Anorexia Nervosa (AN)

1. Anorexia Nervosa (AN) Symptoms & Cause Specifications state: only cover one eating disorder

2. Video clips There are many fascinating films about anorexia on You tube Katies story nhs video clip

3. Clinical characteristics of anorexia nervosa (AN): DSM IV tr First case reported in 1694 ‘Nervous loss of appetite’. Named in 1870 Anorexics display an ‘abnormal’ attitude towards food and eating. It is primarily a female disorder, usually occurring during adolescence. It is characterised by a refusal to maintain normal body weight.

4. Clinical characteristics of anorexia nervosa (AN): DSM IV tr 4 criteria for anorexia: • Anxiety - sufferers fear gaining weight • Individuals need to weigh less than 85% of their normal body weight to be diagnosed as anorexic • The distorted body image is not evident to anorexics themselves – they still see themselves as fat • Amenorrhoea – for more than 3 months

5. Anorexia causes a general physical decline • Cessation of menstruation (amenorrhoea) • Low blood pressure • Dry and cracking skin • Constipation • Insufficient sleep • Depression and low self-esteem • Up to 20% cases of Clinical AN are fatal A BMI of below 18.5 is an indicator & 15 is clinical

6. When does it change from a ‘Diet’ into a ‘Disorder’ (DSM IVr)? When the BMI (Body Mass Index) is equal to or less than 15 (when weight drops below 85% of expected weight by height and frame) However the BMI is only an indicator, it must be accompanied by a distorted body image, an abnormal relationship with food, a morbid fear of gaining weight, cessation of periods (3 months) and denial that there is a problem

7. Why is 15% such an important figure? At puberty a 15% increase in body fat (‘puppy fat’) is required to trigger the release of hormones necessary for the development of secondary sexual characteristics. (Wider hips, breasts, periods, pubic hair etc)

8. What happens if you drop below 15 BMI? Secondary sexual characteristic hormones are no longer produced and the body returns to pre-pubic child-like ‘asexuality’. Narrowing of hips, cessation of periods, breasts shrink, testicular atrophy (males) and these can be permanent!

10. Behavioural symptoms • Irritability & difficulty interacting with other people. • Decrease in concentration levels • Difficulty sleeping and fatigue during the day. • Compulsive and obsessive behaviours around cleanliness, tidiness and exercise.

11. Behavioural symptoms continued… • Obsessive about their body/appearance. • Obsessive about food/ fat/ calories. • High academic achievers. • Constant strive for perfection.

12. Physical symptoms • Weight loss • Dry/flaky skin • Downy hair growing on the face, back and arms. • Hair thinning or loss. • Brittle nails.

13. Medical complications of anorexia: • Slow heart rate • Low blood pressure • Arrhythmia • Constipation • Abdominal pain • Hormone imbalance • Slow thyroid function • Osteoporosis • Kidney failure • Anaemia • Loss of periods • Potential high risk of infection and suppressed immunity • Death

14. Prognosis • Variable – 20% have one episode and recover completely, while 60% follow an episodic pattern of weight gain and relapse over a number of years • Remaining 20% continue to be affected and often require hospitalisation • Mortality rate of those admitted to hospital is over 10% due to starvation or suicide.

15. Explanations for Anorexia The aetiology (cause & progression) of AN is probably explained by a combination of different factors including: • Biological • Psychological • Familial • Socio-cultural In other words the diathesis-stress model Genetic Predisposition + Environmental Trigger = Disorder

16. AN Biological explanations... 1. There may be a genetic origin Family studies have shown that first-degree relatives of AN have an increased risk of developing an eating disorder • Research in twins has shown that MZ have a higher concordance rate than DZ twins for anorexia. Holland et al (1984) found a 56% concordance rate in MZ twins, and only 5% in DZ twins.

18. Biological approach • Assumes our behaviour is controlled by the activity in the CNS, specifically the brain. • The brain itself is organised into regions which have different roles, so a malfunction in one region may cause a behavioural problem in the individual. • Malfunctioning of the hypothalamus plays an important role in the regulation of eating. Animal experiments which involve lesions in a particular part of the hypothalamus have led to either over-eating or starvation in the animals.

19. Biological approach • Neural mechanism dysfunction has been used as an explanation for anorexia in humans. • The lateral hypothalamus (LH) produces hunger and the ventromedial hypothalamus (VMH) reduces hunger. • A malfunction may be the cause of loss of appetite. For some anorexics it is as if their VMH is jammed on.

