Eating Disorders Psychological and Clinical Perspectives: Assessment, diagnosis, treatment and explanations. A critical

1. Eating Disorders Psychological and Clinical Perspectives: Assessment, diagnosis, treatment and explanations. A critical look- what has been ignored? Devinder Rana BSc (Hons) Psychology LM40507 Psychopathology and Abnormal Psychology

2. Aims • By the end of the session you will be able to do the following: • Describe how the DSM-IV-TR defines and distinguishes different eating disorders. • Describe and compare how the biological, psychological and sociocultural perspectives explain the aetiology of eating disorders. • Analyse the different treatments and perspectives and their legal and ethical implications.

3. Eating Disorders 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Eating Disorder Not Otherwise Specified (EDNOS) Binge-eating disorder (proposed diagnosis requiring further study).

4. Anorexia Nervosa

5. Criteria DSM-IV-TR • Refusal to maintain a body weight that is normal for the person’s age and height (i.e., a reduction of body weight to about 85% of what would be normally expected). • Intense fear of gaining weight or becoming fat, even though underweight. • Distorted perception of body shape and size. • Absence of at least three consecutive menstrual cycles. • Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American Psychiatric Association. • In-text citation: APA (2000)

6. Sub-types (APA, 2000).

7. In Context DSM-VI-TR (2000) Criteria • A 5’11 adult weighing 11 stone (70 kilos) falls into the OK category. • A deviation of 15% results in the individual now weighing just over 9 stone and is subsequently classed as anorexic.

8. Epidemiology • 80-90% of suffers are female with typical age onset between 14-18 years old (Pike, 1998). • Weight control remains a long-term issue. • Links with Obsessive Compulsive Disorder • Occur in young children • Occur in boys

9. Ballet dancers (Gelsey Kirkland) and gymnasts (Christy Henrich)

10. Characteristics of Anorexia • Anorexic’s develop eating habits typical of bulimia nervosa (e.g. maintenance of ‘normal’ weight through abnormal eating habits). • Socio-economic and academic achievement link. • Pre-occupation with food- thoughts of eating, preparation of food or watching others eat. • High ‘calorie consumption’ behaviours e.g. gym, running or swimming. • Young, European American Women .

11. Distorted body image • Over estimation of body proportion and distorted body image (Gupta & Johnson, 2000). • Link with depression, anxiety and OCD.

12. Effects of Anorexia • Amenorrhea (lack of menstruation). • Immune infections

14. High/low blood pressure

15. Cracked Skin

16. Brittle hair and bones

17. Cardiotoxicity (heart damage)

18. Consequences • Mortality rate is 12x higher than the mortality rate for females aged 15 to 24 in the general population (Sullivan et al 1995). • Death results from: Physiological consequences from starvation Intentional suicidal behaviour

19. Historical Account and Definition Anorexic nervosa means: “ lack of appetite induced by nervousness”. (Butcher et al, 2007). Lack of appetite is not the real problem.

20. “Self-starvation, resulting in a minimal weight for one's age and height or dangerously unhealthy weight”. • Hudson et al (2006).

21. Greek An: without Orexis: a desire for “ without desire for food” Nevid et al (2008).

22. Central to anorexia nervosa • Fear of gaining weight or becoming fat • Refusal to maintain even a minimal low body weight.

23. Historical Accounts • Accounts in early religious literature (Vandereycken, 2002). • First medical account published in 1689 Richard Morton. • 18 year old girl and 16 year old boy- described as having a: “nervous consumption that caused wasting of body tissue”. • 1873 Sir William Gull in London & Charles Lasegue in Paris independently describe the clinical syndrome and receive its current name.

24. Gull (1888) Described a 14 year old girl: “Without apparent cause, to evidence a repugnance to food, and soon afterwards declined to take whatever, except half a cup of tea or coffee”.

25. Problems with the diagnostic tool: DSM-IV-TR • Women who continue to menstruate but meet all the other diagnostic criteria for anorexia nervosa are just as ill as those who have amenorrhea (Cachelin & Maher, 1998; Garfinkel, 2002). • For men, the equivalent of the menstruation criterion is diminished sexual appetite and lowered testosterone levels (Beaumont, 2002).

