feelings
Bulimia Nervosa (BN)
• Involves episodes of rapid consumption of a
large amount of food (binge), followed by
compensatory behaviours (purge).
– Binge = eating excessive amount of food in < 2 hours
• Typically occur in secret
• May be triggered by stress
– Purge= vomiting, fasting, or excessive exercise
• Note. If binging and purging occur only in the
context of AN then BN not diagnosed
BN (cont.)
• People with BN are afraid of gaining weight
– “A morbid fear of fat”
• 2 subtypes of bulimia nervosa:
1. Purging type
2. Non-purging type
• Compensatory behaviours are fasting or
excessive exercise
• Typically begins in late adolescence or early
adulthood
Other Features of BN
• Comorbid with depression, personality
disorders, anxiety disorders, substance abuse,
and conduct disorder
• Physical side effects
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Potassium depletion
Diarrhea
Changes in electrolytes
Irregularities in the heartbeat
Tearing of tissue in the stomach and throat
Loss of dental enamel
Swollen salivary glands
Binge Eating Disorder
• Recurrent binges (2X / week for at least six months) +
lack of control during the binging episode + distress
about binging
– + rapid eating and eating alone.
• Distinguished from AN by absence of weight loss
• Distinguished from BN by the absence of compensatory
behaviours (e.g., vomiting)
• More prevalent than either AN or BN
– 6% of successful dieters
– 19% of unsuccessful dieters
– Risk factors for developing BED include:
• Childhood obesity, critical comments regarding being
overweight, low self-concept, depression, and childhood
physical or sexual abuse
Etiology of Eating Disorders
Etiology: Biological Factors
Genetics
• AN and BN run in families
• First-degree relatives of young women with AN 4 X > likely to
have the disorder themselves
• AN and BN  in identical twins than fraternal twins
• heritability estimate of 56%
Eating Disorders and the Brain
• Hypothalamus proposed to play a role in AN
• Paraventricular nucleus also implicated
• Abnormal cortisol
•  endogenous opioids due to starvation
•  regional mu-opioid receptor binding in the insular cortex in
BN
•  levels of serotonin metabolites in BN
Socio-Cultural Variables
• Steady progression toward increasing thinness as the
ideal
– Unrealistic cultural pressures
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Scarlett O’Hara effect
 Body dissatisfaction
Activity Anorexia
Gender Influences
Cross-Cultural Influences
– Eating disorders more common in industrialized societies,
such as the United States, Canada, Japan, Australia, and
Europe, than in non-industrialized nations
To Diet or Not to Diet?
• The diet industry is a multi-billion dollar a year
business
• Hedonic system
• Heredity: 20-50% of variability is genetic
• Psychological factors
– Stress, motivation for thinness
– Dieting appears to be a predictor of ED
– False hope syndrome
• Dieting tends to lead to weight fluctuation and is
a health risk factor
Etiology: Psychological Views
Cognitive-Behavioural Views on AN
• Emphasize fear of fatness and body-image disturbance
as the motivating factors that make self-starvation and
weight loss powerful reinforcers
– Behaviours that achieve or maintain thinness are negatively reinforced by the  of anxiety about becoming fat.
– Dieting and weight loss may be + reinforced by the sense
of mastery or self-control they create
• see the thinspiration effect
• Criticism from peers and parents about being overweight
may also contribute to ED
Etiology: Psychological
Views (cont.)
Psychodynamic View
• Disturbed parent-child relationships
• Symptoms of eating disorder fulfill some need or to avoid
growing up sexually
Family Systems Theory
• Relationship between patient and how the symptoms are
embedded in a dysfunctional family structure than may
exhibit the following characteristics:
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Enmeshment
Overprotectiveness
Rigidity
Lack of conflict resolution
Child Abuse
Etiology: Psychological
Views (cont.)
Personality Factors
In AN
• Perfectionistic, shy, and compliant before the onset of
the disorder
In BN
• Histrionic features, affective instability, and an outgoing
social disposition
BN and AN
• High in neuroticism and anxiety and low in self-esteem
• High on traditionalism, indicating strong endorsement
• Narcissism
Cognitive-Behavioural
Theory of BN
Treatment of ED
Up to 90% of people with ED are not in treatment and
those who are in treatment are often resentful
Biological Treatments
• SSRIs in particular fluoxetine (Prozac)
– Frequently used to treat bulimia
– Helps reduce depression, distorted attitudes toward food
and eating
• Unfortunately, SSRIs not consistently effective
• More drop-outs of studies in biological and cognitivebehavioural treatments
• Currently, there is no empirical basis for using
antidepressants to treat AN
Treatment of ED (cont.)
Psychological Treatment of AN
– Two-tiered process
• Immediate goal is to help the patient gain weight
• 2nd goal of treatment is long-term maintenance of weight gain
– Not yet reliably achieved
– CBT of the maintenance of AN
• Based on an extreme need to control eating
• Tendency to judge self-worth in terms of shape and weight
• Treatment has shown
– Schema-Focused Cognitive Behaviour Therapy, Family
Systems Therapy, and Interpersonal Therapy used to treat
EDs
Psychological Treatment of BN
– CBT: treatment of choice for BN and binge eating disorder
Treatment of ED (cont.)
Psychological Treatment of BN
– CBT: treatment of choice for BN and binge eating
disorder
– Goal: to develop normal eating patterns
– Clients:
• Question society’s standards for physical attractiveness
• Uncover and challenge detrimental beliefs about starving
and becoming overweight
• Learn that normal can be maintained with dieting
• Learn assertion skills
– Outcome has its limitations
• Fewer binges and purges , but clients to not feel much better
• Half tend to relapse
Prevention of ED in Canada
• Preventive efforts show reduction of prevalence of ED,
especially for high-risk participants
• The Piran Study
– Ongoing study at an international ballet school in Toronto
– Prevalence of ED: From 50% in 1987 to 15% in 1991, 1996
– Based on participation and changing the ballet school culture
• McVey and Devy Program
– Reduce the impact of media portrayals of unrealistic body
images
• School-based peer support group
• Web-based training program for teachers
Treatment of ED in Canada
• B.C. Children’s Hospital Eating Disorders Program
– Services: Intake, Day Treatment, Outpatient Services,
Inpatient Unit, Residence, Parent-Child Group, Outreach
Provincial Services
• Sheena’s Place, non-profit organization
– Perceived as ‘waiting-rooms’ for hospital-based programs
– Currently offers 50 groups, e.g., University and college
studetns, Unlocking emotional eating
• Obesity is also receiving attention
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