21. Biological explanations... • Another explanation could be Imbalance of serotonin neurotransmitters • Serotonin acts to suppress appetite • Disturbances of the serotonin pathways within the brain have been linked to the onset and maintenance of eating disorders. In particular, it seems that increased serotonin activity in the brain may be responsible for anorexic behavior. • There is considerable evidence that increased serotonin activity in the brain is associated with appetite suppression. In fact, drugs which act on serotonin pathways in the brain are commonly used for the short-term management of obesity. • It has been suggested that food restriction and several other behaviors which are characteristic of anorexia may be associated with increased serotonin activity.

22. Bailer(2007) Found higher serotonin activity in women recovering from binge-eating/purging. And the highest levels of serotonin activity was found in women who showed the most anxiety. High levels of serotonin are associated with jittery, anxious feelings. In order to get rid of these anxious feelings – the person may stop eating. Suggestion is, that it is the anxiety that triggers Anorexia and that AN is just a symptom of getting rid of the anxiety.

23. If serotonin is implicated in anorexia then this would have real world application. It should be possible to treat AN suffers with anti-depressant drugs which alter serotonin levels (SSRI) However Kaye (2001) suggests They are NOT effective until the AN patient is in recovery – the individual’s weight needs to have reached an ‘normal’ level

24. Also Dopamine ….. Kaye 2005 • Found over activity in Dopamine receptors Over activity in dopamine receptors were found in the basal ganglia of 10 women recovering from AN compared to 12 healthy controls. It is suggested this alters the way they interpret ‘rewards’. Good feelings may not be associated with food for example. Again possible drug therapies could be developed in the future if a causal link is established

25. Neurodevelopment There is a possible connection between premature birth and AN. Lack of oxygen could be a factor The child may lack adequate nutrition Double disadvantage  Having an AN mother (genetic transmission) AND Inadequate nutrition in the womb – Bulick (2005) There is support for this explanation of AN. (Favaro 2006) Obstruction of blood supply in the placenta, together with low birth weight and eating difficulties was associated with development of AN in later life.

26. EVOLUTIONARY EXPLANATIONS OF ANOREXIA NERVOSA

27. PSYCHOLOGICAL and NEUROCHEMICAL EXPLANATIONS FOCUS ON ANOREXIA NERVOSA AS A DISORDER…

28. EVOLUTIONARY EXPLANATIONS ASSERT THAT AN MAY HAVE BEEN ADAPTIVE …

29. REPRODUCTIVE SUPPRESSION HYPOTHESIS basic assumptions # weight loss was a strategy for suppressing reproductive capability (Surbey 1987) #when food was in limited supply, pregnancy would have been risky for the mother and survival chances for the infant would have been reduced #in the absence of contraceptives, weight loss would prevent pregnancy at times when it would be too risky

30. REPRODUCTIVE SUPPRESSION HYPOTHESIS based on 2 ‘models’ the reproduction suppression model: because reproduction is costly to females, a female facing conditions temporarily unfavourable to reproduction can increase her lifetime reproductive success by delaying reproduction until conditions improve the critical fat hypothesis: because a minimum amount of body fat (17%) is needed before menstruation begins and additional fat accumulation (22%) is needed to maintain regular ovulation (Frisch, 1985; Frisch and Barbieri, 2002) altering the trajectory of adolescent weight gain, or the loss of five pounds or so, could have been an effective mechanism for controlling sexual maturation and fertility in ancestral females

31. Adapted to Flee Hypothesis • GUISINGER (2003) • EEA >>Famine conditions >>> migration required • Food restriction, hyperactivity, denial of hunger could be an adaptive mechanism that prepares the individual to move to find food • ‘ancestral mechanisms’

33. PSEUDO-NUBILE-FEMALE HYPOTHESIS AN is the result of intra-sexual selection what is intra-sexual selection? It is the process that results in only those characteristics/behaviours that enhance chances of successful same-sex competition for a mate remaining in the gene pool I.e. What makes you more attractive than another potential mate

34. PSEUDO-NUBILE-FEMALE HYPOTHESIS AN is the result of intra-sexual selection how does INTRA-SEXUAL SELECTION lead to AN? - in the ancestral environment, the female shape was a generally reliable indicator of the female’s reproductive history and hence her future reproductive potential - the female nubile, ‘hour-glass’ shape is the product of sexual selection and represents the most desirable visual cue for males; in addition to the hour-glass appearance the hallmark of the nubile shape is its relative thinness compared to older females

35. PSEUDO-NUBILE-FEMALE HYPOTHESIS AN is the result of intra-sexual selection how does INTRA-SEXUAL SELECTION lead to AN? - in the modern age, ‘mating behaviour’ is not necessarily linked with reproduction (2nd marriages, etc); AND female youth is no longer a pre-requisite for reproduction (technology = older mothers) - therefore progressively older females benefit from retaining or recreating the nubile shape.