26. Bulimia Nervosa

27. Criteria DSM-IV-TR • Recurrent episodes of binge eating. binges in a fixed period of time, food far greater than normal circumstances. Lack of control and unable to stop. • Recurrent and inappropriate efforts to compensate for the effects of binge eating. self induced vomiting laxatives excessive exercise thyroid medication • Self-evaluation is excessively influenced by weight and body shape. Source: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2000). American Psychiatric Association. In-text citation: APA (2000)

28. Characteristics • Food is eaten rapidly, secretively, without pleasure in binges where in excess of 5000 calories can be consumed (2x the recommended daily male intake). • Bulimics demonstrate a fear of weight gain and consider themselves to be heavier than they actually are (McKenzie et al 1993) • Approximately 80-90% of individuals will vomit following a period of binging, one third adopt laxative use and others constantly exercise (Anderson et al, 2001). • Long-term problems include digestive issues, dehydration, damage to stomach lining and damage to the teeth. • Fairburn & Beglin (1994) estimate prevalence between 0.5-1%.

29. Anorexia Vs. Bulimia

30. Bulimia and Purging anorexia nervosa • Meets the criteria for binging/purging, also meets the criteria for anorexia nervosa, anorexia nervosa will be diagnosed. • Common anxiety with fear of being fat.

31. 2 types

32. Explanations

33. Complex Interaction Psychological Biological Socio-cultural family Individual

34. Biological Factors Genetics

35. Genetics • Runs in families (Bulik & Tozzi, 2004) • Risk of anorexia nervosa for relatives of people with anorexia nervosa was 11.4x more greater. Bulimia 3.7X higher, than relatives with healthy controls. (Strober et al, 2000). • Relatives of patients with eating disorders are more likely to suffer from other problems, especially mood disorders (Mangweth et al 2003). • However, eating disorders are not densely clustered as are mood disorders and schizophrenia.

36. Twin studies • Anorexia nervosa and bulimia nervosa are hereditable disorders (Bulik & Tozzi, 2004; Fairburn & Harrison, 2003).

37. Genes • Chromosome 1 linked to the susceptibility to the restrictive type of anorexia (Grice et al, 2002). • Bulimia (purging) linked to chromosome 10 (Bulik et al, 2003). • Eating disorders linked to chromosomes involved • Genes responsible for serotonin: low serotonin level (Kaye et al., 2005)

38. Brain: Hypothalamus and GLP-1 • Regulates bodily functions • Lateral hypothalamus: produces hunger when activated • Ventromedial Hypothalamus: reduce hunger when activated • Each part electrically stimulated in animals they decrease/increase eating behaviour (Duggan & Booth, 1986) • Glucagon-like peptide-1 (GLP-1) natural appetite suppressant. • Inject rats they will not eat even after a 24hr fast • Block GLP-1 in the hypothalamus-double food intake (Turton et al., 1996).

39. Weight Set Point Theory • LH, VMH, GLP-1, work together comprise a weight thermostat • Weight set point theory (WSP) (Hallschmid et al., 2004). • Genetic inheritance and early eating patterns determine WSP. • Weight falls below the WSP, hunger increases and metabolic rate decrease. • Diet and fall below WSP, hypothalamic activity produces a preoccupation with food and desire to binge. • Trigger bodily changes- harder to lose weight however little is eaten (Spalter et al., 1993) • Restricting-type anorexia: shut down their inner thermostat and control their eating completely. • Binge-purge pattern: battle spirals (Pinel et al., 2000)

40. The average American woman is 5’4” and 140 pounds. The average American model is 5’11” and 117 pounds.

41. Societal Pressures

42. Current Western standards of female attractiveness have contributed to increases in eating disorders (Jambor, 2001). • Decline Miss America Pageant, average decline of 0.28 pound per year (Garner et al., 1980). • Fashion models, actors, dancers, certain athletes: more prone to eating disorders (Couturier & Lock, 2006). • 20% of gymnast surveyed had an eating disorder (Johnson, 1995). • White upper socioeconomic expressed more concerns about thinness (Mrgo, 985) • Recent years increased in all classes and minority groups (Germer, 2005). • Double standard has made women more inclined to diet and more prone (Cole & Daniel, 2005) • Cruel jokes targeted as obesity are standard in the media (Gilbert et al., 2005) • Deep rooted (Grilo, 2006) • Parents more likely to rate a picture of a chubby child as less friendly, energetic, intelligent and desirable. • 61% of secondary school girls are dieting (Hill, 2006)

43. Battle of Brittan's

44. Timeline 1639 - The Three Graces; Pieter Pauwel Rubens

45. 1887 - Pierre Auguste Renoir, The Bathers

46. 1920 - Thin, short haired flapper

47. 1950 - Monroe (Size 14/16)

48. 1960 - Twiggy Lawson (Aka the beginning of the end.) This was the first time in history that an under weight woman became the standard for the ideal body image.

49. 1988 - Cosmopolitan

50. 2002 - Harper’s Bazaar