36. PSEUDO-NUBILE-FEMALE HYPOTHESIS AN is the result of intra-sexual selection how does INTRA-SEXUAL SELECTION lead to AN? • it is argued that during the EEA most women of reproductive age were either pregnant or lactating and therefore temporarily infertile... therefore, it has been suggested that, to avoid rearing another man’s offspring men must have developed an aversion to even a slight thickening of the waist (Ridley,1993). • such aversion would be expected to be directed towards novel females (i.e., a female who is not already the male’s consort) and should be particularly relevant to the male’s choice of a long term mate.

37. Other possible explanations

38. Psychodynamic explanation How might Freud explain eating disorders?

39. Psychodynamic explanation Freud: A traumatic event in the sufferers childhood Failure to pass through all the milestones of development – such as the oral stage Eating could be a substitute for sexual activity – not eating threatens the development of our body Not eating stops you menstruating – unconscious desire to not grow up Not eating affects development of body – breasts, hips etc

40. Evidence for Psychodynamic explanation Hilda Bruch (1980) • Looked at origins of the illness in childhood. FOUND • Results from poor parenting • Parents don’t cope with children’s needs correctly E.g. • Giving the child food when they are anxious, as if that will solve the problem. • Steiner et al (1991) • Supported Bruch. • Observed adolescents with anorexia • FOUND • The parents were too involved in the child’s appearance, rather than letting the child figure it out on her own • Anticipate their child’s needs instead of letting the child tell them when they are hungry. • Supporting that overs’ views on their body are important (Button & Warren (2001))

41. Evaluation on psychodynamic approach Helps us discover how our past can influence our present and future Unscientific – lacks empirical evidence Psychotherapist could suggest believable traumatic events from the past that actually never happened Shows we have a subconscious and that this affects us without us realising

42. Cognitive Explanation

43. Cognitive Explanation Sufferers of anorexia nervosa often have a misperception of their body. • Faulty thinking • Thinking they are overweight when they are in fact underweight. • 2) Basing self worth on self appearance. • 3) Using eating as self control. Errors in thinking 1) All or nothing – eating one piece of chocolate ruins everything 2) Overgeneralising – thinking you’ll fail in life if you can’t control eating 3) Magnification/minimising – weight loss isn’t serious 4) Magical thinking – life will be complete when I’m a size 4 • Symptoms and signs • Dramatic weight loss over a short period. • Dieting despite being thin. • Fixation on body image. • Harshly criticising oneself. • Feeling fat; despite being thin. • Denial that you are too thin. • Strange food rituals. • Preoccupation with food. • Using diet pills. • Compulsive exercising. • BMI below 18.5/15

44. Evidence for the cognitive explanation Fallon & Rozin (1985) • Male & female participants • Shown body silhouettes increasing in size • Told to rate their current body size, ideal body size and body size the opposite sex would find most attractive FOUND • Men rated ‘current’&’ideal’ close together. And ‘attractive’ as smaller. WHEREAS • Females rated ‘attractive’ body as smaller than their ‘current’. And ‘ideal’ to be smaller than both. • MacKenzie et al (1993) • Interviewed female eating disorder patients & a control group • About body weight, shape & ideals • Then to compare their body to other women's (who were the same size) • FOUND • Women saw themselves as bigger • Females chose ideal weight smaller than control group • Gave pp’s chocolate and a drink and asked to re-estimate their size. • Control group chose no different, other group chose bigger

45. Evaluation of the cognitive approach • Helps show what can help maintain an eating disorder, but not what causes them. • Ethical issue = the explanation sometimes blames the sufferer. • People who are clinically ‘normal’ too have irrational thoughts; what’s the difference? • States the obvious – sufferers of anorexia see themselves as overweight. • Women are generally more dissatisfied with their bodies than men, yet not all have eating disorders.

46. Learning Theory

47. Behaviourist approach • Classical conditioning • Operant conditioning • Social Learning Theory A learned association between eating and anorexia Reinforcement of dieting – ‘’you look amazing!!’’ Imitating desired role models e.g. skinny models

48. Behaviourist approach Classical conditioning food is associated with putting on weight and feeling anxious, and out of control Not eating is associated with losing weight and feelings of relief and reduced anxiety AN is a Learnt behaviour

49. Behaviourist approach Operant conditioning Positive Reinforcement - wow you look great! Negative reinforcement - I ate too many calories. I feel terrible - I must avoid eating so I don’t have to feel this bad again You look better, have you put on a little bit of weight? OUCH!! (punishment)